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BACKGROUND: This study aimed to conduct a systematic review of the cost-effectiveness studies of interventions to increase cervical cancer screening uptake rates in underserved women in Europe. METHODS: A search of Embase, Medline, Global Health, PsychINFO, and NHS Economic Evaluation Database was conducted for studies published between January 2000 and September 2022. Studies were eligible if they analysed the cost-effectiveness of any interventions to improve participation in cervical cancer screening among underserved women of any age eligible to participate in cervical cancer screening in European countries, in any language. Study characteristics and cost-effectiveness results were summarised. Study quality was assessed using the Drummond Checklist, and methodological choices were further compared. RESULTS: The searches yielded 962 unique studies, with 17 of these (from twelve European countries) meeting the eligibility criteria for data extraction. All studies focused on underscreened women as an overarching group, with no identified studies focusing on specific subgroups of underserved women. Generally, self-HPV testing and reminder interventions were shown to be cost-effective to increase the uptake rates. There was also research showing that addressing access issues and adopting different screening modalities could be economically attractive in some settings, but the current evidence is insufficient due to the limited number of studies. CONCLUSION: This systematic review has revealed a gap in the literature on the cost-effectiveness of interventions to improve uptake rates of cervical cancer screening through tailored provision for specific groups of underserved women.
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Studying quasi-experimental data from French hospitals from 2010 to 2013, we test the effects of a substantial diagnosis-related group (DRG) tariff refinement that occurred in 2012, designed to reduce financial risks of French maternity wards. To estimate the resulting DRG incentives with regard to the choice between scheduled C-sections and other modes of child delivery, we predict, based on pre-admission patient characteristics, the probability of each possible child delivery outcome and calculate expected differences in associated tariffs. Using patient-level administrative data, we find that introducing additional severity levels and clinical factors into the reimbursement algorithm had no significant effect on the probability of a scheduled C-section being performed. The results are robust to multiple formulations of DRG financial incentives. Our paper is the first study that focuses on the consequences of a DRG refinement in obstetrics and develops a probabilistic approach suitable for measuring the expected effects of DRG fee incentives in the presence of multiple tariff groups.
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Parto Obstétrico , Hospitais , Criança , Humanos , Feminino , Gravidez , Grupos Diagnósticos Relacionados , FrançaRESUMO
BACKGROUND: Spread of resistant bacteria causes severe morbidity and mortality. Stringent control measures can be expensive and disrupt hospital organization. In the present study, we assessed the effectiveness and cost-effectiveness of control strategies to prevent the spread of Carbapenemase-producing Enterobacterales (CPE) in a general hospital ward (GW). METHODS: A dynamic, stochastic model simulated the transmission of CPE by the hands of healthcare workers (HCWs) and the environment in a hypothetical 25-bed GW. Input parameters were based on published data; we assumed the prevalence at admission of 0.1%. 12 strategies were compared to the baseline (no control) and combined different prevention and control interventions: targeted or universal screening at admission (TS or US), contact precautions (CP), isolation in a single room, dedicated nursing staff (DNS) for carriers and weekly screening of contact patients (WSC). Time horizon was one year. Outcomes were the number of CPE acquisitions, costs, and incremental cost-effectiveness ratios (ICER). A hospital perspective was adopted to estimate costs, which included laboratory costs, single room, contact precautions, staff time, i.e. infection control nurse and/or dedicated nursing staff, and lost bed-days due to prolonged hospital stay of identified carriers. The model was calibrated on actual datasets. Sensitivity analyses were performed. RESULTS: The baseline scenario resulted in 0.93 CPE acquisitions/1000 admissions and costs 32,050 /1000 admissions. All control strategies increased costs and improved the outcome. The efficiency frontier was represented by: (1) TS with DNS at a 17,407 /avoided CPE case, (2) TS + DNS + WSC at a 30,700 /avoided CPE case and (3) US + DNS + WSC at 181,472 /avoided CPE case. Other strategies were dominated. Sensitivity analyses showed that TS + CP might be cost-effective if CPE carriers are identified upon admission or if the cases have a short hospital stay. However, CP were effective only when high level of compliance with hand hygiene was obtained. CONCLUSIONS: Targeted screening at admission combined with DNS for identified CPE carriers with or without weekly screening were the most cost-effective options to limit the spread of CPE. These results support current recommendations from several high-income countries.
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Infecção Hospitalar , Proteínas de Bactérias , Análise Custo-Benefício , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Hospitais , Humanos , beta-LactamasesRESUMO
INTRODUCTION: End-stage renal disease (ESRD) affects 84 000 persons in France and costs an estimated 4.2 billion. Education about their disease empowers patients and allows improved management of their disease and better health outcomes. This study aims to explore whether the addition of an interactive web-based platform to patient education is effective and cost-effective and additionally whether complementing the platform with social functions and features improves its performance. METHODS AND ANALYSIS: Patients with severe, ESRD or post-transplant will be randomised 1:1:1 to either standard therapeutic education; or education using a specific application; or the enhanced interactive app with social features. The total follow-up duration is 18 months. Primary endpoint is the cost utility of using app-based therapeutic intervention; secondary endpoints are: compliance with treatment guidelines, app use (professionals and patients), patients' satisfaction, budget impact analysis. ETHICS AND DISSEMINATION: The findings will inform the deployment and reimbursement of the application. The study has ethical approval by the Ile de France ethics committee. Dissemination of the results will be presented at conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03090828.
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Falência Renal Crônica , Cooperação do Paciente , Humanos , Análise Custo-Benefício , Falência Renal Crônica/terapia , Internet , França , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
Under prospective payment schemes, hospitals may be disincentivised to use high-priced drugs. In this context, supplementary payment schemes have been implemented to fund hospitals beyond hospital tariffs for the use of such technologies. In France, since 2004, an add-on list scheme ensures that listed high-priced drugs are reimbursed by the state, thereby imposing no cost on hospitals while drugs are on the list. Yet little is known about the impact of drug delisting, i.e., when drugs are removed from the add-on list, on hospital utilisation. In this paper, we investigate the effects of delisting for 12 cancer drugs on the volumes prescribed, the generic shares and the purchase prices negotiated by hospitals. Using French hospital-level data over the period 2008-2016, we construct volumes, generic shares and purchase prices at the molecule level to account for potential substitutions across therapeutically equivalent drugs. Hospital fixed effects allow for time-invariant unobserved hospital heterogeneity linked to e.g., prescription preferences or hospitals' bargaining power. Our results indicate that prescription volumes, generic shares and price levels are not systematically affected by delisting, nor do we find evidence of response heterogeneity by hospital type. Overall, our findings mitigate concerns that the financial incentives associated with add-on lists may lead to hospitals over-prescribing high-priced drugs.
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Custos de Medicamentos , Medicamentos Genéricos , França , Hospitais , Humanos , NegociaçãoRESUMO
Purpose This study investigates the impact of an intensive case management program on sick leave days, permanent work incapacity levels and treatment costs for severe vocational injuries set up by the French National Insurance Fund in five health insurance districts. Methods The method employed relies on a four-step matching procedure combining Coarsened Exact Matching and Propensity Score Matching, based on an original administrative dataset. Average Treatment effects on the Treated were estimated using a parametric model with a large set of covariates. Results After one-year follow-up, workers in the treatment group had higher sickness absence rates, with 22 extra days, and the program led to 2.7 (95% CI 2.3-3.1) times more diagnoses of permanent work incapacity in the treatment group. With an estimated yearly operational cost of 2,722 per treated worker, the average total extra treatment cost was 4,569 for treated workers, which corresponds to a cost increase of 29.2% for the insurance fund. Conclusions The higher costs found for the treatment group are mainly due to longer sick leave duration for the moderate severity group, implying higher cash transfers in the form of one-off indemnities. Even though workers in the treated group have more diagnoses of permanent work incapacity, the difference of severity between groups is small. Our results on longer sick leave duration are partly to be explained by interactions between the case managers and the occupational physicians that encouraged patients to stay longer off-work for better recovery, despite the higher costs that this represented for the insurance fund and the well-documented adverse side effects of longer periods off-work.
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Administração de Caso , Licença Médica , Custos de Cuidados de Saúde , Humanos , Fatores de TempoRESUMO
The purpose of this paper is to investigate the potential for segmentation in hospital markets, using the French case where private for-profit providers play an important role having nearly 25% of market shares, and where prices are regulated, leading to quality competition. Using a stylized economic model of hospital competition, we investigate the potential for displacement between vertically differentiated public and private providers, focusing on maternity units where user choice is central. Building over the model, we test the following three hypotheses. First, the number of public maternity units is likely to be much larger in less populated departments than in more populated ones. Second, as the number of public maternity units decreases, the profitability constraint should allow more private players into the market. Third, private units are closer substitutes to other private units than to public units. Building an exhaustive and nationwide data set on the activity of maternity services linked to detailed data at a hospital level, we use an event study framework, which exploits two sources of variation: (1) The variation over time in the number of maternity units and (2) the variation in users' choices. We find support for our hypotheses, indicating that segmentation is at work in these markets with asymmetrical effects between public and private sectors that need to be accounted for when deciding on public market entry or exit.
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Serviços de Saúde Materna/classificação , Setor Privado , Feminino , França , Humanos , Serviços de Saúde Materna/economia , GravidezRESUMO
Seventy-five percent of patients with beta thalassemia (ß-thalassemia) do not have human leukocyte antigen-matched siblings and until recently had no access to a curative treatment. Gene therapy is a promising treatment that can be proposed to these patients. This study estimates its cost and efficacy. In a monocentric retrospective study and cost-efficacy analysis, this study compared the two-year outcomes and costs of patients with ß-thalassemia treated by gene therapy and hematopoietic stem-cell transplantation (HSCT). Grade III and grade IV complications, hospitalizations, and length of stay were extracted from the hospital discharge data. Costs were estimated from hospital accounting information and national cost studies. A total of seven patients with ß-thalassemia treated between 2009 and 2016 were included, of whom four received gene therapy. Patients treated by gene therapy were older and had fewer complications and hospital admissions. Infectious complications were three times more frequent for patients treated with HSCT than for gene therapy. Average costs were 608,086 for patients treated by gene therapy and 215,571 for HSCT. The total cost of the vector was 48% of the total cost of gene therapy. Gene therapy as a curative alternative for patients lacking human leukocyte antigen-matched donors was costlier but resulted in fewer complications than HSCT.
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Terapia Genética , Transplante de Células-Tronco Hematopoéticas , Talassemia beta/genética , Talassemia beta/terapia , Adolescente , Criança , Pré-Escolar , Ensaios Clínicos como Assunto , Análise Custo-Benefício , Terapia Genética/economia , Terapia Genética/métodos , Vetores Genéticos , Doença Enxerto-Hospedeiro/diagnóstico , Doença Enxerto-Hospedeiro/etiologia , Custos de Cuidados de Saúde , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Transplante de Células-Tronco Hematopoéticas/economia , Transplante de Células-Tronco Hematopoéticas/métodos , Humanos , Lactente , Prognóstico , Estudos Retrospectivos , Doadores de Tecidos , Transplante Homólogo , Resultado do Tratamento , Talassemia beta/diagnóstico , Talassemia beta/mortalidadeRESUMO
OBJECTIVES: The aim of this study is to review evidence on the cost-effectiveness of exercise-based interventions in the treatment of chronic conditions a decade after the publication of Roine et al. in 2009 (Roine E, Roine RP, Räsänen P, et al. Int J Technol Assess Health Care. 2009;25:427-454). METHODS: We carried out a review of published articles in PUBMED and JSTOR between January 1, 2008, and December 31, 2016. Full economic evaluations of exercise programs targeting patients with a chronic condition were eligible for inclusion. Data on program, design, and economic characteristics were extracted using a predefined extraction form. The quality of the economic evaluations was appraised using the adjusted Consensus Health Economic Criteria List. RESULTS: A total of 426 articles were identified and thirty-seven studies were selected. Eleven studies dealt with musculoskeletal and rheumatologic disorders, ten with cardiovascular diseases, six with neurological disorders, three with mental illnesses, three with cancers, and four with diabetes, respiratory diseases, or pelvic organ prolapse. In total, 60 percent of exercise programs were dominant or cost-effective. For musculoskeletal and rheumatologic disorders, 72 percent of programs were dominant or cost-effective while this was the case for 57 percent of programs for cardiovascular diseases using a nonsurgical comparator. CONCLUSIONS: There is clear evidence in favor of exercise-based programs for the treatment of musculoskeletal and rheumatologic disorders and, to a lesser extent, for the treatment of cardiovascular diseases. More research is needed to evaluate the cost-effectiveness of physical activity in the treatment of neurological disorders, mental illnesses, cancers, respiratory diseases, and diabetes/obesity.
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Doenças Cardiovasculares/terapia , Análise Custo-Benefício , Exercício Físico , HumanosRESUMO
When evaluating new drugs or treatments eligible for reimbursement, health technology assessment (HTA) agencies are repeatedly faced with cost-effectiveness analyses that evidence lack of adequate data and modeling biases. The case of type 2 diabetes illustrates this difficulty. In spite of its high disease burden, type 2 diabetes is poorly documented through existing cost-effectiveness analyses. We support this statement by an exhaustive literature review that enables us to precisely pinpoint the limitations of models used for the assessment of newly marketed (and expensive) drugs. We find that models are mostly restricted to surrogate endpoints and based on non-inferiority clinical trial data; they also show biases in the choice of comparators and inclusion criteria. Such limitations undermine the scope and applicability of HTA practice guidelines based on cost-effectiveness evidence. Nevertheless, cost-effectiveness models remain an opportunity to better inform decision makers and to reduce the uncertainty surrounding their decisions. HTA agencies are best placed to provide incentives for companies to improve the quality of the cost-effectiveness studies submitted for pricing and reimbursement decisions. One such incentive is to include stages of discussion between the company and the health authority during the evaluation process.
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Viés , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/economia , Modelos Biológicos , Avaliação da Tecnologia Biomédica , Análise Custo-Benefício , França , Humanos , Guias de Prática Clínica como AssuntoRESUMO
The participants in round table 6 of the Giens Workshops 2012 drafted recommendations based on the collective interpretation of important elements of the decree concerning the medico-economic evaluation of health products published a few days earlier (02 October 2012). The medico-economic evaluation (MEE), becomes an additional determinant for fixing the prices of health products by the Health products economic committee (Comité économique des produits de santé, CEPS) via the hierarchisation of treatment strategies, and thus modifies the market access conditions. Limiting the analysis to medicinal products and medical devices for which a major, important or moderate improvement in the medical service rendered (ASMR) or of the expected service (ASA) has been requested and presenting a significant budget impact on the Social Security expenses, excludes health products with ASMR or ASA with a lower level requested which often create complex price fixing problems and often have a major budget impact. This latter concept remains to be defined in detail. The MEE envisaged for the first registration must include the need to confirm or refute the initial hypotheses especially concerning the actual position in the therapeutic strategy at the time of renewal of the registration. For the first registration, the conventional reference to European prices guaranteeing a minimum price to innovative medicinal products, the medico-economic models submitted by the industry to the French Drug Authority (Haute autorité de santé, HAS) must be used to guide the compilation of new data to be requested at the time of the registration renewal and to negotiate the level of the discounts in the framework of a price-volume agreement, if applicable. The MEE will allow comparing the result of the analysis to the model hypothesis at the time of the renewal of the registration, which may contribute to the renegotiation (either up or down) of the price of health goods. The costs related to obtaining new data must be controlled. In order for the MEE to allow confirming the relationship between the price requested and the benefit expected, the group privileges the definition of reference values with an indicative and non-normative value, likely to evolve with time rather than a threshold. Concerning the evaluation procedure: the time to market access must not be lengthened; while the possibility of regular meetings between the industry and the HAS is recommended to avoid methodological divergences. A transitory period should allow the implementation of the entire evaluation procedure which must also take into account the specificities of health products registered before the 3 October 2013.
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Custos de Cuidados de Saúde , Legislação Médica , Garantia da Qualidade dos Cuidados de Saúde , Previdência Social/economia , Tecnologia Biomédica/economia , Tecnologia Biomédica/instrumentação , Tecnologia Biomédica/legislação & jurisprudência , Interpretação Estatística de Dados , França , Custos de Cuidados de Saúde/normas , Humanos , Legislação de Dispositivos Médicos , Garantia da Qualidade dos Cuidados de Saúde/economia , Garantia da Qualidade dos Cuidados de Saúde/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde/métodos , Projetos de Pesquisa , Previdência Social/legislação & jurisprudência , Previdência Social/organização & administraçãoAssuntos
Aprovação de Drogas , Guias de Prática Clínica como Assunto , Administração em Saúde Pública/legislação & jurisprudência , Aprovação de Drogas/economia , Aprovação de Drogas/legislação & jurisprudência , Indústria Farmacêutica/economia , Indústria Farmacêutica/legislação & jurisprudência , Drogas em Investigação/economia , França , Humanos , Reembolso de Seguro de Saúde , Saúde Pública/economia , Saúde Pública/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde/economia , Garantia da Qualidade dos Cuidados de Saúde/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde/normas , Controle de QualidadeRESUMO
The French National Authority for Health (Haute Autorité de Santé, or HAS) was established to assist France's public institutions in optimizing the basket of reimbursable goods and services and to help health care professionals continuously improve their clinical practice by defining best-care standards and identifying relevant tools and methods. HAS carries out single technology assessment (STA) and multiple technology assessment (MTA), assessing both the intrinsic benefit of the new technology and its effectiveness compared with that of existing technologies. A new treatment may not be covered unless it provides either improved benefit or lower cost, and STA is mandatory before a new drug, device, or medical procedure can be added to the benefit list for sickness funds. While HAS recommendations are advisory, the decision-making bodies (the Ministry of Health or the union of sickness funds) accept its findings in most cases.
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Comitês Consultivos/organização & administração , Medicina Baseada em Evidências/organização & administração , Reembolso de Seguro de Saúde/economia , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Avaliação da Tecnologia Biomédica/organização & administração , Conflito de Interesses , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Difusão de Inovações , França , Política de Saúde , Humanos , Cobertura do Seguro/economia , Medicina Estatal/organização & administraçãoRESUMO
CONTEXT: The discussion about improving the efficiency, quality, and long-term sustainability of the U.S. health care system is increasingly focusing on the need to provide better evidence for decision making through comparative effectiveness research (CER). In recent years, several other countries have established agencies to evaluate health technologies and broader management strategies to inform health care policy decisions. This article reviews experiences from Britain, France, Australia, and Germany. METHODS: This article draws on the experience of senior technical and administrative staff in setting up and running the CER entities studied. Besides reviewing the agencies' websites, legal framework documents, and informal interviews with key stakeholders, this analysis was informed by a workshop bringing together U.S. and international experts. FINDINGS: This article builds a matrix of features identified from the international models studied that offer insights into near-term decisions about the location, design, and function of a U.S.-based CER entity. While each country has developed a CER capacity unique to its health system, elements such as the inclusiveness of relevant stakeholders, transparency in operation, independence of the central government and other interests, and adaptability to a changing environment are prerequisites for these entities' successful operation. CONCLUSIONS: While the CER entities evolved separately and have different responsibilities, they have adopted a set of core structural, technical, and procedural principles, including mechanisms for engaging with stakeholders, governance and oversight arrangements, and explicit methodologies for analyzing evidence, to ensure a high-quality product that is relevant to their system.
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Tomada de Decisões Gerenciais , Difusão de Inovações , Medicina Baseada em Evidências/organização & administração , Pesquisa sobre Serviços de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Austrália , Eficiência Organizacional , Medicina Baseada em Evidências/economia , França , Alemanha , Política de Saúde , Pesquisa sobre Serviços de Saúde/economia , Humanos , Comunicação Interdisciplinar , Programas Nacionais de Saúde/organização & administração , Atenção Primária à Saúde/economia , Reino Unido , Estados UnidosRESUMO
Do Primary Care Physicians (PCPs) react strategically to financial incentives and if so how? To address this question, we follow a quasi-natural experiment in Quebec, using a panel system technique. In so doing, we both correct for underestimation biases in earlier time series findings and generate new results on the issue of complementarity/substitution between consultations with varying levels of technicality. Under both techniques, we show that PCPs are sensitive to the enforcement and subsequent temporary removals of expenditure caps and more generally, to changes in consultations' relative prices over time. These results support the existence of a discretionary power over the choice of consultation, PCPs increasing strategically the number of the more technical (and therefore more lucrative) consultations when pressed to defend their income. This finding for primary care parallels the now well-established DRG creep in hospitals. The panel system approach offers a better account of the complexity surrounding PCPs' decision-making process. In particular, it successfully addresses issues of physician heterogeneity, jointness between consultations and temporal breaks and generates robust estimates of PCPs volume and quality reactions to regulatory changes.
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Medicina de Família e Comunidade/economia , Médicos de Família/economia , Padrões de Prática Médica/economia , Atenção Primária à Saúde/economia , Reembolso de Incentivo , Orçamentos , Current Procedural Terminology , Tomada de Decisões , Grupos Diagnósticos Relacionados , Medicina de Família e Comunidade/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Humanos , Modelos Econométricos , Análise Multivariada , Programas Nacionais de Saúde/economia , Médicos de Família/psicologia , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Quebeque , Encaminhamento e Consulta/economia , Encaminhamento e Consulta/estatística & dados numéricosRESUMO
In this article, we assess the recent performance of the French state at containing costs in health care using political science concepts such as path dependency and incentives, which are central to an economic approach. The article focuses on institutional capacities and cultural immobilism and attempts to lay bare the tensions at play in seizing (or not) opportunities for structural change. In particular, we attempt to delineate what constitutes real change in this policy arena (big reforms versus the accumulation of many small policy movements) and to understand the variables at play in the coming together of conjunctures that provide for the big, as well as the underlying structures that allow the accumulation of the small. Except in cases of favorable conjuncture, the analysis bodes very ill for nonincremental reform and, indeed, for significant change over the long term.