Changes in Inequality in Use of Maternal Health Care Services: Evidence from Skilled Birth Attendance in Mauritania for the Period 2007-2015.

Skilled birth attendance is critical to reduce infant and maternal mortality. Health development plans and strategies, especially in developing countries, consider equity in access to maternal health care services as a priority. This study aimed to measure and analyze the inequality in the use of skilled birth attendance services in Mauritania. The study identifies the inequality determinants and explores its changes over the period 2007−2015. The concentration curve, concentration index, decomposition of the concentration index, and Oaxaca-type decomposition technique were performed to measure socioeconomically-based inequalities in skilled birth attendance services utilization, and to identify the contribution of different determinants to such inequality as well as the changes in inequality overtime using data from Mauritania Multiple Indicator Cluster Surveys (MICS) 2007 and 2015. The concentration index for skilled birth attendance services use dropped from 0.6324 (p < 0.001) in 2007 to 0.5852 (p < 0.001) in 2015. Prenatal care, household wealth level, and rural−urban residence contributed most to socioeconomic inequality. The concentration index decomposition and the Oaxaca-type decomposition revealed that changes in prenatal care and rural−urban residence contributed positively to lower inequality, but household economic status had an opposite contribution. Clearly, the pro-rich inequality in skilled birth attendance is high in Mauritania, despite a slight decrease during the study period. Policy actions on eliminating geographical and socioeconomic inequalities should target increased access to skilled birth attendance. Multisectoral policy action is needed to improve social determinants of health and to remove health system bottlenecks. This will include the socioeconomic empowerment of women and girls, while enhancing the availability and affordability of reproductive and maternal health commodities. This policy action can be achieved through improving the availability of obstetric service providers in rural areas; ensuring better distribution and quality of health infrastructure, particularly health posts and health centers; and, ensuring user fees removal for equitable, efficient, and sustainable financial protection in line with the universal health coverage objectives.

Real-World Budget Impact of the Adoption of Insulin Glargine Biosimilars in Primary Care in England (2015-2018).

BACKGROUND: Lantus, the reference insulin glargine used for the treatment of diabetes, lost its patent protection in 2014, opening the market to biosimilar competitors. OBJECTIVE: First, to analyze the adoption rates of insulin glargine biosimilars in primary care in England and estimate the savings realized and missed, since an insulin glargine biosimilar was first used, and second, to assess potential variations in adoption rates across Clinical Commissioning Groups (CCGs). RESEARCH DESIGN AND METHODS: Data sets capturing information on all insulin glargine items prescribed by all general practitioners up to December 2018 were used. Total costs of insulin glargine and uptake rates of biosimilars were calculated. The real-world budget impact was estimated assuming the cost of reference insulin glargine for all items and comparing the total costs in this scenario with the total costs in the real world. The missed savings were estimated assuming the cost of biosimilars for all insulin glargine items. Choropleth maps were generated to assess potential variations in uptake across CCGs. RESULTS: Insulin glargine biosimilars generated savings of £900,000 between October 2015 (time of first prescription) and December 2018. The missed savings amounted to £25.6 million in this period, indicating that only 3.42% of the potential savings were achieved. The analyses demonstrated a large level of variation in the uptake of insulin glargine biosimilars across CCGs, with market shares ranging from 0 to 53.3% (December 2018). CONCLUSIONS: These results may encourage decision makers in England to promote the use of best-value treatments in primary care and to reevaluate variation across CCGs.

Inequalities in prescription rates of anti-osteoporosis drugs in primary care in England: A practice-level prescribing data analysis in 2013-2018.

OBJECTIVE: To investigate potential variations in prescription rates of anti-osteoporosis drugs at the general practitioner (GP) practice level in England, analysing associations of prescription rates with key demographic and socio-economic variables, and its evolution over time. METHODS: A retrospective database analysis was conducted using prescription data from all GP practices in England between April 2013 and September 2018. Potential associations between prescription rates and other variables (sex, age, ethnicity, rural-urban classification and income deprivation) were analysed using mixed-effects Poisson regressions and concentration indices. RESULTS: Alendronic acid was the most frequently prescribed anti-osteoporosis drug. Exploratory and regression analyses showed the association between GP prescriptions and the characteristics of the population they serve. Income deprivation had a statistically significant and negative effect on prescription levels of alendronic acid, denosumab, ibandronic acid and risedronate sodium. Since 2013, denosumab prescriptions exhibited a steep surge in the least income-deprived areas, compared with a modest rise in the most income-deprived areas. Concentration indices indicated a disproportionate concentration of denosumab and, to a lesser extent, ibandronic acid prescriptions among the least income-deprived. The analyses demonstrated that different prescribing behaviours may exist across GPs according to the Clinical Commissioning Group (CCG) to which they belong. CONCLUSIONS: Variation in the prescription of anti-osteoporosis drugs exists across GPs and CCGs in England, this being more prominent for certain drugs (e.g. denosumab) compared with others (e.g. alendronic acid). Inequalities exist in English primary healthcare and we advocate our findings could support the efforts of decision-makers towards a more equitable system.

The Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) questionnaire. A validation study with Spanish schizophrenia spectrum outpatients.

INTRODUCTION: The Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) is a disease-specific subjective Quality of Life (QL) questionnaire for patients with schizophrenia. This study assesses the psychometric properties of the SQLS-R4 when applied to a sample of Spanish schizophrenia spectrum outpatients with stable disease. METHODS: The SQLS-R4 and EUROQOL-5D-5L were completed once by 168 schizophrenia and schizoaffective disorder patients. Of these, 61 also completed the WHOQOL-BREF and 50 completed the SQLS-R4 one week later. Psychometric evaluation of structure, reliability and validity was conducted. RESULTS: Multi-trait scaling confirmed the two multiitem scales. Internal consistency for the two scales (Cronbach’s coefficients>0.89) and the whole questionnaire (0.96) was adequate, as was test–retest reliability (intraclass correlation coefficients>0.79). Correlations with related areas of EUROQOL-5D-5L and WHOQOL-BREF (Spearman’s Rho>0.60) supported convergent validity. Divergent validity was confirmed through low correlations with less-related areas of these two questionnaires (Spearman’s Rho<0.30). Patients with higher levels of depression, more acute episodes and schizoaffective disorder had higher QL limitations. CONCLUSIONS: The SQLS-R4 is a reliable and valid instrument when applied to Spanish outpatients with stable disease. The results of our validation study concur with those of other psychometric studies performed in Europe and other cultural areas.

El cuestionario Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4). Estudio de validación con pacientes españoles ambulatorios del espectro de la esquizofrenia / The Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) questionnaire. A validation study with Spanish schizophrenia spectrum outpatients

Introducción. El cuestionario Schizophrenia Quality of Life Scale Revision-4 (SQLS-R4) es una escala de Calidad de Vida (CV) subjetiva específica para pacientes con esquizofrenia. El presente estudio evalúa sus propiedades psicométricas en una muestra de pacientes ambulatorios españoles del espectro de la esquizofrenia con enfermedad estable. Metodología. Los cuestionarios SQLS-R4 y EURO-QOL-5D-5L fueron completados una vez por 168 pacientes con esquizofrenia y trastorno esquizoafectivo. De ellos, 61 también contestaron el WHOQOL-BREF, y 50 el SQLS-R4 una semana después. Se ha realizado una evaluación psicométrica de su estructura, fiabilidad y validez. Resultados. El análisis multirrasgo-multimétodo confir-ma las dos escalas multi-Items. La consistencia interna de las dos escalas (coeficiente de Cronbach>0,89) y del cuestionario global (0,96) y la fiabilidad test-retest (coeficiente de correlación intraclase>0,79) han sido adecuadas. Las correlaciones con áreas relacionadas del EUROQOL-5D-5L y del WHOQOL-BREF (Spearman-Rho>0,60) y con áreas menos relacionadas de estos dos cuestionarios (<0,30) apoyan la validez convergente y divergente. Pacientes con más ingresos hospitalarios, mayor nivel de depresión y con un diagnóstico de trastorno esquizoafectivo han presentado puntuaciones más altas de CV (mayores limitaciones). Conclusiones. El cuestionario SQLS-R4 es un instrumento fiable y válido en su aplicación a pacientes ambulatorios españoles con enfermedad estable. Los resultados de nuestro estudio de validación coinciden con los de otros estudios psicométricos realizados en Europa y otras áreas culturales

Introduction. The Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) is a disease-specific subjective Quality of Life (QL) questionnaire for patients with schizophrenia. This study assesses the psychometric properties of the SQLS-R4 when applied to a sample of Spanish schizophrenia spectrum outpatients with stable disease. Methods. The SQLS-R4 and EUROQOL-5D-5L were com-pleted once by168 schizophrenia and schizoaffective disorder patients. Of these, 61 also completed the WHOQOL-BREF and 50 completed the SQLS-R4 one week later. Psychometric evaluation of structure, reliability and validity was con-ducted. Results. Multi-trait scaling confirmed the two multi-item scales. Internal consistency for the two scales (Cronbach’s coefficients>0.89) and the whole questionnaire (0.96) was adequate, as was test-retest reliability (intraclass correlation coefficients>0.79). Correlations with related areas of EUROQOL-5D-5L and WHOQOL-BREF (Spearman’s Rho>0.60) supported convergent validity. Divergent validity was confirmed through low correlations with less-related areas of these two questionnaires (Spearman’s Rho<0.30). Patients with higher levels of depression, more acute episodes and schizoaffective disorder had higher QL limitations. Conclusions. The SQLS-R4 is a reliable and valid instrument when applied to Spanish outpatients with stable disease. The results of our validation study concur with those of other psychometric studies performed in Europe and other cultural areas

How the relationship between physical activity and health changes with age.

In the context of age-related declines in physical activity (PA) and the dramatic increase in ageing populations in many countries, this paper sheds further light on the link between PA and self-perceived health (SPH) by examining whether the magnitude of this relationship is age specific. With a sample of 14,456 Spanish individuals aged 18-69, we estimated three levels of intensity in PA using the International Physical Activity Questionnaire. Individuals who did more PA per week showed higher levels of SPH (ß = 0.28; 95% CI 0.24-0.32), and age moderated this relationship, with a positive effect over age 49. People aged 50-59 and 60-69 who practiced PA had higher probabilities of better SPH compared with those aged 40-49 (ß = 0.14; 95% CI 0.04-0.24) and (ß = 0.32; 95% CI 0.21-0.43), respectively. This association between PA and SPH also depended on the intensity of PA, especially for walking (ß = 0.14; 95% CI 0.04-0.24). In particular, in comparison with people age 40-49, a statistically significant relationship with SPH was found among people age 50-59 who walked (ß = 0.22; 95% CI 0.07-0.36) and people age 60-69 who did moderate PA (ß = 0.38; 95% CI 0.23-0.54). This paper provides a major rationale for the design, organisation and implementation of public policies promoting PA and healthy ageing for different age groups.

Valuation and Modeling of EQ-5D-5L Health States Using a Hybrid Approach.

BACKGROUND: The EQ-5D instrument is the most widely used preference-based health-related quality of life questionnaire in cost-effectiveness analysis of health care technologies. Recently, a version called EQ-5D-5L with 5 levels on each dimension was developed. This manuscript explores the performance of a hybrid approach for the modeling of EQ-5D-5L valuation data. METHODS: Two elicitation techniques, the composite time trade-off, and discrete choice experiments, were applied to a sample of the Spanish population (n=1000) using a computer-based questionnaire. The sampling process consisted of 2 stages: stratified sampling of geographic area, followed by systematic sampling in each area. A hybrid regression model combining composite time trade-off and discrete choice data was used to estimate the potential value sets using main effects as starting point. The comparison between the models was performed using the criteria of logical consistency, goodness of fit, and parsimony. RESULTS: Twenty-seven participants from the 1000 were removed following the exclusion criteria. The best-fitted model included 2 significant interaction terms but resulted in marginal improvements in model fit compared to the main effects model. We therefore selected the model results with main effects as a potential value set for this methodological study, based on the parsimony criteria. The results showed that the main effects hybrid model was consistent, with a range of utility values between 1 and -0.224. CONCLUSION: This paper shows the feasibility of using a hybrid approach to estimate a value set for EQ-5D-5L valuation data.

Cost analysis and cost-benefit analysis of a medication review with follow-up service in aged polypharmacy patients.

BACKGROUND: Drug related problems have a significant clinical and economic burden on patients and the healthcare system. Medication review with follow-up (MRF) is a professional pharmacy service aimed at improving patient's health outcomes through an optimization of the medication. OBJECTIVE: To ascertain the economic impact of the MRF service provided in community pharmacies to aged polypharmacy patients comparing MRF with usual care, by undertaking a cost analysis and a cost-benefit analysis. METHODS: The economic evaluation was based on a cluster randomized controlled trial. Patients in the intervention group (IG) received the MRF service and the comparison group (CG) received usual care. The analysis was conducted from the national health system (NHS) perspective over 6 months. Direct medical costs were included and expressed in euros at 2014 prices. Health benefits were estimated by assigning a monetary value to the quality-adjusted life years. One-way deterministic sensitivity analysis was undertaken in order to analyse the uncertainty. RESULTS: The analysis included 1403 patients (IG: n = 688 vs CG: n = 715). The cost analysis showed that the MRF saved 97 € per patient in 6 months. Extrapolating data to 1 year and assuming a fee for service of 22 € per patient-month, the estimated savings were 273 € per patient-year. The cost-benefit ratio revealed that for every 1 € invested in MRF, a benefit of 3.3 € to 6.2 € was obtained. CONCLUSION: The MRF provided health benefits to patients and substantial cost savings to the NHS. Investment in this service would represent an efficient use of healthcare resources.

Incentives and intrinsic motivation in healthcare / Incentivos y motivación intrínseca en la sanidad

Objective: It has been established in the literature that workers within public organisations are intrinsically motivated. This paper is an empirical study of the healthcare sector using methods of qualitative analysis research, which aims to answer the following hypotheses: 1) doctors are intrinsically motivated; 2) economic incentives and control policies may undermine doctors’ intrinsic motivation; and 3) well-designed incentives may encourage doctors’ intrinsic motivation. Method: We conducted semi-structured interviews à-la-Bewley with 16 doctors from Navarre's Healthcare Service (Servicio Navarro de Salud-Osasunbidea), Spain. The questions were based on current theories of intrinsic motivation and incentives to test the hypotheses. Interviewees were allowed to respond openly without time constraints. Relevant information was selected, quantified and analysed by using the qualitative concepts of saturation and codification. Results: The results seem to confirm the hypotheses. Evidence supporting hypotheses 1 and 2 was gathered from all interviewees, as well as indications of the validity of hypothesis 3 based on interviewees’ proposals of incentives. Conclusions: The conclusions could act as a guide to support the optimal design of incentive policies and schemes within health organisations when healthcare professionals are intrinsically motivated (AU)

Objetivo: Ha sido establecido por la literatura que los trabajadores de las organizaciones públicas están intrínsecamente motivados. Este trabajo es un estudio empírico en el sector sanitario que utiliza métodos de investigación del análisis cualitativo, cuyo objetivo es tratar de dar respuesta a las siguientes hipótesis: 1) los médicos son agentes motivados intrínsecamente, 2) los incentivos económicos y las políticas de control pueden minar la motivación intrínseca de los médicos, y 3) los incentivos bien diseñados pueden impulsar la motivación intrínseca de los médicos. Método: Realizamos entrevistas semiestructuradas à-la-Bewley a 16 médicos del Servicio Navarro de Salud-Osasunbidea. Las preguntas fueron diseñadas siguiendo las teorías existentes sobre motivación intrínseca e incentivos, y con el objetivo de responder a las hipótesis planteadas. Los entrevistados tuvieron la oportunidad de contestar a las preguntas sin restricción de tiempo. La información relevante para el objetivo del estudio fue seleccionada, cuantificada y analizada siguiendo los conceptos cualitativos de codificación y saturación. Resultados: Los resultados parecen confirmar las hipótesis formuladas. Todos los entrevistados aportaron evidencia indicando la validez de las hipótesis 1 y 2. También se obtuvieron diferentes propuestas de incentivos por parte de todos los entrevistados que indican la validez de la hipótesis 3. Conclusiones: Las conclusiones pueden ser una guía en el diseño de sistemas y políticas de incentivos óptimos en el seno de las organizaciones sanitarias cuando los profesionales médicos están intrínsecamente motivados (AU)

Incentives and intrinsic motivation in healthcare.

OBJECTIVE: It has been established in the literature that workers within public organisations are intrinsically motivated. This paper is an empirical study of the healthcare sector using methods of qualitative analysis research, which aims to answer the following hypotheses: 1) doctors are intrinsically motivated; 2) economic incentives and control policies may undermine doctors' intrinsic motivation; and 3) well-designed incentives may encourage doctors' intrinsic motivation. METHOD: We conducted semi-structured interviews à-la-Bewley with 16 doctors from Navarre's Healthcare Service (Servicio Navarro de Salud-Osasunbidea), Spain. The questions were based on current theories of intrinsic motivation and incentives to test the hypotheses. Interviewees were allowed to respond openly without time constraints. Relevant information was selected, quantified and analysed by using the qualitative concepts of saturation and codification. RESULTS: The results seem to confirm the hypotheses. Evidence supporting hypotheses 1 and 2 was gathered from all interviewees, as well as indications of the validity of hypothesis 3 based on interviewees' proposals of incentives. CONCLUSIONS: The conclusions could act as a guide to support the optimal design of incentive policies and schemes within health organisations when healthcare professionals are intrinsically motivated.

El EQ-5D como medida de resultados en salud / The EQ-5D as a measure of health outcomes

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Cost-effectiveness analysis of the surgical treatment of female urinary incontinence using slings and meshes.

OBJECTIVE: To determine the cost-utility and cost-effectiveness of the surgical treatment of female urinary incontinence using suburethral slings and prolapse meshes compared with therapeutic abstention. STUDY DESIGN: An economic analysis was performed on 69 women receiving surgical treatment for urinary incontinence using suburethral slings and prolapse meshes. To calculate the procedure's cost-effectiveness, an incremental analysis up to one year was performed using the incremental cost-effectiveness ratio (ICER). The costs were calculated using a cost-by-process model. Answers to the health-related quality of life questionnaires EQ-5D (generic) and International Consultation Incontinence Questionnaire Short-form (specific) were collected before the operation and as well as one month and one year post-operation to calculate the utility, using quality-adjusted life years (QALY), and the effectiveness, respectively. To complete the economic evaluation, we derived confidence ellipses and acceptability curves. The analysis was conducted for the entire sample and also for each type of urinary incontinence. RESULTS: In total, 45 women presented with stress incontinence, 15 with mixed incontinence and 9 with incontinence associated with prolapse. The average cost per patient at one year post-operation was 1220 €. The QALY achieved at one year was 0.046. The results reveal an ICER at one year of 26,288 €/QALY, which is below the cost-effectiveness threshold considered acceptable, and this value was lower for stress incontinence (21,191 €/QALY). The cost-effectiveness was 106.5 €/International Consultation Incontinence Questionnaire Short-form unit. CONCLUSION: Surgery for female urinary incontinence using slings is cost-effective compared with abstention in our public health environment.

The cost of generalized anxiety disorder in primary care settings: results of the ANCORA study.

To assess the cost of illness of generalized anxiety disorder (GAD) in a primary healthcare setting in Spain. A cross-sectional, retrospective study was conducted. The sample comprised patients diagnosed with GAD according to ICD-10 criteria and a control group. Healthcare/non-healthcare resource utilization was recorded retrospectively for the 12 months prior to the study visit. Costs were estimated from a societal perspective. Two models have been produced to study the variables that influence the cost of the illness both, without and with controls. The study enrolled 456 patients [76.8 % women, 49.2 (17.0) years] with GAD and 74 controls without GAD [42.5 % women, 47.9 (16.7) years]. 67.8 % of subjects were on combination therapy (antidepressant + anxiolytic); 6 % were using 2 or more drugs to treat anxiety; and 23.4 % were on monotherapy. Total annual average costs were higher in the GAD group (€7,739 vs. €2,609), with mean costs attributable to GAD of €5,139 (healthcare costs: €1,329, indirect costs: 75 % of total cost, approximately). Age and health status measured by Hamilton Anxiety Rating Scale and clinical global impression were related to costs. The improvements in quality of life measured by EQ-5D index are associated to lower cost. GAD treated in Spanish primary healthcare settings generated considerable healthcare costs and, particularly, loss-of-productivity costs.

Measuring health-related quality of life in drug clinical trials: is it given due importance?

AIM OF THE REVIEW: Efficacy estimations of drug clinical trials have been based on clinical measurements and survival rates. However, advances in psychometric techniques have allowed to incorporate a new dimension based on quality of life. Questionnaires aimed at measuring patients' health status outlook, now enable us to quantify the loss of quality of life caused by disease and the improvement that can be achieved by pharmacological treatments. The Aim of this study is to make a quantitative evaluation of the use of health related quality of life (HRQL) measures in drug clinical trials. METHODS: A systematic review was performed, in duplicate, of the five journals with highest contribution to the ACP Journal Club, i.e. New England Journal of Medicine, JAMA, The Lancet, Annals of Internal Medicine and the British Medical Journal. HRQL measures were evaluated in published articles referring to drug clinical trials. RESULTS: We identified 193 articles that reported the results of clinical trials, of which 28 included QOL measures as secondary end points and two as primary end points: in total, these comprised 16% of the articles analysed. Discussion Without considering the relevance of HRQL measures as a tool in the allocation of resources, it should be included as a health outcome dimension in drug clinical trials. The absence of this evaluation in studies about chronic diseases that affects patients' daily life activities would not be justified. CONCLUSIONS: HRQL measures are not used on a regular basis in drug clinical trials that are reported in the relevant literature. Systematic incorporation of QOL measures into clinical trials would make it possible to measure the benefit obtained from drug treatments taking into account the patients' perceptions. Moreover, it would encourage the development of prospective cost-effectiveness studies with patient recorded data in the context of clinical trials. Our findings have a direct impact on practice. Being conscious of the low use of HRQL in clinical trials, it could contribute to increase the demand for these measures by health care professionals. The manuscript is also a useful tool to identify where basic concepts about HRQL measures can be found.

An analysis of the costs of treating schizophrenia in Spain: a hierarchical Bayesian approach.

BACKGROUND: Health care decisions should incorporate cost of illness and treatment data, particularly for disorders such as schizophrenia with a high morbidity rate and a disproportionately low allocation of resources. Previous cost of illness analyses may have disregarded geographical aspects relevant for resource consumption and unit cost calculation. AIMS: To compare the utilisation of resources and the care costs of schizophrenic patients in four mental-health districts in Spain (in Madrid, Catalonia, Navarra and Andalusia), and to analyse factors that determine the costs and the differences between areas. METHODS: A treated prevalence bottom-up three year follow-up design was used for obtaining data concerning socio-demography, clinical evolution and the utilisation of services. 1997 reference prices were updated for years 1998-2000 in euros. We propose two different scenarios, varying in the prices applied. In the first (Scenario 0) the reference prices are those obtained for a single geographic area, and so the cost variations are only due to differences in the use of resources. In the second situation (Scenario 1), we analyse the variations in resource utilisation at different levels, using the prices applicable to each healthcare area. Bayesian hierarchical models are used to discuss the factors that determine such costs and the differences between geographic areas. RESULTS: In scenario 0, the estimated mean cost was 4918.948 euros for the first year. In scenario 1 the highest cost was in Gava (Catalonia) and the lowest in Loja (Andalusia). Mean costs were respectively 4547.24 and 2473.98 euros. With respect to the evolution of costs over time, we observed an increase during the second year and a reduction during the third year. Geographical differences appeared in follow-up costs. The variables related to lower treatment costs were: residence in the family household, higher patient age and being in work. On the contrary, the number of relapses is directly related to higher treatment costs. No differences were observed between health areas concerning resource utilisation. DISCUSSION: Calculating the costs of a given disease involves two principal factors: the resource utilisation and the prices. In most studies, emphasis is placed on the analysis of resource utilisation. Other evaluations, however, have recognized the implications of incorporating different prices into the final results. In this study we show both scenarios. The factors that determine the cost of schizophrenia for the Spanish case are similar to the factors encountered in studies carried out in other countries. IMPLICATIONS FOR HEALTH POLICIES: Treatment costs may be reduced by the prevention of psychotic symptoms and relapse. IMPLICATIONS FOR FUTURE RESEARCH: The use of the same price data in multicentre studies may not be realistic. More effort should be made to obtain price data from all the centres or countries participating in a study. In the present study, only direct healthcare and social costs have been included. Future research should consider informal and indirect costs.

Estimating the impact of hepatitis C virus therapy on future liver-related morbidity, mortality and costs related to chronic hepatitis C.

BACKGROUND/AIMS: Chronic Hepatitis C virus (HCV) infection is common and often produces a progressive disease. Some studies suggest that HCV related complications will increase in the future. Our aim was to estimate the future morbidity, mortality and costs of chronic HCV infection in a cohort of patients infected by HCV and to evaluate the impact of HCV therapy. METHODS: A mathematical model was used to project over the next 30 years, the HCV related complications and costs in a cohort of 419,895 infected patients representing the HCV infected population in Spain. The impact of HCV therapy with peginterferon and ribavirin in this population was also projected. RESULTS: A gradual decline in the infected population is expected in the future, however, the proportion of patients with cirrhosis will increase by up to 14% and morbidity associated with HCV infection by up to 10% by the year 2030 with a subsequent increment in HCV related costs. However, treating from 10 to 50% of the HCV population will result in a reduction of 6 and 26% in morbidity and 4 and 20% in mortality, respectively. The cost per year of life gained ranges from 6078 for a 29-year-old patient to 8911 for a 59-year-old patient. CONCLUSIONS: In the future, HCV infection mortality, morbidity and associated costs will increase. Treatment of the chronic HCV infected population can eradicate the infection, increase patients' survival and reduce the need for liver transplantation, making this a cost-effective strategy.

Self-perceived health status of schizophrenic patients in Spain: analysis of geographic differences.

This report explores the use of regression models for estimating health status of schizophrenic patients from a Bayesian perspective. The aims are: to obtain a set of values of health states of the EQ-5D based on self-assessed health from a sample of schizophrenic patients; and to analyze the differences in the health status and in patients' perceptions of their health status between four mental health districts in Spain. The authors develop two linear models with dummy variables. The first model seeks to obtain an index of the health status of the patients using a visual analog scale as a dependent variable and the different dimensions of EQ-5D as regressors. The second model enables analysis of the differences between the self-assessed health status in the different geographic areas and also the differences between the patients' self-assessed health states, irrespective of their actual health state, in the different geographic areas. The analysis is done using a Bayesian approach with Gibbs sampling (computer program WinBUGS 1.4). Data concerning self-assessed EQ-5D with visual analog scale from four geographic areas of schizophrenic patients were obtained for the purposes of this analysis. The health status index for this sample was obtained and the differences for this index between the four geographic areas were analyzed. The study reveals variables that explain the differences in patients' health status and health state assessment. Four possible scenarios are considered.

Costs and effectiveness of a syringe distribution and needle exchange program for HIV prevention in a regional setting.

This study assessed the costs and effectiveness of an HIV prevention program based on the distribution of anti-AIDS kits and a needle exchange service which has been in operation in Navarra, Spain, since 1993. Total costs of the program, including production, storage, distribution, and management, were estimated. Effectiveness, defined as the number of averted HIV infections among injection drug users due exclusively to needle use patterns was calculated as a function of the level of coverage of the program using a mathematical model. The estimated number of averted HIV infections ranged from 7.59 (in 1995) to 1.23 (in 2000). Yearly incremental cost-effectiveness ratios (ICER) ranged from euro 8,331 (in 1994) to euro 44,287 (in 2000) per HIV infection averted. With the health care costs of treating an HIV infection estimated at euro 99,371, the program has been cost-saving every year throughout the period considered. One-way sensitivity analysis was performed for five uncertain parameters. The results confirmed our findings. We conclude that this program was cost-saving from the health care system perspective.