Danish Women Make Decisions about Participation in Breast Cancer Screening prior to Invitation Information: An Online Survey Using Experimental Methods

INTRODUCTION

At mammography screening invitation, the Danish Health Authority recommends women aged 50 to 69 y make an informed decision about whether to be screened. Previous studies have shown that women have very positive attitudes about screening participation. Therefore, we hypothesized that Danish women may already have decided to participate in breast cancer screening prior to receiving their screening invitation at age 50 y.

METHODS

We invited a random sample of 2,952 Danish women aged 44 to 49 y (prescreening age) to complete an online questionnaire about barriers to informed screening decision making using the official digital mailbox system in Denmark. We asked participants about their screening intentions using 3 different questions to which women were randomized: screening presented 1) as an opportunity, 2) as a choice, and 3) as an opportunity plus a question about women's stage of decision making. All women completed questions about background characteristics, intended participation in the screening program, use and impact of screening information, and preferences for the decision-making process. Data were linked to sociodemographic register data.

RESULTS

A total of 790 (26.8%) women participated in the study. Herein, 97% (95% confidence interval: 96%-98%) reported that they wanted to participate in breast cancer screening when invited at age 50 y. When presented with the choice compared with the opportunity framing, more women rejected screening. When asked about their stage of decision making, most (87%) had already made a decision about screening participation and were unlikely to change their mind.

CONCLUSION

In our study, almost all women of prescreening age wanted to participate in breast cancer screening, suggesting that providing information at the time of screening invitation may be too late to support informed decision making.

HIGHLIGHTS

Almost all women of prescreening age (44-49 y) in our study wanted to participate in the Danish national mammography screening program starting at age 50 y.Early decision making represents a barrier for informed decision making as women in this study had intentions to participate in breast cancer screening prior to receiving an official screening invitation, and therefore, providing information at the time of screening invitation may be too late to support informed decision making.Very few women rejected screening participation; however, more women rejected screening when the information was framed as an active choice between having or declining breast cancer screening (continue with usual care) compared with presenting only the option of screening with no description of the alternative.Two-thirds of women reading the screening information in this study had unchanged attitudes toward screening after reading the presented information.

The epidemiology and societal costs of myasthenia gravis in Norway: A non-interventional study using national registry data

BACKGROUND AND PURPOSE

With the emergence of new treatment options for myasthenia gravis (MG), there is a need for information regarding epidemiology, healthcare utilization, and societal costs to support economic evaluation and identify eligible patients. We aimed to enhance the understanding of these factors using nationwide systematic registry data in Norway.

METHODS

We received comprehensive national registry data from five Norwegian health- and work-related registries. The annual incidence and prevalence were estimated for the period 2013-2021 using nationwide hospital and prescription data. The direct, indirect (productivity losses) and intangible costs (value of lost life-years [LLY] and health-related quality of life [HRQoL]) related to MG were estimated over a period of 1 year.

RESULTS

In 2021, the incidence of MG ranged from 15 to 16 cases per year per million population depending on the registry used, while the prevalence varied between 208.9 and 210.3 per million population. The total annual societal costs of MG amounted to EUR 24,743 per patient, of which EUR 3592 (14.5%) were direct costs, EUR 8666 (35.0%) were productivity loss, and EUR 12,485 (50.5%) were lost value from LLY and reduced HRQoL.

CONCLUSION

The incidence and prevalence of MG are higher than previously estimated, and the total societal costs of MG are substantial. Our findings demonstrate that productivity losses, and the value of LLY and HRQoL constitute a considerable proportion of the total societal costs.

Increasing melanoma incidence with unchanged mortality: more sunshine, better treatment, increased diagnostic activity, overdiagnosis or lowered diagnostic threshold?

BACKGROUND

Increasing melanoma incidence with less increasing mortality is observed in several countries. This discrepancy is not well understood.

OBJECTIVE

In this study, our aim was to discuss factors (UV exposure, melanoma treatment, diagnostic activity, overdiagnosis, pathologists' diagnostic threshold and clinicians' propensity to remove suspect skin lesions) that may influence melanoma incidence and mortality in Denmark.

METHODS

This was a register study with the number of melanocyte-related lesions and melanoma mortality based on comprehensive national pathology and mortality databases for the period 1999-2019. We investigated melanocyte-related diagnoses and mortality in a population of 5.5 million with national health care system. Age adjusted melanoma mortality and age-adjusted incidence of benign nevi, atypical lesion, or melanoma-in-situ and of invasive melanoma were computed for data analysis.

RESULTS

In total 1,434,798 biopsies were taken from 704,682 individuals (65% female). Mean age at biopsy was 39.8 years in men and 37.6 in women. In men and women, the incidence of invasive melanoma increased by 87% during the period 1999-2011. During the subsequent period it increased by 9% in men but remained unchanged in women. The incidence of melanoma in-situ increased by 476% in men and 357% in women during the study period, while the increases for atypical melanocytic lesions were 1928% and 1686%, respectively. Biopsy rates increased by 153% in men and 118% in women from 1999 through 2011 but fell by 20% in men and 22% in women during the subsequent period. Mortality varied slightly from year to year without any significant time trend for men or women.We identified no evidence of increased UV exposure over the latest 30 years in Denmark. Immunotherapy of advanced melanoma was introduced in Denmark in 2010 and came in general use in 2014.

CONCLUSIONS

Comprehensive national data demonstrate increasing melanoma incidence correlated with increasing biopsy rates, but with no change in mortality. Previously suggested explanations for such a trend are lowered threshold of melanoma diagnosis among pathologists, increased diagnostic activity in the presence of overdiagnosis and improved melanoma treatment. Because the study is observational and because we have more explanatory factors than outcomes, the findings do not warrant conclusions about causal relationships.

Danish Women Want to Participate in a Hypothetical Breast Cancer Screening with Harms and No Reduction in Mortality: A Cross-Sectional Survey

INTRODUCTION

Informed decision making is recommended in breast cancer screening. Decision aids with balanced information on harms and benefits are recommended to support informed decision making. However, informed screening decision making may be challenged by overly positive attitudes toward cancer screening. We hypothesized that a substantial proportion of Danish women would want to participate in screening regardless of the presented information. Therefore, we aimed to estimate the prevalence of Danish women wanting to participate in a hypothetical breast cancer screening offering no reduction in breast cancer mortality but potential harms related to unnecessary treatment.

METHODS

In a cross-sectional study, we invited a random sample of 751 women in the nonscreening population aged 44 to 49 y in the Central Denmark Region to an online questionnaire using the official digital mailbox system. The questionnaire included a description of a hypothetical screening and questions about thoughts on breast cancer, health literacy, and questions on the assessment of the hypothetical screening including intended participation, understanding, and belief in information. Data were linked to register data on sociodemographic factors.

RESULTS

In total, 43.0% (323/751) responded to the questionnaire. Of these, 247 (82.3% [95% confidence interval: 77.5-86.5]) wanted to participate in the hypothetical breast cancer screening (participation group). More than two-thirds in both the participation group and nonparticipation group seemed to understand the presented information. Half of the women who understood the information disbelieved it.

CONCLUSIONS

Exceeding our expectations, a majority of women wanted to participate in a hypothetical screening with potential harms but no reduction in breast cancer mortality. A large proportion understood but disbelieved the screening information. This could indicate that Danish women make their screening decisions based on beliefs rather than presented screening information. This study was registered at ClinicalTrials.gov (Identifier: NCT04509063).

HIGHLIGHTS

The majority of Danish women wanted to participate in a hypothetical breast cancer screening with potential harms related to unnecessary treatment but no reduction in mortality.A large proportion of women understood but disbelieved the hypothetical screening information.Informed decision making may be challenging when women disbelieve the information they receive.Enthusiasm for cancer screening and potential disbelief in information are important factors when developing and improving screening information and invitation.

Gaps and discontinuation of statin treatment in Norway: potential for optimizing management of lipid lowering drugs

AIMS

In clinical practice, many patients do not reach the recommended treatment targets for LDL-cholesterol levels. We aimed to examine treatment patterns and adherence for patients on lipid lowering drugs in Norway to inform future strategies to improve therapies.

METHODS AND RESULTS

We obtained information on all dispensed statins, ezetimibe, and proprotein convertase subtilisin/-kexin 9 (PCSK9) inhibitors 2010-2019 from the Norwegian Prescription Database. Treatment gaps were assessed assuming patients take one tablet per day and were defined to occur if a patient did not refill a prescription when the previous one should have been depleted. Treatment was defined as discontinued when the preceding prescription would have been used and no new subsequent prescription was filled. The mean proportion of days covered (PDC) was calculated by aggregating the total number of tablets dispensed during each calendar year and dividing by 365. Patients 80 years were excluded. A considerable proportion of statin users in Norway had long treatment gaps or discontinuation in treatment. The 19.6% of the patients had treatment gaps of 180 days or more, and 10.8% had gaps or greater than 365 days. Similar results were found for patients on antidiabetics and hypertensives. PDC ranged from 84.9% for simvastatin to 72.2% for ezetimibe (2019). The most common lipid lowering drugs in 2019 were atorvastatin, simvastatin, and ezetimibe.

CONCLUSION

There is a great potential for improving drug adherence and optimizing lipid lowering therapy by switching to more effective statins in greater doses, and more often add ezetimibe and PCSK9 inhibitors to treatment.

Persistence of statin treatment – the impact of analytic method when estimating drug survival

Background: There is ample evidence for several pharmaceutical treatments that adherence in terms oftreatment duration and dose is suboptimal. The actual drug intake cannot be observed directly in prescriptiondatabases, which only register drug redeemed and a limited number of patient characteristics. Consequently,the actual dose and duration of treatment must be inferred from observed redemptions. Persistence can thenbe expressed as treatment duration (also referred to as drug survival).Method: We used data from the Norwegian Prescription Database (NorPD) on redemptions of statins (ATCcodeC10AA) for the period 2010-2019 to explore three methods for determining prescription durations andin turn persistence (treatment duration): (i) The DDD-method using the number of DDD redeemed; (ii) Thedose-unit approach using the number of tablets redeemed; (iii) The reverse waiting time distribution method(WTD), which estimates prescription duration as the 90th percentile of the distribution within which patientsin ongoing treatment will have a new subsequent redemption. The three methods for estimating prescriptionduration were then used to estimate treatment duration using Kaplan Meier (KM) survival functions. For theDDD-method and the dose-unit approach we conducted sensitivity analyses assuming that one DDD or onetablet would last for 1.00, 1.25 or 2.00 days. We also tested the impact of grace periods in sensitivity analyses.Results: Treatment duration and drug survival varied substantially for the same patients depending on thechosen method, duration of a DDD or a tablet, and inclusion of grace periods. The 25th percentile of treatmentduration was 100 days for the DDD approach with one DDD per day, 100 days with the dose-unit approachwith one tablet per day and 453 days with the WTD approach.Conclusion: When estimating treatment duration from prescription databases one should be aware that thesemeasures of persistence are highly influenced by the chosen methodology. The choice of method should beinformed by the clinical context with a preference for use of methods based on a formal model.

Men receive more end-of-life cancer hospital treatment than women: fact or fiction?

BACKGROUND

An important goal of health care systems is equitable access to health care. Previous research, however, indicates that men receive more cancer care and health care resources than women. The aim of this study was to investigate whether there is a gender difference in terms of end-of-life cancer treatment in hospitals in Norway.

MATERIAL AND METHODS

We used nationwide patient-level data from the Norwegian Patient Registry (2013-2017, n = 64,694), and aggregated data from the Norwegian Cause of Death Registry (2013-2018, n = 66,534). We described direct medical costs and utilization of cancer treatment in hospitals (in-patient stays and out-patient clinics) and specialized palliative home care teams by the means of the following variables: gender, type of cancer, age, region of residence, place of death, and use of pharmaceutical anti-cancer treatment last month before death. Generalized linear models with a gamma distribution and log-link function were fitted to identify determinants of direct medical costs in hospital's last year of life.

RESULTS

Women aged 0-69 years had an average direct medical cost in hospitals of €26,117 during the last year of life, compared to €29,540 for men, while they were respectively €19,889 and €22,405 for those aged 70 years or older. These gender differences were confirmed in regression models with gender as the only covariate. Adjusted additionally for the type of cancer, the difference was 11%, while including age as a covariate reduced the difference to 6%. When the place of death was also included, the difference was down to 4%.

DISCUSSION

The gender difference in hospital costs last year of life can largely be explained by age at death and the proportion dying in hospitals. When adjusting for confounding factors, the differences in end-of-life costs in hospitals are minimal.

Phase- and gender-specific, lifetime, and future costs of cancer: A retrospective population-based registry study

Valid estimates of cancer treatment costs are import for priority setting, but few studies have examined costs of multiple cancers in the same setting.We performed a retrospective population-based registry study to evaluate phase-specific (initial, continuing, and terminal phase) direct medical costs and lifetime costs for 13 cancers and all cancers combined in Norway. Mean monthly cancer attributable costs were estimated using nationwide activity data from all Norwegian hospitals. Mean lifetime costs were estimated by combining phase-specific monthly costs and survival times from the national cancer registry. Scenarios for future costs were developed from the lifetime costs and the expected number of new cancer cases toward 2034 estimated by NORDCAN.For all cancers combined, mean discounted per patient direct medical costs were Euros (EUR) 21,808 in the initial 12 months, EUR 4347 in the subsequent continuing phase, and EUR 12,085 in the terminal phase (last 12 months). Lifetime costs were higher for cancers with a 5-year relative survival between 50% and 70% (myeloma: EUR 89,686, mouth/pharynx: EUR 66,619, and non-Hodgkin lymphoma: EUR 65,528). The scenario analyses indicate that future cancer costs are highly dependent on future cancer incidence, changes in death risk, and cancer-specific unit costs.Gender- and cancer-specific estimates of treatment costs are important for assessing equity of care and to better understand resource consumption associated with different cancers.Cancers with an intermediate prognosis (50%-70% 5-year relative survival) are associated with higher direct medical costs than those with relatively good or poor prognosis.

Providing more balanced information on the harms and benefits of cervical cancer screening: A randomized survey among US and Norwegian women

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Additional information did not impact intentions to participate in CC screening.

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Additional information increased uncertainty to seek precancer treatment in Norway.

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Women reported strong system-specific preferences for sources of information.

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Having a prior Pap-test was an important predictor of intentions-to-participate.

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Socioeconomic factors influenced follow-up intentions in the U.S. but not in Norway.

We aimed to identify how additional information about benefits and harms of cervical cancer (CC) screening impacted intention to participate in screening, what type of information on harms women preferred receiving, from whom, and whether it differed between two national healthcare settings. We conducted a survey that randomized screen-eligible women in the United States (n = 1084) and Norway (n = 1060) into four groups according to the timing of introducing additional information. We found that additional information did not significantly impact stated intentions-to-participate in screening or follow-up testing in either country; however, the proportion of Norwegian women stating uncertainty about seeking precancer treatment increased from 7.9% to 14.3% (p = 0.012). Women reported strong system-specific preferences for sources of information: Norwegians (59%) preferred it come from a national public health agency while Americans (59%) preferred it come from a specialist care provider. Regression models revealed having a prior Pap-test was the most important predictor of intentions-to-participate in both countries, while having lower income reduced the probabilities of intentions-to-follow-up and seek precancer treatment among U.S. women. These results suggest that additional information on harms is unlikely to reduce participation in CC screening but could increase decision uncertainty to seek treatment. Providing unbiased information would improve on the ethical principle of respect for autonomy and self-determination. However, the clinical impact of additional information on women’s understanding of the trade-offs involved with CC screening should be investigated. Future studies should also consider country-specific socioeconomic barriers to screening if communication re-design initiatives aim to improve CC screening participation.

Societal cost of cancer in Norway -Results of taking a broader cost perspective

BACKGROUND

The broader cost consequences of diseases may be of interest for a wide range of stakeholders. We aimed to estimate all relevant societal costs of cancer and to provide insight into the relative magnitude of the different cost categories.

METHOD

We used data from eight different health and work-related registries in Norway. Direct, indirect, and intangible costs (value of lost life years) were estimated over a period of one year with a combination of a top-down and a bottom-up costing approach.

RESULTS

The indirect costs (EUR 1,997 million per year) are almost as high as direct costs (EUR 2,154 million), and the value of lost life years and quality of life represents the greatest cost related to cancer (EUR 18,200 million). In addition, cancer is associated with other costs which are commonly omitted from cost-of-illness analyses, including informal nursing (EUR 306 million), patient time costs (EUR 85 million), and excess costs of using public funds (EUR 439 million). Breast and cervical cancer had relatively high work absenteeism costs, while pancreatic and lung cancer had relatively high production costs due to premature deaths.

DISCUSSION

Direct health care costs represent small proportions of the total societal costs of cancer. Costs commonly omitted in cost-of-illness analyses represent a significant cost and should be measured and valued in these analyses.

Negative controls to detect uncontrolled confounding in observational studies of mammographic screening comparing participants and non-participants

BACKGROUND

When comparing mammography-screening participants and non-participants, estimates of reduction in breast-cancer mortality may be biased by poor baseline comparability. We used negative controls to detect uncontrolled confounding.

METHODS

We designed a closed cohort of Danish women invited to a mammography-screening programme at age 50-52 years in Copenhagen or Funen from 1991 through 2001. We included women with a normal screening result in their first-invitation round. Based on their second-invitation round, women were divided into participants and non-participants and followed until death, emigration or 31 December 2014, whichever came first. We estimated hazard ratios (HRs) of death from breast cancer, causes other than breast cancer and external causes. We added dental-care participation as an exposure to test for an independent association with breast-cancer mortality. We adjusted for civil status, parity, age at first birth, educational attainment, income and hormone use.

RESULTS

Screening participants had a lower hazard of breast-cancer death [HR 0.47, 95% confidence interval (CI) 0.32, 0.69] compared with non-participants. Participants also had a lower hazard of death from other causes (HR 0.43, 95% CI 0.39, 0.46) and external causes (HR 0.35, 95% CI 0.23, 0.54). Reductions persisted after covariate adjustment. Dental-care participants had a lower hazard of breast-cancer death (HR 0.75, 95% CI 0.56, 1.01), irrespective of screening participation.

CONCLUSIONS

Negative-control associations indicated residual uncontrolled confounding when comparing breast-cancer mortality among screening participants and non-participants.

Intravitreal therapy for retinal diseases in Norway 2011-2015

PURPOSE

During the past decade, intravitreally administered biologic drugs have advanced the treatment of retinal diseases, such as wet age-related macular degeneration (AMD), diabetic macular oedema and retinal venous occlusions. The drugs as well as the necessary disease management imply considerable economic burden on healthcare systems. This Norwegian study documents the rates of use of intravitreal therapies and intercounty variation over a 5-year period.

METHODS

We collected data from the Norwegian Patient Register for all episodes of care encompassing intravitreal therapy during the period 2011-2015. For each episode, we received information on patient age, sex, county of residence, diagnosis and name of drug injected.

RESULTS

During the study period, 21 277 patients had in total 236 857 episodes of care. The number of intravitreal injections doubled from 2011 to 2015, reaching 63 601 injections in 2015, of which 77% were for diagnosed wet AMD. In 2015, the age-adjusted number of episodes varied from 19 to 55 per 1000 population aged 50+ across Norway's 19 counties. The age-adjusted number of patients treated per 1000 population aged 50+ varied from 5.22 to 8.35.

CONCLUSION

The use of intravitreal injections increased rapidly with wet AMD as the most frequent diagnosis and with varying utilization across Norway's 19 counties. The causes of the varying use of intravitreal therapies could not be established but may reflect variation in disease prevalence, treatment capacity, travel distance to the nearest ophthalmic service and lack of national treatment guidelines. The geographic variation in utilization may challenge policy goals of equitable care and warrants further studies.

Effect of a pharmacist-led intervention on adherence among patients with a first-time prescription for a cardiovascular medicine: a randomized controlled trial in Norwegian pharmacies

Objective

To examine whether a pharmacist‐led intervention improves medication adherence among patients who have filled a first‐time prescription for a cardiovascular medicine.

Methods

Design: Unblinded randomized controlled trial. Setting: 67 Norwegian pharmacies, October 2014–June 2015. Participants: 1480 adults with a first‐time prescription for a cardiovascular medicine. Intervention: Participants in the intervention group received two consultations with a pharmacist 1–2 and 3–5 weeks after filling the prescription. Participants in the control group received care according to usual practice. Main outcome measure: The primary outcome was self‐reported adherence as measured by the 8‐item Morisky Medication Adherence Scale (MMAS‐8), at 7 and 18 weeks after filling the prescription. Adherence from baseline to week 52 was estimated using data from the Norwegian Prescription Database (NPD).

Key Findings

Data from MMAS‐8 showed that 91.3% of the patients in the intervention group were adherent after 7 weeks versus 86.8% in the control group (4.5% difference, 95% CI 0.8–8.2, P = 0.017). The corresponding proportions were 88.7% versus 83.7% after 18 weeks (5.0% difference, 95% CI 0.8–9.2, P = 0.021). NPD data (n = 1294) showed no significant difference in adherence after 52 weeks (95% CI −2.0 to 7.8, P = 0.24). However, adherence among statin users (n = 182) was 66.5% in the intervention group versus 57.4% among new statin users in the general population (n = 1500) (difference 9.1%, 95% CI 1.5–16.0, P = 0.019).

Conclusion

The main outcome measure indicates that a short, structured pharmacist‐led intervention may increase medication adherence for patients starting on chronic cardiovascular medication. However, these findings could not be confirmed by the NPD data analysis.

Utilization of etoricoxib in dental patients in the Nordic countries: a population-based register study

Background: Etoricoxib is a second-generation cyclooxygenase-2-inhibitor approved in 2012 for short-term treatment of pain associated with dental surgery. Objectives: To evaluate etoricoxib utilization in dental patients in the Nordic countries, including its off-label use. Methods: The entire populations of Denmark, Finland, Sweden and Norway with etoricoxib prescriptions written by dentists and dispensed in 2012-2014 were evaluated using national register data. Nationwide estimates of etoricoxib utilization were generated according to year, gender, age, dose and package size. Off-label use in paediatric patients, prescribed doses >90 mg/day or for dental contacts not associated with surgical procedures, and concomitant administration with anticoagulants were evaluated. Results: Utilization of etoricoxib for dental pain was low (1615 prescriptions: Finland, 907; Sweden, 359; Norway, 337; Denmark, 12). Overall, 70% of the prescriptions were without an associated dental procedure. Moreover, 58%, 55%, 10% and 58% of the prescriptions in Denmark, Finland, Sweden and Norway, respectively, were for >90 mg/day doses. Few paediatric prescriptions were dispensed (n < 10), and only a small overlap (n = 21) was observed between etoricoxib and anticoagulant prescriptions. Conclusions: Given the low overall number of prescriptions, it is unlikely that off-label use of etoricoxib within dentistry in the Nordic countries is an important public health concern.

Economic evaluation of lipid lowering with PCSK9 inhibitors in patients with familial hypercholesterolemia: Methodological aspects

BACKGROUND AND AIMS

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have proved to reduce low density lipoprotein cholesterol levels in numerous clinical trials. In two large clinical trials, PCSK9 inhibitor treatment reduced the risk of cardiovascular disease. Our aim was to explore the impact of varying assumptions about clinical effectiveness on health and economic outcomes for patients with familial hypercholesterolemia.

METHODS

We used a previously published and validated Norwegian model for cardiovascular disease. The model was updated with recent data from the world's second largest registry of patients with genetically confirmed familial hypercholesterolemia. We performed analyses for 24 different subgroups of patients based on age, gender, statin tolerance and previous history of cardiovascular disease.

RESULTS

In 1 out of 24 subgroups, PCSK9 inhibitors were cost-effective when effectiveness was modelled using direct relative efficacy as reported in the FOURIER trial. When using assumptions, as suggested in a recent consensus statement from the European Atherosclerosis Society, 14 subgroups were cost-effective.

CONCLUSIONS

Cost-effectiveness of PCSK9 inhibitors depends highly on assumptions regarding effectiveness. Basing assumptions only on randomised controlled trials, and not taking into account varying effects based on baseline cholesterol level, results in much fewer groups being cost-effective.

Predicting Difference in Mean Survival Time from Reported Hazard Ratios for Cancer Patients

Background. Gain in mean survival time from new cancer treatments is a core component of cost-effectiveness analyses frequently used by payers for reimbursement decisions. Due to limited follow-up time, clinical trials rarely report this measure, whereas they often report hazard ratios comparing treatment groups. Aim. We aimed to explore the empirical relationship between gain in mean survival time and the hazard ratio for cancer patients. Methods. We included all patients in Norway diagnosed from 1965 through 2004 with late-stage cancer at the point of diagnosis and with one of the following cancers: stomach, colon, rectal, pancreas, lung and trachea, kidney excluding renal pelvis, and metastasized breast and prostate. Patients were followed until emigration, death, or June 30, 2016, whichever came first. Observed mean survival times and hazard ratios were obtained in subcohorts defined by patients’ sex, age, cancer type, and time period of diagnosis, which had nearly complete follow-up. Based on theoretical considerations, we fitted a linear relationship between observed differences in mean survival and logarithmic hazard ratios. For validation, we estimated differences in mean survival from hazard ratios of bootstrap samples with artificially induced censoring and compared with fitting a Weibull distribution. Results. The relationship between differences in mean survival time and corresponding logarithmic hazard ratios was linear for each of the included cancers. The predicted differences in mean survival of the empirical approach generally had smaller bias than the Weibull approach. Conclusion. For cancer diagnoses with poor prognosis, differences in mean survival times could be predicted from corresponding hazard ratios. This hazard ratio–based approach outperforms or is similar to fitting Weibull models to data with incomplete follow-up, while making fewer assumptions.

Are PCSK9 Inhibitors Cost Effective?

The objective of this study was to review available health economic evaluations of PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors. These drugs reduce low-density lipid cholesterol levels and cardiovascular risk, but their cost effectiveness has been questioned. We searched Medline and Embase for economic evaluations in any language at any time. Studies were included if they analysed any PCSK9 inhibitor compared with either statin alone or in combination with ezetimibe or any other therapy considered standard prior to the introduction of PCSK9 inhibitors. We found ten full health economic evaluations of PCSK9 inhibitors, two from Europe and eight from the United States (US). Six of the eight from the US were from two different consortia that analysed PCSK9 inhibitors at different stages through the development of evidence. All studies generally reported incremental cost-effectiveness ratios above suggested thresholds for cost effectiveness, except one study from Spain. The results of this review indicate that PCSK9 inhibitors in general are not cost effective at the current prices, but lower prices may change the results.

Choosing wisely: a model-based analysis evaluating the trade-offs in cancer benefit and diagnostic referrals among alternative HPV testing strategies in Norway

Background:

Forthcoming cervical cancer screening strategies involving human papillomavirus (HPV) testing for women not vaccinated against HPV infections may increase colposcopy referral rates. We quantified health and resource trade-offs associated with alternative HPV-based algorithms to inform decision-makers when choosing between candidate algorithms.

Methods:

We used a mathematical simulation model of HPV-induced cervical carcinogenesis in Norway. We compared the current cytology-based strategy to alternative strategies that varied by the switching age to primary HPV testing (ages 25–34 years), the routine screening frequency (every 3–10 years), and management of HPV-positive, cytology-negative women. Model outcomes included reductions in lifetime cervical cancer risk, relative colposcopy rates, and colposcopy rates per cervical cancer prevented.

Results:

The age of switching to primary HPV testing and the screening frequency had the largest impacts on cancer risk reductions, which ranged from 90.9% to 96.3% compared to no screening. In contrast, increasing the follow-up intensity of HPV-positive, cytology-negative women provided only minor improvements in cancer benefits, but generally required considerably higher rates of colposcopy referrals compared to current levels, resulting in less efficient cervical cancer prevention.

Conclusions:

We found that in order to maximise cancer benefits HPV-based screening among unvaccinated women should not be delayed: rather, policy makers should utilise the triage mechanism to control colposcopy referrals.

The impact of methicillin-resistant S. aureus on length of stay, readmissions and costs: a register based case-control study of patients hospitalized in Norway

Background

Patients with methicillin-resistant S. aureus (MRSA) are thought to incur additional costs for hospitals due to longer stay and contact isolation. The aim of this study was to assess the costs associated with MRSA in Norwegian hospitals.

Methods

Analyses were based on data fromSouth-Eastern Norway for the year 2012 as registered in the Norwegian Surveillance System for Communicable Diseases and the Norwegian Patient Registry. We used a matched case-control method to compare MRSA diagnosed inpatients with non-MRSA inpatients in terms of length of stay, readmissions within 30 days from discharge, as well as the Diagnosis-Related Group (DRG) based costs.

Results

Norwegian patients with MRSA stayed on average 8 days longer in hospital than controls, corresponding to a ratio of mean duration of 2.08 (CI 95%, 1.75–2.47) times longer.A total of 14% of MRSA positive inpatients were readmitted compared to 10% among controls. However, the risk of readmission was not significantly higher for patients with MRSA. DRG based hospital costs were 0.37 (95% CI, 0.19–0.54) times higher among cases than controls, with a mean cost of EUR13,233(SD 26,899) and EUR7198(SD 18,159) respectively.

Conclusion

The results of this study indicate that Norwegian patients with MRSA have longer hospital stays, and higher costs than those without MRSA.

Practice variation in surgical procedures and IUD-insertions among general practitioners in Norway - a longitudinal study

Background

Studies of Primary Health Care (PHC) reveal considerable practice variations in terms of the range of services provided. In Norway, general practitioners (GPs) are traditionally expected to perform IUD-insertions and several surgical procedures as a part of comprehensive PHC. We aimed to investigate variation in the provision of surgical procedures and IUD-insertions across GPs and over time and explore determinants of such variation.

Methods

Retrospective registry study of Norwegian GPs. From a comprehensive database of GPs’ reimbursement claims, we obtained procedure codes and GP characteristics such as age, gender, list size and municipality characteristics from 2006 through 2013. Multivariable logistic regression models were fitted to explore determinants of practice variation.

Results

We extracted data from 4,828 GPs. In 2013, 91.0, 76.1 and 74.8% were reimbursed at least once for minor and major surgical procedures and IUD-insertion, respectively. Female GPs had lower odds for performing major surgical procedures (OR 0.38, 95% CI 0.32–0.45) and higher odds for performing IUD-insertions (OR 6.28, 95% CI 4.47–8.82) than male GPs. Older GPs and GPs with shorter patient lists were less likely to perform surgical procedures. GPs with longer patient lists had higher odds for performing IUD-insertions. The proportion of GPs performing surgical procedures increased over time, while the proportion decreased for IUD-insertions. The number of IUD-insertions in specialist care increased from 12,575 in 2011 to 15 216 (+21.0%) in 2014.

Conclusion

We observed a large variation in the provision of surgical procedures and IUD-insertions amongst GPs in Norway. The GPs’ age, gender, list size and size of municipality were associated with performing the procedures. Our findings suggest a shift of IUD-insertions from primary to specialist care.

Predicting Mean Survival Time from Reported Median Survival Time for Cancer Patients

BACKGROUND

Mean duration of survival following treatment is a prerequisite for cost-effectiveness analyses used for assessing new and costly life-extending therapies for cancer patients. Mean survival time is rarely reported due to censoring imposed by limited follow-up time, whereas the median survival time often is. The empirical relationship between mean and median survival time for cancer patients is not known.

AIM

To derive the empirical associations between mean and median survival time across cancer types and to validate this empirical prediction approach and compare it with the standard approach of fitting a Weibull distribution.

METHODS

We included all patients in Norway diagnosed from 1960 to 1999 with one of the 13 most common solid tumor cancers until emigration, death, or 31 December 2011, whichever came first. Observed median, restricted mean, and mean survival times were obtained in subcohorts defined by patients' sex, age, cancer type, and time period of diagnosis, which had nearly complete follow-up. Based on theoretical considerations, we fitted a linear relationship between observed means and medians on the log scale. For validation, we estimated mean survival from medians of bootstrap samples with artificially induced censoring and compared with fitting a Weibull distribution.

RESULTS

A linear relationship between log-mean survival time and log-median survival time was identified for the 6 cancers with shortest survival plus metastasized breast and prostate cancers. The predicted means of the empirical approach had smaller bias than the standard Weibull approach.

CONCLUSION

For cancer diagnoses with poor prognosis, mean survival times could be predicted from corresponding medians. This empirical prediction approach is useful for validation of estimates of mean survival time and sensitivity analyses in settings with aggregated data only.

Using novel biomarkers to triage young adult women with minor cervical lesions: a cost-effectiveness analysis

OBJECTIVE

To evaluate the short-term consequences and cost-effectiveness associated with the use of novel biomarkers to triage young adult women with minor cervical cytological lesions.

DESIGN

Model-based economic evaluation using primary epidemiological data from Norway, supplemented with data from European and American clinical trials.

SETTING

Organised cervical cancer screening in Norway.

POPULATION

Women aged 25-33 years with minor cervical cytological lesions detected at their primary screening test.

METHODS

We expanded an existing simulation model to compare 12 triage strategies involving alternative biomarkers (i.e. reflex human papillomavirus (HPV) DNA/mRNA testing, genotyping, and dual staining) with the current Norwegian triage guidelines.

MAIN OUTCOME MEASURES

The number of high-grade precancers detected and resource use (e.g. monetary costs and colposcopy referrals) for a single screening round (3 years) for each triage strategy. Cost-efficiency, defined as the additional cost per additional precancer detected of each strategy compared with the next most costly strategy.

RESULTS

Five strategies were identified as cost-efficient, and are projected to increase the precancer detection rate between 18 and 57%, compared with current guidelines; however, the strategies did not uniformly require additional resources. Strategies involving HPV mRNA testing required fewer resources, whereas HPV DNA-based strategies detected >50% more precancers, but were more costly and required twice as many colposcopy referrals compared with the current guidelines.

CONCLUSION

Strategies involving biomarkers to triage younger women with minor cervical cytological lesions have the potential to detect additional precancers, yet the optimal strategy depends on the resources available as well as decision-makers' and women's acceptance of additional screening procedures.

TWEETABLE ABSTRACT

Women with minor cervical lesions may be triaged more accurately and effectively using novel biomarkers.

The predicted lifetime costs and health consequences of calcium and vitamin D supplementation for fracture prevention-the impact of cardiovascular effects

Some studies indicate that calcium supplementation increases cardiovascular risk. We assessed whether such effects could counterbalance the fracture benefits from supplementation. Accounting for cardiovascular outcomes, calcium may cause net harm and would not be cost-effective. Clinicians may do well considering cardiovascular effects when prescribing calcium supplementation.

INTRODUCTION

Accounting for possible cardiovascular effect of calcium and vitamin D supplementation (CaD), the aims of this study were to assess whether CaD on balance would improve population health and to evaluate the cost-effectiveness of such supplementation.

METHODS

We created a probabilistic Markov simulation model that was analysed at the individual patient level. We analysed 65-year-old Norwegian women with a 2.3 % 10-year risk of hip fracture and a 9.3 % risk of any major fracture according to the WHO fracture risk assessment tool (FRAX®). Consistent with a recent Cochrane review, we assumed that CaD reduces the risk of hip, vertebral, and wrist fractures by 16, 11, and 5 %, respectively. We included the increased risk of acute myocardial infarction (AMI) and stroke under a no-, medium-, and high-risk scenario.

RESULTS

Assuming no cardiovascular effects, CaD supplementation produces improved health outcomes resulting in an incremental gain of 0.0223 quality-adjusted life years (QALYs) and increases costs by €322 compared with no treatment (cost-effectiveness ratio €14,453 per QALY gained). Assuming a Norwegian cost-effectiveness threshold of €60,000 per QALY, CaD is likely to be considered a cost-effective treatment alternative. In a scenario with a medium or high increased risk of cardiovascular events, CaD produces net health losses, respectively, -0.0572 and -0.0784 QALY at additional costs of €481 and €1033.

CONCLUSIONS

We conclude that the magnitude of potential cardiovascular side effects is crucial for the effectiveness and cost-effectiveness of CaD supplementation in elderly women.

Influenced from the start: anchoring bias in time trade-off valuations

Purpose

The de facto standard method for valuing EQ-5D health states is the time trade-off (TTO), an iterative choice procedure. The TTO requires a starting point (SP), an initial offer of time in full health which is compared to a fixed offer of time in impaired health. From the SP, the time in full health is manipulated until preferential indifference. The SP is arbitrary, but may influence respondents, an effect known as anchoring bias. The aim of the study was to explore the potential anchoring effect and its magnitude in TTO experiments.

Methods

A total of 1249 respondents valued 8 EQ-5D health states in a Web study. We used the lead time TTO (LT-TTO) which allows eliciting negative and positive values with a uniform method. Respondents were randomized to 11 different SPs. Anchoring bias was assessed using OLS regression with SP as the independent variable. In a secondary experiment, we compared two different SPs in the UK EQ-5D valuation study TTO protocol.

Results

A 1-year increase in the SP, corresponding to an increase in TTO value of 0.1, resulted in 0.02 higher recorded LT-TTO value. SP had little impact on the relative distance and ordering of the eight health states. Results were similar to the secondary experiment.

Conclusion

The anchoring effect may bias TTO values. In this Web-based valuation study, the observed anchoring effect was substantial. Further studies are needed to determine whether the effect is present in face-to-face experiments.

Using Decision-Analytic Modeling to Isolate Interventions That Are Feasible, Efficient and Optimal: An Application from the Norwegian Cervical Cancer Screening Program

BACKGROUND

Decision makers often need to simultaneously consider multiple criteria or outcomes when deciding whether to adopt new health interventions.

OBJECTIVES

Using decision analysis within the context of cervical cancer screening in Norway, we aimed to aid decision makers in identifying a subset of relevant strategies that are simultaneously efficient, feasible, and optimal.

METHODS

We developed an age-stratified probabilistic decision tree model following a cohort of women attending primary screening through one screening round. We enumerated detected precancers (i.e., cervical intraepithelial neoplasia of grade 2 or more severe (CIN2+)), colposcopies performed, and monetary costs associated with 10 alternative triage algorithms for women with abnormal cytology results. As efficiency metrics, we calculated incremental cost-effectiveness, and harm-benefit, ratios, defined as the additional costs, or the additional number of colposcopies, per additional CIN2+ detected. We estimated capacity requirements and uncertainty surrounding which strategy is optimal according to the decision rule, involving willingness to pay (monetary or resources consumed per added benefit).

RESULTS

For ages 25 to 33 years, we eliminated four strategies that did not fall on either efficiency frontier, while one strategy was efficient with respect to both efficiency metrics. Compared with current practice in Norway, two strategies detected more precancers at lower monetary costs, but some required more colposcopies. Similar results were found for women aged 34 to 69 years.

CONCLUSIONS

Improving the effectiveness and efficiency of cervical cancer screening may necessitate additional resources. Although efficient and feasible, both society and individuals must specify their willingness to accept the additional resources and perceived harms required to increase effectiveness before a strategy can be considered optimal.

Decisions on statin therapy by patients' opinions about survival gains: cross sectional survey of general practitioners

Background

Guidelines for primary prevention of cardiovascular disease provide little guidance on how patients’ preferences should be taken into account. We wanted to explore whether general practitioners (GPs) are sensitive to patient preferences regarding survival gains from statin therapy.

Methods

In a cross sectional, online survey 3,270 Norwegian GPs were presented with a 55 year old patient with an unfavourable cardiovascular risk profile. He expressed preferences for statin therapy by indicating a minimum survival gain that would be considered a substantial benefit. This survival gain varied across six versions of the vignette: 8, 4 and 2 years, and 12, 6 and 3 months, respectively. Participants were randomly allocated to one version only. We asked whether the GPs would recommend the patient to take a statin. Subsequently we asked the GPs to estimate the average survival gain of life long simvastatin therapy for patients with a similar risk profile.

Results

We received 1,296 responses (40 %). Across levels of survival gains (8 years to 3 months) the proportion of GPs recommending statin therapy did not vary significantly (OR per level 1.07, 95 % CI 0.99 to 1.16). The GP’s own estimate of survival gain was a statistically significant predictor of recommending therapy (OR per year adjusted for the GPs’ age, sex, speciality attainment and number of patients listed 3.07, CI 2.55 to 3.69).

Conclusion

GPs were insensitive to patient preferences regarding survival gain when recommending statin therapy. The GPs' recommendations were strongly associated with their own estimates of survival gain.

Dynamic modeling of cost-effectiveness of rotavirus vaccination, Kazakhstan

The government of Kazakhstan, a middle-income country in Central Asia, is considering the introduction of rotavirus vaccination into its national immunization program. We performed a cost-effectiveness analysis of rotavirus vaccination spanning 20 years by using a synthesis of dynamic transmission models accounting for herd protection. We found that a vaccination program with 90% coverage would prevent ≈880 rotavirus deaths and save an average of 54,784 life-years for children <5 years of age. Indirect protection accounted for 40% and 60% reduction in severe and mild rotavirus gastroenteritis, respectively. Cost per life year gained was US $18,044 from a societal perspective and US $23,892 from a health care perspective. Comparing the 2 key parameters of cost-effectiveness, mortality rates and vaccine cost at <US $2.78 per dose, vaccination program costs would be entirely offset. To further evaluate efficacy of a vaccine program, benefits of indirect protection conferred by vaccination warrant further study.

Cost effectiveness of drug-eluting stents as compared with bare metal stents in patients with coronary artery disease

The aim of this study was to estimate the incremental cost effectiveness of replacing bare metal stents (BMS) by drug-eluting stents (DES) when using trial data and registry data. We developed a Markov model (model of cost effectiveness of coronary artery disease) in which 60-year-old patients started by undergoing percutaneous coronary intervention for acute or subacute coronary artery disease. The patients are followed until death or 100 years of age. Data on the occurrence of events (revascularization, acute myocardial infarction, and death) were based on Scandinavian registry data. Separate analyses were conducted with data on effectiveness based on randomized controlled trials and patient registries. On using trial data, it was found that sirolimus-eluting stents (SES) yield 0.003 greater life expectancy and $3300 lower costs than do BMS (dominant strategy). Paclitaxel-eluting stents (PES) yield 0.148 more life years than do SES at additional lifetime costs of $2800 ($21,400 per life year gained). On using registry data, the cost per life year gained was found to be $4900 when replacing BMS with DES. Probabilistic sensitivity analyses, on the other hand, indicate that PES only has a 50%-75% probability of being cost effective, regardless of the type of effectiveness data. DESs are cost effective with current willingness to pay for life year gains. Whether PES or SES is the most effective DES remains uncertain.

Cost and health consequences of treatment of primary biliary cirrhosis with ursodeoxycholic acid

BACKGROUND

Long-term use of ursodeoxycholic acid (UDCA) is the recommended therapy in primary biliary cirrhosis (PBC). The lifetime effectiveness and cost-effectiveness of UDCA in PBC have, however, not been assessed.

AIM

To estimate the health outcomes and lifetime costs of a Norwegian cohort of PBC patients on UDCA.

METHODS

Norwegian PBC patients (n = 182) (90% females; mean age 56.3 ± 8.9 years; Mayo risk score 4.38) who were included in a 5-year open-label study of UDCA therapy were subsequently followed up for up to 11.5 years. The lifetime survival was estimated using a Weibull survival model. The survival benefit from UDCA was based on a randomised clinical trial from Canada, comparing the effect of non-UDCA and UDCA. Survival and costs of standard care vs. standard care plus UDCA were simulated in a Markov model with death and liver transplantation as major events, invoking transition of a patient's state in the model.

RESULTS

The gain in life expectancy for a PBC patient on UDCA compared with standard care was 2.24 years (1.19 years discounted). The lifetime treatment costs were EUR 151,403 and EUR 157,741 (EUR 102,912 and EUR 115,031 discounted) for patients with and without UDCA respectively. A probabilistic sensitivity analysis indicated an 82% probability that UDCA entails both greater life expectancy and lower costs than standard care.

CONCLUSIONS

The results of this study indicate that UDCA therapy is a dominant strategy as it confers reduced morbidity and mortality, as well as cost savings, compared with standard therapy.

What professional activities do general practitioners find most meaningful? Cross sectional survey of Norwegian general practitioners

Background

Health reforms in many countries affect the scope and nature of primary care. General Practitioners (GPs) are expected to spend more time developing public health, preventive health care, coordination of care and teamwork. We aimed to explore which professional activities GPs consider to be meaningful and how they would like to prioritise tasks.

Methods

In a cross sectional online survey 3,270 GPs were invited to consider twenty different activities in general practice. They were asked to rate each of them on a Likert scale anchored from 1 (not meaningful) to 5 (very meaningful). They then selected three activities from the item list on which they would like to spend more time and three activities on which they would like to spend less time. We used multinomial logistic regression to explore associations between the GPs’ preferences for time spent on preventive health care activities and age, gender and practice characteristics.

Results

Approximately 40% (n=1,308) responded. The most meaningful activities were handling common symptoms and complaints (94% scored 4 or 5), chronic somatic diseases (93%), terminal care (80%), chronic psychiatric diseases (77%), risk conditions (76%) and on call emergency services (70%). In terms of priority the same items prevailed except that GPs would like to spend less time on emergency services. Items with low priority were health certificates, practice administration, meetings with local health authorities, medically unexplained symptoms, addiction medicine, follow up of people certified unfit for work, psychosocial problems, preventive health clinics for children and school health services. In multivariate regression models physician and practice characteristics explained no more than 10% of the variability in the GPs’ preferences for time spent on preventive health care services.

Conclusions

The GPs found diagnosis and treatment of diseases most meaningful. Their priorities were partly at odds with those of the health authorities and policy makers.

Impact of effectiveness information format on patient choice of therapy and satisfaction with decisions about chronic disease medication: the "Influence of intervention Methodologies on Patient Choice of Therapy (IMPACT)" cluster-randomised trial in general practice

Background

Risk communication is an integral part of shared decision-making in health care. In the context of interventions for chronic diseases it represents a particular challenge for all health practitioners. By using two different quantitative formats to communicate risk level and effectiveness of a cholesterol-lowering drug, we posed the research question: how does the format of risk information influence patients’ decisions concerning therapy, patients’ satisfaction with the communication as well as confidence in the decision. We hypothesise that patients are less prone to accept therapy when the benefits of long-term intervention are presented in terms of prolongation of life (POL) in months compared to the absolute risk reduction (ARR). We hypothesise that patients presented with POL will be more satisfied with the communication and confident in their decision, suggesting understanding of the time-related term.

Methods/Design

In 2009 a sample of 328 general practitioners (GPs) in the Region of Southern Denmark was invited to participate in a primary care-based clinical trial among patients making real-life clinical decisions together with their GP. Interested GPs were cluster-randomised to inform patients about cardiovascular disease (CVD) risk and the effectiveness of statin therapy using either POL or ARR. The GPs attended a training session before informing their patients. Before training and after the trial period they received a questionnaire about their attitudes to risk communication and the use of numerical information. Patients’ redemptions of statin prescriptions will be registered in a regional prescription database to evaluate a possible association between redemption rates and effectiveness format. The Combined Outcome Measure for Risk Communication And Treatment Decision Making Effectiveness (COMRADE) questionnaire will be used to measure patients’ confidence and satisfaction with the risk communication immediately after the conversation with their GPs.

Discussion

This randomised clinical trial compares the impact of two effectiveness formats on real-life risk communication between patients and GPs, including affective patient outcomes and actual choices about acceptance of therapy. Though we found difficulties in recruiting GPs, according to the study protocol we have succeeded in engaging sufficient GPs for the trial, enabling us to perform the planned analyses.

Trial registration

ClinicalTrials.gov Protocol Registration System http://ww.clinicaltrials.gov/NCT01414751

Impact of transformation of negative values and regression models on differences between the UK and US EQ-5D time trade-off value sets

BACKGROUND

National EQ-5D value sets are developed because preferences for health may vary in different populations. UK values are lower than US values for most of the 243 possible EQ-5D health states. Although similar protocols were used for data collection, analytic choices regarding how to model values from the collected data may also influence national value sets. Participants in the UK and US studies assessed the same subset of 42 EQ-5D health states using the time trade-off (TTO) method. However, different methods were used to transform negative values to a range bounded by 0 and -1, and values for all 243 health states were estimated using two different regression models. The transformation of negative values is inconsistent with expected utility theory, and the choice of which transformation method to use lacks a theoretical foundation.

OBJECTIVES

Our objectives were to assess how much of the observed difference between the UK and US EQ-5D value sets may be explained by the choice of transformation method for negative values relative to the choice of regression model and the differences between elicited TTO values in the respective national studies (datasets).

METHODS

We applied both transformation methods and both regression models to each of the two datasets, resulting in eight comparable value sets. We arranged these value sets in pairs in which one source of difference (transformation method, regression model or dataset) was varied. For each of these paired value sets, we calculated the mean difference between the two matching values for each of the 243 health states. Finally, we calculated the mean utility gain for all possible transitions between pairs of EQ-5D health states within each value set and used the difference in transition scores as a measure of impact from changing transformation method, regression model or dataset.

RESULTS

The mean absolute difference in values was 1.5 times larger when changing the transformation method than when using different datasets. The choice of transformation method had a 3.2 times larger effect on the mean health gain (transition score) than the choice of dataset. The mean health gain in the UK value set was 0.09 higher than in the US value set. Using the UK transformation method on the US dataset reduced this absolute difference to 0.02. The choice of regression model had little overall impact on the differences between the value sets.

CONCLUSIONS

Most of the observed differences between the UK and US value sets were caused by the use of different transformation methods for negative values, rather than differences between the two study populations as reflected in the datasets. Changing the regression model had little impact on the differences between the value sets.

Dynamic modelling of costs and health consequences of school closure during an influenza pandemic

Background

The purpose of this article is to evaluate the cost-effectiveness of school closure during a potential influenza pandemic and to examine the trade-off between costs and health benefits for school closure involving different target groups and different closure durations.

Methods

We developed two models: a dynamic disease model capturing the spread of influenza and an economic model capturing the costs and benefits of school closure. Decisions were based on quality-adjusted life years gained using incremental cost-effectiveness ratios. The disease model is an age-structured SEIR compartmental model based on the population of Oslo. We studied the costs and benefits of school closure by varying the age targets (kindergarten, primary school, secondary school) and closure durations (1–10 weeks), given pandemics with basic reproductive number of 1.5, 2.0 or 2.5.

Results

The cost-effectiveness of school closure varies depending on the target group, duration and whether indirect costs are considered. Using a case fatality rate (CFR) of 0.1-0.2% and with current cost-effectiveness threshold for Norway, closing secondary school is the only cost-effective strategy, when indirect costs are included. The most cost-effective strategies would be closing secondary schools for 8 weeks if R₀=1.5, 6 weeks if R₀=2.0, and 4 weeks if R₀= 2.5. For severe pandemics with case fatality rates of 1-2%, similar to the Spanish flu, or when indirect costs are disregarded, the optimal strategy is closing kindergarten, primary and secondary school for extended periods of time. For a pandemic with 2009 H1N1 characteristics (mild severity and low transmissibility), closing schools would not be cost-effective, regardless of the age target of school children.

Conclusions

School closure has moderate impact on the epidemic’s scope, but the resulting disruption to society imposes a potentially great cost in terms of lost productivity from parents’ work absenteeism.

Communicating treatment effectiveness in the context of chronic disease processes

A better understanding of the risk concept in relation to treatment of chronic disease processes is warranted. Consequences of therapies may be described in terms of risk reductions or postponement of adverse outcomes. This review argues that for most interventions, neither of these measures adequately characterize the distribution of treatment benefit across patients. More focus should be placed on choosing the context-relevant outcome measure and on developing techniques for extracting and communicating 2D outcome measures where the distribution of outcomes across patients is explicitly reflected. Since the distribution of outcomes affects patients' valuation of interventions, more research into risk communication is likely to lead to improved decision making.

Medication effectiveness may not be the major reason for accepting cardiovascular preventive medication: a population-based survey

BACKGROUND

Shared decision-making and patients' choice of interventions are areas of increasing importance, not least seen in the light of the fact that chronic conditions are increasing, interventions considered important for public health, and still non-acceptance of especially risk-reducing treatments of cardiovascular diseases (CVD) is prevalent. A better understanding of patients' medication-taking behavior is needed and may be reached by studying the reasons why people accept or decline medication recommendations. The aim of this paper was to identify factors that may influence people's decisions and reasoning for accepting or declining a cardiovascular preventive medication offer.

METHODS

From a random sample of 4,000 people aged 40-59 years in a Danish population, 1,169 participants were asked to imagine being at increased risk of cardiovascular disease and being offered a preventive medication. After receiving 'complete' information about effectiveness of the medication they were asked whether they would accept medication. Finally, they were asked about reasons for the decision.

RESULTS

A total of 725 (67%) of 1,082 participants accepted the medication offer. Even quite large effects of medication (up to 8 percentage points absolute risk reduction) had a smaller impact on acceptance to medication than personal experience with cardiovascular disease. Furthermore, increasing age of the participant and living with a partner were significantly associated with acceptance. Some 45% of the respondents accepting justified their choice as being for health reasons, and they were more likely to be women, live alone, have higher income and higher education levels. Among those who did not accept the medication offer, 56% indicated that they would rather prefer to change lifestyle.

CONCLUSIONS

Medication effectiveness seems to have a moderate influence on people's decisions to accept preventive medication, while factors such as personal experience with cardiovascular disease may have an equally strong or stronger influence, indicating that practitioners could do well to carefully identify the reasons for their patients' treatment decisions.

Time trade-off and attitudes toward euthanasia: implications of using 'death' as an anchor in health state valuation

PURPOSE

Health state values are by convention anchored to 'perfect health' and 'death.' Attitudes toward death may consequently influence the valuations. We used attitudes toward euthanasia (ATE) as a sub-construct for attitudes toward death. We compared the influence on values elicited with time trade-off (TTO), lead-time TTO (LT-TTO) and visual analogue scale (VAS).Since the 'death' anchor is most explicit in TTO, we hypothesized that TTO values would be most influenced by ATE.

METHODS

Respondents valued eight EQ-5D health states with VAS, then TTO (n = 328) or LT-TTO (n = 484). We measured ATE on a scale from -2 (fully disagree) to 2 (fully agree) and used multiple linear regressions to predict VAS, TTO, and LT-TTO values by ATE, sex, age, and education.

RESULTS

A one-point increase on the ATE scale predicted a mean TTO value change of -.113 and LT-TTO change of -.072. Demographic variables, but not ATE, predicted VAS values.

CONCLUSIONS

TTO appears to measure ATE in addition to preferences for health states. Different ways of incorporating death in the valuation may impact substantially on the resulting values. 'Death' is a metaphysically unknown concept, and implications of attitudes toward death should be investigated further to evaluate the appropriateness of using 'death' as an anchor.

Choice of generic antihypertensive drugs for the primary prevention of cardiovascular disease--a cost-effectiveness analysis

BACKGROUND

Hypertension is one of the leading causes of cardiovascular disease (CVD). A range of antihypertensive drugs exists, and their prices vary widely mainly due to patent rights. The objective of this study was to explore the cost-effectiveness of different generic antihypertensive drugs as first, second and third choice for primary prevention of cardiovascular disease.

METHODS

We used the Norwegian Cardiovascular Disease model (NorCaD) to simulate the cardiovascular life of patients from hypertension without symptoms until they were all dead or 100 years old. The risk of CVD events and costs were based on recent Norwegian sources.

RESULTS

In single-drug treatment, all antihypertensives are cost-effective compared to no drug treatment. In the base-case analysis, the first, second and third choice of antihypertensive were calcium channel blocker, thiazide and angiotensin-converting enzyme inhibitor. However the sensitivity and scenario analyses indicated considerable uncertainty in that angiotensin receptor blockers as well as, angiotensin-converting enzyme inhibitors, beta blockers and thiazides could be the most cost-effective antihypertensive drugs.

CONCLUSIONS

Generic antihypertensives are cost-effective in a wide range of risk groups. There is considerable uncertainty, however, regarding which drug is the most cost-effective.