Short term effects of public smoking bans on health

This paper evaluates the causal negative effect of environmental tobacco exposure on health by exploiting the time and geographical variation in public-place smoking bans implemented in Switzerland between 2007 and 2011. Using monthly data from the universe of Swiss hospitals between 2004 and 2012, we show that the incidence of acute myocardial infarction hospitalizations decreases by about 10-12% immediately after the law implementation. We also find evidence of heterogeneity by age and sex and across income and education groups. In particular, the policy affected mainly men aged 50+ and the regions characterized by a lower level of income and education

Three essays on the role of federalism in the Swiss healthcare system

Switzerland is a country with a strongly decentralized political system, based on federalism and institutions of direct democracy, on a liberal economic culture, and on a well-developed tradition of mutualism and social security (generous social expenditure and welfare system). Switzerland is unique for its high level of decentralization and for the particular distribution of competences and roles between the central State (the Confederation) and the cantonal authorities. This particular setting allows cantons to have significant leeway in the organization of health care and the implementation of specific public policies. This thesis aims to give a contribution to the health economics literature, assessing some of the internal implications of the Swiss federal setting in the health care sector (chapters 1 and 2) and drawing some more general public policy results, exploiting the Swiss context (chapter 3). The first two chapters explore two different sides of the equity of the Swiss health care system. In the first chapter, I assess to what extent the political autonomy allocated to cantons leads to differences in the level of regressivity in the financing of the health care system and over time. The second chapter investigates the role of managed care contracts and higher deductible on the equity in health care utilization. Finally, in the third chapter I carry out a policy evaluation analysis to assess the causal effects of smoking bans on acute myocardial infarction. Different from the other two chapters, this work draws conclusions that abstract from the Swiss context. Switzerland is the perfect setting where to employ our empirical strategy, due to the different times of implementation of the policy if interest. However, the results have external validity. Each work is based on a different database: the first and the third are based on administrative data, while the second one relies on survey data

The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018

Progress towards effective service coverage and financial protection-the two dimensions of Universal Health Coverage (UHC)-has been limited in Kenya in the last decade. The government of Kenya has embarked on a highly ambitious reform programme currently being piloted in four Kenyan counties and aiming at national rollout by 2022. This study provides an updated assessment of the performance of the Kenyan health system in terms of financial protection allowing to monitor trends over time. In light of the UHC initiative, the study provides a baseline to assess the impact of the UHC pilot programme and inform scale-up plans. It also investigates household characteristics associated with catastrophic payments.; Using data from the Kenya Household Health Expenditure and Utilization Survey (KHHEUS) 2018, we investigated the incidence and intensity of catastrophic and impoverishing health expenditure. We used a logistic regression analysis to assess households' characteristics associated with the probability of incurring catastrophic health expenditures.; The results show that the incidence of catastrophic payments is more severe for the poorest households and in the rural areas and mainly due to outpatient services. Results for the impoverishing effect suggest that after accounting for out-of-pocket(OOP) payments, the proportion of poor people increases by 2.2 percentage points in both rural and urban areas. Thus, between 1 and 1.1 million individuals are pushed into poverty due to OOP payments. Among the characteristics associated with the probability of incurring OOP expenditures, socioeconomic conditions, the presence of elderly and of people affected by chronic conditions showed significant results.; Kenya is still lagging behind in terms of protecting its citizens against financial risks associated with ill health and healthcare seeking behaviour. More effort is needed to protect the most vulnerable population groups from the high costs of illness

Determinants of health insurance enrolment in Ghana: evidence from three national household surveys

In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) to move towards Universal Health Coverage. NHIS enrolment is mandatory for all Ghanaians, but the most recent estimates show that coverage stands under 40%. The evidence on the relationship between socio-economic characteristics and NHIS enrolment is mixed, and comes mainly from studies conducted in a few areas. Therefore, in this study we investigate the socio-economic determinants of NHIS enrolment using three recent national household surveys. We used data from the Ghanaian Demographic and Health Survey conducted in 2014, the Multiple Indicator Cluster Survey conducted in 2011 and the sixth wave of the Ghana Living Standard Survey conducted in 2012-13. Given the multilevel nature of the three databases, we use multilevel logistic regression models to estimate the probability of enrolment for women and men separately. We used three levels of analysis: geographical clusters, household and individual units. We found that education, wealth, marital status-and to some extent-age were positively associated with enrolment. Furthermore, we found that enrolment was correlated with the type of occupation. The analyses of three national household surveys highlight the challenges of understanding the complex dynamics of factors contributing to low NHIS enrolment rates. The results indicate that current policies aimed at identifying and subsidizing underprivileged population groups might insufficiently encourage health insurance enrolment

Cost-effectiveness, burden of disease and budget impact of inclisiran : dynamic cohort modelling of a real-world population with cardiovascular disease

Objective: We aimed to estimate the cost-effectiveness, burden of disease and budget impact of inclisiran added to standard-of-care lipid-lowering therapy in the real-world secondary cardiovascular prevention population in Switzerland. Methods: An open-cohort Markov model captured event risks by sex, age and low-density lipoprotein cholesterol based on epidemiological and real-world data. Low-density lipoprotein cholesterol reduction with add-on inclisiran was based on trial results and translated to meta-analysis-based relative risks of cardiovascular events. Unit costs for 2018 were based on publicly available sources, adopting a Swiss healthcare system perspective. Price assumptions of Swiss francs (CHF) 500 and CHF 3,000 per dose of inclisiran were evaluated, combined with uptake assumptions for burden of disease and budget impact. The assessment of cost-effectiveness used a discount rate of 3% per year. We performed deterministic and probabilistic sensitivity analyses, and extensive scenario analyses. Results: Patients treated with inclisiran gained a 0.291 qualityadjusted life-year at an incremental cost per QALY gained of CHF 21,107/228,040 (life-long time horizon, discount rate 3%) under the lower/higher price. Inclisiran prevented 1025 cardiovascular deaths, 3425 acute coronary syndrome episodes, and 1961 strokes in 48,823 patients ever treated during 10 years; the 5-year budget impact was CHF 49.3/573.4 million under the lower/higher price. Estimates were sensitive to calibration targets and treatment eligibility; burden of disease/budget impact results also to uptake. Limitations included uncertainties about model assumptions and the size and characteristics of the population modelled. Conclusions: Inclisiran may be cost-effective at a willingness to pay of CHF 30,000 if priced at CHF 500; a threshold upwards of CHF 250,000 will be required if priced at CHF 3000. Inclisiran could enable important reductions in cardiovascular burden particularly under broader eligibility with a budget impact range from moderate to high depending on price

Healthcare Costs and Health-Related Quality of Life in Older Multimorbid Patients After Hospitalization.

OBJECTIVES We identified factors associated with healthcare costs and health-related quality of life (HRQoL) of multimorbid older adults with polypharmacy. METHODS Using data from the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid older people) trial, we described the magnitude and composition of healthcare costs, and time trends of HRQoL, during 1-year after an acute-care hospitalization. We performed a cluster analysis to identify groups with different cost and HRQoL trends. Using multilevel models, we also identified factors associated with costs and HRQoL. RESULTS Two months after hospitalization monthly mean costs peaked (CHF 7'124) and HRQoL was highest (0.67). They both decreased thereafter. Age, falls, and comorbidities were associated with higher 1-year costs. Being female and housebound were negatively associated with HRQoL, while moderate alcohol consumption had a positive association. Being independent in daily activities was associated with lower costs and higher HRQoL. CONCLUSION Although only some identified potential influences on costs and HRQoL are modifiable, our observations support the importance of prevention before health deterioration in older people with multimorbid illness and associated polypharmacy

Sociodemographic determinants of health insurance enrolment and dropout in urban district of Ghana : a cross-sectional study

Earlier studies have found significant associations between sociodemographic factors and enrolment in the National Health Insurance Scheme (NHIS) in Ghana. These studies were mainly household surveys in relatively rural areas with high incidence of poverty. To expand the scope of existing evidence, this paper examines policy design factors associated with enrolment and dropout of the scheme in an urban poor district using routine secondary data.; This study is a cross-sectional quantitative analysis of 2014-2016 NHIS enrolment data of the Ashiedu Keteke district office. Descriptive and multivariate logistic regression analyses were performed to examine sociodemographic factors associated with NHIS enrolment and dropout.; A total of 215,724 individuals enrolled in the NHIS over the period under study, of which 98,232 (46%) were new members. About 41% of existing members in 2014 dropped out of the NHIS in 2015 and 53% of those in 2015 dropped out in 2016. The indigents (core poor) are significantly more likely to enrol and to drop out of the NHIS. However, the males, informal sector employees, social security and national insurance trust (SSNIT) contributors, and the aged (70+ years) are significantly less likely to enrol in the NHIS but more likely to retain coverage.; A considerable number of members are dropping out of the NHIS. The indigents in particular, are increasingly enrolling in and dropping out of the NHIS whilst the males, informal sector employees, SSNIT contributors and the aged are not enrolling as expected but increasingly retaining coverage. Policy reforms to ensuring continued growth towards realization of universal health coverage should take these factors into consideration

Cost-effectiveness of a structured medication review approach for multimorbid older adults: Within-trial analysis of the OPERAM study

BACKGROUND Inappropriate polypharmacy has been linked with adverse outcomes in older, multimorbid adults. OPERAM is a European cluster-randomized trial aimed at testing the effect of a structured pharmacotherapy optimization intervention on preventable drug-related hospital admissions in multimorbid adults with polypharmacy aged 70 years or older. Clinical results of the trial showed a pattern of reduced drug-related hospital admissions, but without statistical significance. In this study we assessed the cost-effectiveness of the pharmacotherapy optimisation intervention. METHODS We performed a pre-planned within-trial cost-effectiveness analysis (CEA) of the OPERAM intervention, from a healthcare system perspective. All data were collected within the trial apart from unit costs. QALYs were computed by applying the crosswalk German valuation algorithm to EQ-5D-5L-based quality of life data. Considering the clustered structure of the data and between-country heterogeneity, we applied Generalized Structural Equation Models (GSEMs) on a multiple imputed sample to estimate costs and QALYs. We also performed analyses by country and subgroup analyses by patient and morbidity characteristics. RESULTS Trial-wide, the intervention was numerically dominant, with a potential cost-saving of CHF 3'588 (95% confidence interval (CI): -7'716; 540) and gain of 0.025 QALYs (CI: -0.002; 0.052) per patient. Robustness analyses confirmed the validity of the GSEM model. Subgroup analyses suggested stronger effects in people at higher risk. CONCLUSION We observed a pattern towards dominance, potentially resulting from an accumulation of multiple small positive intervention effects. Our methodological approaches may inform other CEAs of multi-country, cluster-randomized trials facing presence of missing values and heterogeneity between centres/countries

Cost-effectiveness of palbociclib in early breast cancer patients with a high risk of relapse: Results from the PENELOPE-B trial

BACKGROUND Patients with hormone receptor-positive, HER2-negative breast cancer who have residual invasive disease after neoadjuvant chemotherapy (NACT) are at a high risk of relapse. PENELOPE-B was a double-blind, placebo-controlled, phase III trial that investigated adding palbociclib (PAL) for thirteen 28-day cycles to adjuvant endocrine therapy (ET) in these patients. Clinical results showed no significant improvement in invasive disease-free survival with PAL. METHODS We performed a pre-planned cost-effectiveness analysis of PAL within PENELOPE-B from the perspective of the German statutory health insurance. Health-related quality of life scores, collected in the trial using the EQ-5D-3L instrument, were converted to utilities based on the German valuation algorithm. Resource use was valued using German price weights. Outcomes were discounted at 3% and modeled with mixed-level linear models to adjust for attrition, repeated measurements, and residual baseline imbalances. Subgroup analyses were performed for key prognostic risk factors. Scenario analyses addressed data limitations and evaluated the robustness of the estimated cost-effectiveness of PAL to methodological choices. RESULTS The effects of PAL on quality-adjusted life years (QALYs) were marginal during the active treatment phase, increasing thereafter to 0.088 (95% confidence interval: -0.001; 0.177) QALYs gained over the 4 years of follow-up. The incremental costs were dominated by PAL averaging EUR 33,000 per patient; costs were higher in the PAL arm but not significantly different after the second year. At an incremental cost-effectiveness ratio of EUR 380,000 per QALY gained, PAL was not cost-effective compared to the standard-of-care ET. Analyses restricted to Germany and other subgroups were consistent with the main results. Findings were robust in the scenarios evaluated. CONCLUSIONS One year of PAL added to ET is not cost-effective in women with residual invasive disease after NACT in Germany