The cost-effectiveness of the treatment of high risk women with osteoporosis, hypertension and hyperlipidaemia in Sweden.

UNLABELLED: This paper assessed the cost-effectiveness of the treatment of high risk women with osteoporosis, hypertension and hyperlipidaemia in Sweden, using one model and a societal perspective. Cost-effective scenarios were found in all these chronic disorders. These findings are of relevance for decisions on the efficient allocation of health care resources. INTRODUCTION: There is a need to assess the cost-effectiveness (CE) of treatment of osteoporosis from a societal perspective and to relate this to the CE of interventions in other disease areas. This is of relevance for decisions on the efficient allocation of health care resources within and between disease areas. The purpose of the paper was to estimate the CE of the treatment and prevention of osteoporosis and to put that into the perspective of treating hypertension and hyperlipidaemia. The CE was assessed for different high risk female populations aged 50-80 years. METHODS: The estimation of CE was based on a model populated with data for Sweden. RESULTS: Compared to no intervention, a 5-year treatment of osteoporosis, hypertension, and hyperlipidaemia, is cost effective for most of the assessed high risk female populations. The cost per gained quality adjusted life year (QALY) for the treatment of a 70-year-old woman never exceeded SEK 330,000 (US$ 44,000), which is generally judged as an acceptable cost for a gained QALY. CONCLUSIONS: The study demonstrates that it is possible to produce reliable estimates of the CE of treatments in different disease areas within the context of a single model.

Cost-effectiveness of the treatment and prevention of osteoporosis--a review of the literature and a reference model.

OBJECTIVE: The purpose of the paper is to update and review the latest developments related to modelling and economic evaluation of osteoporosis in the period 2002-2005 and further to present a reference model for the assessment of the cost-effectiveness of the prevention and treatment of osteoporosis. DISCUSSION: The reference model is intended to be used for fracture specific interventions affecting the risk of fracture. An interface version and an extensive description of the model is available on the internet ( http://www.healtheconomics.se ) and also accessible via the International Osteoporosis Foundation ( http://www.osteofound.org ). The purpose of the reference model is to improve the quality and comparability of cost-effectiveness analysis in the osteoporosis field and to serve as a tool for validation of present and future cost-effectiveness models. The reference model allows the cost-effectiveness analysis to be carried out from a societal perspective including intervention, morbidity and mortality costs. The model has been extensively tested and calibrated, and meets the properties of good decision analytic modelling. The model is a state transition Markov cohort model, which is characterised by a 50-year time horizon divided into one year cycle lengths. The following health states are included: "healthy", "hip fracture", "spine fracture", "wrist fracture", "other fracture", and "dead". CONCLUSION: The model is flexible and allows for the estimation of the cost-effectiveness over different ranges for a selected number of variables (e.g., age, fracture risk, cost of intervention).

The risk and burden of vertebral fractures in Sweden.

The aim of this study was to determine the risk and burden of vertebral fractures judged as those coming to clinical attention and as morphometric fractures. Incidence and utility loss were computed from data from Malmo, Sweden. Clinical fractures accounted for 23% of all vertebral deformities in women and for 42% in men. The average 10-year fracture probability for morphometric fractures increased with age in men from 2.9% at the age of 50 years (7.2% in women) to 8.4 at the age of 85 years (26.7% in women). As expected, probabilities increased with decreasing T-score for hip BMD. Cumulative utility loss from a clinical vertebral fracture was substantial and was 50-62% of that due to a hip fracture depending on age. When incidence of fractures in the population was weighted by disutility, all spine fractures accounted for more morbidity than hip fracture up to the age of 75 years. We conclude that vertebral fractures have a major personal and societal impact that needs to be recognised in algorithms for assessment of risk and in health economic strategies for osteoporosis.

Intravenous levosimendan treatment is cost-effective compared with dobutamine in severe low-output heart failure: an analysis based on the international LIDO trial.

BACKGROUND: Levosimendan, a novel calcium sensitiser, improves cardiac performance and symptoms without increasing oxygen consumption, and decreases the mortality of patients with low-output heart failure. AIMS: To estimate the cost-effectiveness of intravenous treatment with levosimendan compared with dobutamine in patients with severe low-output heart failure. METHODS: This economic evaluation was based on a European clinical trial (LIDO), in which 203 patients with severe heart failure randomly received a 24 h infusion with either levosimendan or dobutamine. Survival and resource utilisation data were collected for 6 months; survival was extrapolated assuming a mean additional lifetime of 3 years based on data from the Cooperative North Scandinavian Enalapril Survival Study trial. Costs were based on study drug usage and hospitalisation in the 6-month follow-up. A sensitivity analysis on dosage of drug and duration of survival was performed. RESULTS: The mean survival over 6 months was 157+/-52 days in the levosimendan group and 139+/-64 days in the dobutamine group (P<0.01). When extrapolated up to 3 years, the gain in life expectancy was estimated at 0.35 years (discounted at 3%). Levosimendan increased the mean cost per patient by 1108, which was entirely due to the cost of the study drug. The incremental cost per life-year saved (LYS) was 3205 at the European level; in the individual countries the cost per LYS ranged between 3091 and 3331. The result was robust in the sensitivity analysis. CONCLUSIONS: Although the patients in the levosimendan group were alive for more days and thus at risk of hospitalisation for longer, there was no increase in hospitalisation or hospitalisation costs with levosimendan treatment. The cost per LYS using levosimendan compares favourably with other cost-effectiveness analyses in cardiology.

Cost effectiveness of bisoprolol in the treatment of chronic congestive heart failure in Sweden: analysis using data from the Cardiac Insufficiency Bisoprolol Study II trial.

OBJECTIVE: To investigate the cost effectiveness of adding the beta-blocker bisoprolol to standard treatment in patients with congestive heart failure (CHF). DESIGN AND SETTING: A cost-effectiveness study was based on the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), a randomised clinical trial investigating the efficacy of adding bisoprolol to standard therapy of CHF. The cost-effectiveness analysis was carried out from a societal perspective. METHODS: Health effects were measured in terms of years of life gained. On the cost side, treatment costs for pharmaceuticals and hospitalisations were included. Data on healthcare resource consumption from CIBIS-II were used and were combined with average Swedish retail prices for medicines, and average costs for hospitalisations based on hospital admissions, in the base case. The costs of added years of life, i.e. consumption net of production during life-years gained were also included. RESULTS: If costs of added years of life were not included, then bisoprolol therapy increased life expectancy at an incremental cost of Swedish kronor (SEK) 13 094 (1999 values) per year of life gained. If costs of added years of life were included, then the incremental cost-effectiveness ratio of bisoprolol therapy was SEK 168 858 per year of life gained. CONCLUSIONS: For patients with CHF with the characteristics of those in CIBIS-II, the cost effectiveness of bisoprolol therapy compares favourably with that of other cardiovascular therapies.

Definition, interpretation and calculation of cost-effectiveness acceptability curves.

This paper discusses the definition, interpretation and computation of cost-effectiveness (CE) acceptability curves. A formal definition of the CE acceptability curve based on the net benefit approach is provided. The curve can be computed using parametric or non-parametric techniques and for both computational approaches we establish a formal relation between the CE acceptability curve and statistical inference based on confidence intervals and P values in CE analysis.

Costs and benefits of laparoscopic surgery--a review of the literature.

The purpose of this paper is to look at the cost-effectiveness of laparoscopic surgery in relation to conventional open surgery. It focuses both on the results and the methods, and aims to identify the need for further studies as well as the appropriate methods of economic evaluation. We searched the literature and identified studies in which "cost" or "cost-effectiveness" was mentioned in relation to open and laparoscopic surgery. Laparoscopic and open surgery were compared for gallbladder disease, inguinal hernia and gastro-oesophageal reflux disease (GORD). Finally, we reviewed studies that focused on cost comparisons of disposable compared with reusable instruments in laparoscopic surgery. We found that the evidence on whether laparoscopic surgery results in lower costs for the health care system than open operations is not conclusive. There are, however, indications that it results in savings in indirect costs from reduced periods of sick leave. There is also an indication that reusable instruments resulted in lower costs for each operation than disposable instruments. We conclude that a prospective, randomised study is the preferred study design in the early stage of the development of a new technique, when it is not fully obvious what the indications for the new technique are. This should be considered when doing economic evaluations of new indications for laparoscopic surgery, for example appendicectomy and non-inguinal hernia repair.

A comparison of patient and social tariff values derived from the time trade-off method.

A social tariff of EuroQol time trade-off (TTO) values was recently presented. We compared the social tariff and patient TTO values among 104 women with mild and severe menopausal symptoms. The social tariff and patient TTO values were elicited both after and before hormone replacement therapy (HRT). There was a close correspondence between social-tariff values and patient TTO values for relatively good health states, whereas the social tariff TTO values were lower than the patient TTO values for severe health states.

A computer model to analyze the cost-effectiveness of hormone replacement therapy.

This paper gives a detailed presentation of a computer model for evaluating the cost-effectiveness (CE) of hormone replacement therapy (HRT), describing the model's design, structure, and data requirements. The model needs data specified for costs, quality of life, risks, and mortality rates. As an illustration, the CE of HRT in Sweden is calculated. Two treatment strategies are evaluated for asymptomatic women: estrogen-only therapy and estrogen combined with a progestin. The model produces similar results compared with earlier studies. The CE ratios improve with the size of the risk reduction and generally with age. Further, estrogen-only therapy is associated with a lower cost per gained effectiveness unit compared with combined therapy. Uncertainty surrounding the long-term effects of HRT means that the CE estimates should be interpreted carefully. The model permits the inclusion of indirect costs and costs in added life-years, allowing the analysis to be made from a societal perspective, which is an improvement relative to previous studies.

Costs of coronary heart disease and stroke: the case of Sweden.

OBJECTIVES: To estimate the annual costs in Sweden of coronary heart disease (CHD) and stroke, and the potential cost savings if these clinical 'events' are avoided. The analysis is undertaken from a societal perspective, including both direct and indirect costs. Costs are calculated for five clinical conditions: (i) acute myocardial infarction (AMI), (ii) angina pectoris (AP), (iii) unstable angina (UA), (iv) congestive heart failure (CHF), and (v) stroke. DESIGN: A retrospective study including patients admitted to the Department of Medicine at Södertälje Hospital during the period January 1993 to March 1995 with CHD or a stroke. Each patient was followed for 1 year after admission to the hospital. To estimate potential cost savings, the patient was used as his or her own control. The potential savings in direct costs if CHD or a stroke is avoided were estimated as the difference between costs for 1 year after and 1 year before the event. The indirect costs were calculated as the difference between the values of market production of goods and services the year before the event and the year after. SETTING: The Department of Medicine at Södertälje Hospital, Södertälje, Sweden. SUBJECTS: The patients included in the study were patients at the Department of Medicine at Södertälje Hospital in Sweden. The inclusion criterion was that the patients should have been admitted for the first time for CHD or stroke during the year 1994. To obtain 25 patients for each clinical category we first had to expand the inclusion period to cover January 1993 to March 1995. Secondly, we also had to include 36 patients with an earlier established uncomplicated CHD or stroke. Despite this, no more than 22 patients with UA were found. INTERVENTIONS: Patients were followed in medical practice. MAIN OUTCOME MEASURES: Costs, direct and indirect costs, and potential savings. RESULTS: The mean direct costs during the year after a clinical event range between Swedish kronor (SEK) 41 000 for CHF and SEK 96 000 for stroke, whereas the mean potential savings in direct costs range from SEK 36 000 for CHF to SEK 91 000 for UA. The potential mean savings in indirect costs range between SEK 24 000 for CHF and SEK 102 000 for AMI. The direct costs for first-time patients are lower than those for patients with an earlier established CHD or stroke. No systematic differences have been found in potential direct cost savings and indirect costs between the two patient groups. CONCLUSIONS: CHD and stroke are associated with high costs during the year after admission to the Department of Medicine. There are also large potential cost savings from the prevention of CHD and stroke. However, further studies, including more patients and costs arising in the municipality, are needed to establish more precise and complete estimates of the costs related to CHD and stroke.

A note on confidence intervals in cost-effectiveness analysis.

How to obtain confidence intervals for cost-effectiveness ratios is complicated by the statistical problems of obtaining a confidence interval for a ratio of random variables. Different approaches have been suggested in the literature, but no consensus has been reached. We propose an alternative simple solution to this problem. By multiplying the effectiveness units by the price per effectiveness unit, both costs and benefits can be expressed in monetary terms and standard statistical techniques can be used to estimate a confidence interval for net benefits. This approach avoids the ratio estimation problem and explicitly recognizes that the price per effectiveness unit has to be known to provide cost-effectiveness analysis with a useful decision rule.

Nonparametric willingness-to-pay measures and confidence statements.

Willingness to pay (WTP) for a health care program can be estimated in contingent valuation (CV) studies by a nonparametric approach. The nonparametric approach is free from distributional assumptions, which is a strength compared with parametric regression-based approaches. However, using a nonparametric approach it is not clear how to obtain confidence statements for WTP estimates, for example, when testing hypotheses regarding differences in mean WTP for different subsamples. The authors propose a procedure that allows statistical testing and confidence interval estimation by employing bootstrap techniques. The method is easy to implement and has low computational costs with modern personal computers. The method is applied to data from a CV study where the WTP for hormone replacement therapy was investigated. The mean WTP was estimated for the full sample and separately for women with mild and severe menopausal symptoms. Using the proposed method, the mean WTP was significantly higher in the group with severe symptoms.

Bootstrap confidence intervals for cost-effectiveness ratios: some simulation results.

Recently, a number of papers have brought up the issue of how to make cost-effectiveness (CE) studies stochastic, i.e. how to obtain confidence intervals for CE ratios. In this note we present a bootstrap procedure for estimating bias-corrected confidence intervals for CE ratios. The bootstrap procedure is tested in a simulation study based on the assumptions made in a recent paper by Wakker and Klaassen in this journal. We test two variants of CE ratio bootstrap confidence intervals. The first is a bootstrap analogue of the parametric method proposed by Wakker and Klaassen which gives results similar to those obtained with the parametric method. However, computing bootstrap confidence intervals directly for the CE ratio produce results closer to the predetermined significance level.

Estimating the costs of hip fracture and potential savings.

This paper examines the determinants of hip fracture costs and further evaluates potential savings in costs when the occurrence of hip fracture is prevented. The costs of hip fracture are comprised of direct costs from health care and the social welfare system. Data were collected for 1,080 postmenopausal women admitted from private residence for primary hip fracture surgery during the year of 1992 in the city of Stockholm, Sweden. It was found that the cost of hip fracture is significantly related to age, mortality the year after a fracture, type of fracture, costs 1 year before a fracture, and hospital admission. The savings in direct costs for an average woman surviving the year after a fracture amount to SEK 210,000.

Willingness to pay for hormone replacement therapy.

This study addresses the question of willingness to pay (WTP) for hormone replacement therapy (HRT) in order to alleviate menopausal symptoms. The woman obtains utility from consumption of goods and health. The purchase of a treatment is represented as a shift in the health production function during the treatment period. The mean WTP for the HRT is estimated using a parametric and a non-parametric method. The mean WTP based on these two methods is similar in both cases and amounts to about SEK 40000 per year. Further, it is shown that the mean WTP is above the mean treatment cost of HRT. Finally, the implied WTP per gained quality adjusted life year (QALY) is estimated at about SEK 120000 and SEK 160000 based on the rating scale (RS) and time trade-off (TTO) methods, respectively.

The impact of hormone replacement therapy on quality of life and willingness to pay.

OBJECTIVE: To measure the gain in quality of life due to hormone replacement therapy for women with mild and severe menopausal symptoms. DESIGN: Prospective study where data on quality of life and willingness to pay were collected by interview. SETTING: Department of Gynaecology at Södertälje Hospital near Stockholm. PARTICIPANTS: One hundred and four women aged 45 to 65 years treated for menopausal symptoms for at least one month. METHODS: Quality of life was measured by the time tradeoff and rating scale methods. The willingness to pay for hormone replacement therapy was investigated using the contingent valuation method. MAIN OUTCOME MEASURES: The quality adjusted life year weight measured with the rating scale and time tradeoff methods, and willingness to pay. RESULTS: The increase in the quality adjusted life year weight due to hormone replacement therapy for women with mild symptoms was 0.26 according to the rating scale method and 0.18 according to the time tradeoff method. For women with severe symptoms the quality adjusted life year weight increased by 0.50 according to the rating scale method and by 0.42 according to the time tradeoff method. The mean willingness to pay for hormone replacement therapy per month was 2300 Swedish krone for women with mild symptoms and 4800 Swedish krone for women with severe symptoms (Pounds 1 = 10.3 Swedish krone). CONCLUSIONS: Hormone replacement therapy leads to a major improvement in quality of life for women with menopausal symptoms. Both for women with mild and severe menopausal symptoms the willingness to pay for the treatment also greatly exceeds the costs, indicating that hormone replacement therapy is economically beneficial for women with menopausal symptoms.

The cost of a hip fracture. Estimates for 1,709 patients in Sweden.

We calculated the costs related to hip fractures and estimated the potential cost savings from preventing hip fractures. Subjects for this retrospective study were 1,709 hip fracture patients admitted for a primary hip fracture during 1992 in Stockholm, Sweden. Direct costs were compiled for the services of hospital orthopedics, hospital geriatrics, nursing homes, home for the elderly, group living, other acute hospital care, and municipal home help. The direct costs per patient during 1 year after a fracture amounted to about USD 40,000. The county council was responsible for 59% of the direct costs during 1 year after a hip fracture, while the remaining 41% were referred to the municipality. In the morbidity group, the potential cost savings per patient from preventing hip fractures was about USD 22,000.

A cost-minimization analysis of laparoscopic cholecystectomy versus open cholecystectomy.

BACKGROUND: Earlier economic analyses have evaluated charges but not costs, and have not considered the cost of production losses associated with open and laparoscopic cholecystectomy. This study attempted to accomplish an economic evaluation of open versus laparoscopic cholecystectomy from the point of view of society. METHODS: A cost-minimization analysis, using a clinical decision model, was performed. The data used were taken from different clinical studies, Swedish national registers, local patient statistics, and hospital accounting systems. The direct and indirect costs were measured. RESULTS: Laparoscopic cholecystectomy resulted in cost savings per patient amounting to about 2,400 SEK (as of 31 August 1994, Pound = 11.90 SEK; $1 = 7.76 SEK) compared with open surgery. CONCLUSIONS: From the point of view of society, laparoscopic cholecystectomy was a cost-saving strategy if at least 68 patients were operated on yearly. However, with regard to hospital costs, open cholecystectomy was less expensive than laparoscopic cholecystectomy.

Value for money? A contingent valuation study of the optimal size of the Swedish health care budget.

The contingent valuation method has been developed in the environmental field to measure the willingness to pay for environmental changes using survey methods. In this exploratory study the contingent valuation method was used to analyse how much individuals are willing to spend in total in the form of taxes for health care in Sweden, i.e. to analyse the optimal size of the 'health care budget' in Sweden. A binary contingent valuation question was included in a telephone survey of a random sample of 1260 households in Sweden. With a conservative interpretation of the data the result shows that 50% of the respondents would accept an increased tax payment to health care of about SEK 60 per month ($1 = SEK 8). It is concluded that the results indicate that the population overall thinks that the current spending on health care in Sweden is on a reasonable level. There seems to be a willingness to increase the tax payments somewhat, but major increases does not seem acceptable to a majority of the population.