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Non-pharmaceutical interventions aimed at reducing the spread of COVID-19 rely largely on voluntary compliance among the target population to be effective, since such measures, which are aimed at the entire population, are very hard to enforce. In this paper, we focus on the impact of different work ethics on the spread of COVID-19. There are indeed reasons to believe that populations with different attitudes toward work will react differently to stay-at-home orders and other policies that forbid people from working. By means of a quantitative analysis, using hybrid model estimators, we test the impact of different work ethics on COVID-19 diffusion in a sample of 30 European countries. Results show that the more a population holds certain beliefs about work-namely, that it is humiliating to receive money without working, that people who do not work become lazy, and that work always comes first-the higher contagion rates of COVID-19 are, ceteris paribus. On the other hand, the more a population perceives work as a social duty, the lower contagion rates are. All this suggests that different work ethics matter in the containment of COVID-19.

This paper examines the role of institutions—notably the degree of administrative decentralisation across levels of government—in health care decision-making and health spending as well as life expectancy. The empirical analysis builds on a new methodology to analyse health sector performance. In particular, the present analysis examines the impact of centralisation versus decentralisation of responsibilities across levels of government, making use of newly collected data on governance and expenditure assignment, as well as non-linear empirical specifications. An interlocking U-shaped relationship is found with respect to expenditure and life expectancy. Under moderate decentralisation, public spending in health care is lower, while life expectancy is higher, compared with more centralised systems; however, in highly decentralised systems, public spending is higher and life expectancy is lower. This finding of a “fish-shaped” relationship for decentralisation and outcomes also helps to understand recent reforms of OECD health systems, which have often reverted towards more moderate degrees of administrative decentralisation. Supplementary Information The online version contains supplementary material available at 10.1007/s10198-021-01390-1.

This paper proposes a first monetary measure of the private costs of celiac disease, including intangible costs (physical symptoms, logistical constraints, etc.) in Switzerland. This auto-immune disease damages the intestine when patients ingest gluten. The only treatment currently available is a gluten-free diet, which implies great nutritional constraints. To get a monetary equivalent of the costs borne by celiac patients, we used a contingent valuation. The scenario suggested to celiac patients a treatment in form of a daily pill, which would allow them to eat normally and avoid any physical pain from celiac disease. Mean Willingness To Pay (WTP) for the treatment is found to be around CHF 87 (approx. USD 87) per month. WTP is positively influenced by direct and indirect costs of the disease. Oppositely, individuals, who find the gluten-free diet healthier are willing to pay less. Finally, unlike symptoms before diagnostic, the current presence or intensity of physical symptoms are found to be insignificant. The latter result can be explained by the fact that, individuals facing stronger symptoms are more likely to adhere strictly to the GFD and hence to reduce their frequency.

In this paper, we examine the variation in the outbreak of COVID-19 across departments in continental France. We use information on the cumulated number of deaths, discharged patients and infections from COVID-19 at the department level, and study how these relate to income inequality, controlling for other factors. We find that unfortunately, inequality kills: departments with higher income inequality face more deaths, more discharged (gravely ill) patients and more infections. While other papers have studied the impact of the level of income on the severity of COVID-19, we find that it is in fact the dispersion across incomes within the same department that drives the results. Our results suggest that individuals in relatively more precarious conditions deserve dedicated policies, to avoid that temporary shocks such as COVID-19 lead to permanent increases in inequality.

The aim of this paper is to examine generic competition in the UK, with a special focus on the role of Health Technology Assessment (HTA) on generic market entry and diffusion. In the UK, where no direct price regulation on pharmaceuticals exists, HTA has a leading role for recommending the use of medicines providing a non-regulatory aspect that may influence the dynamics in the generic market. The paper focuses on the role of Technology Appraisals issued by the National Institute for Health and Care Excellence (NICE). We follow a two-step approach. First, we examine the probability of generic entry. Second, conditional on generic entry, we examine the determinants of generic market share. We use data from IQVIA British Pharmaceutical Index (BPI) for the primary care market for 60 products that lost patent between 2003 and 2012. Our results suggest that market size remains one of the main drivers of generic entry. After controlling for market size, intermolecular substitution and difficulty of manufacturing increase the likelihood of generic entry. After generic entry, our estimates suggest that generic market share is highly state dependent. Our findings also suggest that while NICE recommendations do influence generic uptake, there is only marginal evidence they affect generic entry.

The COVID-19 has been a worldwide pandemic and it needs for studies related to effect on people's demand for insurance during the pandemic which is an important way to transfer risk. However, there is a lack of research linking COVID-19 and people's demand for insurance. The objective of this paper is to investigate the impact of COVID-19 pandemic on issuance demand, using data covering 241 cities on confirmed COVID-19 cases and insurance company revenue in China. The empirical results show that more confirmed COVID-19 cases are associated with greater per capita insurance revenue and the results are robust when considering endogeneity concern. Economically, the per capita insurance revenue increases by 0.896 Yuan for each more confirmed case. In terms of insurance type, the greatest increased insurance revenue is for life insurance, followed by health insurance. We further consider the heterogeneity of regions and find that the impact of COVID-19 on insurance revenue only exists in regions with worse medical treatment conditions or higher medical burden.

Hospital quality indicators provide valuable insights for quality improvement, empower patients to choose providers, and have become a cornerstone of value-based payment. As outcome indicators are cumbersome and expensive to measure, many health systems have relied on proxy indicators, such as structure and process indicators. In this paper, we assess the extent to which publicly reported structure and process indicators are correlated with outcome indicators, to determine if these provide useful signals to inform the public about the outcomes. Quality indicators for three conditions (breast and colorectal cancer, and hip replacement surgery) for Dutch hospitals (2011–2018) were collected. Structure and process indicators were compared to condition-specific outcome indicators and in-hospital mortality ratios in a between-hospital comparison (cross-sectional and between-effects models) and in within-hospital comparison (fixed-effects models). Systematic association could not be observed for any of the models. Both positive and negative signs were observed where negative associations were to be expected. Despite sufficient statistical power, the share of significant correlations was small [mean share: 13.2% (cross-sectional); 26.3% (between-effects); 13.2% (fixed-effects)]. These findings persisted in stratified analyses by type of hospital and in models using a multivariate approach. We conclude that, in the context of compulsory public reporting, structure and process indicators are not correlated with outcome indicators, neither in between-hospital comparisons nor in within-hospital comparisons. While structure and process indicators remain valuable for internal quality improvement, they are unsuitable as signals for informing the public about hospital differences in health outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s10198-021-01333-w.

This paper asks whether marriage decisions of unmarried mature couples are driven by the prospect of financial advantages for the later widowed after one partner has suffered a serious health shock. We hypothesize that, in contrast to traditional marriage models, such health shocks may induce unmarried couples to obtain economic benefits, such as survivors’ pensions in particular, through marriage in advance of one partner’s death. This question has not yet been studied empirically. Hazard models capturing unobserved effects are applied to longitudinal data of the German Socioeconomic Panel. It turns out that the probability of marriage after male partners’ health shocks can increase significantly depending on the amount of expected survivors’ pensions for the (likely) surviving female partners. In contrast, an increased probability of marriage after health shocks to women (depending on the expected financial benefits to men) was not found. These findings are supported by various robustness checks. Economic and political implications are discussed and the results are placed in an international context.

This paper analyzes the epidemiological and economic effects of quarantines. We use a basic epidemiological model, a SEIR-model, that is calibrated to roughly resemble the COVID-19 pandemic, and we assume that individuals that become infected or are isolated on average lose a share of their productivity. An early quarantine postpones but does not alter the course of the pandemic at a cost that increases in the duration and the extent of the quarantine. For quarantines at later stages of the pandemic there is a trade-off between lowering the peak level of infectious people on the one hand and minimizing fatalities and economic losses on the other hand. A longer quarantine dampens the peak level of infectious people and also reduces the total number of infected persons but increases economic losses. Both the peak level of infectious individuals and the total share of the population that will have been infected are U-shaped in relation to the share of the population in quarantine, while economic costs increase in this share. In particular, a quarantine covering a moderate share of the population leads to a lower peak, fewer deaths and lower economic costs, but it implies that the peak of the pandemic occurs earlier.

Results from economic evaluations of long-term outcomes are strongly dependent on the chosen discount rate. A recent review of national guidelines for evaluation of healthcare interventions finds that “the level of currently used discount rates seems relatively high in many countries”. However, this conclusion comes from a comparison to rates derived or observed for investments in safe assets, while rate of return requirements are typically considerably higher when investment involves risk. This paper reviews recent literature on how to account for project-specific risk in determination of the social rate of discount and discusses implications for economic evaluation of healthcare interventions. It concludes that the available empirical evidence strongly suggests that the demand for and consumer value of health and healthcare is co-variant with income, which therefore implies that there is a non-diversifiable risk component of health-related investment.

There is currently little systematic knowledge about the contribution of different factors to the increase in health care spending in high-income countries such as Switzerland. The aim of this paper is to decompose inpatient care costs in the Swiss canton of Zurich by 100 diseases and 42 age/sex groups and to assess the contribution of six factors to the change in aggregate costs between 2013 and 2017. These six factors are population size, age and sex structure, inpatient treated prevalence, utilization in terms of stays per patient, length of stay per case, and costs per treatment day. Using detailed inpatient cost data at the case level, we find that the most important contributor to the change in disease-specific costs was a rise in costs per treatment day. For most conditions, this effect was partly offset by a reduction in the average length of stay. Changes in population size accounted for one third of the total increase, but population structure had only a small positive association with costs. The most expensive cases accounted for the largest part of the increase in costs, but the magnitude of this effect differed across diseases. A better understanding of the factors related to cost changes at the disease level over time is essential for the design of targeted health policies aiming at an affordable health care system.

Background Antimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients. Objective We assess the relative cost-effectiveness of screening programmes compared with no- screening. Methods A microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective. Results In the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs. Conclusion The specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters.

In this population-based cohort study, billing data from German statutory health insurance (BARMER, 10% of population) are used to develop a prioritisation model for COVID-19 vaccinations based on cumulative underlying conditions. Using a morbidity-based classification system, prevalence and risks for COVID-19-related hospitalisations, ventilations and deaths are estimated. Trisomies, behavioural and developmental disorders (relative risk: 2.09), dementia and organic psychoorganic syndromes (POS) (2.23) and (metastasised) malignant neoplasms (1.99) were identified as the most important conditions for escalations of COVID-19 infection. Moreover, optimal vaccination priority schedules for participants are established on the basis of individual cumulative escalation risk and are compared to the prioritisation scheme chosen by the German Government. We estimate how many people would have already received a vaccination prior to escalation. Vaccination schedules based on individual cumulative risk are shown to be 85% faster than random schedules in preventing deaths, and as much as 57% faster than the German approach, which was based primarily on age and specific diseases. In terms of hospitalisation avoidance, the individual cumulative risk approach was 51% and 28% faster. On this basis, it is concluded that using individual cumulative risk-based vaccination schedules, healthcare systems can be relieved and escalations more optimally avoided. Supplementary Information The online version contains supplementary material available at 10.1007/s10198-021-01408-8.

In Italy, the COVID-19 pandemic and the death of many elderly people have put in evidence the uneven territorial distribution of nursing homes, which have amplified the spread and severity of the pandemic. By applying a pooled OLS model to the Italian regions, over the 2010-18 period, we investigate the demand factors, market forces and institutional drivers of the spatial distribution of residential healthcare for the elderly. Using a fine-grained approach that considers specific regional and age-related elements and the market environment, which can reduce or increase the pressure on regional governments to provide formal assistance, we find that the financial resources and the availability of unemployed women as potential caregivers explain the distribution of expenditure better than the health needs of the elderly. As a result, the expenditure is concentrated in richer and more financially autonomous regions and it is not congruent with the distribution of chronicity, health and frailty factors or income among the elderly. These critical issues of the care services for frail elderly people, related to a highly decentralized governance and resulting in fragmented, market-driven provision, could be attacked only by a national reform.

Achieving high vaccination rates is important for overcoming an epidemic. This study investigates the association between religious faith and intentions to become vaccinated against COVID-19 in Israel and Japan. Most of Israel’s population is monotheistic, whereas most Japanese are unaffiliated with any religion. Therefore, our findings might be applicable to various countries that differ in their religions and levels of religiosity. We conducted almost identical large-scale surveys four times in Israel and five times in Japan from March to June 2020 to obtain panel data. We found that intentions of getting vaccinated depend on people’s level of religiosity in a non-linear way. Those who have strong religious beliefs are less likely to become vaccinated than those who say they are less religious. Two other factors that play a role in this relationship are religious denomination in Israel and identifying with a religion in Japan. Supplementary Information The online version contains supplementary material available at 10.1007/s10198-021-01389-8.

This paper examines the behaviour of mental health care providers in response to marginal payment incentives induced by a discontinuous per diem reimbursement schedule with varying tariff rates over the length of stay. The analyses use administrative data on 12,627 cases treated in 82 psychiatric hospitals and wards in Germany. We investigate whether substantial reductions in marginal reimbursement per inpatient day led to strategic discharge behaviour once a certain length of stay threshold is exceeded. The data do not show gaps and bunches at the duration of treatment when marginal reimbursement decreases. Using logistic regression models, we find that providers did not react to discontinuities in marginal reimbursement by significantly reducing inpatient length of stay around the threshold. These findings are robust in terms of different model specifications and subsamples. The results indicate that if regulators aim to set incentives to decrease LOS, this might not be achieved by cuts in reimbursement over LOS. Electronic supplementary material The online version of this article (10.1007/s10198-020-01241-5) contains supplementary material, which is available to authorized users.

Objective The study objective of this analysis was to determine the cost-effectiveness of vaborem (meropenem-vaborbactam) compared to the best available therapy (BAT) in adult patients with carbapenem-resistant Enterobacteriaceae—Klebsiella pneumoniae carbapenemase (CRE-KPC) infections from the perspective of the UK National Health Service (NHS) and Personal Social Services (PSS). Methods A decision tree model was developed to conduct a cost-effectiveness analysis for Vaborem compared to BAT in CRE-KPC patients over a 5 year time horizon. The model structure for Vaborem simulated the clinical pathway of patients with a confirmed CRE-KPC infection. Model inputs for clinical effectiveness were sourced from the TANGO II trial, and published literature. Costs, resource use and utility values associated with CRE-KPC infections in the UK were sourced from the British National Formulary, NHS reference costs and published sources. Results Over a 5 year time horizon, Vaborem use increased total costs by £5165 and increased quality-adjusted life years (QALYs) by 0.366, resulting in an incremental cost-effectiveness ratio (ICER) of £14,113 per QALY gained. The ICER was most sensitive to the probability of discharge to long-term care (LTC), the annual cost of LTC and the utility of discharge to home. At thresholds of £20,000/QALY and £30,000/QALY, the probability of Vaborem being cost-effective compared to BAT was 79.85% and 94.93%, respectively. Conclusion Due to a limited cost impact and increase in patient quality of life, vaborem can be considered as a cost-effective treatment option compared to BAT for adult patients with CRE-KPC infections in the UK.

Objective Large reductions in inpatient length of stay and inpatient bed supply have occurred across health systems in recent years. However, the direction of causation between length of stay and bed supply is often overlooked. This study examines the impact of changes to inpatient bed supply, as a result of recession-induced healthcare expenditure changes, on emergency inpatient length of stay in Ireland between 2010 and 2015. Study design We analyse all public hospital emergency inpatient discharges in Ireland from 2010 to 2015 using the administrative Hospital In-Patient Enquiry dataset. We use changes to inpatient bed supply across hospitals over time to examine the impact of bed supply on length of stay. Linear, negative binomial, and hospital–month-level fixed effects models are estimated. Results U-shaped trends are observed for both average length of stay and inpatient bed supply between 2010 and 2015. A consistently large positive relationship is found between bed supply and length of stay across all regression analyses. Between 2010 and 2012 while length of stay fell by 6.4%, our analyses estimate that approximately 42% (2.7% points) of this reduction was associated with declines in bed supply. Conclusion Changes in emergency inpatient length of stay in Ireland between 2010 and 2015 were closely related to changes in bed supply during those years. The use of length of stay as an efficiency measure should be understood in the contextual basis of other health system changes. Lower length of stay may be indicative of the lack of resources or available bed supply as opposed to reduced demand for care or the shifting of care to other settings.

Objective This study aimed to assess the psychometric properties of three generic preference-based measures and compare their performance in a sample of Hong Kong general population. Methods Data used for this analysis were obtained from a cross-sectional telephone-based survey in July 2020. Participants were asked to complete several measures, including The EuroQol five-dimensional five levels (EQ-5D-5L), Recovering Quality of Life-Utility Index (ReQoL-UI) and ICEpop CAPability measure for adults (ICECAP-A). Acceptability, reliability, convergent and discriminant validity of three measures were assessed as well as the agreement between these instruments. Results Based on data from 500 participants to the survey, a lower mean score of the ICECAP-A (mean = 0.85) was observed compared to the other two measures (meanReQoL-UI = 0.92; meanEQ-5D-5L = 0.92). All three measures showed an acceptable internal consistency reliability (Cronbach’s alpha = 0.74, 0.82 and 0.77, respectively) as well as good test–retest reliability (intra-class correlation coefficient = 0.74, 0.82 and 0.77, respectively). Correlation analyses confirmed satisfactory convergent validity and the ability of the measures to differentiate between participants with different health or from socioeconomic status groups. The Bland–Altman plot revealed poor agreement between the three measures. Conclusions This study confirmed that EQ-5D-5L, ReQoL-UI and ICECAP-A were psychometrically robust to measure HRQoL in the general HK population. The EQ-5D-5L was more suitable for assessing physical HRQoL, whereas the ICECAP-A and ReQoL-UI were more appropriate for measuring interventions aimed at improving people’s well-being and mental health.

Objectives To identify and provide lists of procedures and drugs related to diagnosis and treatment of breast cancer. These lists can be used for the estimation of the cost of illness. Methods The method consists of identifying lists of procedures/interventions/drugs related to the tumour of interest, drawn by a panel of expert clinicians and oncologists on the basis of clinical guidelines and current practice. The lists are applied to data referring to breast cancer female patients, collected by population-based Cancer Registries and linked at individual level with information on health care treatments. A comparison with lists obtained via the matched control method is implemented. Results The distribution of administered procedures and drug prescriptions is coherent with the patient clinical pathway: surgery is the main cause of hospitalization in the first year since diagnosis, diagnostic and monitoring interventions are more frequent in the following years (recurrences detection), and at end-of-life (palliative care). Most outpatient services are due to diagnosis and monitoring, one third of services in the first year since diagnosis is radiotherapy and chemotherapy. Drugs prescribed to patients and sold in pharmacy include hormonal drugs as first course treatment and analgesics as palliative care. Conclusions This direct method represents a valid alternative to the matched control method in describing patterns of care and costs related to the entire disease pathway. It is particularly suitable in case of cancer sites with complex patterns of care, such as breast cancer. The lists of codes developed here are based on international classification systems and can be easily applicable to other countries.

Background Equity in access to scheduled surgery has been a topic of attention of researchers and decision-makers on healthcare. Most studies analyse the number of days that patients wait before undergoing surgery, and ignore patients that have been on the waiting list but have not benefited from surgery. This study contributes to the existing literature on waiting lists by analysing cancellations along with surgery episodes. Methods We use a database comprising all patients that entered the waiting list for scheduled surgeries in the Portuguese National Health Service from 2011 to 2015 (around 3 million observations) and estimate survival models to explain waiting times, where cancellations are introduced as censored data. Results The cancellation rate is significant (around 14%), and has a considerable impact on results: ignoring cancellations biases estimates, in particular for gender differences (that are overestimated without cancelations), and for the age effect (that is underestimated). Conclusion Thus, our approach provides a more accurate understanding of the impact that several factors have on overall access to scheduled surgery.

Unwarranted variation in the quality of care challenges the sustainability of healthcare systems. Especially in decentralised healthcare systems, it is crucial to understand the drivers behind regional differences in hospital qualities such as unplanned readmissions. This paper examines the factors that influence the risk of unplanned hospital readmission and the geographic disparity of readmission rate in Italy. We use hospital discharge data from 2010 to 2015 for patients above 65 years old admitted with Acute Myocardial Infarction. Employing hierarchical models, we identified the patient and hospital-level determinants for unplanned readmission. In line with the literature, the risk of readmission increases with age and being male, while hospitals with higher patient volume and capacity tend to have lower unplanned readmission. In particular, we find that after patient risk-adjustments, there are differential effects of hospitalisation length-of-stay on the probability of readmission across the hospitals that are governed by different payment systems. For hospitals under a prospective payment system, the effect of length-of-stay in reducing the probability of readmission is weaker than hospitals under an ex-post global budget, but the overall readmission rates are the lowest. Moreover, there are substantial geographic variations in readmission rate across Local Health Authority and regions, and these variations of unplanned readmission are explained by differences in hospital length-of-stay and surgical procedures used. Our results demonstrate that differential hospital behaviours can be one of the potential mechanisms that drive geographic quality disparities.

The great economic crisis in 2008 has affected the welfare of the population in countries such as Italy. Although there is abundant literature on the impact of the crisis on physical health, very few studies have focused on the causal implications for mental health and health care. This paper, therefore, investigates the impact of the recent economic crisis on hospital admissions for severe mental disorder at small geographic levels in Italy and assesses whether there are heterogeneous effects across areas with distinct levels of income. We exploit 9-year (2007–2015) panel data on hospital discharges, which is merged with employment and income composition at the geographic units that share similar labour market structures. Linear and dynamic panel analysis are used to identify the causal effect of rising unemployment rate on severe mental illness admissions per 100,000 residents to account for time-invariant heterogeneity. We further create discrete income levels to identify the potential socioeconomic gradients behind this effect across areas with different economic characteristics. The results show a significant impact of higher unemployment rates on admissions for severe mental disorders after controlling for relevant economic factors, and the effects are concentrated on the most economically disadvantaged areas. The results contribute to the literature of spatio-temporal variation in the broader determinants of mental health and health care utilisation and shed light on the populations that are most susceptible to the effects of the economic crisis.

Purpose Preference-based measures are essential for producing quality-adjusted life years (QALYs) that are widely used for economic evaluations. In the absence of such measures, mapping algorithms can be applied to estimate utilities from disease-specific measures. This paper aims to develop mapping algorithms between the MacNew Heart Disease Quality of Life Questionnaire (MacNew) instrument and the English and the US-based EQ-5D-5L value sets. Methods Individuals with heart disease were recruited from six countries: Australia, Canada, Germany, Norway, UK and the US in 2011/12. Both parametric and non-parametric statistical techniques were applied to estimate mapping algorithms that predict utilities for MacNew scores from EQ-5D-5L value sets. The optimal algorithm for each country-specific value set was primarily selected based on root mean square error (RMSE), mean absolute error (MAE), concordance correlation coefficient (CCC), and r-squared. Leave-one-out cross-validation was conducted to test the generalizability of each model. Results For both the English and the US value sets, the one-inflated beta regression model consistently performed best in terms of all criteria. Similar results were observed for the cross-validation results. The preferred model explained 59 and 60% for the English and the US value set, respectively. Linear equating provided predicted values that were equivalent to observed values. Conclusions The preferred mapping function enables to predict utilities for MacNew data from the EQ-5D-5L value sets recently developed in England and the US with better accuracy. This allows studies, which have included the MacNew to be used in cost-utility analyses and thus, the comparison of services with interventions across the health system.

Background Discrete choice experiments (DCEs) are widely used to elicit health state preferences. However, additional information is required to transform values to a scale with dead valued at 0 and full health valued at 1. This paper presents DCE-VAS, an understandable and easy anchoring method with low participant burden based on the visual analogue scale (VAS). Methods Responses from 1450 members of the UK general public to a discrete choice experiment (DCE) were analysed using mixed logit models. Latent scale valuations were anchored to a full health = 1, dead = 0 scale using participants’ VAS ratings of three states including the dead. The robustness of results was examined. This included a filtering procedure with the influence each individual respondent had on valuation being calculated, and those whose influence was more than two standard deviations away from the mean excluded. Results Coefficients in all models were in the expected direction and statistically significant. Excluding respondents who self-reported not understanding the VAS task did not significantly influence valuation, but excluding a small number who valued 33333 extremely low did. However, after eight respondents were removed via the filtering procedure, valuations were robust to removing other participants. Conclusion DCE-VAS is a feasible way of anchoring DCE results to a 0–1 anchored scale with low additional respondent burden.

There is growing interest in the use of “distributionally-sensitive” forms of economic evaluation that capture both the impact of an intervention upon average population health and the distribution of that health amongst the population. This review aims to inform the conduct of distributionally sensitive evaluations in the UK by answering three questions: (1) How averse are the UK public towards inequalities in lifetime health between socioeconomic groups? (2) Does this aversion differ depending upon the type of health under consideration? (3) Are the UK public as averse to inequalities in health between socioeconomic groups as they are to inequalities in health between neutrally framed groups? EMBASE, MEDLINE, EconLit, and SSCI were searched for stated preference studies relevant to these questions in October 2017. Of the 2155 potentially relevant papers identified, 15 met the predefined hierarchical eligibility criteria. Seven elicited aversion to inequalities in health between socioeconomic groups, and eight elicited aversion between neutrally labelled groups. We find general, although not universal, evidence for aversion to inequalities in lifetime health between socioeconomic groups, albeit with significant variation in the strength of that preference across studies. Second, limited evidence regarding the impact of the type of health upon aversion. Third, some evidence that the UK public are more averse to inequalities in lifetime health when those inequalities are presented in the context of socioeconomic inequality than when presented in isolation. Electronic supplementary material The online version of this article (10.1007/s10198-019-01126-2) contains supplementary material, which is available to authorized users.

Policymakers often suggest that expansion of care in community settings may ease increasing pressures on hospital services. Substitution may lower overall health system costs, but complementarity due to previously unidentified needs might raise them. We used new national data on community and primary medical care services in England to undertake system-level analyses of whether activity in the community acts as a complement or a substitute for activity provided in hospitals. We used two-way fixed effects regression to relate monthly counts of community care and primary medical care contacts to emergency department attendances, outpatient visits and admissions for 242 hospitals between November 2017 and September 2019. We then used national unit costs to estimate the effects of increasing community activity on overall system expenditure. The findings show community care contacts to be weak substitutes with all types of hospital activity and primary care contacts are weak substitutes for emergency hospital attendances and admissions. Our estimates ranged from 28 [95% CI 21, 45] to 517 [95% CI 291, 7265] community care contacts and from 34 [95% CI 17, 1283] to 1655 [95% CI − 1995, 70,145] GP appointments to reduce one hospital service visit. Primary care and planned hospital services are complements. Increases in community services and primary care activity are both associated with increased overall system expenditure of £34 [95% CI £156, £54] per visit for community care and £41 [95% CI £78, £74] per appointment in general practice. Expansion of community-based services may not generate reductions in hospital activity and expenditure. Supplementary Information The online version contains supplementary material available at 10.1007/s10198-021-01329-6.

Objectives Cancer diagnoses at later stages are associated with a decrease in health-related quality of life (HRQOL). Health state utility values (HSUVs) reflect preference-based HRQOL and can vary based on cancer type, stage, treatment, and disease progression. Detecting and treating cancer at earlier stages may lead to improved HRQOL, which is important for value assessments. We describe published HSUVs by cancer type and stage. Methods A systematic review was conducted using Embase, MEDLINE®, EconLit, and gray literature to identify studies published from January 1999 to September 2019 that reported HSUVs by cancer type and stage. Disutility values were calculated from differences in reported HSUVs across cancer stages. Results From 13,872 publications, 27 were eligible for evidence synthesis. The most frequent cancer types were breast (n = 9), lung (n = 5), colorectal (n = 4), and cervical cancer (n = 3). Mean HSUVs decreased with increased cancer stage, with consistently lower values seen in stage IV or later-stage cancer across studies (e.g., − 0.74, − 0.44, and − 0.51 for breast, colorectal, and cervical cancer, respectively). Disutility values were highest between later-stage (metastatic or stage IV) cancers compared to earlier-stage (localized or stage I–III) cancers. Conclusions This study provides a summary of HSUVs across different cancer types and stages that can inform economic evaluations. Despite the large variation in HSUVs overall, a consistent decline in HSUVs can be seen in the later stages, including stage IV. These findings indicate substantial impairment on individuals’ quality of life and suggest value in early detection and intervention.

Objectives Medical devices are potentially good candidates for coverage with evidence development (CED) schemes, as clinical data at market entry are often sparse and (cost-)effectiveness depends on real-world use. The objective of this research was to explore the diffusion of CED schemes for devices in Europe, and the factors that favour or hamper their utilization. Methods We conducted structured interviews with 25 decision-makers from 22 European countries to explore the characteristics of existing CED programmes for devices, and how decision makers perceived 13 pre-identified challenges associated with initiating and operating CED schemes for devices. We also collected data on individual schemes that were either initiated or still ongoing in the last 5 years. Results We identified seven countries with CED programmes for devices and 78 ongoing schemes. The characteristics of CED programmes varied across countries, including eligibility criteria, roles and responsibilities of stakeholders, funding arrangements, and type of decisions being contemplated at the outset of each scheme. We observed a high variability in how decision makers perceived CED-related challenges possibly reflecting country-specific arrangements and different experiences with CED. One general finding across all countries was that relatively little attention was paid to the evaluation of schemes, both during and at their completion. Conclusions CED programmes for devices with different characteristics exist in Europe. Decision-makers’ perceptions differ on the challenges associated with these schemes. More exchange of knowledge and experience will help decision makers anticipate the likely challenges in CED schemes for devices, and to learn from good practices existing elsewhere.

Aim The EQ-5D is a generic measure of health that is widely applied for health economic and non-economic purposes. Population norms can be used to facilitate the interpretation of EQ-5D data. The objective of this study was to develop a set of pooled normative EQ-5D-3L values for the five largest European economies (EUR5). Methods EQ-5D-3L index values based on the time trade-off (TTO) were available for all EUR5 countries (n = 21,425): France, Germany, Italy, Spain, and the United Kingdom (UK). Country-specific data sets were aggregated and weighted to facilitate the derivation of norms for gender and age groups. Analyses included equal weighting and weighting by population and economy size. Norms were also calculated using the European visual analog scale-based value set (European VAS), the EQ VAS and separately by dimension. Results Pooled mean (SD) population weighted TTO values for males/females were 0.967 (0.122)/0.959 (0.118) for ages 18–24; 0.965 (0.096)/0.954 (0.117) for ages 25–34; 0.943 (0.165)/0.936 (0.169) for ages 35–44; 0.934 (0.150)/0.921 (0.157) for ages 45–54; 0.896 (0.188)/0.875 (0.197) for ages 55–64; 0.900 (0.158)/0.839 (0.218) for ages 65–74; and 0.830 (0.234)/0.756 (0.291) for ages 75 and older. Mean values decreased and variance increased with age; females had slightly lower mean values than males across all age bands. The unequal weighting approaches produced similar point estimates with smaller variances. Mean values for the European VAS were slightly lower than those for the TTO-based index. Discussion Normative EQ-5D-3L values can be used to benchmark the outcomes of treated patients against the health of the general population. EUR5 norms may be useful in research applications inferring to Europe or the European Union as a whole, particularly when sample size precludes analysis at the country level.

Background Cancer patients have one of the highest health care expenditures (HCE) at the end of life. However, the growth of HCE at the end of life remains poorly documented in the literature. Objective To describe monthly reimbursed expenditure during the last year of life among cancer patients, by performing detailed analysis according to type of expenditure and the person’s age. Method Data were derived from the Système national des données en santé (SNDS) [national health data system], which comprises information on ambulatory and hospital care. Analyses focused on general scheme beneficiaries (77% of the French population) treated for cancer who died in 2015. Results Average reimbursed expenditure during the last year of life was €34,300 per person in 2015, including €21,100 (62%) for hospital expenditure. "Short-stays hospital" and "rehabilitation units" stays expenditure were €14,700 and €2000, respectively. Monthly expenditure increased regularly towards the end of life, increasing from 12 months before death €2000 to €5200 1 month before death. The highest levels of expenditure did not concern the oldest people, as average reimbursed expenditure was €50,300 for people 18–59 years versus €25,600 for people 80–90 years. Out-of-pocket payments varied only slightly according to age, but increased towards the end of life. Conclusion A marked growth of HCE was observed during the last 4 months of life, mainly driven by hospital expenditure, with a more marked growth for younger people.

Introduction The objective of this study was to estimate the lifetime risk of hospitalization associated with all major human papillomavirus (HPV)-related diseases in Italy. Moreover, a preliminary vaccination effect was also performed. Methods A retrospective, nonrandomized, observational study was developed based on patients hospitalized between 2006 and 2018 in Italy. All hospitalizations were identified through administrative archives, according to the International Classification of Diseases (ICD-9 CM). Information related to the hospital discharges of all accredited public and private hospitals, both for ordinary and day care regimes, was taken into account. We included hospitalizations related to resident patients presenting one of the ICD-9-CM codes as primary or secondary diagnosis: genital warts (GW); ‘cervical intraepithelial neoplasia (CIN)’ (067.32–067.33); ‘condyloma acuminatum’ (078.11); ‘anal cancers’ (AC) (154.2–154.8); oropharyngeal cancers (OC): ‘oropharyngeal cancer’(146.0–146.9) and ‘head, face and neck cancers’ (171.0); genital cancers (GC): ‘penis cancer’ (187.1–187.9) and ‘cervical cancer’ (180.0–180.9). Data were stratified by birth year and divided into two groups: (a) cohort born before 1996 (not vaccinable) and (b) cohort born after 1997 (vaccinable—first cohort that could be vaccinated at the beginning of immunization schedule in girls since 2008 in Italy). Disease-specific hospitalization risks for both groups were estimated by sex, year and age. Results Epidemiological data demonstrate that the peak hospitalization risk occurred at 24–26 years of age for GW (both male and female); 33–41 and 47–54 years for AC males and females, respectively; 53–59 and 52–58 years for OC males and females, respectively; and 54–60 and 39–46 years for GC males and females, respectively. Focusing on GW and GC, vaccinable females demonstrate a significant reduction in hospitalization risks (− 54% on average) compared to nonvaccinable females until 21 years of age (maximum follow-up available for girls born after 1997). Comparing the same birth cohort of males, no differences in hospitalization risk were found. Conclusions These results support the importance of primary prevention strategies in Italy and suggest that increased VCRs and time of observation (genital cancers for which vaccination is highly effective, have a latency of some decades) will provide useful information for decision-makers.

Objectives To assess the cost-effectiveness (CE) of transcatheter aortic valve implantation (TAVI) in Italy, considering patient groups with different surgical risk. Methods A Markov model with a 1-month cycle length, comprising eight different health states, defined by the New York Heart Association functional classes (NYHA I–IV), with and without stroke plus death, was used to estimate the CE of TAVI for intermediate-, high-risk and inoperable patients considering surgical aortic valve replacement or medical treatment as comparators according to the patient group. The Italian National Health System perspective and 15-year time horizon were considered. In the base-case analysis, effectiveness data were retrieved from published efficacy data and total direct costs (euros) were estimated from national tariffs. A scenario analysis considering a micro-costing approach to estimate procedural costs was also considered. The incremental cost-effectiveness ratio (ICER) was expressed both in terms of costs per life years gained (LYG) and costs per quality adjusted life years (QALY). All outcomes and costs were discounted at 3% per annum. Univariate and probabilistic sensitivity analyses (PSA) were performed to assess robustness of results. Results Over a 15-year time horizon, the higher acquisition costs for TAVI were partially offset in all risk groups because of its effectiveness and safety profile. ICERs were €8338/QALY, €11,209/QALY and €10,133/QALY, respectively, for intermediate-, high-risk and inoperable patients. ICER values were slightly higher in the scenario analysis. PSA suggested consistency of results. Conclusions TAVI would be considered cost-effective at frequently cited willingness-to-pay thresholds; further studies could clarify the CE of TAVI in real-life scenarios.

Background Uncertainty in model-based cost-utility analyses is commonly assessed in a probabilistic sensitivity analysis. Model parameters are implemented as distributions and values are sampled from these distributions in a Monte Carlo simulation. Bootstrapping is an alternative method that requires fewer assumptions and incorporates correlations between model parameters. Methods A Markov model-based cost–utility analysis comparing oromucosal spray containing delta-9-tetrahidrocannabinol + cannabidiol (Sativex®, nabiximols) plus standard care versus standard spasticity care alone in the management of multiple sclerosis spasticity was performed over a 5-year time horizon from the Belgian healthcare payer perspective. The probabilistic sensitivity analysis was implemented using a bootstrap approach to ensure that the correlations present in the source clinical trial data were incorporated in the uncertainty estimates. Results Adding Sativex® spray to standard care was found to dominate standard spasticity care alone, with cost savings of €6,068 and a quality-adjusted life year gain of 0.145 per patient over the 5-year analysis. The probability of dominance increased from 29% in the first year to 94% in the fifth year, with the probability of QALY gains in excess of 99% for all years considered. Conclusions Adding Sativex® spray to spasticity care was found to dominate standard spasticity care alone in the Belgian healthcare setting. This study showed the use of bootstrapping techniques in a Markov model probabilistic sensitivity analysis instead of Monte Carlo simulations. Bootstrapping avoided the need to make distributional assumptions and allowed the incorporation of correlating structures present in the original clinical trial data in the uncertainty assessment.

The goal of this study is to provide empirical evidence of the impact of nurse staffing levels on seven nursing-sensitive patient outcomes (NSPOs) at the hospital unit level. Combining a very large set of claims data from a German health insurer with mandatory quality reports published by every hospital in Germany, our data set comprises approximately 3.2 million hospital stays in more than 900 hospitals over a period of 5 years. Accounting for the grouping structure of our data (i.e., patients grouped in unit types), we estimate cross-sectional, two-level generalized linear mixed models (GLMMs) with inpatient cases at level 1 and units types (e.g., internal medicine, geriatrics) at level 2. Our regressions yield 32 significant results in the expected direction. We find that differentiating between unit types using a multilevel regression approach and including postdischarge NSPOs adds important insights to our understanding of the relationship between nurse staffing levels and NSPOs. Extending our main model by categorizing inpatient cases according to their clinical complexity, we are able to rule out hidden effects beyond the level of unit types. Supplementary Information The online version contains supplementary material available at 10.1007/s10198-021-01292-2.

Background Previous literature has examined the societal costs of mental illness, but few studies have estimated the costs associated with mental well-being. In this study, a prospective analysis was conducted on Danish data to determine 1) the association between mental well-being (measured in 2016) and government expenditure in 2017, specifially healthcare costs and sickness benefit transfers. Methods Data stem from a Danish population-based survey of 3,508 adults (aged 16 + years) in 2016, which was linked to Danish registry data. A validated scale (WEMWBS) was used for the assessment of mental well-being. Costs are expressed in USD PPP. A two-part model was applied to predict costs in 2017, adjusting for sociodemographics, health status (including psychiatric morbidity and health behaviour), as well as costs in the previous year (2016). Results Each point increase in mental well-being (measured in 2016) was associated with lower healthcare costs ($− 42.5, 95% CI = $− 78.7, $− 6.3) and lower costs in terms of sickness benefit transfers ($− 23.1, 95% CI = $− 41.9, $− 4.3) per person in 2017. Conclusions Estimated reductions in costs related to mental well-being add to what is already known about potential savings related to the prevention of mental illness. It does so by illustrating the savings that could be made by moving from lower to higher levels of mental well-being both within and beyond the clinical range. Our estimates pertain to costs associated with those health-related outcomes that were included in the study, but excluding other social and economic outcomes and benefits. They cover immediate cost estimates (costs generated the year following mental well-being measurement) and not those that could follow improved mental well-being over the longer term. They may therefore be considered conservative from a societal perspective. Population approaches to mental health promotion are necessary, not only to potentiate disease prevention strategies, but also to reduce costs related to lower levels of mental well-being in the non-mental illness population. Our results suggest that useful reductions in both health care resource use and costs, as well as in costs due to sick leave from the workplace, could be achieved from investment in mental well-being promotion within a year.

BackgroundThe German hospital-to-home discharge management of geriatric patients has long been criticized. The implementation of the American Transitional Care Model (TCM) could help to reduce readmissions and costs. The objective of this review was to check the scientific evidence of the cost-effectiveness of the TCM.MethodsA systematic literature search in six databases for the time period of 26 years was conducted. The studies had to meet all pre-defined inclusion criteria. The data extraction is based on a criteria chart from literature. The methodological quality was assessed using the tools of the National Heart, Lung, and Blood Institute as well as the Consensus Health Economic Criteria list. The results transferability to German health care system was explained based on the criteria from the literature.ResultsThree American studies met all criteria. They showed partial cost analyses but no full economic analyses. It could be assumed that the economic effect of the TCM changes over time. The costs of a care coordinator could not be determined because few detailed information was reported. The TCM may have negative consequences for hospitals. The results are not transferable to Germany.ConclusionThere is no scientific evidence for the cost-effectiveness of the defined TCM. The optimal TCM duration still needs to be clarified. A detailed overview with units and prices and an additional consideration of the hospital perspective could help to make the information more transparent when deciding about the TCM implementation. A full economic analysis under German conditions or for similar European countries is necessary.

Objectives Multiple studies showed positive effects of Lutetium-Octreotate (LO) treatment in neuroendocrine tumours. LO has been used in the Netherlands since the 1980s and recently received the orphan status shortly after the acquisition by Novartis. Since then, the official list price has increased sixfold. From a value-based pricing perspective, we analysed the impact of the increase in price on the incremental cost-effectiveness ratio (ICER) of LO treatment compared to optimal best supportive care, a high dose of Octreotide long-acting release (O-LAR), using the clinical data of the NETTER-1 trial. Methods A Markov model was developed to evaluate the costs per quality-adjusted life-year (QALY) for LO treatment compared to O-LAR from the healthcare perspective. A scenario analysis was conducted to compare the cost-effectiveness with the initial and increased price level of the LO-treatment. Results At the increased price level, the cost-effectiveness analysis rendered a deterministic ICER of €53,500 per QALY, while at the initial pricing, the ICER was €19,000 per QALY. The probabilistic sensitivity analysis (PSA) showed that LO had a high probability of being cost-effective at both the increased and initial price level, considering a cost-effectiveness threshold of €80,000. Conclusions Even at the increased price level, LO treatment can still be considered cost-effective using the applicable Dutch willingness-to-pay threshold of 80,000 euro per QALY. Considering the public scrutiny in relation to this price increase, these outcomes raise the question whether traditional cost-effectiveness methods are sufficient in fully capturing the societal acceptance of prices of new medicines.

Background Evidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence on cost-effectiveness is limited and based on small datasets. The aim of our study was to conduct an economic evaluation of the German OGCM for geriatric hip fracture patients. Methods This retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a hip fracture in 2014, and were treated in hospitals providing OGCM (OGCM group) or standard care (control group). Health care costs from payer and societal perspective, life years gained (LYG) and cost-effectiveness were investigated within 1 year. We applied weighted gamma and two-part models, and entropy balancing to account for the lack of randomisation. We calculated incremental cost-effectiveness ratios (ICER) and employed the net-benefit approach to construct cost-effectiveness acceptability curves. Results 14,005 patients were treated in OGCM, and 10,512 in standard care hospitals. Total average health care costs per patient were higher in the OGCM group: €1181.53 (p p Conclusion Survival improved in hospitals providing OGCM. Costs were found to increase, driven by inpatient and long-term care. The cost-effectiveness depends on the willingness-to-pay. The ICER is likely to improve with a longer follow-up.