Antihypertensive drugs: a perspective on pharmaceutical price erosion and its impact on cost-effectiveness

OBJECTIVE

When comparators' prices decrease due to market competition and loss of exclusivity, the incremental clinical effectiveness required for a new technology to be cost-effective is expected to increase; and/or the minimum price at which it will be funded will tend to decrease. This may be, however, either unattainable physiologically or financially unviable for drug development. The objective of this study is to provide an empirical basis for this discussion by estimating the potential for price decreases to impact on the cost-effectiveness of new therapies in hypertension.

METHODS

Cost-effectiveness at launch was estimated for all antihypertensive drugs launched between 1998 and 2008 in the United Kingdom using hypothetical degrees of incremental clinical effectiveness within the methodologic framework applied by the UK National Institute for Health and Clinical Excellence. Incremental cost-effectiveness ratios were computed and compared with funding thresholds. In addition, the levels of incremental clinical effectiveness required to achieve specific cost-effectiveness thresholds at given prices were estimated.

RESULTS

Significant price decreases were observed for existing drugs. This was shown to markedly affect cost-effectiveness of technologies entering the market. The required incremental clinical effectiveness was in many cases greater than physiologically possible so, as a consequence, a number of products might not be available today if current methods of economic appraisal had been applied.

CONCLUSIONS

We conclude that the definition of cost-effectiveness thresholds is fundamental in promoting efficient innovation. Our findings demonstrate that comparator price attrition has the potential to put pressure in the pharmaceutical research model and presents a challenge to new therapies being accepted for funding.

Patients' preferences for osteoporosis drug treatment: a discrete choice experiment

Active case finding for osteoporosis is used to identify patients at high fracture risk who may benefit from preventive drug treatment. We investigated the relative weight that women place on various aspects of preventive drugs in a discrete choice experiment. Our patients said they were prepared to take preventive drugs even if side effects were expected.

INTRODUCTION

Active case finding for osteoporosis is used to identify patients who may benefit from preventive drugs. We aimed to elicit the relative weight that patients place on various aspects of preventive drug treatment for osteoporosis.

METHODS

We designed a discrete choice experiment, in which women had to choose between drug profiles that differed in five treatment attributes: effectiveness, side effects (nausea), total treatment duration, route of drug administration, and out-of-pocket costs. We included 120 women aged 60 years and older, identified by osteoporosis case finding in 34 general practices in the Netherlands. A conditional logit regression model was used to analyse the relative importance of treatment attributes, the trade-offs that women were willing to make between attributes, and their willingness to pay.

RESULTS

All treatment attributes proved to be important for women's choices. A reduction of the relative 10-year risk of hip fracture by 40% or more by the drug was considered to compensate for nausea as a side effect. Women were prepared to pay an out-of-pocket contribution for the currently available drug treatment (bisphosphonate) if the fracture risk reduction was at least 12%.

CONCLUSIONS

Women identified by active osteoporosis case finding stated to be prepared to take preventive drugs, even if side effects were expected and some out-of-pocket contribution was required.

Human papillomavirus triage of women with persistent borderline or mildly dyskaryotic smears: Comparison of costs and side effects of three alternative strategies

The conventional direct referral to colposcopy of persistent borderline or mildly dyskaryotic (BMD) smears in cervical cancer screening leads to considerable unnecessary referrals and associated anxiety and costs. This may be improved by including testing for oncogenic human papillomavirus (HPV) in the triage. We assessed costs and side effects (referrals, treatments and time in follow-up) for 3 possible HPV triage strategies (immediate HPV testing, a 6-month delay in HPV testing, a 2-stage combination of both) and compared them with the conventional strategy. The assessments are based on recent Dutch data from various national databases and trials. We estimated that the referral rate could be reduced by 49, 58 and 58% with immediate, delayed and 2-stage HPV testing, respectively. As a consequence, the average length of follow-up, as well as average costs, also decrease. Therefore, we advocate including HPV testing before referring to colposcopy. Among the 3 HPV strategies, analysis of additional aspects favors implementation of immediate HPV testing.

Individual differences in the use of the response scale determine valuations of hypothetical health states: an empirical study

Background

The effects of socio-demographic characteristics of the respondent, including age, on valuation scores of hypothetical health states remain inconclusive. Therefore, we analyzed data from a study designed to discriminate between the effects of respondents' age and time preference on valuations of health states to gain insight in the contribution of individual response patterns to the variance in valuation scores.

Methods

A total of 212 respondents from three age groups valued the same six hypothetical health states using three different methods: a Visual Analogue Scale (VAS) and two variants of the Time trade-off (TTO). Analyses included a generalizability study, principal components analysis, and cluster analysis.

Results

Valuation scores differed significantly, but not systematically, between valuation methods. A total of 36.8% of variance was explained by health states, 1.6% by the elicitation method, and 0.2% by age group. Individual differences in the use of the response scales (e.g. a tendency to give either high or low TTO scores, or a high or low scoring tendency on the VAS) were the main source of remaining variance. These response patterns were not related to age or other identifiable respondent characteristics.

Conclusion

Individual response patterns in this study were more important determinants of TTO or VAS valuations of health states than age or other respondent characteristics measured. Further valuation research should focus on explaining individual response patterns as a possible key to understanding the determinants of health state valuations.

Effectiveness of a back pain prevention program: a cluster randomized controlled trial in an occupational setting

STUDY DESIGN

A cluster randomized controlled trial and economic evaluation with a 12-month follow-up and with work department as the unit of randomization.

OBJECTIVE

To evaluate the effectiveness of a prevention program for low back pain (LBP) in an occupational setting with an economic evaluation.

SUMMARY OF BACKGROUND DATA

LBP accounts for high economic costs in Western societies. Little is known on the effectiveness and related costs and savings of prevention programs for LBP.

METHODS

The study population consisted of workers in physically demanding jobs from 9 large companies located throughout The Netherlands. In each company, 2 comparable work units were randomly allocated, resulting in 18 clusters with 258 workers assigned to the intervention group and 231 workers to the control group.

RESULTS

Results in our study did not show significant differences in effects or costs savings of the program. Indirect costs related to work absence and productivity losses accounted for the majority (84%) of total costs due to LBP.

CONCLUSIONS

This study provides no evidence for the adoption of this worksite prevention program for LBP.

Guidelines for the Conduction of Follow-up Studies Measuring Injury-Related Disability

BACKGROUND

Scientific knowledge on functional outcome after injury is limited. During the past decade, a variety of measures have been used at various moments in different study populations. Guidelines are needed to increase comparability between studies.

METHODS

A working group of the European Consumer Safety Association conducted a literature review of empirical studies into injury-related disability (1995-2005). We included injury from all levels of severity and selected studies using generic health status measures with both short-term and long-term follow up. The results were used as input for a consensus procedure toward the development of guidelines for defining the study populations, selecting the health status measures, selecting the timings of the assessments, and data collection procedures.

RESULTS

The group reached consensus on a common core of health status measures and assessment moments. The group advises to use a combination of EuroQol-5D and Health Utilities Mark III in all studies on injury-related disability. This combination covers all relevant health domains, is applicable in all kinds of injury populations and in widely different age ranges, provides a link with utility scores, and has several practical advantages (e.g., brevity, availability in different languages). For specific types of injury, the common core may be supplemented by injury-specific measures. The group advises a common core of assessments at 1, 2, 4, and 12 months after injury.

CONCLUSIONS

Our guidelines should be tested and may lead to improved and more consistent epidemiologic data on the incidence, severity, and duration of injury-related disability.

Methodological issues in comparing injury incidence across countries

The primary objective was to describe the methodological challenges and devise solutions to compare injury incidence across countries. The research design was a mixed methods study, consisting of a consultation with an expert group and comparison of injury surveillance systems and data from ten European countries. A subset of fractures, selected radiologically verifiable fractures and a method of checking the national representativeness of sample emergency department data were devised and are proposed for further development. These methodological considerations and developments will be further refined and tested and should prove useful tools for those who need to compare injury incidence data across countries.

Reduced productivity after sickness absence due to musculoskeletal disorders and its relation to health outcomes

OBJECTIVES

This prospective cohort study quantified the reduced productivity of workers on full duty after sickness absence from a musculoskeletal disorder and determined the effect of health parameters such as perceived pain, functional disability, and general health on reduced productivity.

METHODS

Workers were included who were returning to work from 2- to 6-week sickness absence due to a musculoskeletal disorder. Self-administered questionnaires at baseline, after return to work, and at a 12-month follow-up were used to collect information on productivity and health status. Logistic regression analyses evaluated the determinants of reduced productivity and determined the level of productivity loss shortly after return to work.

RESULTS

Reduced productivity was prevalent for 60% of the workers after they returned to work, and for 40% still at the 12-month follow-up. The initial musculoskeletal disorder caused 75% of the productivity loss shortly after return to work and 60% at the follow-up. Among those with productivity loss, the median loss for an 8-hour workday was 1.6 hours shortly after return to work and also at the follow-up. Worse physical health, more functional disability, and poorer relations with the supervisor were associated with productivity loss shortly after return to work, whereas recurrent sick leave was the greatest predictor of productivity loss at the follow-up.

CONCLUSIONS

Reduced productivity was common among workers returning to full duty after sickness absence due to a musculoskeletal disorder. Productivity loss illustrates the importance of the timing of return to work, especially among workers with residual functional disability after return to work. Moreover, the supervisor should be engaged early in the return-to-work process to guarantee an early, sustainable, and productive return to work for the employee.

Health problems lead to considerable productivity loss at work among workers with high physical load jobs

OBJECTIVE

To assess the feasibility and validity of two instruments for the measurement of health-related productivity loss at work.

STUDY DESIGN AND SETTING

A cross-sectional study was conducted in two occupational populations with a high prevalence of health problems: industrial workers (n=388) and construction workers (n=182). We collected information on self-reported productivity during the previous 2 weeks and during the last work day with the Health and Labor Questionnaire (HLQ) and the Quantity and Quality instrument (QQ), with added data on job characteristics, general health, presence of musculoskeletal complaints, sick leave, and health-care consumption. For construction workers, we validated self-reported productivity with objective information on daily work output from 19 work site observations.

RESULTS

About half the workers with health problems on the last working day reported reduced work productivity (QQ), or 10.7% of all industrial workers and 11.8% of all construction workers, resulting in a mean loss of 2.0 hr/day per worker with reduced work productivity. The proportion of workers with reduced productivity was significantly lower on the HLQ: 5.3% of industrial workers and 6.5% of construction workers. Reduced work productivity on the HLQ and the QQ was significantly associated with musculoskeletal complaints, worse physical, mental and general health, and recent absenteeism. The QQ and HLQ questionnaires demonstrated poor agreement on the reporting of reduced productivity. Self-reported productivity on the QQ correlated significantly with objective work output (r=.48).

CONCLUSION

Health problems may lead to considerable sickness presenteeism. The QQ measurement instrument is better understandable, and more feasible for jobs with low opportunities for catching up on backlogs.

An economic evaluation of the use of TNP on full-thickness wounds

OBJECTIVE

Topical negative pressure (TNP) (vacuum therapy) is frequently used in the management of acute, traumatic, infected and chronic full-thickness wounds. This prospective clinical randomised trial compared the costs of TNP with conventional therapy (moist gauze) in the management of full-thickness wounds that required surgical closure.

METHOD

The direct medical costs of the total number of resources needed to achieve a healthy, granulating wound bed that was 'ready for surgical therapy' were calculated.

RESULTS

Fifty-four patients admitted to a department of plastic and reconstructive surgery were recruited into the trial. Cost analysis showed significantly higher mean material expenses for wounds treated with TNP (414euros+/-229euros [SD]) compared with conventional therapy (15euros+/-11euros; p<0.0001 ), but significantly lower mean nursing expenses (33euros+/-31 euros and 83euros+/-58euros forTNP and conventional therapy respectively; p<0.0001). Hospitalisation costs were lower in theTNP group (1788euros+/-1060euros) than in the conventional treatment group (2467euros+/-1336euros; p<0.043) due to an on average shorter duration until they were'ready for surgical therapy'. There was no significant difference in total costs per patient between the two therapies (2235euros+/-1301euros for TNP versus 2565euros+/-1384euros for conventional therapy).

CONCLUSION

TNP had higher material costs. However, these were compensated by the lower number of time-consuming dressing changes and the shorter duration until they were 'ready for surgical therapy', resulting in the therapy being equally as expensive as conventional moist gauze.

DECLARATION OF INTEREST

This work was partly supported by the Plastic and Reconstructive Surgery Esser Foundation, and KCI Medical, Houten,The Netherlands. The authors have no conflicts of interest.

The relationship between productivity and health-related quality of life: An empirical exploration in persons with low back pain

OBJECTIVE

In economic evaluation of health care programmes normally health-related quality of life is part of measurement of a programme's effectiveness and productivity part of its costs. In this paper the relationship between quality of life and productivity is highlighted and empirically assessed in persons suffering from low back pain.

METHODS

A secondary analysis was performed on data from a sample of 483 patients treated for low back pain. Periodically, both quality of life (EQ-5D) and productivity indicators for both paid and unpaid work were measured. Mean EQ-5D scores were compared for groups of patients classified by level of productivity. The relationship between quality of life and productivity was also assessed using Spearman rank correlation coefficients.

RESULTS

Mean EQ-5D scores for patients without productivity losses were a half to a full standard deviation higher than for patients with the lowest levels of productivity. The correlation between quality of life and productivity was moderate.

CONCLUSION

Lower levels of quality of life were associated with efficiency loss and absenteeism. However, due to the moderate strength of the relation the use of information on quality of life to model productivity costs in case of absence of productivity data was not recommended.

The relationship between productivity and health-related QOL: an exploration

In economic evaluation of healthcare programmes both QOL and productivity of patients are aspects to be studied. Normally, the former is part of the measurement of the effectiveness of the programme and the latter is part of the measurement of its costs. In this paper we highlight the relationship between QOL and productivity. Two aspects are discussed: (i) the relationship between perceived productivity and health-state valuations; and (ii) the observed relationship between productivity and QOL. The first aspect relates to the fact that in health-state valuations, respondents may consider income changes and ability to work. While this may have important methodological and practical implications, little empirical evidence exists in this area. The second aspect relates to the fact that the observed productivity of individuals is expected to be related to their health-related QOL. Worse health states are expected to be associated with lower productivity. Again, empirical investigation is lacking; however, this relationship may prove important, for instance in modelling productivity costs with use of information on QOL. This paper explores these relationships between productivity and QOL to stimulate debate and research in this area.

Setting priorities in injury prevention: the application of an incidence based cost model

OBJECTIVES

To make detailed calculations on the direct medical costs of injuries in the Netherlands to support priority setting in prevention.

METHODS

A computerised, incidence based model for cost calculations was developed and incidence figures derived from the Dutch Injury Surveillance System (LIS) which provides national estimates of the annual number of patients treated at an emergency department. A comprehensive set of cost elements (that is, health care segments) was obtained from health care registrations and a LIS patient survey. Patients were assigned to specific groups based on LIS characteristics (for example, age, injury type). Average costs per patient group were calculated for each cost element and total costs estimated by adding costs for all patient groups.

RESULTS

The direct costs of injury average 2000 guilders per injury patient attending an emergency department. Home and leisure injuries account for over half of the costs, although cost per patient is highest for motor vehicle injuries. Injuries to the lower extremities account for almost half of the total costs and are incurred mainly in the home or recreation. Motor vehicle crashes are the major cause of head injuries.

CONCLUSIONS

The model permits continuous and detailed monitoring of injury costs. Estimates can be compiled for any LIS patient group or injury subcategory. The results can be used to rank injuries for prioritisation of prevention by injury categories (for example, traffic, home, or leisure), or by specific scenarios (for example, fall at home).

Healthcare costs of intellectual disability in the Netherlands: a cost-of-illness perspective

Healthcare costs are continuously increasing, and impose a strong responsibility on governments for an adequate allocation of resources among healthcare provisions and patients. The aims of the present study were to describe the healthcare costs of intellectual disability (ID) and other mental disorders in the context of the total costs of all other diseases, and to determinate the future need of healthcare resources, especially for ID and mental disorders. The present authors performed a top-down cost-of-illness study comprising all healthcare costs of the Netherlands in 1994. Data on healthcare use were obtained for all 22 healthcare sectors, and used to ascribe costs to disease groups, age and sex. Costs of mental disorders are by far the largest in the Dutch healthcare system. Some 25.8% of total disease-specific costs could be ascribed to mental disorders: psychiatric conditions, 10.6%; ID, 9.0%; and dementia, 6.2%. There are large differences between age and sex groups. The costs of ID and schizophrenia are higher among men, and the costs of dementia and depression are higher among women. The age pattern shows two peaks: the first occurs at 25-35 years of age (ID and psychiatric conditions); and the second at 75-85 years of age (dementia). Time trends between 1988 and 1994 show an average annual growth rate of 5.2% for total healthcare costs: psychiatric conditions, 4.8%; ID, 5.4%; and dementia, 9.4%. Demographic projections suggest a less-than-average cost increase for ID and psychiatric disorders (with annual growth rates of 0.2% and 0.4%, respectively) compared to the costs of dementia and total healthcare (with annual growth rates of 1.6% and 0.9%, respectively). Intellectual disability and mental disorders represent a large part of healthcare use in the Netherlands. The costs will inevitably increase because of the ageing of the population and increasing life expectancy among people with disabilities. Non-specific cost containment measures may endanger the quality of care for vulnerable people at younger and older ages.

Cost analysis of PAPNET-assisted vs. conventional Pap smear evaluation in primary screening of cervical smears

OBJECTIVE

To assess the difference in costs between PAPNET-assisted and conventional microscopy of cervical smears when used as a primary screening tool.

STUDY DESIGN

We performed time measurements of the initial screening of smears by four cytotechnologists in one laboratory. Time was measured in 816 conventionally screened smears and in 614 smears with PAPNET-assisted screening. Data were collected on the components of initial screening, clerical activities and other activities in the total work time of cytotechnologists in the routine situation and on resource requirements for both techniques.

RESULTS

PAPNET saved an average of 22% on initial screening time per smear. Due to costs of processing and additional equipment, the costs of PAPNET-assisted screening were estimated to be $2.85 (and at least $1.79) higher per smear than conventional microscopy. The difference in costs is sensitive to the rate of time saving, the possibility of saving on quality control procedures and the component of the initial screening time in the total work time of cytotechnologists.

CONCLUSION

Although PAPNET is time saving as compared with conventional microscopy, the associated reduction in personnel costs is outweighed by the costs of scanning the slides and additional equipment. This conclusion holds under a variety of assumptions. Using PAPNET instead of conventional microscopy as a primary screening tool will make cervical cancer screening less cost-effective unless the costs of PAPNET are considerably reduced and its sensitivity and/or specificity are considerably improved.

Demographic and epidemiological determinants of healthcare costs in Netherlands: cost of illness study

OBJECTIVES

To determine the demands on healthcare resources caused by different types of illnesses and variation with age and sex.

DESIGN

Information on healthcare use was obtained from all 22 healthcare sectors in the Netherlands. Most important sectors (hospitals, nursing homes, inpatient psychiatric care, institutions for mentally disabled people) have national registries. Total expenditures for each sector were subdivided into 21 age groups, sex, and 34 diagnostic groups.

SETTING

Netherlands, 1994.

MAIN OUTCOME MEASURES

Proportion of healthcare budget spent on each category of disease and cost of health care per person at various ages.

RESULTS

After the first year of life, costs per person for children were lowest. Costs rose slowly throughout adult life and increased exponentially from age 50 onwards till the oldest age group (> or = 95). The top five areas of healthcare costs were mental retardation, musculoskeletal disease (predominantly joint disease and dorsopathy), dementia, a heterogeneous group of other mental disorders, and ill defined conditions. Stroke, all cancers combined, and coronary heart disease ranked 7, 8, and 10, respectively.

CONCLUSIONS

The main determinants of healthcare use in the Netherlands are old age and disabling conditions, particularly mental disability. A large share of the healthcare budget is spent on long term nursing care, and this cost will inevitably increase further in an ageing population. Non-specific cost containment measures may endanger the quality of care for old and mentally disabled people.

[The cost of sickness in the Netherlands in 1994; the main determinants were advanced age and disabling conditions]

OBJECTIVE

To estimate the costs of health care in 1994, the development of the costs assigned to specific diseases, and the future costs.

DESIGN

Descriptive.

SETTING

Erasmus University, Department of Public Health, Rotterdam, the Netherlands.

METHOD

For each health care sector, costs were allocated to 62 diagnostic groups, age and sex making maximal use of national registries and other sources with data on health care use in the Netherlands.

RESULTS

More than 80% of the 60 billion Dutch guilders that were spent on health care in 1994 could be assigned to specific diseases. Most costs were made for non-fatal diseases like mental deficiency, dementia and musculoskeletal disease. Except for cardiovascular disease, the share of major causes of death in the total costs was not significant. Average costs per inhabitant were low during youth and adulthood but increased exponentially with age from age 50 onwards. Between 1988 en 1994, health care costs experienced an annual growth rate of 5.2%, caused by price and wage increases (one half), ageing (a quarter) and other effects on health care costs such as epidemiological and technological change (a quarter).

CONCLUSION

The main determinants of health care use in the Netherlands were old age and disabling conditions. Due to ageing and other influences, real health care costs in the years to come will increase by an average annual rate of 2.4%.