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OBJECTIVES: To estimate the long-term impact of treatment with perindopril on costs and health effects in patients with stable coronary artery disease in Poland. METHODS: The cost-effectiveness analysis was based on data from a randomized double-blind, placebo-controlled trial. A decision-tree analysis was employed, including Monte Carlo and bootstrapping techniques. This study was a sub-study of the EUROPA (European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease) trial (n = 12 218; mean follow-up 4.2 years). Resource use was based on data from Polish EUROPA study patients (n = 1251), while effectiveness was based on the whole EUROPA study. The health gain of perindopril in life-years was based on overall EUROPA study results, and the adapted Polish life expectancy of patients not dying during the trial. Costs were calculated in new Polish zloty (PLN), year 2003 values; €1 = PLN4.053. Only direct healthcare costs related to cardiovascular events and medication use were studied. RESULTS: When observed mortality was combined with life expectancy beyond the end of the study, perindopril use showed a gain in life expectancy of 0.182 life-years (SD +/- 0.129) at a cost of PLN1983 (SD +/- 103) with discounting of 5% per annum on costs and no discounting on effects. This resulted in an incremental cost-effectiveness ratio (ICER) of PLN10 896 per life-year gained. The probability that the ICER for perindopril was below the threshold of PLN60 000 was 88%. The overall results were insensitive to discount rates for costs and life-years. CONCLUSIONS: Perindopril leads to a reduction in the risk of coronary events among patients with stable heart disease. When the expected improvement in life expectancy is combined with associated medical costs, there is a high probability that perindopril is cost effective, given the threshold of PLN60 000 per life-year gained. [ABSTRACT FROM AUTHOR]

Which costs and benefits to consider in economic evaluations of healthcare interventions remains an area of much controversy. Unrelated medical costs in life-years gained is an important cost category that is normally ignored in economic evaluations, irrespective of the perspective chosen for the analysis. National guidelines for pharmacoeconomic research largely endorse this practice, either by explicitly requiring researchers to exclude these costs from the analysis or by leaving inclusion or exclusion up to the discretion of the analyst. However, the inclusion of unrelated medical costs in life-years gained appears to be gaining support in the literature.This article provides an overview of the discussions to date. The inclusion of unrelated medical costs in life-years gained seems warranted, in terms of both optimality and internal and external consistency. We use an example of a smoking-cessation intervention to highlight the consequences of different practices of accounting for costs and effects in economic evaluations. Only inclusion of all costs and effects of unrelated medical care in life-years gained can be considered both internally and externally consistent. Including or excluding unrelated future medical costs may have important distributional consequences, especially for interventions that substantially increase length of life. Regarding practical objections against inclusion of future costs, it is important to note that it is becoming increasingly possible to accurately estimate unrelated medical costs in life-years gained. We therefore conclude that the inclusion of unrelated medical costs should become the new standard. [ABSTRACT FROM AUTHOR]

Mortality rates in neonatal surgery have dropped markedly, illustrating the enormous progress made. Yet, new questions have arisen. To mention one, health care budgets have tightened. It follows that the effects of medical interventions should be weighted against their costs. As evidence was particularly sparse, we set out to analyse cost-effectiveness of neonatal surgery. The purpose of this article is to summarise our findings and to review recent studies. Moreover, this article explains the relevance of cost-effectiveness analysis and explores how cost-effectiveness interacts with other determinants of health care priority setting. Our research revealed that treatments for two common diagnostic categories in neonatal surgery (congenital anorectal malformations and congenital diaphragmatic hernia) produce good cost-effectiveness. Other groups also published cost-effectiveness studies in the field of neonatal surgery, although their number is still small. Contemporaneously, the economic aspects of health care have captured the interest of policy makers. Importantly, this is not to say that there are no other factors playing a role in priority setting, foremost among which are ethical questions and arguments of equity. This article concludes that, according to present evidence, neonatal surgery yields good value for money and contributes to equity in health. [ABSTRACT FROM AUTHOR]

Background: Depressive disorder is one of the most common disorders, and is highly prevalent in chronically ill patients. The presence of comorbid depression has a negative influence on quality of life, health care costs, selfcare, morbidity, and mortality. Early diagnosis and well-organized treatment of depression has a positive influence on these aspects. Earlier research in the USA has reported good results with regard to the treatment of depression with a collaborative care approach and an antidepressant algorithm. In the UK 'Problem Solving Treatment' has proved to be feasible. However, in the general hospital setting this approach has not yet been evaluated. Methods/Design: CC: DIM (Collaborative Care: Depression Initiative in the Medical setting) is a two-armed randomised controlled trial with randomisation at patient level. The aim of the trial is to evaluate the treatment of depressive disorder in general hospitals in the Netherlands based on a collaborative care framework, including contracting, 'Problem Solving Treatment', antidepressant algorithm, and manual-guided self-help. 126 outpatients with diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular diseases will be randomised to either the intervention group or the control group. Patients will be included if they have been diagnosed with moderate to severe depression, based on the DSM-IV criteria in a two-step screening method. The intervention group will receive treatment based on the collaborative care approach; the control group will receive 'care as usual'. Baseline and follow-up measurements (after 3, 6, 9, and 12 months) will be performed by means of questionnaires. The primary outcome measure is severity of depressive symptoms, as measured with the PHQ-9. The secondary outcome measure is the cost-effectiveness of these treatments according to the TiC-P, the EuroQol and the SF-36. Discussion: Earlier research has indicated that depressive disorder is a chronic, mostly recurrent illness, which tends to cluster with physical comorbidity. Even though the treatment of depressive disorder based on the guidelines for depression is proven effective, these guidelines are often insufficiently adhered to. Collaborative care and 'Problem Solving Treatment' will be specifically tailored to patients with depressive disorders and evaluated in a general hospital setting in the Netherlands. [ABSTRACT FROM AUTHOR]

Background: Costs of inpatient days in hospitals are frequently the main drivers of total treatment costs, and their unit cost can markedly affect the outcomes of an economic evaluation. In many countries, the availability of unit cost data is limited and unit costs are often based on data from hospitals participating in clinical trials.Objective: To provide data about unit costs of inpatient hospital days in The Netherlands from a healthcare provider's perspective and to give an insight into the extent to which cost categories and total costs differ between hospitals.Design: Unit costs were collected from 22 wards and 11 intensive care units (ICUs) of general and university hospitals involved in clinical trials with 'piggybacked' economic evaluations. Direct costs, such as costs of nursing and medical materials, were calculated by dividing the annual cost per category of the nursing department by the annual number of inpatient days. Indirect costs, such as overheads and accommodation, were allocated to the nursing departments by applying direct allocation. All costs were expressed in 1998 euros (EUR).Results: The mean costs per inpatient day were EUR230 (range: EUR154-EUR311) in general hospitals and EUR323 (range: EUR209-EUR400) in university hospitals. The mean costs per inpatient day in an ICU were EUR1125 (EUR919-EUR1560). Between 38-48% of the total costs were made up of nursing costs. All cost categories showed wide variations between hospitals.Conclusions: The results of this study were used to develop standard costs for inpatient days in The Netherlands and may contribute to the comparability and generalisability of economic evaluations. [ABSTRACT FROM AUTHOR]

The lack of a uniform costing methodology is often considered a weakness of economic evaluations that hinders the interpretation and comparison of studies. Standardisation is therefore an important topic within the methodology of economic evaluations and in national guidelines that formulate the formal requirements for studies to be considered when deciding on the reimbursement of new medical therapies. Recently, the Dutch Manual for Costing: Methods and Standard Costs for Economic Evaluations in Health Care (further referred to as ‘the manual’) has been published, in addition to the Dutch guidelines for pharmacoeconomic research. The objectives of this article are to describe the main content of the manual and to discuss some key issues of the manual in relation to the standardisation of costs. The manual introduces a six-step procedure for costing. These steps concern: the scope of the study; the choice of cost categories; the identification of units; the measurement of resource use; the monetary valuation of units; and the calculation of unit costs. Each step consists of a number of choices and these together define the approach taken. In addition to a description of the costing process, five key issues regarding the standardisation of costs are distinguished. These are the use of basic principles, methods for measurement and valuation, standard costs (average prices of healthcare services), standard values (values that can be used within unit cost calculations), and the reporting of outcomes. The use of the basic principles, standard values and minimal requirements for reporting outcomes, as defined in the manual, are obligatory in studies that support submissions to acquire reimbursement for new pharmaceuticals. Whether to use standard costs, and the choice of a particular method to measure or value costs, is left mainly to the investigator, depending on the specific study setting. In conclusion, several instruments are available to increase standardisation in costing methodology among studies. These instruments have to be used in such a way that a balance is found between standardisation and the specific setting in which a study is performed. The way in which the Dutch manual tries to reach this balance can serve as an illustration for other countries. [ABSTRACT FROM AUTHOR]

The article describes the nature of medium term consequences and the method of health estimation using Dutch macro-economic sectoral models. These models are reply to comments given by authors Magnus Johanneson and Göran Karlsson on indirect costs estimation of medical care. The controversy arises with respect to long term absence, disability and mortality of their comments. Johanneson and Karlsson argue that no indirect costs of disease will occur after the friction period. They focus on the role of internal labour reserves and the role of unemployment in their method. They find indirect costs much smaller than estimates based on human capital approach. The article presents the model to advise Dutch government and parliament on short term and medium term economic development. The economic aspects of medium term concern the influence of absence in work on labour productivity, labour costs per unit of output and the degree of international competitiveness. This also holds for the impact of disability premiums on labour supply and labour costs.

Portfolio theory has been suggested as a means to improve the risk–return characteristics of investments in health-care programs through diversification when costs and effects are uncertain. This approach is based on the assumption that the investment proportions are not subject to uncertainty and that the budget can be invested in toto in health-care programs.In the present paper we develop an algorithm that accounts for the fact that investment proportions in health-care programs may be uncertain (due to the uncertainty associated with costs) and limited (due to the size of the programs). The initial budget allocation across programs may therefore be revised at the end of the investment period to cover the extra costs of some programs with the leftover budget of other programs in the portfolio.Once the total budget is equivalent to or exceeds the expected costs of the programs in the portfolio, the initial budget allocation policy does not impact the risk–return characteristics of the combined portfolio, i.e., there is no benefit from diversification anymore.The applicability of portfolio methods to improve the risk–return characteristics of investments in health care is limited to situations where the available budget is much smaller than the expected costs of the programs to be funded. [ABSTRACT FROM AUTHOR]

It is normally stated that an economic evaluation should take the societal perspective and that this implies the incorporation of all costs and effects, regardless of where these occur. Nevertheless, this broad perspective may be in conflict with the narrower perspective of the health-care decision-makers we are usually trying to aid. In this article, it is argued that not all costs have to be considered equally important for health-care decision-making and that there is a discrepancy between the economically preferred societal perspective and the aim of aiding health-care decision-makers. This is related to the concept of local rationality. Three reasons why some costs may be considered more important for health-care decision-makers than others are: 1) relevance; 2) equity; and 3) responsibility. We suggest that it may be useful to adopt a two-perspective approach as a standard, presenting one cost-effectiveness ratio following a strict health-care perspective and one following the common societal perspective. The health-care perspective may assist the health-care policymaker better in achieving health-care goals, while the societal perspective indicates whether the local rationality of the narrow health-care perspective is also in line with societal optimality. More research on actual decisions should provide more insight into the relative weights attached to different types of costs. [ABSTRACT FROM AUTHOR]