Systematic Review of the Cost of Illness of Parkinson's Disease from a Societal Perspective.

Previous reviews on the cost of illness (COI) of Parkinson's disease (PD) have often focused on health-care costs due to PD, underestimating its effects on other sectors. This systematic review determines the COI of PD from a societal perspective. The protocol was registered in PROSPERO (ID: CRD42023428937). Embase, Medline, and EconLit were searched up to October 12, 2023, for studies determining the COI of PD from a societal perspective. From 2812 abstracts, 17 studies were included. The COI of PD averaged €20,911.37 per patient per year, increasing to almost €100,000 in the most severely affected patients. Health-care costs accounted for 46.1% of total costs, followed by productivity loss (37.4%) and costs to patient and family (16.4%). The COI of PD strongly varied between different geographical regions, with costs in North America 3.6 times higher compared to Asia. This study is the first to identify the relative importance of different cost items. Most important were reduced employment, government benefits, informal care, medication, nursing homes, and hospital admission. There was strong variety in the cost items that were included, with 55.2% of cost items measured in fewer than half of articles. Our review shows that PD-COI is high and appears in various cost sectors, with strong variety in the cost items included in different studies. Therefore, a guideline for the measurement of COI in PD should be developed to harmonize this. This article provides a first step toward the development of such a tool by identifying which cost items are most relevant. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Assessing the Health and Welfare Benefits of Interventions Using the Wider Societal Impacts Framework.

OBJECTIVES: Health technology assessment bodies advocate capturing the value of interventions in terms of their benefits to health and broader welfare. The wider societal impacts (WSI) framework considers how changes in health alter a person's net contribution to society-that is, what they produce minus what they consume. In this research, we review this framework and explore the scope to differentiate WSI by equity-relevant sociodemographic characteristics. METHODS: This research updates previous calculations using publicly available data from population-based surveys in the United Kingdom. We then estimate for 199 chronic conditions: (1) WSI for the average person with the condition and (2) gain in WSI for an improvement of 0.1 in health-related quality of life score. RESULTS: The nature and availability of information varied across population-based surveys and precluded analyses to examine WSI by population subgroup. Our updated estimates mirrored earlier findings that consideration of the broader societal impacts of health would reprioritize interventions compared with assessment on health alone. For example, for the same improvement in health, a woman experiencing diseases of the circulatory system has the highest potential gain in WSI (£354/month) whereas a man experiencing HIV has the lowest potential gain (£233/month). CONCLUSIONS: The WSI framework provides a simple, indirect method to inform resource allocation decisions. Understanding the equity implications of this approach was hindered by differences in the information collected across population-based surveys. Findings demonstrate the potential reprioritization that may occur if the broader welfare benefits of health interventions were used to inform coverage decisions.

Pneumococcal Vaccination Strategies in 50-Year-Olds to Decrease Racial Disparities: A US Societal Perspective Cost-Effectiveness Analysis.

OBJECTIVES: This study assesses the impact of expanding pneumococcal vaccination to all 50-year-olds to decrease racial disparities by estimating from the societal perspective, the cost-effectiveness of 20-valent pneumococcal conjugate vaccine (PCV20) and 15-valent conjugate vaccine followed by 23-valent polysaccharide vaccine (PCV15/PPSV23) for 50-year-olds. METHODS: A Markov model compared the cost-effectiveness of PCV20 or PCV15/PPSV23 in all general population 50- and 65-years-olds compared with current US recommendations and with no vaccination in US Black and non-Black cohorts. US data informed model parameters. Pneumococcal disease societal costs were estimated using direct and indirect costs of acute illness and of pneumococcal-related long-term disability and mortality. Hypothetical 50-year-old cohorts were followed over their lifetimes with costs and effectiveness discounted 3% per year. Deterministic and probabilistic sensitivity analyses assessed model uncertainty. RESULTS: In Black cohorts, PCV20 for all at ages 50 and 65 was the least costly strategy and had greater effectiveness than no vaccination and current recommendation strategies, whereas PCV15/PPSV23 at 50 and 65 cost more than $1 million per quality-adjusted life year (QALY) gained compared with PCV20 at 50 and 65. In non-Black cohorts, PCV20 at 50 and 65 cost $62 083/QALY and PCV15/PPSV23 at 50 and 65 cost more than $1 million/QALY with current recommendations, again being more costly and less effective. In probabilistic sensitivity analyses, PCV20 at 50 and 65 was favored in 85.7% (Black) and 61.8% (non-Black) of model iterations at a $100 000/QALY gained willingness-to-pay threshold. CONCLUSIONS: When considering the societal costs of pneumococcal disease, PCV20 at ages 50 and 65 years in the general US population is a potentially economically viable strategy, particularly in Black cohorts.

A review of HTA guidelines on societal and novel value elements.

OBJECTIVES: Health technology assessment (HTA) organizations vary in terms of how they conduct assessments. We assess whether and to what extent HTA bodies have adopted societal and novel elements of value in their economic evaluations. METHODS: After categorizing "societal" and "novel" elements of value, we reviewed fifty-three HTA guidelines. We collected data on whether each guideline mentioned each societal or novel element of value, and if so, whether the guideline recommended the element's inclusion in the base case, sensitivity analysis, or qualitative discussion in the HTA. RESULTS: The HTA guidelines mention on average 5.9 of the twenty-one societal and novel value elements we identified (range 0-16), including 2.3 of the ten societal elements and 3.3 of the eleven novel value elements. Only four value elements (productivity, family spillover, equity, and transportation) appear in over half of the HTA guidelines, whereas thirteen value elements are mentioned in fewer than one-sixth of the guidelines, and two elements receive no mention. Most guidelines do not recommend value element inclusion in the base case, sensitivity analysis, or qualitative discussion in the HTA. CONCLUSIONS: Ideally, more HTA organizations will adopt guidelines for measuring societal and novel value elements, including analytic considerations. Importantly, simply recommending in guidelines that HTA bodies consider novel elements may not lead to their incorporation into assessments or ultimate decision making.

Cost of illness of chronic kidney disease in Lebanon: from the societal and third-party payer perspectives.

BACKGROUND: Chronic kidney disease (CKD) is the 12th leading cause of death worldwide. Cost-of-illness studies of CKD are scarce in developing countries. This study aims to estimate the cost of illness of all stages of CKD in Lebanon, from early stages until dialysis and kidney transplantation. The secondary objective is to identify factors related to the highest financial burden. METHODS: This is a cross-sectional study of CKD patients who presented to two nephrology clinics during November 2020. Their medical and administrative records were reviewed for collection of demographics, CKD characteristics, direct medical costs (medications, diagnostic tests, hospitalizations, inpatient care, outpatient care), direct non-medical costs (transportation) and indirect costs (productivity losses) for one year. Kruskal Wallis test was used to compare the costs between different CKD stages and categories. Logistic regression analysis was used to evaluate risk factors associated with costs. RESULTS: The sample included 102 non-dialysis CKD patients, 40 hemodialysis, 8 peritoneal dialysis and 10 transplant patients. Their mean age was 66.74 ± 15.36 years, 57.5% were males and 42.5% diabetics. The total median cost per year of CKD across all categories was assessed to be 7,217,500 Lebanese Pounds (3,750,000-35,535,250; 1 $USD = 1515 LBP in 2019) from the societal perspective and 5,685,500 LBP (2,281,750- 32,386,500) from the third-party payer perspective. Statistical analysis showed a higher total cost in hemodialysis (p < 0.001), higher cost of medications in transplant (p < 0.001) and higher cost in technique modality in peritoneal dialysis (p < 0.001). In a sub-analysis of hemodialysis patients, dialysis vintage negatively correlated with total societal cost (r = -0.391, p = 0.013); the regression analysis found diabetes as a risk factor for higher cost (OR = 2.3; 95%CI: 0.638,8.538; p = 0.201). In the subcategory of CKD-ND patients, age correlated with total societal cost (r = 0.323, p = 0.001); diabetes and coronary artery disease were significantly associated with higher total cost (OR = 2.4; 95%CI: 1.083,5.396; p = 0.031; OR = 3.7; 95%CI: 1.535,8.938; p = 0.004). CONCLUSIONS: This cost of illness study showed a high burden of hemodialysis and peritoneal dialysis cost compared to transplant and non-dialysis CKD patients. It revealed a significantly higher cost of medications in transplant patients. Health policies should target interventions that prevent end-stage kidney disease and encourage kidney transplantation.

Validity of data collection methods for time spent, professional involvement and treatment volume for the purpose of cost-effectiveness studies in dentistry.

OBJECTIVES: Economic evaluations can support provision of adequate and affordable oral care, requiring valid information on costs. The aim was to assess the validity of (a) patients' self-report (PS) and routine electronic patient records (EPR) regarding time spent per visit and (b) PS regarding types of treatment and type of dental professionals involved. METHODS: Data were collected in four dental clinics regarding time spent using PS and EPR, on types of treatment and dental professionals involved using PS. As reference standard for time spent, independent research assistants (RA) collected data on time per visit using stopwatches. As reference standard for types of treatment and of dental professionals involved, we used the dental clinic's Electronic Patient Files (DEPF). The two one-sided tests (TOST) equivalence procedure for the difference between paired means for time and kappa statistics for treatment and professional were used to assess agreement of data collection methods with the reference standards. RESULTS: Equivalence and agreement was good between (a) PS and RA registration concerning waiting time, appointment time and total time spent and (b) EPR and DEPF concerning appointment time. Agreement between PS and DEPF concerning types of treatment was moderate to fair (kappa values between 0.49 and 0.56 for preventive consultation, restoration, radiographs and extractions and between 0.15 and 0.26 for fluoride applications and sealants). Agreement between PS and DEPF for dental professional involved was fair (kappa = 0.41). CONCLUSIONS: Data collection regarding time using PS and EPR was valid. Data collection via PS on treatment and professionals involved were not sufficiently valid and should occur via DEPF.

Friction Costs and the Chain of Vacancies Problem: A Novel Vacancy Multiplier Solution.

OBJECTIVES: A key criticism of applying the friction cost approach (FCA) to productivity cost estimation is its focus on a single friction period. A more accurate estimate of the friction cost of worker absence requires consideration of the chain of secondary vacancies arising from the opening of a new primary vacancy. Currently, empirical evidence on this is almost absent. We suggest an original approach to empirically estimate productivity costs that include a chain of secondary vacancies. METHODS: The vacancy multiplier is based on labor market flows and transition probabilities between states of employment, unemployment, and economic inactivity. It is a summed infinite geometric series using a common ratio et - the probability of an employed person filling a new job vacancy in a given year. We report vacancy multipliers for 30 European countries for 2011-2019. RESULTS: The average multiplier across Europe is 2.21 (standard deviation [SD] = 0.40) in 2019, meaning that every new primary vacancy created a chain of secondary vacancies that increased the primary friction cost by a factor of 2.21. The equivalent multiplier is 1.99 (SD = 0.37) between 2011 and 2019. Romania had the lowest country-specific multiplier (1.11 in 2011), and Greece the highest (4.51 in 2011). CONCLUSIONS: Our results highlight the extent of underestimation of current FCA costs, comprise a resource for future researchers, and provide an implementable formula to compute the multiplier for other countries.

Modeling the Cost-Utility of Treatment Sequences for Multiple Sclerosis.

OBJECTIVES: Most patients with multiple sclerosis (MS) switch between disease-modifying therapies (DMTs) during their lifetime. Our aim was to develop an MS cost-utility model that takes treatment switching into account to provide a more realistic estimate of treatment benefit than previous models that assume lifetime use of 1 DMT. METHODS: A treatment sequence model using a microsimulation framework with a lifetime time horizon and a societal perspective was developed in R. Clinical plausibility and decision rules for switching were defined in consultation with Dutch MS neurologists. The ability of DMTs to prevent relapses and delay disease progression was modeled by applying DMT-specific estimates derived from a network meta-analysis of randomized controlled trials to natural history data. A total of 2 treatment strategies were compared: a first-line DMT sequence (peginterferon-glatiramer-teriflunomide-interferon-beta-dimethyl fumarate) and an escalation DMT sequence (peginterferon-glatiramer-ocrelizumab-natalizumab-alemtuzumab). Scenario analyses explored impact of alternative sources of natural history data, societal versus healthcare perspective, and condition-specific versus generic utilities. Predicted short-term switches (<5 years) were externally validated with Dutch claims data on DMT use. RESULTS: Short-term switches predicted by the model compared well with Dutch claims data. Transition from relapsing-remitting MS to secondary progressive MS was delayed by the escalation sequence (24.7 vs 20.3 years on first-line sequence). Model results were sensitive to utility values and medical resource consumption was a large driver of uncertainty. CONCLUSIONS: This microsimulation model overcomes the limitation of previous models by modeling treatment sequences. Because it better reflects clinical reality, it facilitates incorporating cost-utility information in clinical guidelines.

Cost and quality-of-life impacts of community treatment orders (CTOs) for patients with psychosis: economic evaluation of the OCTET trial.

PURPOSE: Current RCT and meta-analyses have not found any effect of community treatment orders (CTOs) on hospital or social outcomes. Assumed positive impacts of CTOs on quality-of-life outcomes and reduced hospital costs are potentially in conflict with patient autonomy. Therefore, an analysis of the cost and quality-of-life consequences of CTOs was conducted within the OCTET trial. METHODS: The economic evaluation was carried out comparing patients (n = 328) with psychosis discharged from involuntary hospitalisation either to treatment under a CTO (CTO group) or voluntary status via Section 17 leave (non-CTO group) from the health and social care and broader societal perspectives (including cost implication of informal family care and legal procedures). Differences in costs and outcomes defined as quality-adjusted life years (QALYs) based on the EQ-5D-3L or capability-weighted life years (CWLYs) based on the OxCAP-MH were assessed over 12 months (£, 2012/13 tariffs). RESULTS: Mean total costs from the health and social care perspective [CTO: £35,595 (SD: £44,886); non-CTO: £36,003 (SD: £41,406)] were not statistically significantly different in any of the analyses or cost categories. Mental health hospitalisation costs contributed to more than 85% of annual health and social care costs. Informal care costs were significantly higher in the CTO group, in which there were also significantly more manager hearings and tribunals. No difference in health-related quality of life or capability wellbeing was found between the groups. CONCLUSION: CTOs are unlikely to be cost-effective. No evidence supports the hypothesis that CTOs decrease hospitalisation costs or improve quality of life. Future decisions should consider impacts outside the healthcare sector such as higher informal care costs and legal procedure burden of CTOs.

The broader societal impacts of COVID-19 and the growing importance of capturing these in health economic analyses.

AbstractThe rapid spread of the current COVID-19 pandemic has affected societies worldwide, leading to excess mortality, long-lasting health consequences, strained healthcare systems, and additional strains and spillover effects on other sectors outside health (i.e., intersectoral costs and benefits). In this perspective piece, we demonstrate the broader societal impacts of COVID-19 on other sectors outside the health sector and the growing importance of capturing these in health economic analyses. These broader impacts include, for instance, the effects on the labor market and productivity, education, criminal justice, housing, consumption, and environment. The current pandemic highlights the importance of adopting a societal perspective to consider these broader impacts of public health issues and interventions and only omit these where it can be clearly justified as appropriate to do so. Furthermore, we explain how the COVID-19 pandemic exposed and exacerbated existing deep-rooted structural inequalities that contribute to the wider societal impacts of the pandemic.

Friction cost approach methodology in pharmacoeconomic analyses.

The use of a societal perspective in pharmacoeconomic analyses is a widely discussed topic. One of the fundamental problems of using the social perspective is the inconsistency of indirect costs calculation. We searched published articles on the use and differences of Human capital approach (HCA) and Friction cost approach (FCA) methods using the Web of Science database using keywords. We analyzed the information obtained from relevant publications. We obtained an overview of recommendations for the use of a social perspective in the world. We summarized and highlighted the necessary information about the differences between the FCA and HCA procedures. We have identified the key variables used in the FCA method when evaluating productivity cost, and we have proposed a procedure for obtaining them. We recommend creating a uniform methodology that could increase the comparison of individual analyses from different countries and contribute to data transferability.

Phenolic acids and antioxidant potential of Caragana frutex shoots.

The phenolic acid composition of flowering Caragana frutex shoots was analyzed by the HPLC method. The quantitative content of seven phenolic acids and their derivatives has been determined: gallic, p-hydroxyphenyl acetic, chlorogenic, caffeic, р-coumaric, trans-ferulic, and sinapic) acids. Sinapic acid (513.0 μg/g) and chlorogenic acid (98.4 μg/g) predominate among phenolic acid derivatives. The antioxidant activity of Caragana frutex shoots determined by the ABTS method equaled 9368.51 ± 30.07 μg/g expressed as Trolox equivalent.

Five pillars for societal perspective.

In economic evaluation, the healthcare perspective has gradually given way to use of the societal perspective, as this perspective is often advocated for support in making optimal societal decisions. In practice, economic evaluations conducted from the societal perspective ignore, fail to measure and/or fail to monetize many of the costs that fall outside of the healthcare sector. To limit bias and increase decision-supportive power, researchers could strengthen their evaluations by adhering to a few basic principles. Five "pillars for the societal perspective" are proposed. First, who bears the cost and who does not is irrelevant. Second, it is imperative to consider including costs for sectors outside the healthcare sector. Third, both high frequent costs and costs with high unit prices should be considered. Fourth, double counting should be avoided. And fifth, researchers should reflect on choices related to costs, i.e. cost omission and problems with identifying, measuring, and valuing costs.

Exploring the identification, validation, and categorization of the cost and benefits of criminal justice in mental health: the PECUNIA project.

BACKGROUND: Mental health disorders and their treatments produce significant costs and benefits in both healthcare and non-healthcare sectors. The latter are often referred to as intersectoral costs and benefits (ICBs). Little is known about healthcare-related ICBs in the criminal justice sector and how to include these in health economics research. OBJECTIVES: The triple aim of this study is (i) to identify healthcare-related ICBs in the criminal justice sector, (ii) to validate the list of healthcare-related ICBs in the criminal justice sector on a European level by sector-specific experts, and (iii) to classify the identified ICBs. METHODS: A scientific literature search in PubMed and an additional grey literature search, carried out in six European countries, were used to retrieve ICBs. In order to validate the international applicability of the ICBs, a survey was conducted with an international group of experts from the criminal justice sector. The list of criminal justice ICBs was categorized according to the PECUNIA conceptual framework. RESULTS: The full-text analysis of forty-five peer-reviewed journal articles and eleven grey literature sources resulted in a draft list of items. Input from the expert survey resulted in a final list of fourteen unique criminal justice ICBs, categorized according to the care atom. CONCLUSION: This study laid further foundations for the inclusion of important societal costs of mental health-related interventions within the criminal justice sector. More research is needed to facilitate the further and increased inclusion of ICBs in health economics research.

Future of Patients in Healthcare Evaluation: The Patient-Informed Reference Case.

The "Reference Case" was developed to facilitate comparability among published cost-effectiveness analyses intended to contribute to decisions about the broad allocation of healthcare resources. Although the societal perspective is recommended for Reference Case analyses, empirical estimations rarely adequately represent the patient perspective, and more often, healthcare system or payer perspectives are used. In this commentary, we discuss the evolution of the Reference Case over the past 20 years and how it now needs to further evolve. This should begin with a patient-informed societal perspective. A realignment of the societal perspective to better include patient perspectives in CEA creates a conduit for patient inclusion. Engaging patients to both derive patient-informed value elements and prioritize value elements using stated preference methods will lead to patient inclusion in the societal perspective and a patient-informed Reference Case analysis.

Value co-creation in healthcare: evidence from innovative therapeutic alternatives for hereditary angioedema.

BACKGROUND: Our research focuses on the co-creation of value in healthcare with reference to a case of hereditary angioedema with C1 inhibitor deficiency (C1-INH-HAE). Our work is mainly based on the concept of value co-creation in healthcare. The aim of this study is to assess the impact of an alternative treatment strategy - self-administration - by focusing on treatment outcomes and costs to understand if innovative therapeutic solutions can create value for patients and healthcare systems. METHODS: This paper compares home-based and hospital-based therapeutic strategies (independent of treatment type) with a cost minimization analysis. It encompasses compliance issues and focuses on both payer and societal perspectives, also benefiting from an operationalization of the service-dominant logic model for healthcare delivery. Data were collected over a 6-month period (August 2014-January 2015) through monthly patient interviews. Archival data were used for variable measurement. RESULTS: Thirty-nine out of 62 patients enrolled in the study, experienced at least one HAE attacks, equally distributed between home and hospital-based strategies. No evidence of correlation between therapeutic strategy and disease severity score (p = 0.351), compliance (p = 0.399), and quality of life (p = 0.971), were found. Total direct cost per attack amounts to € 1224 for home-based strategy with respect to € 1454 for hospital-based strategy, with a savings of € 230. The economic advantage of the home-based strategy almost doubles if the societal perspective was considered due to a further savings of €169 (less missed work/school days and no travel expenses). CONCLUSIONS: Our study suggests that home-based therapies represent a feasible strategy for managing C1-INH-HAE and may result in lower costs and increased value for both patients and the healthcare systems. The findings are relevant to the debate on and extend the extant literature to provide a broader view of value co-creation dynamics for home-based therapies in healthcare and their positive effects. The insights are relevant to practitioners and policy makers.

A participatory supportive return to work program for workers without an employment contract, sick-listed due to a common mental disorder: an economic evaluation alongside a randomized controlled trial.

BACKGROUND: Mental disorders are associated with high costs for productivity loss, sickness absence and unemployment. A participatory supportive return to work (RTW) program was developed in order to improve RTW among workers without an employment contract, sick-listed due to a common mental disorder. The program contained a participatory approach, integrated care and direct placement in a competitive job. The aim of this study was to evaluate the cost-effectiveness and cost-utility of this new program, compared to usual care. In addition, its return on investment was evaluated. METHODS: An economic evaluation was conducted alongside a 12-month randomized controlled trial. A total of 186 participants was randomly allocated to the new program (n = 94) or to usual care (n = 92). Effect measures were the duration until sustainable RTW in competitive employment and quality-adjusted life years (QALYs) gained. Costs included intervention costs, medical costs and absenteeism costs. Registered data of the Dutch Social Security Agency were used to assess the duration until sustainable RTW, intervention costs and absenteeism costs. QALYs and medical costs were assessed using three- or six-monthly questionnaires. Missing data were imputed using multiple imputations. Cost-effectiveness analysis and cost-utility analysis were conducted from the societal perspective. A return on investment analysis was conducted from the social insurer's perspective. Various sensitivity analyses were performed to assess the robustness of the results. RESULTS: The new program had no significant effect on the duration until sustainable RTW and QALYs gained. Intervention costs and medical costs were significantly higher in the intervention group. From the societal perspective, the maximum probability of cost-effectiveness for duration until sustainable RTW was 0.64 at a willingness to pay of about €10 000/day, and 0.27 for QALYs gained, regardless of the willingness to pay. From the social insurer's perspective, the probability of financial return was 0.18. CONCLUSIONS: From the societal perspective, the new program was neither cost-effective in improving sustainable RTW nor in gaining QALYs. From the social insurer's perspective, the program did not result in a positive financial return. Therefore, the present study provided no evidence to support its implementation. TRIAL REGISTRATION: The trial was listed at the Dutch Trial Register (NTR) under NTR3563 on August 7, 2012.

CONCEPTUALIZATIONS OF THE SOCIETAL PERSPECTIVE WITHIN ECONOMIC EVALUATIONS: A SYSTEMATIC REVIEW.

OBJECTIVES: The aim of this study was to investigate how the societal perspective is conceptualized in economic evaluations and to assess how intersectoral costs and benefits (ICBs), that is, the costs and benefits pertaining to sectors outside the healthcare sector, impact their results. METHODS: Based on a search in July 2015 using PubMed, Embase, CINAHL, and PsychINFO, a systematic literature review was performed for economic evaluations which were conducted from a societal perspective. Conceptualizations were assessed in NVivo version 11 using conventional and directed content analysis. Trial-based evaluations in the fields of musculoskeletal and mental disorders were analyzed further, focusing on the way ICBs impact the results of economic evaluations. RESULTS: A total of 107 studies were assessed, of which 74 (69.1 percent) provided conceptualizations of the societal perspective. These varied in types of costs included and in descriptions of cost bearers. Labor productivity costs were included in seventy-two studies (67.3 percent), while only thirty-eight studies (35.5 percent) included other ICBs, most of which entailed informal care and/or social care costs. ICBs within the educational and criminal justice sectors were each included five times. Most of the trial-based evaluations analyzed further (n = 21 of 28) reported productivity costs. In nine, these took up more than 50 percent of total costs. In several studies, criminal justice and informal care costs were also important. CONCLUSIONS: There is great variety in the way the societal perspective is conceptualized and interpreted within economic evaluations. Use of the term "societal perspective" is often related to including merely productivity costs, while other ICBs could be relevant as well.

Cost-effectiveness of medical primary prevention strategies to reduce absolute risk of cardiovascular disease in Tanzania: a Markov modelling study.

BACKGROUND: Cardiovascular disease (CVD) is a growing cause of mortality and morbidity in Tanzania, but contextualized evidence on cost-effective medical strategies to prevent it is scarce. We aim to perform a cost-effectiveness analysis of medical interventions for primary prevention of CVD using the World Health Organization's (WHO) absolute risk approach for four risk levels. METHODS: The cost-effectiveness analysis was performed from a societal perspective using two Markov decision models: CVD risk without diabetes and CVD risk with diabetes. Primary provider and patient costs were estimated using the ingredients approach and step-down methodologies. Epidemiological data and efficacy inputs were derived from systematic reviews and meta-analyses. We used disability- adjusted life years (DALYs) averted as the outcome measure. Sensitivity analyses were conducted to evaluate the robustness of the model results. RESULTS: For CVD low-risk patients without diabetes, medical management is not cost-effective unless willingness to pay (WTP) is higher than US$1327 per DALY averted. For moderate-risk patients, WTP must exceed US$164 per DALY before a combination of angiotensin converting enzyme inhibitor (ACEI) and diuretic (Diu) becomes cost-effective, while for high-risk and very high-risk patients the thresholds are US$349 (ACEI, calcium channel blocker (CCB) and Diu) and US$498 per DALY (ACEI, CCB, Diu and Aspirin (ASA)) respectively. For patients with CVD risk with diabetes, a combination of sulfonylureas (Sulf), ACEI and CCB for low and moderate risk (incremental cost-effectiveness ratio (ICER) US$608 and US$115 per DALY respectively), is the most cost-effective, while adding biguanide (Big) to this combination yielded the most favourable ICERs of US$309 and US$350 per DALY for high and very high risk respectively. For the latter, ASA is also part of the combination. CONCLUSIONS: Medical preventive cardiology is very cost-effective for all risk levels except low CVD risk. Budget impact analyses and distributional concerns should be considered further to assess governments' ability and to whom these benefits will accrue.

IS THE LINK BETWEEN HEALTH AND WEALTH CONSIDERED IN DECISION MAKING? RESULTS FROM A QUALITATIVE STUDY.

OBJECTIVES: The aim of this study was to explore whether wealth effects of health interventions, including productivity gains and savings in other sectors, are considered in resource allocations by health technology assessment (HTA) agencies and government departments. To analyze reasons for including, or not including, wealth effects. METHODS: Semi-structured interviews with decision makers and academic experts in eight countries (Australia, France, Germany, Italy, Poland, South Korea, Sweden, and the United Kingdom). RESULTS: There is evidence suggesting that health interventions can produce economic gains for patients and national economies. However, we found that the link between health and wealth does not influence decision making in any country with the exception of Sweden. This is due to a combination of factors, including system fragmentation, methodological issues, and the economic recession forcing national governments to focus on short-term measures. CONCLUSIONS: In countries with established HTA processes and methods allowing, in principle, the inclusion of wider effects in exceptional cases or secondary analyses, it might be possible to overcome the methodological and practical barriers and see a more systematic consideration of wealth effect in decision making. This would be consistent with principles of efficient priority setting. Barriers for the consideration of wealth effects in government decision making are more fundamental, due to an enduring separation of budgets within the public sector and current financial pressures. However, governments should consider all relevant effects from public investments, including healthcare, even when benefits can only be captured in the medium- and long-term. This will ensure that resources are allocated where they bring the best returns.