Bridging the gap between health and non-health investments: moving from cost-effectiveness analysis to a return on investment approach across sectors of economy

When choosing from a menu of treatment alternatives, the optimal treatment depends on the objective function and the assumptions of the model. The classical decision rule of cost-effectiveness analysis may be formulated via two different objective functions: (i) maximising health outcomes subject to the budget constraint or (ii) maximising the net benefit of the intervention with the budget being determined ex post. We suggest a more general objective function of (iii) maximising return on investment from available resources with consideration of health and non-health investments. The return on investment approach allows to adjust the analysis for the benefits forgone by alternative non-health investments from a societal or subsocietal perspective. We show that in the presence of positive returns on non-health investments the decision-maker's willingness to pay per unit of effect for a treatment program needs to be higher than its incremental cost-effectiveness ratio to be considered cost-effectiv

Decision rules and uncertainty in the economic evaluation of health care technologies

Health is often regarded as the most precious good of all. This is frequently illustrated by the widespread opinion that no expense should be spared to maintain one's health. However, in most societies the awareness that health care expenditure should be controlled in one way or another is highly prevalent. In most Western countries health care expenditure expanded substantially over the past decades, not only in absolute terms but also as a proportion of the Gross Domestic Product (GDP). In 2000, The Netherlands, Switzerland and the USA spent 8.1 o/o, 10.7 o/o and 13.0% of their GDP on health care. In the same countries in 1980 the expenditure for health care was 7.5o/o, 7.6% and 8.7%, respectively ('Vv11!VV.oecd.org). In the face of mounting pressure to contain health care resource consumption, policy-makers are increasingly forced to consider an economics perspective when judging whether a new medical technology should be financed

Intranasal Influenza Vaccine in a Working Population

In the present study, we assessed the incidence of adverse events and influenza-like symptoms in a working population in Switzerland that was vaccinated against influenza. A total of 12,582 individuals of working age (<65 years old) were offered a free influenza vaccine of their choice (injectable or intranasal vaccine) in October and November 2000. Of these individuals, 1600 were vaccinated against influenza. Ninety-seven percent of the vaccine recipients chose the intranasal vaccine, and 3% chose the injectable influenza vaccine. The incidence of influenza-like symptoms and side effects was 13% and 36%, respectively. Individuals who chose the intranasal vaccine were more likely to report side effects (OR, 3.23; 95% CI, 1.29-8.08). Facial paralysis was observed in 11 patients and was the most severe adverse event associated with the intranasal influenza vaccine. As a result of these adverse events, the intranasal vaccine was removed from the market in the fall of 200

Portfolio Theory and Cost-Effectiveness Analysis: A Further Discussion

AbstractObjectivesPortfolio theory has been suggested as a means to improve the risk–return characteristics of investments in health-care programs through diversification when costs and effects are uncertain. This approach is based on the assumption that the investment proportions are not subject to uncertainty and that the budget can be invested in toto in health-care programs.MethodsIn the present paper we develop an algorithm that accounts for the fact that investment proportions in health-care programs may be uncertain (due to the uncertainty associated with costs) and limited (due to the size of the programs). The initial budget allocation across programs may therefore be revised at the end of the investment period to cover the extra costs of some programs with the leftover budget of other programs in the portfolio.ResultsOnce the total budget is equivalent to or exceeds the expected costs of the programs in the portfolio, the initial budget allocation policy does not impact the risk–return characteristics of the combined portfolio, i.e., there is no benefit from diversification anymore.ConclusionThe applicability of portfolio methods to improve the risk–return characteristics of investments in health care is limited to situations where the available budget is much smaller than the expected costs of the programs to be funded

Patients' awareness of the potential benefit of smoking cessation. A study evaluating self-reported and clinical data from patients referred to an oral medicine unit

The present study analyzed history of smoking and willingness to quit smoking in patients referred for diagnosis and treatment of different oral mucosal lesions. Prior to the initial clinical examination, patients filled in a standardized questionnaire regarding their current and former smoking habits and willingness to quit. Definitive diagnoses were classified into three groups (benign/reactive lesions, premalignant lesions and conditions, and malignant diseases) and correlated with the self-reported data in the questionnaires. Of the 980 patients included, 514 (52%) described themselves as never smokers, 202 (21%) as former smokers, and 264 (27%) as current smokers. In the group of current smokers, 23% thought their premalignant lesions/conditions were related to their smoking habit, but only 15% of the patients with malignant mucosal diseases saw that correlation. Only 14% of the smokers wanted to commence smoking cessation within the next 30days. Patients with malignant diseases (31%) showed greater willingness to quit than patients diagnosed with benign/reactive lesions (11%). Future clinical studies should attempt (1) to enhance patients' awareness of the negative impact of smoking on the oral mucosa and (2) to increase willingness to quit in smokers referred to a dental/oral medicine settin

Immune Reconstitution in HIV-Infected Patients

The prognosis of patients infected with human immunodeficiency virus (HIV) type 1 has dramatically improved since the advent of potent antiretroviral therapies (ARTs), which have enabled sustained suppression of HIV replication and recovery of CD4 T cell counts. Knowledge of the function of CD4 T cells in immune reconstitution was derived from large clinical studies demonstrating that primary and secondary prophylaxis against infectious agents, such as Pneumocystis jirovecii (Pneumocystis carinii), Mycobacterium avium complex, cytomegalovirus, and other pathogens, can be discontinued safely once CD4 T cell counts have increased beyond pathogen-specific threshold levels (usually >200 CD4 T cells/mm3) for 3-6 months. The downside of immune reconstitution is an inflammatory syndrome occurring days to months after the start of ART, with outcomes ranging from minimal morbidity to fatal progression. This syndrome can be elicited by infectious and noninfectious antigens. Microbiologically, the possible pathogenic pathways involve recognition of antigens associated with ongoing infection or recognition of persisting antigens associated with past (nonreplicating) infection. Specific antimicrobial therapy, nonsteroidal anti-inflammatory drugs, and/or steroids for managing immune reconstitution syndrome should be considere

Assessment of bone channels other than the nasopalatine canal in the anterior maxilla using limited cone beam computed tomography

Purpose: The anterior maxilla, sometimes also called premaxilla, is an area frequently requiring surgical interventions. The objective of this observational study was to identify and assess accessory bone channels other than the nasopalatine canal in the anterior maxilla using limited cone beam computed tomography (CBCT). Methods: A total of 176 cases fulfilled the inclusion criteria comprising region of interest, quality of CBCT image, and absence of pathologic lesions or retained teeth. Any bone canal with a minimum diameter of 1.00mm other than the nasopalatine canal was analyzed regarding size, location, and course, as well as patient gender and age. Results: A total of 67 accessory canals ≥1.00mm were found in 49 patients (27.8%). A higher frequency of accessory canals was observed in males (33.0%) than in females (22.7%) (p=0.130). Accessory canals occurred more frequently in older rather than younger patients (p=0.115). The mean diameter of accessory canals was 1.31±0.26mm (range 1.01-2.13mm). Gender and age did not significantly influence the diameter. Accessory canals were found palatal to all anterior teeth, but most frequently palatal to the central incisors. In 56.7%, the accessory canals curved superolaterally and communicated with the ipsilateral alveolar extension of the canalis sinuosus. Conclusions: The study confirms the presence of bone channels within the anterior maxilla other than the nasopalatine canal. More than half of these accessory bone canals communicated with the canalis sinuosus. From a clinical perspective, studies are needed to determine the content of these accessory canal

Assessment of smoking behaviour in a dental setting: a 1-year follow-up study using self-reported questionnaire data and exhaled carbon monoxide levels

Objectives: This study analyses the changes in smoking habits over the course of 1year in a group of patients referred to an oral medicine unit. Materials and methods: Smoking history and behaviour were analysed at baseline and after 1year based on a self-reported questionnaire and on exhaled carbon monoxide levels [in parts per million (ppm)]. During the initial examination, all smokers underwent tobacco use prevention and cessation counselling. Results: Of the initial group of 121 patients, 98 were examined at the follow-up visit. At the baseline examination, 33 patients (33.67%) indicated that they were current smokers. One year later, 14 patients (42.24% out of the 33 smokers of the initial examination) indicated that they had attempted to stop smoking at least once over the follow-up period and 15.15% (5 patients) had quit smoking. The mean number of cigarettes smoked per day by current smokers decreased from 13.10 to 12.18 (p = 0.04). The exhaled CO level measurements showed very good correlation with a Spearman's coefficient 0.9880 for the initial visit, and 0.9909 for the follow-up examination. For current smokers, the consumption of one additional cigarette per day elevated the CO measurements by 0.77ppm (p < 0.0001) at the baseline examination and by 0.84ppm (p < 0.0001) at the 1-year follow-up. Conclusions: In oral health care, where smoking cessation is an important aspect of the treatment strategy, the measurement of exhaled carbon monoxide shows a very good correlation with a self-reported smoking habit. Clinical relevance: Measurement of exhaled carbon monoxide is a non-invasive, simple and objective measurement technique for documenting and monitoring smoking cessation and reduction

Cost-Effectiveness of Genotypic Antiretroviral Resistance Testing in HIV-Infected Patients with Treatment Failure

BACKGROUND: Genotypic antiretroviral resistance testing (GRT) in HIV infection with drug resistant virus is recommended to optimize antiretroviral therapy, in particular in patients with virological failure. We estimated the clinical effect, cost and cost-effectiveness of using GRT as compared to expert opinion in patients with antiretroviral treatment failure. METHODS: We developed a mathematical model of HIV disease to describe disease progression in HIV-infected patients with treatment failure and compared the incremental impact of GRT versus expert opinion to guide antiretroviral therapy. The analysis was conducted from the health care (discount rate 4%) and societal (discount rate 2%) perspective. Outcome measures included life-expectancy, quality-adjusted life-expectancy, health care costs, productivity costs and cost-effectiveness in US Dollars per quality-adjusted life-year (QALY) gained. Clinical and economic data were extracted from the large Swiss HIV Cohort Study and clinical trials. RESULTS: Patients whose treatment was optimized with GRT versus expert opinion had an increase in discounted life-expectancy and quality-adjusted life-expectancy of three and two weeks, respectively. Health care costs with and without GRT were $US 421,000 and$US 419,000, leading to an incremental cost-effectiveness ratio of $US 35,000 per QALY gained. In the analysis from the societal perspective, GRT versus expert opinion led to an increase in discounted life-expectancy and quality-adjusted life-expectancy of three and four weeks, respectively. Health care costs with and without GRT were$US 551,000 and $US 549,000, respectively. When productivity changes were included in the analysis, GRT was cost-saving. CONCLUSIONS: GRT for treatment optimization in HIV-infected patients with treatment failure is a cost-effective use of scarce health care resources and beneficial to the society at large