The relative importance of education and health behaviour for health and wellbeing.

BACKGROUND: Indicators of socioeconomic position (SEP) and health behaviours (HB) are widely used predictors of health variations. Their relative importance is hard to establish, because HB takes a mediating role in the link between SEP and health. We aim to provide new knowledge on how SEP and HB are related to health and wellbeing. METHODS: The analysis considered 14,713 Norwegians aged 40-63. Separate regressions were performed using two outcomes for health-related quality of life (EQ-5D-5 L; EQ-VAS), and one for subjective wellbeing (Satisfaction with Life Scale). As predictors, we used educational attainment and a composite measure of HB - both categorized into four levels. We adjusted for differences in childhood financial circumstances, sex and age. We estimated the percentage share of each predictor in total explained variation, and the relative contributions of HB in the education-health association. RESULTS: The reference case model, excluding HB, suggests consistent stepwise education gradients in health-related quality of life. The gap between the lowest and highest education was 0.042 on the EQ-5D-5 L, and 0.062 on the EQ-VAS. When including HB, the education effects were much attenuated, making HB take the lion share of the explained health variance. HB contributes 29% of the education-health gradient when health is measured by EQ-5D-5 L, and 40% when measured by EQ-VAS. For subjective wellbeing, we observed a strong HB-gradient, but no education gradient. CONCLUSION: In the institutional context of a rich egalitarian country, variations in health and wellbeing are to a larger extent explained by health behaviours than educational attainment.

Related variations: A novel approach for detecting patterns of regional variations in healthcare utilisation rates.

Regional variations in healthcare utilisation rates are ubiquitous and persistent. In settings where an aggregate national health service budget is allocated primarily on a per capita basis, little regional variation in total healthcare utilisation rates will be observed. However, for specific treatments, large variations in utilisation rates are observed, iymplying a substitution effect at some point in service delivery. The current paper investigates the extent to which this substitution effect occurs within or between specialties, particularly distinguishing between emergency versus elective care. We used data from Statistics Norway and the Norwegian Patient Registry on eight somatic surgeries for all patients treated from 2010 to 2015. We calculated Diagnosis-Related Group (DRG) -weight per capita in 19 hospital regions. We applied principal component analysis (PCA) to demonstrate patterns in DRG-weight, annual relative changes in DRG-weight, and DRG-weight production for elective care. We show that treatments with similar characteristics cluster within regions. Treatment frequency explains 29% of the total variation in treatment rates. In a dynamic model, treatments with a high degree of emergency care are negatively correlated with treatments with a high degree of elective care. Furthermore, when considering only elective care treatments, the substitution effect occurs between specialties and explains 49% of the variation. When designing policies aimed at reducing regional variations in healthcare utilisation, a distinction between elective and emergency care as well as substitution effects need to be considered.

Inequality in quality-adjusted life expectancy by educational attainment in Norway: an observational study.

BACKGROUND: Health inequalities are often assessed in terms of life expectancy or health-related quality of life (HRQoL). Few studies combine both aspects into quality-adjusted life expectancy (QALE) to derive comprehensive estimates of lifetime health inequality. Furthermore, little is known about the sensitivity of estimated inequalities in QALE to different sources of HRQoL information. This study assesses inequalities in QALE by educational attainment in Norway using two different measures of HRQoL. METHODS: We combine full population life tables from Statistics Norway with survey data from the Tromsø study, a representative sample of the Norwegian population aged ≥ 40. HRQoL is measured using the EQ-5D-5L and EQ-VAS instruments. Life expectancy and QALE at 40 years of age are calculated using the Sullivan-Chiang method and are stratified by educational attainment. Inequality is measured as the absolute and relative gap between individuals with lowest (i.e. primary school) and highest (university degree 4 + years) educational attainment. RESULTS: People with the highest educational attainment can expect to live longer lives (men: + 17.9% (95%CI: 16.4 to 19.5%), women: + 13.0% (95%CI: 10.6 to 15.5%)) and have higher QALE (men: + 22.4% (95%CI: 20.4 to 24.4%), women: + 18.3% (95%CI: 15.2 to 21.6%); measured using EQ-5D-5L) than individuals with primary school education. Relative inequality is larger when HRQoL is measured using EQ-VAS. CONCLUSION: Health inequalities by educational attainment become wider when measured in QALE rather than LE, and the degree of this widening is larger when measuring HRQoL by EQ-VAS than by EQ-5D-5L. We find a sizable educational gradient in lifetime health in Norway, one of the most developed and egalitarian societies in the world. Our estimates provide a benchmark against which other countries can be compared.

Amplified disparities: The association between spousal education and own health.

Positive associations between own educational attainment and own health have been extensively documented. Studies have also shown spousal educational attainment to be associated with own health. This paper investigates the extent to which spousal education contributes to the social gradient in health, net of own education; and whether parts of a seeming spousal education effect are attributable to differences in early-life human capital, as measured by respondents' height and childhood living standard. Furthermore, we investigate the relative contribution of predictors in the regression analysis by use of Shapley value decomposition. We use data from a comprehensive health survey from Northern Norway (conducted in 2015/16, N = 21,083, aged 40 and above). We apply three alternative health outcome measures: the EQ-5D-5L index, a visual analogue scale (EQ-VAS) and self-rated health. In all models considered, spousal education is generally positively significant for both men and women. The results also suggest that spousal education is generally more important for men than women. In the sub-sample of individuals having a spouse, decomposition analyses showed that the relative contribution of spousal education to the goodness-of-fit in men's (women's) health was 13% (14%) with the EQ-5D-5L; 25% (20%) with the EQ-VAS and; 30% (21%) with self-rated health. Heterogeneity analyses showed stronger spousal education effects in younger age groups. In conclusion, we have provided empirical evidence that spousal education may contribute to explaining the amplified health gradient in an egalitarian country like Norway.

Inequality of opportunity in a land of equal opportunities: The impact of parents' health and wealth on their offspring's quality of life in Norway.

BACKGROUND: The literature on Inequality of opportunity (IOp) in health distinguishes between circumstances that lie outside of own control vs. efforts that - to varying extents - are within one's control. From the perspective of IOp, this paper aims to explain variations in individuals' health-related quality of life (HRQoL) by focusing on two separate sets of variables that clearly lie outside of own control: Parents' health is measured by their experience of somatic diseases, psychological problems and any substance abuse, while parents' wealth is indicated by childhood financial conditions (CFC). We further include own educational attainment which may represent a circumstance, or an effort, and examine associations of IOp for different health outcomes. HRQoL are measured by EQ-5D-5L utility scores, as well as the probability of reporting limitations on specific HRQoL-dimensions (mobility, self-care, usual-activities, pain & discomfort, and anxiety and depression). METHOD: We use unique survey data (N = 20,150) from the egalitarian country of Norway to investigate if differences in circumstances produce unfair inequalities in health. We estimate cross-sectional regression models which include age and sex as covariates. We estimate two model specifications. The first represents a narrow IOp by estimating the contributions of parents' health and wealth on HRQoL, while the second includes own education and thus represents a broader IOp, alternatively it provides a comparison of the relative contributions of an effort variable and the two sets of circumstance variables. RESULTS: We find strong associations between the circumstance variables and HRQoL. A more detailed examination showed particularly strong associations between parental psychological problems and respondents' anxiety and depression. Our Shapley decomposition analysis suggests that parents' health and wealth are each as important as own educational attainment for explaining inequalities in adult HRQoL. CONCLUSION: We provide evidence for the presence of the lasting effect of early life circumstances on adult health that persists even in one of the most egalitarian countries in the world. This suggests that there may be an upper limit to how much a generous welfare state can contribute to equal opportunities.

Combining education and income into a socioeconomic position score for use in studies of health inequalities.

BACKGROUND: In studies of social inequalities in health, there is no consensus on the best measure of socioeconomic position (SEP). Moreover, subjective indicators are increasingly used to measure SEP. The aim of this paper was to develop a composite score for SEP based on weighted combinations of education and income in estimating subjective SEP, and examine how this score performs in predicting inequalities in health-related quality of life (HRQoL). METHODS: We used data from a comprehensive health survey from Northern Norway, conducted in 2015/16 (N = 21,083). A composite SEP score was developed using adjacent-category logistic regression of subjective SEP as a function of four education and four household income levels. Weights were derived based on these indicators' coefficients in explaining variations in respondents' subjective SEP. The composite SEP score was further applied to predict inequalities in HRQoL, measured by the EQ-5D and a visual analogue scale. RESULTS: Education seemed to influence SEP the most, while income added weight primarily for the highest income category. The weights demonstrated clear non-linearities, with large jumps from the middle to the higher SEP score levels. Analyses of the composite SEP score indicated a clear social gradient in both HRQoL measures. CONCLUSIONS: We provide new insights into the relative contribution of education and income as sources of SEP, both separately and in combination. Combining education and income into a composite SEP score produces more comprehensive estimates of the social gradient in health. A similar approach can be applied in any cohort study that includes education and income data.

Who keeps on working? The importance of resilience for labour market participation.

BACKGROUND: It is widely recognized that individuals' health and educational attainments, commonly referred to as their human capital, are important determinants for their labour market participation (LMP). What is less recognised is the influence of individuals' latent resilience traits on their ability to sustain LMP after experiencing an adversity such as a health shock. AIM: We investigate the extent to which resilience is independently associated with LMP and moderates the effect of health shocks on LMP. METHOD: We analysed data from two consecutive waves of a Norwegian prospective cohort study. We followed 3,840 adults who, at baseline, were healthy and worked full time. Binary logistic regression models were applied to explain their employment status eight years later, controlling for age, sex, educational attainment, health status at baseline, as well as the occurrences of three types of health shocks (cardiovascular diseases, cancer, psychological problems). Individuals' resilience, measured by the Resilience Scale for Adults (RSA), entered as an independent variable and as an interaction with the indicators of health shocks. In separate models, we explore the role of two further indicators of resilience; locus of control, and health optimism. RESULTS: As expected, health shocks reduce the probability to keep on working full-time. While both the RSA and the two related indicators all suggest that resilience increases the probability to keep on working, we did not find evidence that resilience moderates the association between health shocks and LMP. CONCLUSION: Higher levels of resilience is associated with full-time work as individuals age.

Explaining subjective social status in two countries: The relative importance of education, occupation, income and childhood circumstances.

In the literature on social inequalities in health, subjective socioeconomic position (SEP) is increasingly applied as a determinant of health, motivated by the hypothesis that having a high subjective SEP is health-enhancing. However, the relative importance of determinants of subjective SEP is not well understood. Objective SEP indicators, such as education, occupation and income, are assumed to determine individuals' position in the status hierarchy. Furthermore, an extensive literature has shown that past childhood SEP affects adult health. Does it also affect subjective SEP? In this paper, we estimate the relative importance of i) the common objective SEP indicators (education, occupation and income) in explaining subjective SEP, and ii) childhood SEP (childhood financial circumstances and parents' education) in determining subjective SEP, after controlling for objective SEP. Given that the relative importance of these factors is expected to differ across institutional settings, we compare data from two countries: Australia and Norway. We use data from an online survey based on adult samples, with N ≈ 1400 from each country. Ordinary least squares regression is conducted to assess how objective and childhood SEP indicators predict subjective SEP. We use Shapley value decomposition to estimate the relative importance of these factors in explaining subjective SEP. Income was the strongest predictor of subjective SEP in Australia; in Norway, it was occupation. Of the childhood SEP variables, childhood financial circumstances were significantly associated with subjective SEP, even after controlling for objective SEP. This association was the strongest in the Norwegian sample. Only the mother's education had a significant impact on subjective SEP. Our findings highlight the need to understand the specific mechanisms between objective and subjective SEP as determinants of inequalities in health, and to assess the role of institutional factors in influencing these complex relationships.

Health and wellbeing in Norway: Population norms and the social gradient.

Measures of health-related quality of life are important in health technology assessments, and useful when analysing health inequalities across population sub-groups. This paper provides population norms on health and wellbeing in Norway based on two waves of a comprehensive health survey: Wave 6 of The Tromsø Study conducted in 2007/08 (N = 12,981) and Wave 7 conducted in 2015/16 (N = 21,083). By use of these data, the paper aims to provide new insight on how different measures of health and wellbeing, and different indicators for socio-economic position, will affect the magnitude of a reported social gradient in health. We apply validated multi-item instruments for measuring health and subjective well-being; the health state utility instrument EQ-5D, and the satisfaction with life scale, as well as a direct valuation of health on a visual analogue scale. We apply three indicators for socio-economic position; education, occupation and household income, each measured along four levels. After descriptive statistics, regression analyses are performed separately for men and women, adjusted for age, to explain the magnitude of the social gradient along each socio-economic indicator. The social gradient in health showed a consistent positive trend, along all three socio-economic indicators; it was strongest with income, and weakest with education. When health had been valued directly on a visual analogue scale, the gradient was steeper than when valued indirectly via the EQ-5D descriptive system. The social gradient in subjective well-being also showed consistent positive trends, except with education as the socio-economic indicator. We have shown that the magnitude of the social gradient critically depends on which socio-economic indicator is used, and whether health is being measured indirectly via the EQ-5D descriptive system or directly on a visual analogue scale. The strongest gradient in subjective well-being was observed with income as the socio-economic indicator.

A conceptual map of health-related quality of life dimensions: key lessons for a new instrument.

PURPOSE: Quality-adjusted life years (QALYs) represent a critical metric in economic evaluations impacting key healthcare decisions in many countries. However, there is widespread disagreement as to which is the best of the health state utility (HSU) instruments that are designed to measure the Q in the QALY. Instruments differ in their descriptive systems as well as their valuation methodologies; that is, they simply measure different things. We propose a visual framework that can be utilized to make meaningful comparisons across HSU instruments. METHODS: The framework expands on existing HRQoL models, by incorporating four distinctive continua, and by putting HRQoL within the broader notion of subjective well-being (SWB). Using this conceptual map, we locate the five most widely used HSU-instruments (EQ-5D, SF-6D, HUI, 15D, AQoL). RESULTS: By individually mapping dimensions onto this visual framework, we provide a clear picture of the significant conceptual and operational differences between instruments. Moreover, the conceptual map demonstrates the varying extent to which each instrument moves outside the traditional biomedical focus of physical health, to also incorporate indicators of mental health and social well-being. CONCLUSION: Our visual comparison provides useful insights to assess the suitability of different instruments for particular purposes. Following on from this comparative analyses, we extract some important lessons for a new instrument that cover the domains of physical, mental and social aspects of health, i.e. it is in alignment with the seminal 1948 WHO definition of health.

Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial.

BACKGROUND: Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. OBJECTIVE: The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. METHODS: An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. RESULTS: This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. CONCLUSIONS: This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. TRIAL REGISTRATION: ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX).

Testing alternative regression models to predict utilities: mapping the QLQ-C30 onto the EQ-5D-5L and the SF-6D.

PURPOSE: The purpose of the study was to compare alternative statistical techniques to find the best approach for converting QLQ-C30 scores onto EQ-5D-5L and SF-6D utilities, and to estimate the mapping algorithms that best predict these health state utilities. METHODS: 772 cancer patients described their health along the cancer-specific instrument (QLQ-C30) and two generic preference-based instruments (EQ-5D-5L and SF-6D). Seven alternative regression models were applied: ordinary least squares, generalized linear model, extended estimating equations (EEE), fractional regression model, beta binomial (BB) regression, logistic quantile regression and censored least absolute deviation. Normalized mean absolute error (NMAE), normalized root mean square error (NRMSE), r-squared (r2) and concordance correlation coefficient (CCC) were used as model performance criteria. Cross-validation was conducted by randomly splitting internal dataset into two equally sized groups to test the generalizability of each model. RESULTS: In predicting EQ-5D-5L utilities, the BB regression performed best. It gave better predictive accuracy in terms of all criteria in the full sample, as well as in the validation sample. In predicting SF-6D, the EEE performed best. It outperformed in all criteria: NRMSE = 0.1004, NMAE = 0.0798, CCC = 0.842 and r2 = 72.7% in the full sample, and NRMSE = 0.1037, NMAE = 0.0821, CCC = 0.8345 and r2 = 71.4% in cross-validation. CONCLUSIONS: When only QLQ-C30 data are available, mapping provides an alternative approach to obtain health state utility data for use in cost-effectiveness analyses. Among seven alternative regression models, the BB and the EEE gave the most accurate predictions for EQ-5D-5L and SF-6D, respectively.

Assessment of outcome measures for cost-utility analysis in depression: mapping depression scales onto the EQ-5D-5L.

BACKGROUND: Many clinical studies including mental health interventions do not use a health state utility instrument, which is essential for producing quality-adjusted life years. In the absence of such utility instrument, mapping algorithms can be applied to estimate utilities from a disease-specific instrument.AimsWe aim to develop mapping algorithms from two widely used depression scales; the Depression Anxiety Stress Scales (DASS-21) and the Kessler Psychological Distress Scale (K-10), onto the most widely used health state utility instrument, the EQ-5D-5L, using eight country-specific value sets. METHOD: A total of 917 respondents with self-reported depression were recruited to describe their health on the DASS-21 and the K-10 as well as the new five-level version of the EQ-5D, referred to as the EQ-5D-5L. Six regression models were used: ordinary least squares regression, generalised linear models, beta binomial regression, fractional logistic regression model, MM-estimation and censored least absolute deviation. Root mean square error, mean absolute error and r2 were used as model performance criteria to select the optimal mapping function for each country-specific value set. RESULTS: Fractional logistic regression model was generally preferred in predicting EQ-5D-5L utilities from both DASS-21 and K-10. The only exception was the Japanese value set, where the beta binomial regression performed best. CONCLUSIONS: Mapping algorithms can adequately predict EQ-5D-5L utilities from scores on DASS-21 and K-10. This enables disease-specific data from clinical trials to be applied for estimating outcomes in terms of quality-adjusted life years for use in economic evaluations.Declaration of interestNone.

Education and health and well-being: direct and indirect effects with multiple mediators and interactions with multiple imputed data in Stata.

BACKGROUND: Previous methods for assessing mediation assume no multiplicative interactions. The inverse odds weighting (IOW) approach has been presented as a method that can be used even when interactions exist. The substantive aim of this study was to assess the indirect effect of education on health and well-being via four indicators of adult socioeconomic status (SES): income, management position, occupational hierarchy position and subjective social status. METHODS: 8516 men and women from the Tromsø Study (Norway) were followed for 17 years. Education was measured at age 25-74 years, while SES and health and well-being were measured at age 42-91 years. Natural direct and indirect effects (NIE) were estimated using weighted Poisson regression models with IOW. Stata code is provided that makes it easy to assess mediation in any multiple imputed dataset with multiple mediators and interactions. RESULTS: Low education was associated with lower SES. Consequently, low SES was associated with being unhealthy and having a low level of well-being. The effect (NIE) of education on health and well-being is mediated by income, management position, occupational hierarchy position and subjective social status. CONCLUSION: This study contributes to the literature on mediation analysis, as well as the literature on the importance of education for health-related quality of life and subjective well-being. The influence of education on health and well-being had different pathways in this Norwegian sample.

Preference Weighting of Health State Values: What Difference Does It Make, and Why?

BACKGROUND: Most patient-reported outcome measures apply a simple summary score to assess health-related quality of life, whereby equal weight is normally assigned to each item. In the generic preference-based instruments, utility weighting is essential whereby health state values are estimated through preference elicitation and complex algorithms. OBJECTIVES: To examine the extent to which preference-weighted value sets differ from unweighted values in the five-level EuroQol five-dimensional questionnaire and the 15D instrument, on the basis of a comprehensive data set from six member countries of the Organisation for Economic Co-operation and Development, each with a representative healthy sample and seven disease groups (N = 7933). METHODS: Construct validities were examined. The level of agreement between preference-weighted and unweighted values was also assessed using intraclass correlation coefficient (ICC), Bland-Altman plots, and reduced major axis regression. RESULTS: The performances of preference-weighted and unweighted measures were comparable with regard to convergent and known-group validities for each instrument. Although unweighted values in the five-level EuroQol five-dimensional questionnaire differ considerably from the preference-weighted values at the individual level, the discrepancy is minimal at the group level with a mean difference of 0.023. The ICC (0.96) and the Bland-Altman plot also suggest strong overall agreement. For the 15D, both the ICC (0.99) and the Bland-Altman plot revealed almost perfect agreement, with a negligible mean difference of -0.001. Results from the reduced major axis regression also showed small bias. CONCLUSIONS: Overall, preference weighting has minimal effect if the unweighted values are anchored on the same scale as the preference-weighted value sets.

Health state utility instruments compared: inquiring into nonlinearity across EQ-5D-5L, SF-6D, HUI-3 and 15D.

PURPOSE: Different health state utility (HSU) instruments produce different utilities for the same individuals, thereby compromising the intended comparability of economic evaluations of health care interventions. When developing crosswalks, previous studies have indicated nonlinear relationships. This paper inquires into the degree of nonlinearity across the four most widely used HSU-instruments and proposes exchange rates that differ depending on the severity levels of the health state utility scale. METHODS: Overall, 7933 respondents from six countries, 1760 in a non-diagnosed healthy group and 6173 in seven disease groups, reported their health states using four different instruments: EQ-5D-5L, SF-6D, HUI-3 and 15D. Quantile regressions investigate the degree of nonlinear relationships between these instruments. To compare the instruments across different disease severities, we split the health state utility scale into utility intervals with 0.2 successive decrements in utility starting from perfect health at 1.00. Exchange rates (ERs) are calculated as the mean utility difference between two utility intervals on one HSU-instrument divided by the difference in mean utility on another HSU-instrument. RESULTS: Quantile regressions reveal significant nonlinear relationships across all four HSU-instruments. The degrees of nonlinearities differ, with a maximum degree of difference in the coefficients along the health state utility scale of 3.34 when SF-6D is regressed on EQ-5D. At the lower end of the health state utility scale, the exchange rate from SF-6D to EQ-5D is 2.11, whilst at the upper end it is 0.38. CONCLUSION: Comparisons at different utility levels illustrate the fallacy of using linear functions as crosswalks between HSU-instruments. The existence of nonlinear relationships between different HSU-instruments suggests that level-specific exchange rates should be used when converting a change in utility on the instrument used, onto a corresponding utility change had another instrument been used. Accounting for nonlinearities will increase the validity of the comparison for decision makers when faced with a choice between interventions whose calculations of QALY gains have been based on different HSU-instruments.

Modelling Nonlinearities and Reference Dependence in General Practitioners' Income Preferences.

This paper tests for the existence of nonlinearity and reference dependence in income preferences for general practitioners. Confirming the theory of reference dependent utility within the context of a discrete choice experiment, we find that losses loom larger than gains in income for Norwegian general practitioners, i.e. they value losses from their current income level around three times higher than the equivalent gains. Our results are validated by comparison with equivalent contingent valuation values for marginal willingness to pay and marginal willingness to accept compensation for changes in job characteristics. Physicians' income preferences determine the effectiveness of 'pay for performance' and other incentive schemes. Our results may explain the relative ineffectiveness of financial incentive schemes that rely on increasing physicians' incomes. Copyright © 2015 John Wiley & Sons, Ltd.

Health Economics and Radium-223 (Xofigo®) in the Treatment of Metastatic Castration-Resistant Prostate Cancer (mCRPC): A Case History and a Systematic Review of the Literature.

OBJECTIVES: Prostate cancer (PC) is the most common cancer in Western countries. Recent advances in the treatment of metastatic castration resistant prostate cancer (mCRPC) have caused significant pressure on health care budgets. We aimed to exemplify this dilemma presenting an example, radium-223 (Xofigo®), and review the literature. METHODS: A 74-year-old man diagnosed with mCRPC was referred to our department in October 2014 for radium-223 therapy. We faced the following dilemma: is radium-223 standard therapy? Is it cost-effective? Medline was searched employing the following search criteria: "radium-223", "alpharadin", "Xofigo" and "prostate". Exclusion and inclusion criteria were applied. Guidelines and cost-effectiveness analyses were focused. We also searched the websites of ASCO, ESMO and ISPOR. The web was searched, using Yahoo and Google search engines, for Health Technology Assessments (HTAs). RESULTS: 181 publications were identified in the Medline database. Only four studies included the word "cost", three "economics" and none "budget" in heading or abstract. None of the publications were thorough of cost analysis (cost-effectiveness, cost-utility, cost-minimizing or cost-of-illness analysis). Six HTAs and eight national guidelines were identified. The cost per quality adjusted life years was indicated €80.000-94,000. HTAs concluded reimbursement being not recommendable or no ultimate statement could be made. One pointed towards a limited use with caution. CONCLUSION: Guidelines were based on data from randomized clinical trials (RCTs). Health economics was not considered when guidelines were made. Most HTAs concluded this therapy not cost-effective or there was insufficient data for final conclusions. Licensing and reimbursement processes should be run simultaneously.

Young doctors' preferences for payment systems: the influence of gender and personality traits.

OBJECTIVE: Activity-based payment contracts are common among doctors, but to what extent are they preferred? The aim of this paper is to elicit young doctors' preferences for alternative payment systems before they have adapted to an existing system. We examine the existence of gender differences and the extent to which personality traits determine preferences. METHODS: A cross-sectional survey of all final-year medical students and all interns in Norway examined the extent to which preferences for different payment systems depend on gender and personality traits. Data analysis relied on one-way ANOVA and multinomial logistic regression. RESULTS: The current activity-based payment systems were the least preferred, both in hospitals (16.6%) and in general practice (19.7%). The contrasting alternative "fixed salary" achieved similar relative support. Approximately half preferred the hybrid alternative. When certainty associated with a payment system increased, its appeal rose for women and individuals who are less prestige-oriented, risk-tolerant or effort-tolerant. Activity-based systems were preferred among status- and income-oriented respondents. CONCLUSION: The vast majority of young doctors prefer payment systems that are less activity-based than the current contracts offered in the Norwegian health service. Recruitment and retention in less prestigious medical specialities might improve if young doctors could choose payment systems corresponding with their diverse preferences.