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Chronic hepatitis C virus (HCV) infection affects 170 million individuals worldwide. As it is detected incidentally through the evaluation of liver function tests or at the time of blood donor testing, it is usually clinically silent until the advanced stages of liver disease have occurred, when treatment is less effective and shortages of donor liver organs limit the therapeutic options. Combination therapy with ribavirin and pegylated interferon has resulted in sustained viral negative response rates of 54–61%. Because treatment is expensive and not uniformly effective, and because not all chronically infected patients will develop complications, concerns have arisen regarding the cost effectiveness of combination therapy.This paper reviews the public health and individual implications of HCV infections. Because of the latency of infection, numerous country-specific population analyses suggest that HCV will cause an increasing number of liver-related deaths over the next 10 years, despite the dramatic drop in incidence over the past 10–15 years. These deaths will be related to prevalent HCV infection from transfusion and injection drug use prior to identification of the virus and availability of screening tests in the late 1980s and early 1990s. HCV can reduce life expectancy and impair quality of life, yet not all patients will develop progressive liver disease, and antiviral treatment may have associated adverse effects.Finally, to assess the value of antiviral drugs for HCV infection, this paper reviews studies examining the costs of antiviral drugs and of the disease itself along with response to antiviral therapy and the cost effectiveness of antiviral therapy. Although antiviral therapy appears to be expensive, when also considering the likelihood of sustained viral response to therapy, and the cost savings, quality-of-life improvement and prolongation of life expectancy from the prevention of HCV complications, antiviral treatment for HCV appears to be cost effective when compared with other well accepted medical interventions. [ABSTRACT FROM AUTHOR]

This paper outlines recent advances in the methods of cost-benefit analysis (CBA). Economic evaluations in healthcare can be criticised for, amongst other things, the inappropriate use of incremental cost-effectiveness ratios and the reporting of benefits in terms of cost savings, such as treatment costs averted. Many such economic evaluations are, according to the ‘scientific’ definition, CBAs. The ‘balance-sheet’ (or opportunity cost) approach is a form of CBA which can be used to identify who bears the costs and who reaps the benefits from any change. Whilst the next stage in a CBA, as defined in health economics, would require that all costs and benefits be valued in monetary terms, the balance-sheet approach, however, advocates that available monetary values can be augmented by other measures of cost and benefit. As such, this approach, which has a theoretical basis, is proposed as a practical prescription for CBA and highlights the notion that unquantified benefits are important and can be included within CBAs even when monetarisation is not possible. Recent methodological developments in monetary valuation for use in CBA are the development of the technique of willingness to pay, the use of conjoint analysis (CA) to elicit willingness-to-pay (WTP) values and advances in the debate on the inclusion of production gains in CBAs. Whilst acknowledging that there have been developments in each of these areas, it is claimed there has also been progress in using CBA as a framework for evaluation, as reflected by the balance-sheet approach. The paper concludes by stating that almost all types of economic evaluation have an element of the ‘cost-benefit’ approach in them. The important issue is to focus on the policy question to be addressed and to outline the relevant costs and benefits in a manner which assists the evaluation of welfare changes resulting from changes in healthcare delivery. The focus should not be on moulding a question to fit a hybrid definition of an analytical technique. [ABSTRACT FROM AUTHOR]

In many countries, including Thailand, there is an increasing impetus to use economic evaluation to allow more explicit and transparent healthcare priority setting. However, an important question for policy makers in low- and middle-income countries is whether it is appropriate and feasible to introduce economic evaluation data into healthcare priority-setting decisions. In addition to ethical, social and political issues, information supply challenges need to be addressed. This paper systematically reviewed the literature on economic evaluation of health technology in Thailand published between 1982 and 2005. Its aim was to analyse the quantity, quality and targeting of economic evaluation studies that can provide a framework for those conducting similar reviews in other settings. The review revealed that, although the number of publications reporting economic evaluations has increased significantly in recent years, serious attention needs to be given to the quality of reporting and analysis. Furthermore, there is an absence of economic evaluation publications for 15 of the top 20 major health problems in Thailand, indicating a poor distribution of research resources towards the determination of cost-effective interventions for diminishing the disease burden of certain major health problems. If economic evaluation is only useful for policy makers when performed correctly and reported accurately, these findings depict information barriers to using economic evaluation to assist health decision-making processes in Thailand. [ABSTRACT FROM AUTHOR]

Objective: To estimate the cost effectiveness (from the UK NHS and personal social services perspective) of the cholinesterase inhibitors donepezil, rivastigmine and galantamine compared with usual care in the treatment of mild to moderately severe Alzheimer's disease. Patients had a mean age of 74 years, a mean disease duration of 1 year and a mean Alzheimer's disease assessment scale-cognitive subscale score of 24.Methods: A pharmacoeconomic model was used to predict long-term outcomes over a 5-year time horizon and to estimate the cost effectiveness of cholinesterase inhibitors for the management of Alzheimer's disease. The model structure is informed by a systematic review of the literature on the clinical and cost effectiveness of cholinesterase inhibitors and a review of the literature on the costs and outcomes associated with treatment for Alzheimer's disease. The main outcome measure used was the cost per quality-adjusted life-year (QALY) gained. All healthcare costs (excluding cholinesterase inhibitor costs) were indexed to pounds sterling (2003 values). Drug costs are 2005 values. Multivariate probabilistic sensitivity analysis and scenario analysis were undertaken to assess uncertainty in the results.Results: The clinical benefits on cognition from treatment with cholinesterase inhibitors resulted in an incremental cost per QALY gained ranging from 53,780 pounds sterling to 74,735 pounds sterling, over 5 years (vs usual care). Uncertainty analysis suggests that the probability of any of these treatments having an incremental cost per QALY of < 30,000 pounds sterling is < 21%. The key determinants of cost effectiveness were the effectiveness of treatment, the mean treatment cost and the cost savings associated with an expected delay in disease progression.Conclusions: Results presented in this paper suggest that the use of cholinesterase inhibitors may not be a cost-effective use of NHS resources. Guidance from the National Institute for Health and Clinical Effectiveness (NICE) in the UK on their judgements surrounding the acceptability of technologies as an effective use of resources, indicates there would need to be special reasons for accepting cholinesterase inhibitors as a cost-effective use of NHS resources. [ABSTRACT FROM AUTHOR]

The continued growth in the economic evaluation of healthcare over the past 25 years has led to a shortage of trained health economists globally, leading to a number of universities and/or national governments developing specialised health economics programmes to train more health economists. One of the common problems with many of these training programmes is that they only educate new health economists to the Masters level, and as such they are unable to cover the many skills needed by a successful health economist. Furthermore, government and industry interests have ensured that economic evaluation is a heavily regulated environment that gives little incentive to seek further education. These two related factors (under-education and over-regulation) have lead to a situation where economic evaluation methods may adversely limit innovation of therapeutics and devices in clinical areas that perform badly when evaluated on the cost per QALY scale. The good news, however, is that the tide is turning and theoretically sound adjustments (such as risk adjustments and stated preferences) to the current paradigm are now being considered. This, of cause, is just the tip of the iceberg with other important issues such as time preference and the endogeneity of preference remaining very much under-researched areas in health. This paper concludes that many of these real-world issues, such as patient preferences, can be avoided by using artificial objective functions such as cost per QALY, but this comes at the cost of irrelevance and the misallocation of resources. If we are to meet all of the future challenges in economic evaluation in healthcare then we must focus more on advanced education and far less on the regulation of health economists. [ABSTRACT FROM AUTHOR]

For practical reasons, in order to carry out economic evaluations of collective decisions, total costs will generally be compared with total benefits; hence, individuals' willingness to pay (WTP) or quality-adjusted life-years (QALYs) have to be estimated at an aggregate level. So far, aggregation has usually been done by taking the individuals' mean WTP or the unweighted number of QALYs. Since the aggregation process is closely related to the way that income, health and/or utility of different individuals are compared and weighted, it also has significant equity implications. Thus. the explicit (or, more often, implicit) assumptions behind the aggregation process will largely affect how health and welfare are distributed is society. The aggregation problem in economic evaluation is certainly not trivial, but is seldom addressed in current practice. This paper shows the underlying assumptions of aggregate cost-benefit analysis (CBA) and cost-effectiveness analysis/cost-utility analysis (CEA/CUA), and it emphasises the particularly strong assumptions which have to be made when QALYs are interpreted as utilities in the welfare economics sense. Naturally, the appropriate method to choose depends on what is to be maximised: welfare or health. If decisions of resource allocation are to be based on economic welfare theory, then CBA should be preferred. However, if QALYs are interpreted as measures of health, rather than as utilities, then CEA/CUA would be appropriate. [ABSTRACT FROM AUTHOR]

The resources available for healthcare are limited compared with demand, if not need, and all healthcare systems, regardless of their financing and organisation, employ mechanisms to ration or prioritise finite healthcare resources. This paper reviews alternative approaches that can be used to allocate healthcare resources. It discusses the problems encountered when allocating healthcare resources according to free market principles. It then proceeds to discuss the advantages and disadvantages of alternative resource allocation approaches that can be applied to public health systems. These include: (i) approaches based on the concept of meeting the needs of the population to maximising its capacity to benefit from interventions; (ii) economic approaches that identify the most efficient allocation of resources with the view of maximising health benefits or other measures of social welfare; (iii) approaches that seek to ration healthcare by age; and (iv) approaches that resolve resource allocation disputes through debate and bargaining. At present, there appears to be no consensus about the relative importance of the potentially conflicting principles that can be used to guide resource allocation decisions. It is concluded that whatever shape tomorrow's health service takes, the requirement to make equitable and efficient use of finite healthcare resources will remain. [ABSTRACT FROM AUTHOR]

The introduction of expensive disease-modifying agents for the treatment of multiple sclerosis (MS) has created the potential for patients with MS to become higher contributors to healthcare spending. In an attempt to make formulary and reimbursement choices for these agents, decision-makers may look to the literature for guidance. This critical review attempts to decipher a consistent message from the available economic literature regarding the relationship between disease severity and cost in MS. In the 2 studies that have examined MS disease severity, a positive correlation with total (direct and indirect) cost, indirect cost and some, if not all, components of direct cost was reported. In studies taking the societal perspective, the majority of total costs were indirect. This paper documents the high burden of MS on society and serves to guide the decision-maker in interpreting the MS economic literature such that this information can be optimally utilised to make informed resource allocation decisions. [ABSTRACT FROM AUTHOR]

An important consideration when establishing priorities in healthcare is the likely effect that alternative allocations will have on the health-related quality of life (HR-QOL) of the relevant population. This paper considers some of the important issues and controversies surrounding the valuation of HR-QOL. It considers the theoretical and empirical evidence regarding 3 crucial questions: (i) what is to be valued?; (ii) how is it to be valued?; and (iii) who is to value it? Many important yet unresolved issues emerge and directions for future research are suggested. It is argued that this research agenda should have the gathering and analysis of qualitative data at its forefront. [ABSTRACT FROM AUTHOR]

Traditionally, US teaching hospitals have subsidised research by charging higher costs for treatment; however, this approach is being challenged. The growth of managed-care organisations, concerned about maximising profits, has led many to argue that clinical research will be damaged, whether by the loss of internal funds for research or by reductions in the numbers of patients available for studies. This review examines the evidence on which this argument is based. There is some evidence that managed-care organisations are refusing to cover patients who are involved in clinical trials, although, in general, they are receptive towards research providing that it is explicit and seen as relevant. The indirect effects of competition are, arguably, more important. Although many academic centres have established strategies to protect research funds, those working in the most competitive healthcare environments are obtaining fewer externally funded research grants. They are also publishing fewer papers and are working in climates that are seen as less supportive, with less ability to undertake research that is not externally funded. There is little evidence that managed care is reducing access to patients for clinical research. The growth of managed care is, together with certain other trends, also influencing the nature of clinical research. The overall consequences of these different factors are difficult to predict, although there are grounds for concern about recruitment and retention of junior researchers. The relationship between the various actors involved in healthcare and research is dynamic and, as pressure is excerpted in a particular direction, others adapt. It may be some time before the consequences of policies being enacted now are apparent. [ABSTRACT FROM AUTHOR]