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Abstract This study was performed to assess the main reasons for the unfavorable cost effectiveness of lung transplantation compared with that of heart and liver transplantation. Costs, effects, and cost-effectiveness ratios of Dutch lung, heart, and liver transplantation programs were compared. The data are based on three Dutch technology assessments of transplantation, with minor adjustments for time and methods. In result, mainly follow-up costs of lung transplantation are higher than costs of heart and liver transplantation - US $150,300, US $121,500, and US $95,300, respectively - in the first 3 years after transplantation. The survival gain realized by lung transplantation is small (4.4 years) compared with heart (8.8 years) and liver (14.7years) transplantation. Costs per life-year gained were US $77,000, US $38,000, and US $26,000 for lung, heart, and liver transplantation, respectively. The unfavorable cost effectiveness of lung transplantation is largely related to a relatively small survival gain and high follow-up costs.

Given the recognized need to examine cost-effectiveness data in addition to clinical data when making decisions relating to choice of clinical interventions, there is a growinginterest and experience in undertaking economic evaluations alongside clinical trials. It has been argued, when an economic evaluation is necessary for assessing the cost-effectiveness of a medical intervention, the integration of both the medical and clinical issues need to be included at the start of designing a clinical trial. A proposal has been made for how clinical researchers and health economists may cooperate successfully at the successive phases in designing a clinical trial. Therefore, discussion points for clinical researchers and health economists are given, and the possible methodological consequences of adding an economic evaluation to a trial are addressed.

This article dicusses the individuals choice to engage in informal care as an issue for economic evaluation. Traditional methods used in economic evaluation studies for valuing time spent on informal care are discussed and an alternative method is put forward that incorporates the quality of life of caregivers as an outcome measure to represent the effects on caregivers. The methodological issues concerning the valuation of informal caregivers time are becoming more important as new drugs and other health care technologies are introduced for patients with diseases that are typically associated with informal care.

Despite an expanding number of centres which provide lung transplantation, information about the incremental costs of lung transplantation is scarce. From 1991 until 1995, in The Netherlands a technology assessment was performed which provided information about the incremental costs of lung transplantation. Costs in the situation with and without a transplantation programme were compared from a lifetime perspective. Because randomization was ethically inadmissible, only costs in the situation with the programme were observed. Both conventional treatment costs and costs of the transplantation programme were registered. Costs in the situation without the programme were based on the conventional treatment costs in the situation with the programme. Due to the study period of four years, long term follow-up costs were estimated. The total incremental costs per transplanted patient were estimated at Dfl 466 767 (5% discounted costs). The main part of these costs was caused by the high costs during the lifetime follow-up of the patients. © 1997 John Wiley & Sons, Ltd.

This paper comments on the recently published guidelines of the Washington Panel on incorporation of indirect non-medical costs, or productivity costs, in economic evaluations of health care. Traditionally the human capital or more recently the friction cost method is used to measure these costs. The Panel, however, recommends incorporating productivity costs as health effects in the denominator of the C/E ratio. This paper argues that incorporation of productivity costs in cost-effectiveness analysis expressed as health effects is not correct. Only direct health related effects on quality of life that cannot be meaningfully monetarized should be considered as health effects. Furthermore, measuring productivity costs in terms of quality of life may lead to misrepresentation of these costs from a societal viewpoint. This misrepresentation occurs because of the existence of social security systems and private insurance compensating for income reductions from disease. Furthermore, the patient's viewpoint is useful for quality of life measurement, but not for measuring productivity costs from a societal perspective. Finally, alternative recommendations are formulated for incorporating societal productivity costs in economic evaluations of health care. © 1997 by John Wiley & Sons, Ltd.

Despite an expanding number of centres which provide lung transplantation, information about the incremental costs of lung transplantation is scarce. From 1991 until 1995, in The Netherlands a technology assessment was performed which provided information about the incremental costs of lung transplantation. Costs in the situation with and without a transplantation programme were compared from a lifetime perspective. Because randomization was ethically inadmissible, only costs in the situation with the programme were observed. Both conventional treatment costs and costs of the transplantation programme were registered. Costs in the situation without the programme were based on the conventional treatment costs in the situation with the programme. Due to the study period of four years, long term follow‐up costs were estimated. The total incremental costs per transplanted patient were estimated at Dfl 466 767 (5% discounted costs). The main part of these costs was caused by the high costs during the lifetime follow‐up of the patients. © 1997 John Wiley & Sons, Ltd.

University of Wisconsin (UW) solution is now commonly used as a single-flush solution during multiorgan procurement for effective preservation of all intraabdominal organs including the kidney. Many kidneys from single kidney donors are still preserved in Eurocollins solution and the question is whether preservation in UW solution is more cost-effective. A European randomized multicenter trial was organized by the Department of Surgery of Leiden University in close cooperation with Eurotransplant to study the efficacy of UW solution as compared with EC solution. On the basis of this trial we found that at three months after transplant 92.4 of the patients in the UW group had a functioning graft in comparison with 88.4 in the EC group (similar figures after one year were 88.2 and 82.5, P0.04), while health care expenditure during these first three months was on average US 700 lower for the UW group than for the EC group, taking into account the price difference in the preservation fluids. The long-term benefits of using UW solution as compared with EC solution were conservatively estimated at US 7000 per patient reflecting the additional expenses for dialysis in the EC group. We concluded that the extra costs of using UW solution instead of EC solution (US 230 per kidney) can be easily earned back within three months and that the long-term savings of such a strategy are considerable. Moreover, the health status of patients in the UW group is expected to be better on the average than in the EC group. Simply reacting to the price tag of the UW solution may be penny-wise but pound-foolish.

Couples who are subfertile for unknown reasons or because of male factors spontaneously conceive at an estimated rate of about 2 percent per cycle. Counseling of these couples has proved difficult because of a paucity of high-quality comparative studies. This prospective, randomized trial randomly assigned 258 couples with idiopathic or male subfertility to receive a maximum of six cycles of intrauterine insemination (IUI) in the spontaneous cycle, IUI after mild ovarian hyperstimulation, or in vitrofertilization (IVF). The primary end point was pregnancy resulting in a live birth. The couples had had idiopathic subfertility for at least 3 years or male subfertility for 1 year or longer. IUI alone was performed 20 to 30 hours after the endogenous LH surge was detected. Mild hyperstimulation was produced using a low dose of FSH. IVF utilized controlled ovarian hyperstimulation by a gonadotropin-releasing hormone agonist and human menopausal gonadotropin or FSH. Brief stimulation was used in women older than 38 years.