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

OBJECTIVE: To evaluate the short-term consequences and cost-effectiveness associated with the use of novel biomarkers to triage young adult women with minor cervical cytological lesions. DESIGN: Model-based economic evaluation using primary epidemiological data from Norway, supplemented with data from European and American clinical trials. SETTING: Organised cervical cancer screening in Norway. POPULATION: Women aged 25-33 years with minor cervical cytological lesions detected at their primary screening test. METHODS: We expanded an existing simulation model to compare 12 triage strategies involving alternative biomarkers (i.e. reflex human papillomavirus (HPV) DNA/mRNA testing, genotyping, and dual staining) with the current Norwegian triage guidelines. MAIN OUTCOME MEASURES: The number of high-grade precancers detected and resource use (e.g. monetary costs and colposcopy referrals) for a single screening round (3 years) for each triage strategy. Cost-efficiency, defined as the additional cost per additional precancer detected of each strategy compared with the next most costly strategy. RESULTS: Five strategies were identified as cost-efficient, and are projected to increase the precancer detection rate between 18 and 57%, compared with current guidelines; however, the strategies did not uniformly require additional resources. Strategies involving HPV mRNA testing required fewer resources, whereas HPV DNA-based strategies detected >50% more precancers, but were more costly and required twice as many colposcopy referrals compared with the current guidelines. CONCLUSION: Strategies involving biomarkers to triage younger women with minor cervical cytological lesions have the potential to detect additional precancers, yet the optimal strategy depends on the resources available as well as decision-makers' and women's acceptance of additional screening procedures. TWEETABLE ABSTRACT: Women with minor cervical lesions may be triaged more accurately and effectively using novel biomarkers.

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

UNLABELLED: Some studies indicate that calcium supplementation increases cardiovascular risk. We assessed whether such effects could counterbalance the fracture benefits from supplementation. Accounting for cardiovascular outcomes, calcium may cause net harm and would not be cost-effective. Clinicians may do well considering cardiovascular effects when prescribing calcium supplementation. INTRODUCTION: Accounting for possible cardiovascular effect of calcium and vitamin D supplementation (CaD), the aims of this study were to assess whether CaD on balance would improve population health and to evaluate the cost-effectiveness of such supplementation. METHODS: We created a probabilistic Markov simulation model that was analysed at the individual patient level. We analysed 65-year-old Norwegian women with a 2.3 % 10-year risk of hip fracture and a 9.3 % risk of any major fracture according to the WHO fracture risk assessment tool (FRAX®). Consistent with a recent Cochrane review, we assumed that CaD reduces the risk of hip, vertebral, and wrist fractures by 16, 11, and 5 %, respectively. We included the increased risk of acute myocardial infarction (AMI) and stroke under a no-, medium-, and high-risk scenario. RESULTS: Assuming no cardiovascular effects, CaD supplementation produces improved health outcomes resulting in an incremental gain of 0.0223 quality-adjusted life years (QALYs) and increases costs by €322 compared with no treatment (cost-effectiveness ratio €14,453 per QALY gained). Assuming a Norwegian cost-effectiveness threshold of €60,000 per QALY, CaD is likely to be considered a cost-effective treatment alternative. In a scenario with a medium or high increased risk of cardiovascular events, CaD produces net health losses, respectively, -0.0572 and -0.0784 QALY at additional costs of €481 and €1033. CONCLUSIONS: We conclude that the magnitude of potential cardiovascular side effects is crucial for the effectiveness and cost-effectiveness of CaD supplementation in elderly women.

Cost-effectiveness of cervical cancer screening with primary human papillomavirus testing in Norway.

BACKGROUND: New screening technologies and vaccination against human papillomavirus (HPV), the necessary cause of cervical cancer, may impact optimal approaches to prevent cervical cancer. We evaluated the cost-effectiveness of alternative screening strategies to inform cervical cancer prevention guidelines in Norway. METHODS: We leveraged the primary epidemiologic and economic data from Norway to contextualise a simulation model of HPV-induced cervical cancer. The current cytology-only screening was compared with strategies involving cytology at younger ages and primary HPV-based screening at older ages (31/34+ years), an option being actively deliberated by the Norwegian government. We varied the switch-age, screening interval, and triage strategies for women with HPV-positive results. Uncertainty was evaluated in sensitivity analysis. RESULTS: Current cytology-only screening was less effective and more costly than strategies that involve switching to primary HPV testing in older ages. For unvaccinated women, switching at age 34 years to primary HPV testing every 4 years was optimal given the Norwegian cost-effectiveness threshold ($83,000 per year of life saved). For vaccinated women, a 6-year screening interval was cost-effective. When we considered a wider range of strategies, we found that an earlier switch to HPV testing (at age 31 years) may be preferred. CONCLUSIONS: Strategies involving a switch to HPV testing for primary screening in older women is expected to be cost-effective compared with current recommendations in Norway.

Cost-effectiveness of screening for abdominal aortic aneurysm in the Netherlands and Norway.

BACKGROUND: The aim of this study was to determine the cost-effectiveness of ultrasound screening for abdominal aortic aneurysm (AAA) in men aged 65 years, for both the Netherlands and Norway. METHODS: A Markov model was developed to simulate life expectancy, quality-adjusted life-years, net health benefits, lifetime costs and incremental cost-effectiveness ratios for both screening and no screening for AAA. The best available evidence was retrieved from the literature and combined with primary data from the two countries separately, and analysed from a national perspective. A threshold willingness-to-pay (WTP) of €20,000 and €62,500 was used for data from the Netherlands and Norway respectively. RESULTS: The additional costs of the screening strategy compared with no screening were €421 (95 per cent confidence interval 33 to 806) per person in the Netherlands, and the additional life-years were 0·097 (-0·180 to 0·365), representing €4340 per life-year. For Norway, the values were €562 (59 to 1078), 0·057 (-0·135 to 0·253) life-years and €9860 per life-year respectively. In Norway the results were sensitive to a decrease in the prevalence of AAA in 65-year-old men to 1 per cent, or lower. Probabilistic sensitivity analyses indicated that AAA screening has a 70 per cent probability of being cost-effective in the Netherlands with a WTP threshold of €20,000, and 70 per cent in Norway with a threshold of €62,500. CONCLUSION: Using this model, screening for AAA in 65-year-old men would be highly cost-effective in both the Netherlands and Norway.

HPV mRNA tests for the detection of cervical intraepithelial neoplasia: a systematic review.

OBJECTIVE: Perform a systematic review to determine the test performance of HPV mRNA testing compared to DNA testing using CIN2+ as the target condition. METHODS: We searched bibliographic databases (MEDLINE, EMBASE and Cochrane Library) from January 1996 through August 2010 using a predefined search strategy. The reference standard used to diagnose precancerous lesions was histologically confirmed cervical intraepithelial neoplasia 2+ (CIN2+). Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. Sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratios were calculated for each study. In addition, we fitted a series of summary receiver operating characteristics (SROC) curves. A subgroup analysis was performed according to specific inclusion covariates. RESULTS: Out of 3179 potentially relevant citations, 12 publications (11 studies) met our inclusion criteria. The included studies were of varying methodological quality, and were predominately performed in a secondary screening setting. Eight studies investigated the performance of the PreTect Proofer/NucliSENS EasyQ, two studies investigated the performance of the APTIMA assay and one study investigated both mRNA tests on the same patient samples. Due to few studies and considerable clinical heterogeneity, pooling of data was not possible. Instead, we compiled a 'best evidence synthesis' for E6/E7 mRNA HPV testing. Sensitivities ranged from 0.41 to 0.86 and from 0.90 to 0.95 for the PreTect Proofer/Easy Q and APTIMA assay, respectively. Specificities ranged from 0.63 to 0.97 and from 0.42 to 0.61 for the PreTect Proofer/Easy Q and APTIMA assay, respectively. The SROC curves for both mRNA tests were to the left of the diagonal and the APTIMA assay performed closest to the DNA tests. CONCLUSION: The review suggests that mRNA tests have diagnostic relevance, but additional studies and economic evaluations must be conducted in order to make a solid conclusion regarding the clinical applicability of HPV mRNA testing.

Cost-effectiveness analyses of elective orthopaedic surgical procedures in patients with inflammatory arthropathies.

OBJECTIVE: To examine the costs per quality-adjusted life year (QALY) gained for surgical interventions in patients with inflammatory arthropathies, and to compare the costs per QALY gained for replacement versus non-replacement surgical interventions. METHODS: In total, 248 patients [mean age 57 (SD 13) years, 77% female] with inflammatory arthropathies underwent orthopaedic surgical treatment and responded to mail surveys at baseline and during follow-up (3, 6, 9, and 12 months). Questionnaires included the quality-of-life EuroQol-5D (EQ-5D) and Short Form-6D (SF-6D) utility scores. The health benefit from surgery was subsequently translated into QALYs. The direct treatment costs in the first year were, for each patient, derived from the hospital's cost per patient accounting system (KOSPA). The costs per QALY were estimated and future costs and benefits were discounted at 4%. RESULTS: Improvement in utility at 1-year follow-up was 0.10 with EQ-5D and 0.03 with SF-6D (p < 0.05). The estimated 10-year cost per QALY gained was EUR 5000 for hip replacement surgery (EUR18 600 using SF-6D) and EUR 10 500 (EUR 48 500 using SF-6D) for all replacement procedures. The 5-year cost per QALY was EUR 17 800 for non-replacement surgical procedures measured by EQ-5D (SF-6D: EUR 67 500). CONCLUSIONS: Elective orthopaedic surgery in patients with inflammatory arthropathies was cost-effective when measured with EQ-5D, and some procedures were also cost-effective when SF-6D was used in the economic evaluations. Hip replacement surgery was most cost-effective, irrespective of the method of analysis.

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

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

Health-related quality of life in diabetes: The associations of complications with EQ-5D scores.

BACKGROUND: The aim of this study was to describe how diabetes complications influence the health-related quality of life of individuals with diabetes using the individual EQ-5D dimensions and the EQ-5D index. METHODS: We mailed a questionnaire to 1,000 individuals with diabetes type 1 and 2 in Norway. The questionnaire had questions about socio-demographic characteristics, use of health care, diabetes complications and finally the EQ-5D descriptive system. Logistic regressions were used to explore determinants of responses in the EQ-5D dimensions, and robust linear regression was used to explore determinants of the EQ-5D index. RESULTS: In multivariate analyses the strongest determinants of reduced MOBILITY were neuropathy and ischemic heart disease. In the ANXIETY/DEPRESSION dimension of the EQ-5D, "fear of hypoglycaemia" was a strong determinant. For those without complications, the EQ-5D index was 0.90 (type 1 diabetes) and 0.85 (type 2 diabetes). For those with complications, the EQ-5D index was 0.68 (type 1 diabetes) and 0.73 (type 2 diabetes). In the linear regression the factors with the greatest negative impact on the EQ-5D index were ischemic heart disease (type 1 diabetes), stroke (both diabetes types), neuropathy (both diabetes types), and fear of hypoglycaemia (type 2 diabetes). CONCLUSIONS: The EQ-5D dimensions and the EQ-5D seem capable of capturing the consequences of diabetes-related complications, and such complications may have substantial impact on several dimensions of health-related quality of life (HRQoL). The strongest determinants of reduced HRQoL in people with diabetes were ischemic heart disease, stroke and neuropathy.

Fluctuating functions related to quality of life in advanced Parkinson disease: effects of duodenal levodopa infusion.

OBJECTIVE: To assess fluctuations in quality of life (QoL) and motor performance in patients with advanced Parkinson disease (PD) treated with continuous daytime duodenal levodopa/carbidopa infusion or conventional therapy. METHODS: Of 18 patients completing a 6-week trial (DIREQT), 12 were followed for up to 6 months and assessed using electronic diaries and the PD Questionnaire-39 (PDQ-39). RESULTS: During the trial and follow-up, major diurnal fluctuations were observed, especially for hyperkinesia, 'off' time, ability to walk and depression. Duodenal infusion was associated with significantly more favourable outcomes compared with conventional treatment for satisfaction with overall functioning, 'off' time and ability to walk, with improved outcomes with PDQ-39. CONCLUSIONS: Relative to conventional treatment, infusion therapy may stabilize and significantly improve motor function and patient's QoL. The potential for daily fluctuation in PD symptoms means single measures of treatment effectiveness can result in bias in effect estimates and hence repeated measures are recommended.

Costs and health consequences of chlamydia management strategies among pregnant women in sub-Saharan Africa.

OBJECTIVES: Chlamydia is the most common bacterial sexually transmitted infection worldwide and a major cause of morbidity-particularly among women and neonates. We compared costs and health consequences of using point-of-care (POC) tests with current syndromic management among antenatal care attendees in sub-Saharan Africa. We also compared erythromycin with azithromycin treatment and universal with age-based chlamydia management. METHODS: A decision analytical model was developed to compare diagnostic and treatment strategies, using Botswana as a case. Model input was based upon (1) a study of pregnant women in Botswana, (2) literature reviews and (3) expert opinion. We expressed the study outcome in terms of costs (US$), cases cured, magnitude of overtreatment and successful partner treatment. RESULTS: Azithromycin was less costly and more effective than erythromycin. Compared with syndromic management, testing all attendees on their first visit with a 75% sensitive POC test increased the number of cases cured from 1500 to 3500 in a population of 100,000 women, at a cost of US$38 per additional case cured. This cost was lower in high-prevalence populations or if testing was restricted to teenagers. The specific POC tests provided the advantage of substantial reductions in overtreatment with antibiotics and improved partner management. CONCLUSIONS: Using POC tests to diagnose chlamydia during antenatal care in sub-Saharan Africa entails greater health benefits than syndromic management does-and at acceptable costs-especially when restricted to younger women. Changes in diagnostic strategy and treatment regimens may improve people's health and even reduce healthcare budgets.

Cost-effectiveness of antenatal screening for neonatal alloimmune thrombocytopenia.

OBJECTIVES: To estimate the costs and health consequences of three different screening strategies for neonatal alloimmune thrombocytopenia (NAIT). DESIGN: Cost-utility analysis on the basis of a decision tree that incorporates the relevant strategies and outcomes. SETTING: Three health regions in Norway encompassing a 2.78 million population. POPULATION: Pregnant women (n = 100,448) screened for human platelet antigen (HPA) 1a and anti-HPA 1a antibodies, and their babies. METHOD: Decision tree analysis. In three branches of the decision tree, pregnant women entered a programme while in one no screening was performed. The three different screening strategies included all HPA 1a negative women, only HPA 1a negative, HLA DRB3*0101 positive women or only HPA 1a negative women with high level of anti-HPA 1a antibodies. Included women underwent ultrasound examination and elective caesarean section 2-4 weeks before term. Severely thrombocytopenic newborn were transfused immediately with compatible platelets. MAIN OUTCOME MEASUREMENTS: Quality-adjusted life years (QALYs) and costs. RESULTS: Compared with no screening, a programme of screening and subsequent treatment would generate between 210 and 230 additional QALYs among 100,000 pregnant women, and at the same time, reduce health care costs by approximately 1.7 million euros. The sensitivity analyses indicate that screening is cost effective or even cost saving within a wide range of probabilities and costs. CONCLUSION: Our calculations indicate that it is possible to establish an antenatal screening programme for NAIT that is cost effective.

Local and national electronic databases in Norway demonstrate a varying degree of validity.

OBJECTIVE: The aim of the present study was to examine the validity of local and national electronic databases using medical records as gold Standard. STUDY DESIGN AND SETTING: All hospital admissions with ICD 9-code 820.X (hip fracture) in a 1-year period were identified in the electronic discharge registers of the hospitals in Oslo and in the national electronic database (The Norwegian Patient Register). Medical records for all patients identified by the discharge registers and the logbooks of the operating theater of the hospitals were retrieved, and the diagnosis was verified. RESULTS: Compared with the total number of fractures confirmed in medical records, the electronic discharge register of one of the hospitals underestimated the number of fractures by 46%, whereas the two other overestimated the number by 17% and 19%. For the national electronic database, an overall overestimation of 19% was found. CONCLUSION: The present findings question the validity of electronic databases and thus have implications for epidemiologic studies.

Epidemiology of hip fractures in Oslo, Norway.

The incidence of hip fractures in Oslo has shown a secular increase during the past decades. The main aims of the present study were to report the current incidence of hip fractures in Oslo and to determine whether there is a seasonal variation in the occurrence of fractures. Using the electronic diagnosis registers and the lists of the operating theater for the hospitals in Oslo with somatic care, all patients with ICD-9 code 820.X (hip fracture) from May 1, 1996 to April 30, 1997 were identified. Medical records for all identified patients were obtained and diagnosis was verified. Using the population of Oslo on January 1, 1997 as the population at risk, the age- and gender-specific annual incidence rates were calculated. These rates were compared with those for 1988/89 and 1978/79. Outdoor temperature data for Oslo were obtained to study the relation between temperature and number of hip fractures. A total number of 1316 hip fractures was included, of which 78% occurred in women. An exponential increase in incidence with age was observed in both genders. The age-adjusted fracture rates per 10,000 for the age group > or =50 years were 118.0 and 44.0 in 1996/97, 124.3 and 44.9 in 1988/89, and 104.5 and 35.8 in 1978/79 for women and men, respectively. There was no significant seasonal variation in the incidence of hip fractures and no correlation between mean outdoor temperature and number of fractures for each month in 1996/97. The data show that the incidence of hip fractures in Oslo has not changed significantly during the last decade, and it is still the highest reported. The cold climate of Oslo does not seem to contribute to the high incidence.

Criteria for TNF-targeted therapy in rheumatoid arthritis: estimates of the number of patients potentially eligible.

Tumour necrosis factor (TNF) antagonists or blocking agents represent a major advance in the treatment of rheumatoid arthritis (RA), but their use raises economic concerns because of the high drug cost. Population-based patient registers with clinical data allow the estimation of the proportion of patients with RA who are eligible for TNF antagonist therapy according to recent consensus statements on TNF-targeted therapy. Data were derived from a representative county-based (500,000 population) register of patients with RA. Of 894 patients aged between 18 and 70 years, 636 (71%) [females 80%, mean (SD) age 53.6 (12.2) years and mean (SD) disease duration 12.2 (9.3) years] had a clinical and radiographic examination. The eligibility for TNF-targeted therapy was estimated from the following criteria: (i) previous or current therapy with at least one disease-modifying antirheumatic agent (DMARD); and (ii) active disease. Disease activity criteria were set to 28-swollen joint count (28-SJC) > or = 6, 28-tender joint count > or = 6, and erythrocyte sedimentation rate (ESR) > or = 28 mm/hour or C-reactive protein (CRP) > or = 20 mg/L. Sensitivity analyses were performed varying some of these disease activity parameters. Of the 636 patients, as many as 526 (83%) had previously or were currently using DMARDs and 98 (15%) fulfilled both the DMARD and activity criteria, thus being the maximum number of patients considered for TNF-targeted therapy. If the most stringent criteria were used (ever DMARD, 28-SJC > or = 12 and ESR > or = 50 mm/hour or CRP > or = 40 mg/L) only 15 of the 626 (2%) would be candidates for TNF-targeted therapy. In a population of 1 million, assuming a prevalence of 2000 patients with RA under the age of 70 years, the number of candidates for TNF-targeted therapy would be 40 to 300, depending on the disease activity criteria. Stringent ESR and CRP criteria would lead to a major reduction in the number of eligible patients. These utilisation data imply annual drug costs in the range of $US 480,000 to $US 3,600,000 for TNF antagonists for RA per 1 million population. Further economic evaluations are needed to determine for which groups such treatment is warranted from a health economics perspective.

Does admission to a medical department improve patient life expectancy?

Doubts about the effectiveness of medical care in improving patient health have been raised by epidemiological studies and by studies of geographical variation and inappropriate use of health care. To investigate this problem, the life expectancy gain (LEG) from consecutive admissions to a department of internal medicine during a six-week period was assessed by two expert panels, each consisting of an internist, a surgeon, and a general practitioner. The mean LEG for all admissions was 2.25 years (n = 422). Sixty-one percent had a LEG of 0.10 years or less, while 5% had a LEG of more than 9.98 years. In a probabilistic sensitivity analysis, the mean LEG remained greater than zero under assumptions of overestimated positive LEG and underestimated negative LEG. We conclude that the life expectancy of the majority of the patients was not influenced by the admission, but that a minority had substantial gains, resulting in a high overall mean LEG.

Effect of the remuneration system on the general practitioner's choice between surgery consultations and home visits.

OBJECTIVE: To assess the influence of the remuneration system, municipality, doctor, and patient characteristics on general practitioners' choices between surgery and home visits. DESIGN: Prospective registration of patient contacts during one week for 116 general practitioners (GPs). SETTING: General practice in rural areas of northern Norway. MAIN OUTCOME MEASURE: Type of GP visit (surgery v home visit). RESULTS: The estimated home visit rate was 0.14 per person per year. About 7% (range 0-39%) of consultations were home visits. Using multilevel analysis it was found that doctors paid on a "fee for service" basis tended to choose home visits more often than salaried doctors (adjusted odds ratio 1.90, 99% confidence interval 0.98, 3.69), but this was statistically significant for "scheduled" visits only (adjusted OR 4.50, 99% CI 1.67, 12.08). Patients who were older, male, and who were living in areas well served by doctors were more likely to receive home visits. CONCLUSION: In the choice between home visits and surgery consultations, doctors seem to be influenced by the nature of the remuneration when the patient's problem is not acute. Although home visiting is a function of tradition, culture, and organisational characteristics, the study indicates that financial incentives may be used to change behaviour and encourage home visiting.

Do general practitioner hospitals reduce the utilisation of general hospital beds? Evidence from Finnmark county in north Norway.

STUDY OBJECTIVE: To assess whether populations with access to general practitioner hospitals (GP hospitals) utilise general hospitals less than populations without such access. DESIGN: Observational study comparing the total rates of admissions and of occupied bed days in general hospitals between populations with and without access to GP hospitals. Comparisons were also made separately for diagnoses commonly encountered in GP hospitals. SETTING: Two general hospitals serving the population of Finnmark county in north Norway. PATIENTS: 35,435 admissions based on five years' routine recordings from the two hospitals. MAIN RESULTS: The total rate of admission to general hospitals was lower in peripheral municipalities with a GP hospital than in central municipalities without this kind of institution, 26% and 28% lower for men and women respectively. The corresponding differences were 38% and 52%, when analysed for occupied bed days. The differences were most pronounced for patients with respiratory diseases, cardiac failure, and cancer who are primarily or intermediately treated or cared for in GP hospitals, and for patients with stroke and fractures, who are regularly transferred from general hospitals to GP hospitals for longer term follow up care. CONCLUSION: GP hospitals seem to reduce the utilisation of general hospitals with respect to admissions as well as occupied bed days.

Cost and health consequences of reducing the population intake of salt.

STUDY OBJECTIVE: The aim was to estimate health and economic consequences of interventions aimed at reducing the daily intake of salt (sodium chloride) by 6 g per person in the Norwegian population. Health promotion (information campaigns), development of new industry food recipes, declaration of salt content in food and taxes on salty food/subsidies of products with less salt, were possible interventions. DESIGN: The study was a simulation model based on present age and sex specific mortality in Norway and estimated impact of blood pressure reductions on the risks of myocardial infarction and stroke as observed in Norwegian follow up studies. A reduction of 2 mm Hg systolic blood pressure (range 1-4) was assumed through the actual interventions. The cost of the interventions in themselves, welfare losses from taxation of salty food/subsidising of food products with little salt, cost of avoided myocardial infarction and stroke treatment, cost of avoided antihypertensive treatment, hospital costs in additional life years and productivity gains from reduced morbidity and mortality were included. RESULTS: The estimated increase in life expectancy was 1.8 months in men and 1.4 in women. The net discounted (5%) cost of the interventions was minus $118 millions (that is, cost saving) in the base case. Sensitivity analyses indicate that the interventions would be cost saving unless the systolic blood pressure reduction were less than 2 mm Hg, productivity gains were disregarded or the welfare losses from price interventions were high. CONCLUSION: Population interventions to reduce the intake of salt are likely to improve the population's health and save costs to society.

The general practitioner's use of time: is it influenced by the remuneration system?

The practice pattern of 116 general practitioners in 60 rural municipalities in Northern Norway was studied with respect to length of consultation, the weekly number of consultations and the proportion of return visits. The average length of consultation was 14 mins, and only slightly lower for fee-for-service (FFS) doctors (13.7) than for salaried ones (14.8). The weekly average number of surgery consultations was higher for FFS doctors than for the salaried (63 vs 49), but the weekly number of hours spent consulting and the proportion of return visits were about the same. Further, the characteristics of the health care system (doctor density and doctor turnover) were associated with variations in the doctors' use of time. The most consistent effects, even if weak, were the age and sex of the patients. The strongest effects on the length of consultation were referrals and various medical procedures. This suggests that in this instance the medical condition at hand would appear to have a greater influence on the doctors' use of time than either the remuneration system or other characteristics of the health care system. Although the association between the doctors' use of time and the type of remuneration was weak, the study indicates that the type of remuneration does matter. Consequently, financial incentives can be used to influence the practice pattern of GPs.

Medical specialists' choice of location: the role of geographical attachment in Norway.

The relation between current place of work (area of the country) and factors that might possibly represent doctors geographical attachments was studied in a sample of 322 Norwegian medical specialists. Location of hospital residency, age and geographical origin of spouse were associated with current location. Geographical attachment seems to influence doctors' locational choices from start of medical school until the end of their residency. The probability that a doctor shall locate in peripheral areas may increase from less than 10% to more than 50% if the doctor has the residency training in the periphery. Hence, favoring entrance to medical schools of students from the underserved areas, and location of graduate and postgraduate medical training in the underserved areas, as far as it is feasible while still maintaining medical standards, is suggested by the study.