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Graphic representation was used to explore to what extent the number needed to treat (NNT) conveys the appropriate notion of benefit for the individual patient in interventions aimed at delaying adverse events. A sample of the Danish population (n = 675) was interviewed face to face, and asked whether they would consent to a hypothetical drug that reduces the risk of heart attack. The benefit of the drug was expressed in terms of NNT and was randomly set at 10, 25, 50, 100, 200, and 400. NNT does not convey information on the proportion of patients being helped by an intervention or the size of the delay of the adverse event intended to be prevented. The proportion of people consenting to the hypothetical drug was about 80%, irrespective of NNT, and some of those who rejected the drug misinterpreted the meaning of NNT. Lay people may have difficulties in understanding the meaning of NNT, and clinicians may do well to use the NNT with caution until more is known about how patients comprehend it. [Copyright &y& Elsevier]

Objective: We sought to identify predictors of preferences for cesarean among pregnant women, and estimate how different predictors influence preferences. Study Design: This was a cross-sectional study based on the Norwegian Mother and Child Cohort Study (n = 58,881). Results: Of the study population, 6% preferred cesarean over vaginal delivery. While 2.4% of nulliparous had a strong preference for cesarean, the proportion among multiparous was 5.1%. The probability that a woman, absent potential predictors, would have a cesarean preference was similar (<2%) for both nulliparous or multiparous. In the presence of concurrent predictors such as previous cesarean, negative delivery experience, and fear of birth, the predicted probability of a cesarean request ranged from 20–75%. Conclusion: The proportion of women with a strong preference for cesarean was higher among multiparous than nulliparous women, but the difference was attributable to factors such as previous cesarean or fear of delivery and not to parity per se. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to test the hypothesis that obstetricians'' choice of delivery method is influenced by their risk attitude and perceived risk of complaints and malpractice litigation. Study Design: The choice of delivery method in ambiguous cases was studied in a nationwide survey of Norwegian obstetricians (n = 716; response rate, 71%) using clinical scenarios. The risk attitude was measured by 6 items from the Jackson Personality Inventory-Revised. Results: The proportion of obstetricians consenting to the cesarean request varied both within and across the scenarios. The perceived risk of complaints and malpractice litigation was a clear determinant of obstetricians'' choice of cesarean in all of the clinical scenarios, whereas no impact was observed for risk attitude. Conclusion: Obstetricians'' judgments about cesarean request in ambiguous clinical cases vary considerably. Perceived risk of complaints and litigation is associated with compliance with the requested cesarean. [Copyright &y& Elsevier]

Abstract: Objectives: In EuroQol five-dimensional questionnaire valuation studies, each participant typically assesses more than 10 hypothetical health states by using the time trade-off (TTO) method. We wanted to explore potential learning effects when using the TTO method, that is, whether the valuations were affected by the number of previously rated health states (the sequence number). Methods: We included 3773 respondents from the US EQ-5D valuation study, each of whom valued 12 health states (plus unconscious) in random order. With linear regression, we used sequence number to predict mean and standard deviations across all health states. We repeated the analysis separately for TTO responses indicating a state better than death and a state worse than death. Each TTO value requires a specific number of choice iterations. To test whether respondents used fewer iterations with experience, we used linear regression with sequence number as the independent variable and number of iterations as the dependent variable. Results: Mean TTO values were fairly stable across the sequence number, but analyzing state better than death and state worse than death values separately revealed a tendency toward more extreme values: state better than death values increased by 0.02, while state worse than death values decreased by 0.21 (P < 0.0001) over the full sequence. The standard deviations increased slightly, while the number of choice iterations was the same over the sequence number. The findings were stable across the levels of health state severity, age, and sex. Conclusions: TTO values become more extreme with increasing experience. Because of the randomized valuation order, these effects do not bias specific health states; however, they reduce the overall validity and reliability of TTO values. [Copyright &y& Elsevier]

Background: Decision makers often need to simultaneously consider multiple criteria or outcomes when deciding whether to adopt new health interventions.Objectives: Using decision analysis within the context of cervical cancer screening in Norway, we aimed to aid decision makers in identifying a subset of relevant strategies that are simultaneously efficient, feasible, and optimal.Methods: We developed an age-stratified probabilistic decision tree model following a cohort of women attending primary screening through one screening round. We enumerated detected precancers (i.e., cervical intraepithelial neoplasia of grade 2 or more severe (CIN2+)), colposcopies performed, and monetary costs associated with 10 alternative triage algorithms for women with abnormal cytology results. As efficiency metrics, we calculated incremental cost-effectiveness, and harm-benefit, ratios, defined as the additional costs, or the additional number of colposcopies, per additional CIN2+ detected. We estimated capacity requirements and uncertainty surrounding which strategy is optimal according to the decision rule, involving willingness to pay (monetary or resources consumed per added benefit).Results: For ages 25 to 33 years, we eliminated four strategies that did not fall on either efficiency frontier, while one strategy was efficient with respect to both efficiency metrics. Compared with current practice in Norway, two strategies detected more precancers at lower monetary costs, but some required more colposcopies. Similar results were found for women aged 34 to 69 years.Conclusions: Improving the effectiveness and efficiency of cervical cancer screening may necessitate additional resources. Although efficient and feasible, both society and individuals must specify their willingness to accept the additional resources and perceived harms required to increase effectiveness before a strategy can be considered optimal. [ABSTRACT FROM AUTHOR]

Abstract: Background: We aimed to estimate the societal costs of rotavirus cases among children less than 5 years in Kazakhstan, an upper-middle income country in Central Asia. Methods: Data on medical, non-medical and indirect costs were collected for 190 patients less than 5 years, hospitalized with severe diarrhea in 2009 in two pediatric hospitals. Data on resource use for moderate and mild diarrhea cases were obtained from published sources. A probabilistic sensitivity analysis was performed to explore uncertainty in cost estimates. Results: Approximately 4,000 severe, 30,700 moderate, and 122,900 mild rotavirus cases were estimated annually in children <5 years old. The mean societal cost of a severe, moderate and mild rotavirus case was estimated at US$ 454, 82, and 21, respectively. The total annual cost of rotavirus disease was $37.53 million or on average $107.36 for a child under 5 years old in Kazakhstan. Ninety-four percent of total costs (35.13 million) are indirect costs (productivity losses) from fatal cases and parents’ job absenteeism, while direct medical costs account for 2.04 million (5.4%), and direct non-medical for 0.46 million (1.2%). Conclusions: Rotavirus-associated diarrhea represents a significant economic burden in Kazakhstan, largely due to indirect costs. The costs of rotavirus infections should be considered when planning further preventive actions, including the introduction of rotavirus vaccination. [Copyright &y& Elsevier]

Abstract: Background: Streptococcus pneumoniae is a frequent bacterial cause of serious infections that may cause permanent sequelae and death. A 7-valent conjugate vaccine may reduce the incidence of pneumococcal disease, but some previous studies have questioned the cost-effectiveness of the vaccine. The aim of this study was to estimate costs and health consequences of adding this pneumococcal vaccine to the Norwegian childhood vaccination programme, taking the possibility of herd immunity into account. Methods: We developed a simulation model (Markov-model) using data on the risk of pneumococcal disease in Norway, the efficacy of the vaccine as observed in clinical trials from other countries and adjusted for serotype differences, the cost of the vaccine and quality of life for patients with sequelae from pneumococcal disease. The results were expressed as incremental (additional) costs (in euros; €1.00≈NOK8.37), incremental life years and incremental quality adjusted life years. Four different sets of main results are presented: costs and (quality adjusted) life years, with and without indirect costs (the value of lost production due to work absenteeism) and with and without potential herd immunity (i.e. childhood vaccination protects adults against pneumococcal disease). Results: When indirect costs were disregarded, and four vaccine doses used, the incremental cost per life year gained was €153,000 when herd immunity was included, and €311,000 when it was not. When accounting for indirect costs as well, the cost per life year gained was €58,000 and €124,000, respectively. Assuming that three vaccine doses provide the same protection as four, the cost per life year gained with this regimen was €90,000 with herd immunity and €184,000 without (when indirect costs are disregarded). If indirect costs are also included, vaccination both saves costs and gains life years. Interpretation/conclusion: In Norway, governmental guidelines indicate that only interventions with cost per life year of less than €54,000 should be implemented. This implies that four dose vaccination is not cost-effective even if decision makers includes both herd immunity and indirect costs in their decisions. If three doses offer the same protection as four doses, however, vaccination would be cost-saving when indirect costs are included, but not with only herd immunity. Comment: In the autumn of 2005, the Norwegian Government decided to include PCV-7 in the vaccination program. This analysis was used by the Ministry of Health and Ministry of Finance during the decision process. [Copyright &y& Elsevier]

Background: Information on the benefits of therapeutic interventions can ve expressed in various ways, including relative risk reduction, absolute risk reduction, and number needed to treat (NNT). An alternative to such risk-based measures is postponement of an adverse outcome (eg, hip fracture in the case of osteoporosis).Objective: The goal of this study was to examine whether laypersons'' perception of the benefit of an osteoporosis therapy differs when it is presented in terms of the NNT to avoid 1 hip fracture compared with the duration of postponement of hip fracture.Methods: This was a cross-sectional, randomized, controlled trial. Face-to-face interviews of a representative sample of the Danish population were conducted in respondents'' homes. Respondents were randomized to receive information about the benefits of a hypothetical osteoporosis intervention either in terms of different magnitudes of NNT (10, 50, 100, or 400) or different durations of postponement of hip fracture (1 month, 6 months, 1 year, or 4 years). Participants were subsequently asked if they would consent to the intervention.Results: A total of 1728 individuals were contacted at home and asked if they would take part in a face-to-face interview; 967 (56%) were successfully interviewed. The age (mean age, 44.5 years; range, 20–74 years) and sex distrivution (51% male, 50% female) of the sample was similar to that of the general Danish population. Based on NNTs of 10, 50, 100, and 400, the proportions of responsiveness [Copyright &y& Elsevier]