Impact of subtypes and comorbidities on breast cancer relapse and survival in population-based studies.

OBJECTIVE: To study the impact of subtypes and comorbidities on breast cancer (BC) relapse and survival in the heterogeneous patients of the real world. METHODS: We identified patients diagnosed with BC between January 2003 and December 2005 from six population-based Swiss cancer registries. Clinicopathologic data was completed with information on locoregional and distant relapse and date and cause of death for over 10-years. We approximated BC subtypes using grade and the immunohistochemical panel for oestrogen, progesterone and human epidermal growth factor 2 (HER2) receptor status. We studied factors affecting relapse and survival. RESULTS: Luminal A-like subtype represented 46% of all newly diagnosed BC (N = 1831), followed by luminal B-like (N = 1504, 38%), triple negative (N = 436, 11%) and HER2 enriched (N = 204, 5%). We observed regional disparities in subtype prevalence that contribute to explain regional differences in survival formerly described. Disease relapse and BC specific mortality differed by subtype and were lower for luminal A like tumours than for other subtypes for any stage at diagnosis. After a median follow-up of 10.9 years, 1311 (33%) had died, half of them 647 (16%) due to another disease, showing the importance of comorbidities. Omission of systemic therapies in selected patients was not associated with poorer BC specific survival, BC subtype and life expectancy playing a role. CONCLUSIONS: Information on tumour subtype is necessary for an adequate interpretation of population-based BC studies. Measures of comorbidity or frailty help in the evaluation of quality of care in the highly heterogeneous patients of the real world.

Prevalence and direct medical costs of end-stage renal disease in patients with type 2 diabetes mellitus in Switzerland for 2001.

BACKGROUND: The prevalence of end-stage renal disease (ESRD) in patients with type 2 diabetes mellitus (type 2 DM) has increased in recent decades throughout the world. In most industrialised countries, diabetic nephropathy in type 2 diabetics is the most frequent cause of ESRD. AIMS: The prevalence and direct medical costs for the insurance funds in Switzerland were determined for ESRD in patients with type 2 DM. METHODS: Prevalence was determined on the basis of a written retrospective cross-sectional analysis covering all centres for dialysis and transplantation in Switzerland. Costs were calculated separately for the three different therapeutic options for ESRD - haemodialysis, peritoneal dialysis and renal transplantation. Costs were calculated on the basis of the percentage of the patients in this cross-sectional study who received each of these treatments. Cost data from the Swiss Union for the Social Duties of the Insurance Funds (SVK) were used for all three treatments. SVK data were not available for some phases of transplantation, and for these phases the consumption of health resources was determined by interviewing experts on the telephone, using a questionnaire. RESULTS: The cross-sectional study in the dialysis and transplantation centres was based on full collection of data. In Switzerland in the year 2001, the prevalence of ESRD in patients with type 2 DM came to 73.0 per million inhabitants. The direct medical costs of this complication came to a total of CHF 46,065,788 (0.1% of the total health expenditure). This corresponds to CHF 1570 per 100,000 inhabitants per day. 81.6% of these costs are for haemodialysis, 7.1% for peritoneal dialysis and 11.4% for renal transplantation. ESRD costs are CHF 215 per patient per day. CONCLUSIONS: The prevalence of ESRD in patients with type 2 DM in Switzerland was 73.0 per million inhabitants in 2001. The costs of this avoidable late complication are considerable.

Cost-effectiveness of a pneumococcal conjugate immunisation program for infants in Switzerland.

OBJECTIVE: To compare projected economic costs and health benefits associated with using pneumococcal conjugate heptavalent vaccine as routine immunisation in healthy children in Switzerland. DESIGN: A cost-utility analysis was performed from both the societal as well as the sickness funds' perspective. SETTING: Simulated birth cohorts of 80,000 children (the approximate size of a birth cohort in Switzerland) were followed from birth up to age of 5. MAIN OUTCOME MEASURES: Reduction in disease burden, costs of vaccination, cost-utility ratio (cost per quality-adjusted life year (QALY)). RESULTS: With a vaccine coverage of 70% vaccination of newborns only would avert 4 deaths, 8 cases of meningitis, 37 cases of other invasive pneumococcal disease, 150 cases of pneumococcal pneumonia and about 2700 cases of otitis media (OM) per year. The net cost of the vaccination program would be 22 Mio. CHF per year for society and about 19 Mio. CHF for the sickness funds. This results in a cost-utility ratio of 35,700 CHF (approximately 26,300 USD (1)) per QALY from the societal perspective and 39,300 CHF (28,900 USD) per QALY from the sickness funds' perspective. Additional catch-up vaccination of all infants <24 months in the years after vaccine introduction would result in additional benefits at a cost of 33,600 CHF per additional QALY gained. However, if the catch-up vaccination should include all children <60 months, each additional QALY would be gained at a very high cost (162,000 CHF per additional QALY). CONCLUSIONS: Routine vaccination of healthy infants <2 years in Switzerland can reduce mortality and long term neurologic impairment resulting from invasive pneumococcal disease at a reasonable cost-utility ratio.

European healthcare policies for controlling drug expenditure.

In the last 20 years, expenditures on pharmaceuticals - as well as total health expenditures - have grown faster than the gross national product in all European countries. The aim of this paper was to review policies that European governments apply to reduce or at least slow down public expenditure on pharmaceutical products. Such policies can target the industry, the wholesalers and retailers, prescribers, and patients. The objectives of pharmaceutical policies are multidimensional and must take into account issues relating to public health, public expenditure and industrial incentives. Both price levels and consumption patterns determine the level of total drug expenditure in a particular country, and both factors vary greatly across countries. Licensing and pricing policies intend to influence the supply side. Three types of pricing policies can be recognised: product price control, reference pricing and profit control. Profit control is mainly used in the UK. Reference pricing systems were first used in Germany and The Netherlands and are being considered in other countries. Product price control is still the most common method for establishing the price of drugs. For the aim of fiscal consolidation, price-freeze and price-cut measures have been frequently used in the 1980s and 1990s. They have affected all types of schemes. For drug wholesalers and retailers, most governments have defined profit margins. The differences in price levels as well as the introduction of a Single European Pharmaceutical Market has led to the phenomenon of parallel imports among member countries of the European Union. This may be facilitated by larger and more powerful wholesalers and the vertical integration between wholesalers and retailers. To control costs, the use of generic drugs is encouraged in most countries, but only few countries allow pharmacists to substitute generic drugs for proprietary brands. Various interventions are used to reduce the patients' demand for drugs by either denying or limiting reimbursement of products and providing an incentive for patients to reduce their consumption of drugs. These interventions include defining a list either of drugs reimbursed (positive list) or one of drugs not reimbursed (negative list), and patient co-payments, which require patients to pay a proportion of the cost of a prescribed product or a fixed charge. Policies intended to affect physicians' prescribing behaviour include guidelines, information (about price and less expensive alternatives) and feedback, and the use of budgetary restrictions.

Economic evaluation of immunization strategies.

Resources used to provide health care are vast but not limitless. When clinicians are asked to participate in decisions for large groups of patients (in a managed care context, in an institution, or at the level of local health authorities), the balance between consumption of resources and the benefits of an intervention is important. Clinicians may use cost-effectiveness and cost-benefit studies to inform such decisions (but not to make them). Because of differences in methods, the presentation of results, and country-specific parameters, economic evaluations of the same vaccination strategy by different groups may have divergent results. In this article, we review methodologic issues, limitations, and ethical considerations related to economic evaluations of immunization strategies, focusing on immunizations associated with travel.

High dose lisinopril in heart failure: economic considerations.

UNLABELLED: BACKGROUND AND OBJECTIVES. In Switzerland, heart failure (HF) is one of the ten most common causes of hospitalization in patients older than 65 and the second most common in those over 80 years. 17% of the population in Switzerland is in this age class. The expenditures associated with HF are thus considerable. High doses of the angiotensin-converting enzyme (ACE) inhibitor lisinopril in patients with heart failure have been shown to significantly reduce the risk of death or hospitalization for heart failure and for any reason. The objective of the present study was to analyze the economic implications of using high doses of lisinopril in the Swiss health care system setting, both from the societal perspective and from that of the Swiss health insurers. PATIENTS AND METHODS: Using published data from the ATLAS Trial, we computed the monthly probability of death and of hospital admission for heart failure, ischemic events, other cardiovascular causes and any reason per patient for both arms of the trial. Swiss resource use patterns and Swiss unit costs were used to calculate expected monthly expenditures per patient from the third party payer perspective and from the societal viewpoint. Extensive sensitivity analyses were performed to test the robustness of our results. RESULTS: Expected monthly expenditures from the third party payer perspective are 347 Euro per patient in the low dose group and 319 Euro in the high dose group. This represents expected savings of 28 Euro per patient monthly. Because the public sector pays more than 50% of hospital costs, the savings from the societal viewpoint are greater. Expected monthly costs from the societal perspective are 762 Euro in the low dose group and 670 Euro in the high dose group per patient. This results in expected monthly savings of 92 Euro. Sensitivity analysis shows that the use of high doses of ACE inhibitor lisinopril does not result in higher health care expenditures for the whole system or even savings through a wide variety of practice patterns and unit costs. CONCLUSIONS: Based on the results of the ATLAS study, high doses of lisinopril are associated with a reduction in the number of hospitalizations for HF and for any reason and with a statistically non-significant reduction in mortality. The additional expenditures incurred because of prescription of high doses are offset by the savings in hospital costs. These are important considerations, given the increasing number of people aged 65 and older in Switzerland, and the prevalence of heart failure in this age group.