Cost-effectiveness analysis of germ-line BRCA testing in women with breast cancer and cascade testing in family members of mutation carriers.

PURPOSE: To evaluate the cost-effectiveness of BRCA testing in women with breast cancer, and cascade testing in family members of BRCA mutation carriers. METHODS: A cost-effectiveness analysis was conducted using a cohort Markov model from a health-payer perspective. The model estimated the long-term benefits and costs of testing women with breast cancer who had at least a 10% pretest BRCA mutation probability, and the cascade testing of first- and second-degree relatives of women who test positive. RESULTS: Compared with no testing, BRCA testing of affected women resulted in an incremental cost per quality-adjusted life-year (QALY) gained of AU$18,900 (incremental cost AU$1,880; incremental QALY gain 0.10) with reductions of 0.04 breast and 0.01 ovarian cancer events. Testing affected women and cascade testing of family members resulted in an incremental cost per QALY gained of AU$9,500 compared with testing affected women only (incremental cost AU$665; incremental QALY gain 0.07) with additional reductions of 0.06 breast and 0.01 ovarian cancer events. CONCLUSION: BRCA testing in women with breast cancer is cost-effective and is associated with reduced risk of cancer and improved survival. Extending testing to cover family members of affected women who test positive improves cost-effectiveness beyond restricting testing to affected women only.

Supply and demand in physician markets: a panel data analysis of GP services in Australia.

To understand the trends in any physician services market it is necessary to understand the nature of both supply and demand, but few studies have jointly examined supply and demand in these markets. This study uses aggregate panel data on general practitioner (GP) services at the Statistical Local Area level in Australia spanning eight years to estimate supply and demand equations for GP services. The structural equations of the model are estimated separately using population-weighted fixed effects panel modelling with the two stage least squares formulation of the generalised method of moments approach (GMM (2SLS)). The estimated price elasticity of demand of [Formula: see text] is comparable with other studies. The direct impact of GP density on demand, while significant, proves almost immaterial in the context of near vertical supply curves. Supply changes are therefore due to shifts in the position of the curves, partly determined by a time trend. The model is validated by comparing post-panel model predictions with actual market outcomes over a period of three years and is found to provide surprisingly accurate projections over a period of significant policy change. The study confirms the need to jointly consider supply and demand in exploring the behaviour of physician services markets.

Inequalities in bariatric surgery in Australia: findings from 49,364 obese participants in a prospective cohort study.

OBJECTIVES: To investigate variation, and quantify socioeconomic inequalities, in the uptake of primary bariatric surgery in an obese population. DESIGN, SETTING AND PARTICIPANTS: Prospective population-based cohort study of 49,364 individuals aged 45-74 years with body mass index (BMI)≥30 kg/m2. Data from questionnaires (distributed from 1 January 2006 to 31 December 2008) were linked to hospital and death data to 30 June 2010. The sample was drawn from the 45 and Up Study (approximately 10% of New South Wales population aged 45 included, response rate approximately 18%). MAIN OUTCOME MEASURES: Rates of bariatric surgery and adjusted rate ratios (RRs) in relation to health and sociodemographic characteristics. RESULTS: Over 111,757 person-years (py) of follow-up, 312 participants had bariatric surgery, a rate of 27.92 per 10,000 py (95% CI, 24.91-31.19). Rates were highest in women, those living in major cities and those with diabetes, and increased significantly with a higher BMI and number of chronic health conditions. Adjusted RRs were 5.27 (95% CI, 3.18-8.73) for those with annual household income≥ $70 000 versus those with household income<$20,000, and 4.01 (95% CI, 2.41-6.67) for those living in areas in the least disadvantaged quintile versus those in the most disadvantaged quintile. Having versus not having private health insurance (age- and sex-adjusted RR, 9.25; 95% CI, 5.70-15.00) partially explained the observed inequalities. CONCLUSIONS: Bariatric surgery has been shown to be cost-effective in treating severe obesity and associated illnesses. While bariatric surgery rates in Australia are higher in those with health problems, large socioeconomic inequalities are apparent. Our findings suggest these procedures are largely available to those who can afford private health insurance and associated out-of-pocket costs, with poor access in populations who are most in need. Continuing inequalities in access are likely to exacerbate existing inequalities in obesity and related health problems.

Twenty-year trends in the incidence and prevalence of diagnosed anogenital warts in Canada.

BACKGROUND: A vaccine has recently been licensed in many countries that protects against the human papillomavirus types 6, 11, 16, and 18. Types 6 and 11 account for approximately 90% of anogenital warts (AGWs). We describe the 20-year trends in the incidence and prevalence of AGWs in Manitoba, Canada. METHODS: We used linked population-based hospital and physician databases for Manitoba for 1984 to 2004. Cases were identified using tariff (billing) and ICD codes. A case was considered to be incident if it was preceded by a 12-month interval free period of AGWs care. Otherwise, it was deemed to be prevalent. An episode was considered over once a 12-month interval had elapsed without an AGW claim. RESULTS: Approximately 25,000 Manitobans were diagnosed with AGWs between 1985 and 2004. The annual age-standardized incidence rates peaked in 1992 (men, 149.9/100,000; women 170.8/100,000). In recent years, the rates have been increasing again, particularly for men. The male:female incidence rate ratio increased from 0.76 in 1985 to 1.25 in 2004. The highest incidence rate tended to be in those aged 20 to 24 years. Trends in prevalence were similar. Prevalence in 2004 was 165.2/100,000 for men and 128.4/100,000 for women. CONCLUSIONS: These population-based findings suggest that AGWs are a substantial burden to Manitobans and that their pattern has changed over time, with incidence and prevalence becoming higher in men than women. Monitoring the future trends in AGWs will provide an early marker of the effectiveness and duration of protection of human papillomavirus vaccination at a population level.

A cost analysis of producing vaccines in developing countries.

Developing country vaccine manufacturers (DCVMs) supply over half of the vaccines used in developing country immunisation programs. Decisions by developing countries to establish vaccine manufacturing should be based on economic viability, however reliable assessments of vaccine production costs are lacking. This study aimed to quantify the cost of establishing vaccine manufacturing facilities and producing vaccines in developing countries. This study estimates vaccine production costs in developing countries based on twelve vaccines produced by eight DCVMs. The results were based on estimates of the capital and operating costs required to establish vaccine manufacturing facilities under three hypothetical scenarios of production scale and scope. Cost patterns were then compared to vaccine prices paid by countries in both industrialized and developing country markets. The cost of producing vaccines in developing countries was estimated to be on average US$ 2.18 per dose, ranging between US$ 0.98 and US$ 4.85 for different vaccine types and formulations. Vaccine costs-per-dose decrease as production scale and scope increase. Cost-per-dose is mainly driven by fixed costs, but at a scale of production over 20 million doses per year it becomes driven by variable costs. Under the three hypothetical scenarios used, costs-per-dose of vaccines produced by developing countries were around 47% lower than vaccine prices in developing-country markets and 84% lower than prices in industrialized-country markets. This study has found that local production of vaccines in developing countries exhibits both economies of scale and economies of scope. The lower costs relative to prices suggests that a producer surplus and potential profits may be attainable in both developing and developed country markets, supporting sustainable production.

A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia.

BACKGROUND: Type 2 diabetes is rapidly growing as a proportion of the disease burden in Australia as elsewhere. This study addresses the cost effectiveness of an integrated approach to assisting general practitioners (GPs) with diabetes management. This approach uses a centralized database of clinical data of an Australian Division of General Practice (a network of GPs) to co-ordinate care according to national guidelines. METHODS: Long term outcomes for patients in the program were derived using clinical parameters after 5 years of program participation, and the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model, to project outcomes for 40 years from the time of diagnosis and from 5 years post-diagnosis. Cost information was obtained from a range of sources. While program costs are directly available, and costs of complications can be estimated from the UKPDS model, other costs are estimated by comparing costs in the Division with average costs across the state or the nation. The outcome and cost measures are used derive incremental cost-effectiveness ratios. RESULTS: The clinical data show that the program is effective in the short term, with improvement or no statistical difference in most clinical measures over 5 years. Average HbA1c levels increased by less than expected over the 5 year period. While the program is estimated to generate treatment cost savings, overall net costs are positive. However, the program led to projected improvements in expected life years and Quality Adjusted Life Expectancy (QALE), with incremental cost effectiveness ratios of $A8,106 per life-year saved and $A9,730 per year of QALE gained. CONCLUSIONS: The combination of an established model of diabetes progression and generally available data has provided an opportunity to establish robust methods of testing the cost effectiveness of a program for which a formal control group was not available. Based on this methodology, integrated health care delivery provided by a network of GPs improved health outcomes of type 2 diabetics with acceptable cost effectiveness, which suggests that similar outcomes may be obtained elsewhere.

Differential impacts of health care in Australia: trend analysis of socioeconomic inequalities in avoidable mortality.

BACKGROUND: Recent avoidable mortality trends in Australia suggest that health care has made a substantial contribution to reducing mortality. This study investigates if the benefits of health care have been distributed equally by comparing declines in avoidable with non-avoidable mortality over time by socioeconomic status (SES). METHODS: We calculated avoidable and non-avoidable mortality rates in Australia by small areas for 1986, 1991, 1997 and 2002. We performed pooled cross-sectional trend analysis of indirectly standardized mortality rates by SES and year, modelling using Poisson regression with over-dispersion. Socioeconomic inequalities were quantified using the relative (RII) and slope (SII) index of inequality. RESULTS: The annual percentage decline in avoidable mortality at the higher end of the socioeconomic continuum (5.0%; 95% CI: 4.7-5.4%) was larger than at the lower end (3.5%; 3.2-3.8%), with increasing relative inequality between 1986 (RII = 1.54; 1.46-1.63) and 2002 (RII = 2.00; 1.95-2.06), greater than that in non-avoidable mortality (P = 0.036). In absolute terms, avoidable deaths fell annually by 7.4 (6.9-7.8) and 8.4 (7.9-8.9) deaths per 100 000 at the higher and lower end of the spectrum, respectively, with absolute inequality decreasing between 1986 (SII = 97.8; 87.6-107.9) and 2002 (SII = 81.5; 74.6-88.5). CONCLUSIONS: Health care has contributed to decreasing the absolute SES mortality gap. However, advantaged people have obtained a disproportionate benefit of health care, contributing to widening relative health inequalities. A universal heath care system does not guarantee equality in health-care-related outcomes.

Is there evidence for dual causation between malaria and socioeconomic status? Findings from rural Tanzania.

Malaria's relationship with socioeconomic status at the macroeconomic level has been established. This is the first study to explore this relationship at the microeconomic (household) level and estimate the direction of association. Malaria prevalence was measured by parasitemia, and household socioeconomic status was measured using an asset based index. Results from an instrumental variable probit model suggest that socioeconomic status is negatively associated with malaria parasitemia. Other variables that are significantly associated with parasitemia include age of the individual, use of a mosquito net on the night before interview, the number of people living in the household, whether the household was residing at their farm home at the time of interview, household wall construction, and the region of residence. Matching estimators indicate that malaria parasitemia is associated with reduced household socioeconomic status.

Attributes and weights in health care priority setting: A systematic review of what counts and to what extent.

In most societies resources are insufficient to provide everyone with all the health care they want. In practice, this means that some people are given priority over others. On what basis should priority be given? In this paper we are interested in the general public's views on this question. We set out to synthesis what the literature has found as a whole regarding which attributes or factors the general public think should count in priority setting and what weight they should receive. A systematic review was undertaken (in August 2014) to address these questions based on empirical studies that elicited stated preferences from the general public. Sixty four studies, applying eight methods, spanning five continents met the inclusion criteria. Discrete Choice Experiment (DCE) and Person Trade-off (PTO) were the most popular standard methods for preference elicitation, but only 34% of all studies calculated distributional weights, mainly using PTO. While there is heterogeneity, results suggest the young are favoured over the old, the more severely ill are favoured over the less severely ill, and people with self-induced illness or high socioeconomic status tend to receive lower priority. In those studies that considered health gain, larger gain is universally preferred, but at a diminishing rate. Evidence from the small number of studies that explored preferences over different components of health gain suggests life extension is favoured over quality of life enhancement; however this may be reversed at the end of life. The majority of studies that investigated end of life care found weak/no support for providing a premium for such care. The review highlights considerable heterogeneity in both methods and results. Further methodological work is needed to achieve the goal of deriving robust distributional weights for use in health care priority setting.

The relationship between body mass index and hospitalisation rates, days in hospital and costs: findings from a large prospective linked data study.

BACKGROUND: Internationally there is limited empirical evidence on the impact of overweight and obesity on health service use and costs. We estimate the burden of hospitalisation-admissions, days and costs-associated with above-normal BMI. METHODS: Population-based prospective cohort study involving 224,254 adults aged ≥45y in Australia (45 and Up Study). Baseline questionnaire data (2006-2009) were linked to hospitalisation and death records (median follow-up 3.42y) and hospital cost data. The relationships between BMI and hospital admissions and days were modelled using zero-inflated negative binomial regression; generalised gamma models were used to model costs. Analyses were stratified by sex and age (45-64, 65-79, ≥80y), and adjusted for age, area of residence, education, income, smoking, alcohol-intake and private health insurance status. Population attributable fractions were also calculated. RESULTS: There were 459,346 admissions (0.55/person-year) and 1,483,523 hospital days (1.76/person-year) during follow-up. For ages 45-64y and 65-79y, rates of admissions, days and costs increased progressively with increments of above-normal BMI. Compared to BMI 22.5-<25kg/m2, rates of admissions and days were 1.64-2.54 times higher for BMI 40-50kg/m2; costs were 1.14-1.24 times higher for BMI 27.5-<30kg/m2, rising to 1.77-2.15 times for BMI 40-50kg/m2. The BMI-hospitalisation relationship was less clear for ≥80y. We estimated that among Australians 45-79y, around 1 in every 8 admissions are attributable to overweight and obesity (2% to overweight, 11% to obesity), as are 1 in every 6 days in hospital (2%, 16%) and 1 in every 6 dollars spent on hospitalisation (3%, 14%). CONCLUSIONS: The dose-response relationship between BMI and hospital use and costs in mid-age and older Australians in the above-normal BMI range suggests even small downward shifts in BMI among these people could result in considerable reductions in their annual health care costs; whether this would result in long-term savings to the health care system is not known from this study.

Economic evaluations of screening programs: a review of methods and results.

BACKGROUND: The economics of screening is part of the broader area of the economics of prevention, and is concerned with the allocation of resources to screening activities when confronted with the problem of scarcity. ISSUES: One important aspect of the economics of screening is the economic evaluation of screening programs. Economic evaluation involves a systematic assessment of the costs and benefits of screening. RESULTS: A review of methods and results of economic evaluations of screening produces no generalizable conclusion about the economic desirability or otherwise, of screening programs. Each particular screening program must be evaluated on its merits. There is no evidence of any systematic tendency for screening programs to be more or less cost-effective than other prevention or treatment programs. Across all programs, substantial disparities have been found in cost-effectiveness. CONCLUSIONS: The challenge in the future will be to secure the re-allocations of resources necessary to maximize health gains from limited health care resources, rather than to undertake the analyses on which such re-allocations would be based.

Policy change and private health insurance: did the cheapest policy do the trick?

From the introduction of Australia's national health insurance scheme (Medicare) in 1984 until recently, the proportion of the population covered by private health insurance declined steadily. Following an Industry Commission inquiry into the private health insurance industry in 1997, a number of policy changes were effected in an attempt to reverse this trend. The main policy changes were of two types: "carrots and sticks" financial incentives that provided subsidies for purchasing, or tax penalties for not purchasing, private health insurance; and lifetime community rating, which aimed to revise the community rating regulations governing private health insurance in Australia. This paper argues that the membership uptake that has occurred recently is largely attributable to the introduction of lifetime community rating which goes some way towards addressing the adverse selection associated with the previous community rating regulations. This policy change had virtually no cost to government. However, it was introduced after subsidies for private health insurance were already in place. The chronological sequencing of these policies has resulted in substantial increases in government expenditure on private health insurance subsidies, with such increases not being a cause but rather an effect of increased demand for private health insurance. The paper also considers whether the decline in membership that has occurred since the implementation of lifetime community rating presages the re-emergence of an adverse selection problem in private health insurance. Much of the decline to date may be attributable to failure on the part of some members to honour premium payments when they first fell due. However, the changing age composition of the insured pool since September 2000, resulting in an increasing average age of those insured, suggests the possible reappearance of an adverse selection dynamic. Thus the 'trick' delivered by lifetime community ratings may not be maintained in the longer term.

Moving towards universal health insurance in China: performance, issues and lessons from Thailand.

China is now in the course of implementing a new round of health system reforms. Universal health insurance coverage through the basic social medical insurance system is high on the reform agenda. This paper examines the performance of China's current social medical insurance system in terms of revenue collection, risk pooling, the benefit package, and provider payment mechanisms based on a literature review and publicly available data. On the basis of critical assessment, the paper attempts to address the issues challenging China as it moves towards universal coverage. Focusing in particular on the reform experience in Thailand as it implemented universal coverage, the following policy implications for further reform in China are articulated, taking into account China's particular circumstances: firstly, the gaps in the benefit package across different schemes should be further reduced; secondly, the prevailing fee-for-service payment system needs to be transformed; thirdly, the primary health care delivery and referral system needs to be strengthened in coordination with the reform of the health insurance system; and fourthly, raising the risk pooling level and integrating fragmented insurance schemes should be long-run objectives of reform.

Risk equalisation and voluntary health insurance markets: The case of Australia.

In April 2007, Australia introduced a risk equalisation (RE) scheme (de facto a claims equalisation scheme), which replaced an extant reinsurance scheme that had operated since 1976. This scheme is one of a number of policy measures that the Australian Government has instituted to support the voluntary private health insurance (PHI) market which is subject to mandatory community rating and the attendant problem of selection. The latter has been a persistent concern in the Australian PHI market since the introduction of Australia's universal, compulsory national health insurance scheme Medicare. This paper presents a brief overview of Australia's health care financing arrangements and, in particular, focuses on the history, structure and functioning of the RE scheme. It provides an exposition of the operation of the scheme and empirical evidence of the scheme's effects in its first full year of operation, 2007-08. The paper makes three contributions: first, it provides the only detailed overview of the functioning of the Australian RE scheme published to date; second, it presents the first empirical measures of the scheme's operation at the level of the 38 individual PHI funds; and third, it describes the systematic differences in the scheme's operation with respect to large and small funds. Thus, this paper provides a number of insights into the operation and outcomes of the Australian RE scheme following its first year of operation.

Economic burden of malaria in rural Tanzania: variations by socioeconomic status and season.

OBJECTIVE: To determine the economic burden of malaria in a rural Tanzanian setting and identify any differences by socioeconomic status and season. METHODS: Interviews of 557 households in south eastern Tanzania between May and December 2004, on consumption and malaria-related costs. RESULTS: Malaria-related expenses were significantly higher in the dry, non-malarious season than in the rainy season. Households sought treatment more frequently and from more expensive service providers in the dry season, when they have more money. Malaria expenses did not vary significantly across socioeconomic status quintiles, but poorer households spent a higher proportion of their consumption in both seasons. CONCLUSION: Poorer households bear a greater economic burden from malaria relative to their consumption than better-off households. Households are particularly vulnerable to malaria in the rainy season, when malaria prevalence is highest but liquidity is lower. Alternative strategies to assist households to cope with seasonal liquidity issues, including insurance, should be investigated.

Mycobacterium ulcerans treatment costs, Australia.

Mycobacterium ulcerans gives rise to severe skin ulceration that can be associated with considerable illness. The cost of diagnosis, treatment, and lost income has never been assessed in Australia. A survey of 26 confirmed cases of the disease in Victoria was undertaken. Data were collected on demographic details, diagnostic tests, treatment, time off work, and travel to obtain treatment. All costs are reported in Australian dollars in 1997-98 prices. The cost varies considerably with disease severity. For mild cases, the average direct cost is 6,803 Australian dollars, and for severe cases 27,681 Australian dollars. Hospitalization accounts for 61% to 90% of costs, and indirect costs amount to 24% of the total per case. M. ulcerans can be an expensive disease to diagnose and treat. Costs can be reduced by early diagnosis and definitive treatment. Research is needed to find cost-effective therapies for this disease.

The cost-effectiveness of pneumococcal conjugate vaccination in Australia.

BACKGROUND: Pneumococcal conjugate vaccine, 7 valent (PCV7) is the most costly vaccine yet considered for publicly funded programs. In mid 2001, Australia funded PCV7 for high-risk groups only (indigenous children and children with certain underlying medical conditions). World wide, non-industry-funded studies and studies using cost-utility measures are sparse. We undertook an independent economic analysis of PCV7 compared with no vaccination in the non high-risk Australian childhood population using cost-utility and cost-effectiveness measures. METHODS: The incidence of invasive pneumococcal disease (IPD), non-bacteraemic pneumonia and otitis media was estimated using representative urban Australian data, or by extrapolation from comparable industrialised countries. A decision-analytic model was developed for a hypothetical birth cohort using the age-specific vaccine coverage from the Californian randomised controlled trial of PCV7. Health outcomes were measured by life-years saved and deaths and disability-adjusted life-years (DALYs) averted. In line with government guidelines, only direct costs were considered in 1997-1998 Australian dollars. RESULTS: For a birth cohort of 250,000, the gross cost of vaccination is $ 78.6 million. Subtracting treatment cost savings, the net cost (discounted) is $ 61.7 million. In undiscounted terms, vaccination prevents 13.7 deaths, 11.2 (82%) from IPD and the remainder from non-bacteraemic pneumonia. The discounted cost per death avoided is $ 5.0 million, per life-year saved $ 230,130 and per DALY averted $ 121,100, giving a break-even vaccine price of $ 15.40 per dose. These estimates are most sensitive to the unit cost per dose of vaccine, estimates of incidence and vaccine efficacy against non-bacteraemic pneumonia and the discount rate. The cost per DALY reduced to $ 81,000 with a discount rate of 3% rather than 5% and to $ 90,000 with the most favourable assumptions concerning pneumonia reduction. DISCUSSION: With a vaccine price of $ 90 per dose, mid-range estimates of impact against non-bacteraemic pneumonia, and discount rate of 5%, a PCV7 program for infants not at high risk of IPD is at the upper limit of cost per DALY previously approved under Australian pharmaceutical funding guidelines. The impact of PCV7 against non-bacteraemic pneumonia is poorly defined, but its importance to cost-effectiveness in resource rich and resource poor settings warrants further studies or analysis to give greater precision to this outcome.

The direct cost of managing patients with chronic hepatitis B infection in Australia.

GOALS: To estimate the average annual cost of managing a patient with chronic hepatitis B (CHB) disease in Australia. BACKGROUND: Little is known about the prevalence or economic burden of hepatitis B viral (HBV) infection in Australia, despite it being recognized as a significant cause of morbidity and mortality. STUDY: A retrospective analysis of 149 patients with CHB disease in six disease states (noncirrhotic CHB, compensated and decompensated cirrhosis, hepatocellular carcinoma, liver transplantation in year 1, and liver transplantation in subsequent posttransplantation years) was conducted. The cost of palliative care for 53 patients with chronic hepatitis and hepatocellular carcinoma was also estimated, based on data from a palliative care unit. RESULTS: The average annual costs (year-2001 AUS$) for each disease state per patient were: noncirrhotic CHB, 1233 dollars (95% CI 939 dollars-1544 dollars); compensated cirrhosis, 1394 dollars (95% CI 975 dollars-1797 dollars); decompensated cirrhosis, 11,961 dollars (95% CI 6993 dollars-18,503 dollars); liver transplantation in year 1, 144,392 dollars (SD, 115,374 dollars); liver transplantation in year 2+, 23,160 dollars (SD, 19,289 dollars); and hepatocellular carcinoma, 11,753 dollars (95% CI 7385 dollars-17,159 dollars). Within the noncirrhotic CHB group, the cost of managing active disease was 1778 dollars (95% CI 1212 dollars-2374 dollars) compared with 758 dollars (95% CI 519 dollars-1045 dollars) for inactive disease. The average cost of palliative care for patients with chronic hepatitis and hepatocellular carcinoma was 6307 dollars (95% CI 4848 dollars-8187 dollars). Multivariate statistical analysis indicated that age, sex, marital status, country of birth, and duration of follow-up were not statistically significant in explaining variation in costs. CONCLUSIONS: The cost of managing patients with CHB disease varies significantly between the noncirrhotic CHB/compensated cirrhosis states and the other four disease states. Within the noncirrhotic CHB state, there is also a significant difference between the cost of managing active and inactive disease. These results will be useful in future cost-effectiveness analyses of prevention and treatment options.