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This paper provides a new and more robust test of the descriptive validity of the constant rate discounted utility model in medical decision analysis. The constant rate discounted utility model is compared with two competing theories, Harvey's (1986) proportional discounting model and Loewenstein and Prelec's (1992) hyperbolic discounting model. To compare the various intertemporal models, previous studies on intertemporal preferences for health assumed a specific parametric form of the utility function for life-years and no discounting within the time periods that health states are experienced. The present study avoids such confounding assumptions by focusing on the axiomatic structure of the discounting models. The present study further differs by using choices instead of matching to elicit intertemporal preferences. The experimental results provide support for decreasing timing aversion, the condition underlying the proportional and the hyperbolic discounting model, but they violate stationarity, the central condition of the constant rate discounted utility model. There is some ambiguity whether the violations of stationarity are primarily caused by an immediacy effect. The results confirm violations of stationarity in choice-based elicitations tasks, in contrast with the results from Ahlbrecht and Weber (1997) which supported stationarity in choices over monetary outcomes. Copyright 2001 Academic Press.

We find that the actual willingness to pay for various consumer goods can be manipulated by an uninformative anchor, replicating Ariely et al. (2003). We furthermore demonstrate that the anchoring effect decreases but does not vanish with higher cognitive ability.

We carry out a double blind dictator game experiment where the anonymous recipients are randomly drawn from the Swedish general population, and any donations are mailed to the recipients. About a third of the subjects donate some money.

In this paper we estimate a "Grossman" model of demand for health based on Swedish micro data. The data set consists of a random sample of over 5000 individuals taken from the Swedish adult population. Health capital is measured by a categorical measure of overall health status, and an ordered probit model is used to econometrically estimate the demand for health equation. The results are consistent with the theoretical predictions and show that the demand for health increases with income and education and decreases with age, male gender, overweight, living in big cities and being single.

A key recommendation of the recent Panel on Cost-Effectiveness in Health and Med icine was that cost-effectiveness analyses be carried out from a societal perspective. The authors show that two of the Panel's recommendations concerning costs are not consistent with a societal perspective, and how to correct those inconsistencies. In its recommendations concerning costs resulting from morbidity, the Panel advises ex cluding lost income from costs in the belief that individuals take income changes into account when they respond to the quality-of-life questions that are used to calculate quality-adjusted life years (QALYs). It is shown that even if individuals do consider income changes in responding to these quality-of-life questions, this recommendation would seriously underestimate production losses due to morbidity, since individuals do not bear a major part of lost production. In its recommendations concerning costs resulting from mortality, the Panel does not require that health care costs for "unre lated" illness and non-health care consumption and production during added life years be included in the Reference Case. It is shown that omitting these costs will seriously distort comparisons of programs at different ages and favor programs that extend life over those that improve quality of life. This can be corrected by including total con sumption minus production in added life-years among costs. Key words: cost-effec tiveness analysis; societal perspective; public policy; resource allocation; Panel on Cost-Effectiveness in Health and Medicine. (Med Decis Making 1999; 19:371-377)

This paper estimates a “Grossman” model of demand for health. We measure health status on a 0 (dead) to 1 (full health) cardinal scale by the rating scale method and the time trade-off method. We also use a categorical measure of overall health status commonly used in quality of life measurements. To estimate the demand for health equations, the Tobit technique is used for the rating scale and time trade-off health measure. The ordered probit model is used for the categorical health measure. The demand for health decreases with the price of medical care, age, overweight, smoking and living alone, and increases with income, education and the level of sporting activities.

A social tariff of EuroQol time trade-off (TTO) values was recently presented. We compared the social tariff and patient TTO values among 104 women with mild and severe menopausal symptoms. The social tariff and patient TTO values were elicited both after and before hormone replacement therapy (HRT). There was a close correspondence between social-tariff values and patient TTO values for relatively good health states, whereas the social tariff TTO values were lower than the patient TTO values for severe health states. Copyright © 1999 John Wiley & Sons, Ltd.

Background: This study examined health-related quality of life in a general population in relation to different socioeconomic variables. Method: The study was cross-sectional and was conducted in Uppsala county, Sweden, which had approximately 290,000 inhabitants In 1995. The study was based on a self-administered postal questionnaire sent to a random sample of 8,000 inhabitants aged 20-84 years, with a response rate of 68%. Health-related quality of life was measured on a 0 (dead) to 1 (full health) cardinal scale by two methods used to measure health-state utilities In economic evaluations, i.e. the rating scale method and the time trade-off method. Results: The mean age was 46 years and approximately 54% were women. Almost 70% were married or cohabrtors. Approxiamtely 33% of the respondents had less than high-school education and 26% had a university degree. The mean income was SEK 13,000 per month and the proportion unemployed was 4.5%. The proportions of blue-collar workers, white-collar workers and self-employed were 40, 50 and 10% respectively. With the rating scale method, the mean health-state utility decreased from 0.86 in the youngest age group (20-29 years) to 0.63 (80- years) in the oldest age group and from 0.94 to 0.61 with the time trade-off method. Quality of life increased with income, education and social group and decreased with being single and unemployed. Conclusion: These methods are useful In assessing hearth-related quality of life in the general population and that quality of life varies substantially among different sodoeconomic groups.

Dolan [Dolan, P., 1998, The measurement of individual utility and social welfare. Journal of Health Economics, Vol. 17, pp. 39-52] in a recent paper suggested an empirical method for estimating the shape of the social welfare function. Using a simple theoretical model it is shown that Dolan's proposed empirical method has no theoretical foundation. The main problem with the approach is that it measures only the altruistic values that individuals attach to other peoples' health status and ignores the utility that individuals attach to their own health status.

This paper gives a detailed presentation of a computer model for evaluating the cost-effectiveness (CE) of hormone replacement therapy (HRT), describing the model's design, structure, and data requirements. The model needs data specified for costs, quality of life, risks, and mortality rates. As an illustration, the CE of HRT in Sweden is calculated. Two treatment strategies are evaluated for asymptomatic women: estrogen-only therapy and estrogen combined with a progestin. The model produces similar results compared with earlier studies. The CE ratios improve with the size of the risk reduction and generally with age. Further, estrogen-only therapy is associated with a lower cost per gained effectiveness unit compared with combined therapy. Uncertainty surrounding the long-term effects of HRT means that the CE estimates should be interpreted carefully. The model permits the inclusion of indirect costs and costs in added life-years, allowing the analysis to be made from a societal perspective, which is an improvement relative to previous studies.

Gneezy [Gneezy, U., 2005. Deception: the role of consequences. American Economic Review 95, 384–394.] recently showed that lying is costly. Using the same experimental design we test whether there is a gender difference in deception. We find that men are significantly more likely than women to lie to secure a monetary benefit.

We compare different contingent valuation question formats with each other and with observed behaviour for a non-monetary estimation task, the expected number of kilometers travelled by automobile. Open-ended questions, open-ended follow-up questions, dichotomous choice (DC) questions, and double-bound DC questions are included. The single and double-bound DC questions result in an estimated mean about twice as high as the actual value and the open-ended mean. The DC question overestimation seems to be due to an anchoring effect leading to ‘yea-saying’ behaviour. Our results about the difference between DC questions and open-ended questions is consistent with the pattern observed in contingent valuations studies of the willingness to pay. Our results indicates that DC questions seem to be associated with a general overestimation problem that is present even for simple non-monetary estimation tasks.

Experimental data comparing hypothetical and real dichotomous choice responses for two different goods were used to estimate a statistical bias function to calibrate the hypothetical yes responses. The probability that a hypothetical yes response would be a real yes response was estimated as a function of . the individual's self-assessed certainty of the hypothetical yes response assessed on a 0)10 scale and a variable representing the price level. Without calibration the hypothetical yes responses significantly exceeded the proportion of real yes responses, but after calibration the null hypothesis of no difference between hypothetical and real responses could not be rejected in any of the experiments.

In this paper, we develop a simple model of the benefits and costs of being on a waiting list. The model shows that complex factors are in operation, implying that a shorter waiting time need not necessarily be preferred to a longer waiting time. We also present an empirical study, where a sample of Swedes are offered the possibility of purchasing private insurance, thus reducing waiting time for surgery beyond the three-month guarantee offered by the public sector health care system. Respondents could choose between two insurance contracts. A `spike' model, where the probability of a zero WTP is strictly positive, was developed and estimated to obtain demand functions for private insurance.

In the standard gamble and time trade-off methods of health state utility assessment, a specified health state and an alternative are compared. This alternative can be framed in terms of a loss or a gain in reference to the first health state. In this paper, we test whether this framing affects the estimated health state utilities. The experiment was carried out on a group of pharmacy students, randomly divided between the loss or gain version ( n =182). The null hypothesis of no difference between the loss and gain versions is rejected for the standard gamble method, but not for the time trade-off method.

OBJECTIVES For contingent valuation to provide valid values for policy making, it is important that respondents be well informed about the goods they are asked to value. Few studies, however, have tested the impact of providing this information This study assessed the impact of risk information on patients' willingness to pay for autologous blood donation and derived the willingness to pay in a sample of informed patients. METHODS Patients were randomized either to receive information about the risks of complications from allogeneic (volunteer) blood transfusions or to base their willingness to pay responses on their own prior knowledge. Four hundred twelve autologous blood donors were recruited from three study sites. Self-administered questionnaires collected information on willingness to pay, risk perceptions, and socioeconomic information. RESULTS As predicted by our theoretical model, providing risk information reduced the variance in the willingness to pay for autologous blood donation. A tendency for information to reduce the willingness to pay was also found, suggesting that uninformed patients, on average, overestimate the risks of allogeneic blood transfusions. The median willingness to pay in the informed sample was approximately $750 to $1,100, depending on the estimation method, compared with $800 to $1,900 in the uninformed group. Willingness to pay was significantly related to perceived transfusion risk, personal income, and dread of transfusions. CONCLUSIONS Our results are consistent with an economic model where individuals update their prior risk perceptions with new information. The willingness to pay in the informed sample was far higher than the costs of autologous blood donation, suggesting that total benefits outweigh the costs of the procedure.

Use of the contingent valuation method is controversial among economists because it is based on hypothetical rather than real choices. Previous experiments have suggested that the commonly used dichotomous choice contingent valuation method leads to hypothetical bias, i.e., overestimates the real willingness to pay. We carried out an experiment to compare the dichotomous choice contingent valuation method with real purchase decisions for a consumer good. We confirm previous findings that hypothetical yes responses overestimate real purchase decisions, but we cannot reject the null hypothesis that definitely sure yes responses correspond to real purchase decisions.

Traditionally, economic evaluations in terms of cost-effectiveness analysis are based, explicitly or implicitly, on the assumption of constant returns to scale. This assumption has been criticized in the literature and the role of cost-effectiveness as a tool for decision making has been questioned. In this paper we analyze the case of increasing returns to scale due to fixed capital costs. Cost-effectiveness analysis is regarded as a tool for estimating a cost function. To this cost function two types of decision rules can be applied, the budget approach and the constant price approach. It is shown that in the presence of fixed capital costs the application of these two decision rules to a specific patient group will give different results. The budget approach may lead to suboptimizations, while using the price as a decision rule will give optimal solutions. With fixed capital costs and when an investment can be used for treating several patient groups, these groups are no longer independent. Therefore the cost-effectiveness analysis has to be performed simultaneously for all patient groups that are potential users of the investment.

Background In asthma, a substantial impact of disease is on quality of life rather than survival. To date, the quality of life effects of asthma have not been quantitated. Objective The purpose of this study was to quantitate the quality of life effects of asthma via measurement of the health utility of asthmatic patients, and the willingness to pay for an asthma cure. A second goal was to analyze how these measures are related to the different dimensions of quality of life as measured by general and disease specific quality of life instruments. Methods Health utilities were measured on a scale between 0 and 1 using the rating scale, time trade off, and standard gamble methods. Willingness to pay was elicited using both the dichotomous choice and the bidding game approach. Quality of life was assessed using both a generic instrument (the SF-36) and a disease-specific instrument (the Asthma TyPE). Results Sixty-nine patients with asthma were surveyed. The mean health utility was 0.68 with the rating scale method, 0.89 with the time trade off, and 0.91 with the standard gamble. On average, patients were willing to pay between $200 to $350 dollars more per month for an asthma cure. Nearly all correlations between dimensions of quality of life, health state utilities, and willingness to pay were in the expected direction. Conclusion The two quality of life instruments performed about equally well in terms of being correlated with and being able to explain the responses to the health state utility questions and the willingness to pay questions. Correlations between the dimensions of the Asthma TyPE and the SF-36 were also fairly high. Further work should focus on validating and refining the different methods of quantitating quality of life for asthma patients.

We identify common genetic variants associated with cognitive performance using a two-stage approach, which we call the proxyphenotype method. First, we conduct a genome-wide association study of educational attainment in a large sample (n = 106,736), which produces a set of 69 education-associated SNPs. Second, using independent samples (n = 24,189), we measure the association of these education-associated SNPs with cognitive performance. Three SNPs (rs1487441, rs7923609, and rs2721173) are significantly associated with cognitive performance after correction for multiple hypothesis testing. In an independent sample of older Americans (n = 8,652), we also show that a polygenic score derived from the education-associated SNPs is associated with memory and absence of dementia. Convergent evidence from a set of bioinformatics analyses implicates four specific genes (KNCMA1, NRXN1, POU2F3, and SCRT). All of these genes are associated with a particular neurotransmitter pathway involved in synaptic plasticity, the main cellular mechanism for learning and memory. Refereed/Peer-reviewed

Recent research demonstrates that a wide range of political attitudes, beliefs, and behaviors canbe explained in part by genetic variation. However, these studies have not yet identied themechanisms that generate such a relationship. Some scholars have speculated that psychologicaltraits mediate the relationship between genes and political participation, but so far there havebeen no empirical tests. Here we focus on the role of three psychological traits that are believed toinuence political participation: cognitive ability, personal control, and extraversion. Utilizinga unique sample of more than 2,000 Swedish twin pairs, we show that a common genetic factorcan explain most of the relationship between these psychological traits and acts of politicalparticipation as well as predispositions related to participation. While our analysis is not adenitive test, our results suggest an upper bound for a proposed mediation relationship betweengenes, psychological traits, and political participation. Nature, nurture, and political attitudes and behavior

We compare hypothetical and real payments in a Vickrey auction. The use of hypothetical payments overestimates the real willingness to pay. The results cast doubt on the validity of hypothetical willingness to pay questions for the typical respondent.

Objective To measure the gain in quality of life due to hormone replacement therapy for women with mild and severe menopausal symptoms. Design Prospective study where data on quality of life and willingness to pay were collected by interview. Setting Department of Gynaecology at Sodertalje Hospital near Stockholm. Participants One hundred and four women aged 45 to 65 years treated for menopausal symptoms for at least one month. Methods Quality oflife was measured by the time tradeoff and rating scale methods. The willingness to pay for hormone replacement therapy was investigated using the contingent valuation method. Main outcome measures The quality adjusted life year weight measured with the rating scale and time tradeoff methods, and willingness to pay. Results The increase in the quality adjusted life year weight due to hormone replacement therapy for women with mild symptoms was 0.26 according to the rating scale method and 0.18 according to the time tradeoff method. For women with severe symptoms the quality adjusted life year weight increased by 0.50 according to the rating scale method and by 0.42 according to the time tradeoff method. The mean willingness to pay for hormone replacement therapy per month was 2300 Swedish krone for women with mild symptoms and 4800 Swedish krone for women with severe symptoms (£1 = 10.3 Swedish krone). Conclusions Hormone replacement therapy leads to a major improvement in quality of life for women with menopausal symptoms. Both for women with mild and severe menopausal symptoms the willingness to pay for the treatment also greatly exceeds the costs, indicating that hormone replacement therapy is economically beneficial for women with menopausal symptoms.

It has been shown that the difference between consumption and production during life years gained should be included as a cost in cost-effectiveness analysis. In this study the authors estimate the impact of including these future costs on the cost-effective ness of the treatment of hypertension in Sweden. The cost per quality-adjusted life year (QALY) gained changes little among young men and women due to the addition of future costs, but increases by about $14,000 for middle-aged men and women and about $27,000 for older men and women. When future costs are not included, the cost per QALY gained is generally lowest among older men and women, but when future costs are included, the cost per QALY gained is generally lowest among middle-aged men and women. The authors conclude that the total resource consequences of changes in mortality should be routinely considered in cost-effectiveness analyses. Key words: Cost-effectiveness analysis; economic evaluation; costs; societal per spective. (Med Decis Making 1997;17:382-389)

In this study we report an attempt to measure the value adult Swedes impute to an increased survival probability at high ages. A rating scale between the worst possible quality of life (= 1) and the best possible quality of life (= 10) is used to indicate the quality of life a person expects to achieve at an advanced age. We find a highly significant correlation between this quality measure and the insurance premium a person is willing to pay in exchange for a programme increasing the expected length of life by one year, conditional on having survived until the age of 75 years. The (maximum) insurance premium the average person is willing to pay for such a programme is less than $1500. The willingness to pay increase with a person's age, but at a low rate. The implied average marginal rate of time preference is about 1 percent.

Pliskin, Shepard, and Weinstein identified three preference conditions that ensure that quality-adjusted life years (QALYs) represent preferences over gambles over chronic health profiles. This paper presents an experimental test of the descriptive validity of two of these preference assumptions: utility independence and constant proportional tradeoff. Eighty students at the Stockholm School of Economics and 92 students at Erasmus University Rotterdam participated in the experiment. The results of the ex periment support the descriptive validity of constant proportional tradeoff: both within groups and between groups constant proportional tradeoff could not be rejected. The results are less supportive of the descriptive validity of utility independence. Within- groups utility independence was rejected. Between-groups utility independence could not be rejected, but this may have been due to a lack of statistical power. Analysis of the individual responses revealed that without adjustment for imprecision of preference, 39 respondents (22.8%) satisfied constant proportional tradeoff. Twenty-three respon dents (13.4%) satisfied utility independence without adjustment for imprecision of pref erence. However, because of the relative unfamiliarity of the respondents with both the health states to be evaluated and the methods of health-state-utility measurement, it is likely that the respondents' preferences were imprecise. Adjusted for imprecision of preference, the upper estimates of the proportions of respondents who satisfied constant proportional tradeoff and utility independence, respectively, were 90.1% (155 respondents) and 75.6% (130 respondents). Pliskin et al. further derived that if an individual's preferences satisfy both constant proportional tradeoff and utility indepen dence, then these preferences can be represented by a more general, risk-adjusted QALY model. Without adjustment for imprecision of preference, ten respondents (5.8%) satisfied both constant proportional tradeoff and utility independence. Adjusted for imprecision of preference, the upper estimate of the proportion of respondents who satisfied both constant proportional tradeoff and utility independence was 68.6% (118 respondents). The results of this study indicate that constant proportional tradeoff holds approximately. The evidence is much weaker for utility independence, however. This has important implications for the use of QALY-type measures in medical decision making. Key words: QALYs; health utility measurements; medical decision making; individual preferences. (Med Decis Making 1996;17:21-32)

Background The Scandinavian Simvastatin Survival Study (4S) showed that lowering cholesterol levels with simvastatin reduces mortality and morbidity in patients with angina pectoris or previous acute myocardial infarction. Before the widespread use of cholesterol-lowering drugs in such patients is recommended, its cost effectiveness should be demonstrated. We estimated the cost effectiveness of simvastatin treatment to lower cholesterol levels in relation to the age, sex, and cholesterol level before treatment of patients with coronary heart disease. Methods We estimated the cost per year of life gained with simvastatin therapy. To model the increased life expectancy, hazard functions from 4S were used. The costs studied included those of the intervention and the direct and indirect costs associated with morbidity from coronary causes. We prepared separate estimates for men and women at various ages (from 35 to 70 years) and total cholesterol levels before treatment (213 to 309 mg per deciliter). Results ...

We estimate the value of a ‘blip’, i.e. an immediate small reduction, in the hazard rate for a random sample of Swedes. Since the risk reduction is age-independent (2 ‘extra saved lives’ out of 10,000 during the next year), we can examine how the value of a statistical life varies with age. We also show how blip data can be used to obtain a lower bound for the value of a permanent change in an individual's hazard rate. The value of a life exhibits an inverted-U shape with respect to age, peaking at the age of 40, and lies within the $3 to $7 million interval where most reasonable estimates are clustered according to Viscusi's (1992) survey.

This paper compares the relative performance of quality adjusted life years (QALYs) based on quality weights elicited by rating scale (RS), time trade-off (TTO) and standard gamble (SG). The standard against which relative performance is assessed is individual preference elicited by direct ranking. The correlation between predicted and direct ranking is significantly higher for TTO-QALYs than for RS-QALYs and SG-QALYs. This holds both based on mean Spearman rank correlation coefficients calculated per individual and based on two social choice rules: the method of majority voting and the Borda rule. Undiscounted TTO-QALYs are more consistent with direct ranking than discounted TTO-QALYs.

In recent years, there has been a growing interest in the contingent valuation method for measurement of monetary values of various commodities. However, the validity and reliability of the method need to be examined thoroughly. This paper reports results of a test of scope and question order effects in a contingent valuation experiment in the health care field. Using three binary valuation questions, data were collected on willingness to pay for superior treatment of reflux oesophagitis. To test for scope effects, different probabilities of successful short- and long-term treatments were evaluated using a split sample approach. The presence of question order effects was tested by assigning respondents to different question orders. The contingent valuation method proved sensitive to changes in scope in that the willingness to pay increased with the probability of being free from symptoms and with a reduced risk of having a relapse once recovered. Also, regression analysis indicate that people who suffer from severe reflux oesophagitis are more willing to pay for more effective treatment. No question order effects were detected in the data.

In this study, one group of respondents is offered to purchase a safety device to be installed in their cars, while another group is offered a public safety program (improved road quality) which results in the same size risk reduction. In terms of the value of a statistical life, our results are very reasonable. However, the WTP for the private safety device ishigher than the WTP for the public safety measure. Drawing on a model developed by Jones-Lee (1991), we show that some types of altruists may, but need not, be willing to pay more for a private risk reduction than for a uniform risk reduction of the same magnitude. Still, our empirical results are surprising, and further empirical research seems warranted.

The Swedish Priorities Investigation [1] proposes that no account should be taken of a patient's age when allocating health care resources. Measures to save an old person's life are to be given the same priority as measures to save a young person's life. In the present study it is shown that the attitude of the Swedish population to this age-related problem is dramatically different from that laid down in the priorities investigation. On average, people are willing to sacrifice thirty-five 70-year-olds to save one 30-year-old. It is also shown that a measure which increases life-expectancy by 1 year, conditional on having survived until the age of 75 years, is given a low weighting. The (maximum) insurance premium the average Swede is willing to pay for such a programme is about £700.

To compare the costs of health care programs with the benefits, the values of changes in health status must be expressed in monetary terms. The development of methods to estimate willingness to pay for changes in health status is therefore of interest. This paper reports the results of a contingent valuation study measuring willingness to pay for reductions in angina pectoris attacks. An innovative study design allowed analysis of the data on willingness to pay using two approaches, a binary question and a bid ding-game technique. Percentage reductions in anginal attacks were varied randomly in different subsamples, and data were collected about angina pectoris status, attack rate, and income to test the internal validity of the contingent valuation method. Will ingness to pay for a 50% reduction in the attack rate for three months was estimated to be about SEK 2,500 ($345) with the binary approach, and about SEK 2,100 ($290) using the bidding-game technique. Regression analyses showed that income, angina pectoris status, attack rate, and percentage reduction in attack rate were all related to willingness to pay, in agreement with the authors' hypothesis. Key words: willingness to pay; contingent valuation; angina pectoris; cost-benefit analysis. (Med Decis Mak ing 1996;16:248-253)

Over the last decade there has been tremendous interest in economic evaluations of healthcare programmes, especially in the pharmaceutical field. Economic evaluations started about 30 years ago as rather crude analyses, in which the value of improved health was measured in terms of increased labour production. Now, more refined methods are available to measure health changes in terms of quality-adjusted life-years gained or willingness to pay. It is important to continue this development, and major fields for future work include the incorporation of quality-of-life measurements into economic evaluations and the linking of cost-effectiveness and cost-benefit analyses into a unified framework of economic evaluation. How to incorporate distributional issues is another important area. Finally, it seems crucial to further explore the link between economic evaluation and decision making, since the purpose of economic evaluations is to affect decision making.

An analysis of the cost-effectiveness of simvastatin was conducted, based on the Scandinavian Simvastatin Survival Study (4S). The total cost of hospitalization in the placebo group was 52.8 million Swedish kronor (SEK) (5.15 million pounds), compared with SEK 36.0 million (3.51 million pounds) in the simvastatin group. This amounts to a 32% reduction, or a saving of SEK 16.8 million (1.6 million pounds) or SEK 7560 (738 pounds) per patient. The net cost per patient for the duration of the study (5.4 years) was SEK 13,540 (1324 pounds). Simvastatin treatment saved an estimated 0.377 undiscounted life years (0.240 life years discounted at 5% per annum). The cost of simvastatin therapy per discounted life-year saved was therefore SEK 56,400 (5502 pounds). Sensitivity analysis, examining the effect of different life expectancies, costs of initiation and monitoring of simvastatin therapy, and discount rates, showed the results to be stable. Conclusion. The cost per life-year saved of simvastatin in the treatment of post-myocardial infarction and angina patients, as determined from 4S data, is well within the range normally considered cost-effective.

Objective. To evaluate the cost-effectiveness of two types of advice (usual and intensive) to lower cardiovascular risk, with or without pharmacological medication aimed at lowering cholesterol levels. Design. Prospective, randomized, controlled clinical study of 18 months' duration. Setting. Thirty-two primary health care centres in Sweden. Subjects. A total of 384 males, aged 30–59 years, with at least one cardiovascular risk factor in addition to moderate primary hyperlipidaemia; of these, 355 completed the 18-month follow-up. Interventions. Intensive advice consisted of group sessions led by a health care professional; the usual level of advice was given at follow-up visits. The pharmacological intervention consisted of pravastatin. The goal was to achieve a 15% reduction in cholesterol. Main outcome measures. Cost per life-year gained based on the change in serum cholesterol and the net intervention cost of the four treatment options. Results. The usual level of advice and intensive advice in combination with pharmacological treatment achieved no incremental effects and were not considered in the cost-effectiveness analysis. The cost per life-year gained of pharmacological treatment compared with intensive advice decreased. The cost per life-year gained of pharmacological treatment compared with no treatment was about $61 000, if no adverse consequences on noncardiovascular mortality were assumed. Conclusions. According to the results of the CELL trial, intensive advice is not a cost-effective strategy compared with lipid-lowering drug treatment. However, it is also doubtful whether drug treatment as primary prevention is cost-effective compared with no treatment in the studied patient population.

The objective of this study was to analyze the problem of interpreting change scores of ordinal health status measures for clinical research or practice. Methods used included exploration of the generation of change scores in the physical ability scale of the SF-36, one of the most widely used generic health status instruments. Resulting data are presented as the ranking of items according to baseline score; a percentage of patients with severe difficulty and Rasch analysis provided the same rank order of item difficulty. On the interval scale provided by the Rasch model a concentration of items reflecting moderate difficulty occurred. This "inflates" numerical gains for patients with moderate disability compared to patients with very severe or minor physical disability. Calibration of change scores using patient perception of the level of change in function showed important variation of numerical gains with baseline. We conclude that numerically equal gains may differ in their meaning depending on baseline health status. It is recommended that distribution of baseline health status measures and distribution of responders by baseline status be reported in evaluative studies.

The aim of this note is to estimate the discount rates that individuals in the present generation in Sweden use to discount lives saved in future generations at different points in time. A binary survey question, where individuals choose between saving lives in their own generation versus saving lives in future generations, was administered in a general population sample of 850 individuals. Three time horizons of 20, 50 and 100 years were used in three different subsamples. Logistic regression analysis was used to estimate the discount rate. The estimated annual discount rate is 25% for the 20 year time horizon, 12% for the 50 year time horizon and 8% for the 100 year time horizon.

It has become increasingly popular to carry out cost-effectiveness analyses in economic evaluations of healthcare programmes. Cost-effectiveness analysis is based on the maximisation of the health effects for a given amount of resources. However, many published studies fail to report the results of cost-effectiveness analysis in a way that is consistent with this underlying aim. The aim of this article is to demonstrate the decision rules of cost-effectiveness analysis in an easily accessible way for practitioners in the field. A hypothetical example is used to demonstrate the decision rules of cost-effectiveness analysis, and we also show how to estimate the appropriate incremental cost-effectiveness ratios and how to exclude dominated alternatives. It is then shown how fixed budgets or predetermined prices per effectiveness unit can be used as decision rules to maximise health effects and to determine which programmes to implement on the basis of incremental cost-effectiveness ratios. We hope that the article will contribute towards an increased understanding and application of the appropriate decision rules of cost-effectiveness analysis, so that the results of cost-effectiveness analyses can be interpreted meaningfully by decision makers.

Misoprostol is a prostaglandin E1 analogue which reduces both gastric ulcerations and clinically important bleeding in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs). Economic evaluations of prophylactic use of misoprostol with NSAIDs differ in their conclusions mainly because of different assumptions regarding the absolute risk reduction of symptomatic ulcers. Assuming a conservative estimate of the absolute risk reduction based on new effectiveness data, all studies would have concluded that misoprostol prophylaxis results in net costs in the general population of NSAID users. However, in the elderly with a clearly increased risk of gastrointestinal (GI) lesions and ulcer complications, and an increased hospitalisation rate, misoprostol may be cost saving. Also, in the elderly the gain in quality of life seems to offset the uncertain reduction in quality of life due to the adverse effects of misoprostol. However, the suggestion that misoprostol prophylaxis in the elderly is cost effective or cost saving needs to be confirmed in further studies.

Economic variables such as income, education, and occupation are known to affect mortality and morbidity, such as cardiovascular disease, and have also been shown to be partly heritable. However, very little is known about which genes influence economic variables, although these genes may have both a direct and an indirect effect on health. We report results from the first large-scale collaboration that studies the molecular genetic architecture of an economic variable-entrepreneurship-that was operationalized using self-employment, a widely-available proxy. Our results suggest that common SNPs when considered jointly explain about half of the narrow-sense heritability of self-employment estimated in twin data (σg (2)/σP (2) = 25%, h (2) = 55%). However, a meta-analysis of genome-wide association studies across sixteen studies comprising 50,627 participants did not identify genome-wide significant SNPs. 58 SNPs with p

Genetic College Many genomic elements in humans are associated with behavior, including educational attainment. In a genome-wide association study including more than 100,000 samples, Rietveld et al. (p. 1467 , published online 30 May; see the Perspective by Flint and Munafò ) looked for genes related to educational attainment in Caucasians. Small genetic effects at three loci appeared to impact educational attainment.

The contingent valuation method has been developed in the environmental field to measure the willingness to pay for environmental changes using survey methods. In this exploratory study the contingent valuation method was used to analyse how much individuals are willing to spend in total in the form of taxes for health care in Sweden, i.e. to analyse the optimal size of the ‘health care budget’ in Sweden. A binary contingent valuation question was included in a telephone survey of a random sample of 1260 households in Sweden. With a conservative interpretation of the data the result shows that 50% of the respondents would accept an increased tax payment to health care of about SEK 60 per month ($1 = SEK 8). It is concluded that the results indicate that the population overall thinks that the current spending on health care in Sweden is on a reasonable level. There seems to be a willingness to increase the tax payments somewhat, but major increases does not seem acceptable to a majority of the population.

This paper examines the relationship between cost-effectiveness analysis and cost-benefit analysis. Provided that a cost-effectiveness analysis includes all the relevant societal costs, it is shown that a cost-effectiveness analysis can be interpreted as a cost-benefit analysis where the willingness to pay per effectiveness unit is assumed to be constant and the same for everyone. To relax this assumption the willingness to pay per effectiveness unit can be allowed to vary depending on for instance the size of the health effects and the target population. It is argued that cost-effectiveness analysis is best viewed as a subset of cost-benefit analysis, where the aim of the analysis is to estimate the cost function of producing health effects. It is also concluded that to interpret and use cost-effectiveness analysis as a tool to maximize the health effects for one specified real-world budget, will be inconsistent with a societal perspective and is likely to lead to major problems of suboptimization.

It is common in cost-effectiveness analyses of health care to only include health care costs, with the argument that some fictive ‘health care budget’ should be used to maximize the health effects. This paper provides a criticism of the ‘health care budget’ approach to cost-effectiveness analysis of health care. It is argued that the approach is ad hoc and lacks theoretical foundation. The approach is also inconsistent with using a fixed budget as the decision rule for cost-effectiveness analysis. That is the case unless only costs that fall into a single annual actual budget are included in the analysis, which would mean that any costs paid by the patients should be excluded as well as any future cost changes and all costs that fall on other budgets. Furthermore the prices facing the budget holder should be used, rather than opportunity costs. It is concluded that the ‘health care budget’ perspective should be abandoned and the societal perspective reinstated in economic evaluation of health care.