André J.H.A. Ament

Criteria list for assessment of methodological quality of economic evaluations : Consensus on Health Economic Criteria

OBJECTIVES The aim of the Consensus on Health Economic Criteria (CHEC) project is to develop a criteria list for assessment of the methodological quality of economic evaluations in systematic reviews. The criteria list resulting from this CHEC project should be regarded as a minimum standard. METHODS The criteria list has been developed using a Delphi method. Three Delphi rounds were needed to reach consensus. Twenty-three international experts participated in the Delphi panel. RESULTS The Delphi panel achieved consensus over a generic core set of items for the quality assessment of economic evaluations. Each item of the CHEC-list was formulated as a question that can be answered by yes or no. To standardize the interpretation of the list and facilitate its use, the project team also provided an operationalization of the criteria list items. CONCLUSIONS There was consensus among a group of international experts regarding a core set of items that can be used to assess the quality of economic evaluations in systematic reviews. Using this checklist will make future systematic reviews of economic evaluations more transparent, informative, and comparable. Consequently, researchers and policy-makers might use these systematic reviews more easily. The CHEC-list can be downloaded freely from http://www.beoz.unimaas.nl/chec/.

Modeling the Future Burden of Stroke in the Netherlands Impact of Aging, Smoking, and Hypertension

Background and Purpose— In the near future, the number of stroke patients and their related healthcare costs are expected to rise. The purpose of this study was to estimate this expected increase in stroke patients in the Netherlands. We sought to determine what the future developments in the number of stroke patients due to demographic changes and trends in the prevalence of smoking and hypertension in terms of the prevalence, incidence, and potential years of life lost might be. Methods— A dynamic, multistate life table was used, which combined demographic projections and existing stroke morbidity and mortality data. It projected future changes in the number of stroke patients in several scenarios for the Dutch population for the period 2000 to 2020. The model calculated the annual number of new patients by age and sex by using incidence rates, defined by age, sex, and major risk factors. The change in the annual number of stroke patients is the result of incident cases minus mortality numbers. Results— Demographic changes in the population suggest an increase of 27% in number of stroke patients per 1000 in 2020 compared with 2000. Extrapolating past trends in the prevalence of smoking behavior, hypertension, and stroke incidence resulted in an increase of 4%. Conclusions— The number of stroke patients in the Netherlands will rise continuously until the year 2020. Our study demonstrates that a large part of this increase in the number of patients is an inevitable consequence of the aging of the population.

Cost of Stroke in the Netherlands From a Societal Perspective

BACKGROUND AND PURPOSE Cerebrovascular disorders are associated with a high level of morbidity and mortality and call for considerable resources. The objective of this study was to determine from a societal perspective the medical consumption (direct costs) and productivity losses (indirect costs) caused by cerebrovascular disorders in the Netherlands. METHODS This study can be characterized as a cost-of-illness study based on prevalence data. All data gathered refer to 1993. Cerebrovascular disorders are defined according to the International Classification of Diseases, 9th Revision (ICD-9) classification. Data from medical registrations and national statistics have been analyzed. For both direct and indirect costs, volume and cost components are presented. To test the likelihood of the assumptions, a sensitivity analysis was performed. RESULTS The cost of cerebrovascular disorders in the Netherlands in 1993 amounted to 2.5 billion Dutch guilders, of which 1.9 billion were spent on medical consumption. It was found that direct costs are generated mainly by the long-term care of inpatients (nursing homes and hospitals). The productivity losses were relatively low in comparison with other diseases, probably due to the fact that most patients with cerebrovascular disorders are elderly. CONCLUSIONS More than 3% of the Dutch annual healthcare budget is spent on patients suffering from cerebrovascular disorders. Costs in the future may be influenced by, among other things, demographic changes, new therapies, and cost-reduction programs introduced by the government.

Adding cognitive therapy to dietetic treatment is associated with less relapse in obesity

OBJECTIVE The treatment of obesity is universally disappointing; although usually some weight loss is reported directly after treatment, eventual relapse to, or even above, former body weight is common. In this study it is tested whether the addition of cognitive therapy to a standard dietetic treatment for obesity might prevent relapse. It is argued that the addition of cognitive therapy might not only be effective in reducing weight and related concerns, depressed mood, and low self-esteem, but also has an enduring effect that lasts beyond the end of treatment. METHODS Non-eating-disordered overweight and obese participants in a community health center (N=204) were randomly assigned to a group dietetic treatment+cognitive therapy or a group dietetic treatment+physical exercise. RESULTS Both treatments were quite successful and led to significant decreases in BMI, specific eating psychopathology (binge eating, weight-, shape-, and eating concerns) and general psychopathology (depression, low self-esteem). In the long run, however, the cognitive dietetic treatment was significantly better than the exercise dietetic treatment; participants in the cognitive dietetic treatment maintained all their weight loss, whereas participants in the physical exercise dietetic treatment regained part (25%) of their lost weight. CONCLUSION Cognitive therapy had enduring effects that lasted beyond the end of treatment. This potential prophylactic effect of cognitive therapy is promising; it might be a new strategy to combat the global epidemic of obesity.

Utilities of the EQ-5D: transferable or not?

BackgroundWithin the framework of economic evaluations, the transferability of utility scores between jurisdictions remains unclear. The EQ-5D is a generic instrument for measuring health-related quality of life in economic evaluations, which can be used for comparing utility scores across countries. At present, the EQ-5D has several national value sets or tariffs. Nevertheless, utility estimates from foreign studies are often used directly for cost-effectiveness estimates, without adapting by applying the appropriate national value set. It is unclear if this practice is advisable, due to dissimilarities between the national value sets.ObjectiveTo examine the effects of differences in national EQ-5D value sets on absolute and marginal utilities of health states, and determine to what degree these differences can be explained by methodological factors.MethodsFirst, the relative importance of the EQ-5D domains for the utility estimates was compared across the 15 value sets. Second, two hypothetical health states for a depressed patient and a pain patient (21232 and 33321) were selected for additional analysis, by comparing the utilities as scored by the value sets. The marginal influence of a one-level deterioration in a domain of these health states on the utility estimate was then determined. Third, the differences between the value sets were examined in more detail by using multilevel analysis to examine the role of methodological differences in the valuation studies.ResultsDifferences can be perceived between the national value sets of the EQ-5D in the preferences for the domains. The utilities of the two hypothetical health states show that the value sets differ substantially. Furthermore, the differences between the marginal values of the deteriorations are large, which can be explained partly by the type of valuation method. Other methodological differences also influence the value sets.ConclusionAll results indicate that the differences between the EQ-5D value sets are considerable and should not be ignored. The differences can largely be explained by methodological differences in the valuation studies. The remaining differences may reflect cultural dissimilarities between countries. Therefore, further research should focus on investigating the transferability of utilities across countries or agreeing on a standard to perform valuation studies. For the time being, transferring utilities from one country to another without any adjustment is not advisable.

Economic Evaluation in Stroke Research A Systematic Review

BACKGROUND AND PURPOSE The purpose of this review is to provide insight into the quality of economic evaluation in the field of cerebrovascular diseases (CVD) on the basis of a systematic analysis. METHODS A literature search was performed using several sources. Trial-based full economic evaluation studies, were included in this review. The quality of the studies was independently assessed by 2 reviewers using a checklist. RESULTS Twenty-three articles were found to comply with our inclusion and exclusion criteria. Only a few studies mentioned the perspective of the study, and in these cases it was always the societal perspective. The majority of the studies were cost-minimization and cost-effectiveness analyses based on cohort studies. All studies included healthcare costs, and in some instances patient and family costs were considered. Costs were usually measured by tariffs. Clinical end points and mortality were used to measure effects. Cost and effect measurements were based on hospital records. CONCLUSIONS Only a few full economic evaluations have been undertaken in the domain of CVD. In most of the studies, the technical execution and methodology were limited.

Cost of illness studies in health care: a comparison of two cases

Cost of illness (COI) studies describe the economic burden of disease on society. In this article a standard procedure for a COI study is developed, including the explicit definition of the disease, choice of relevant variables and appraisal of direct and indirect costs. COI studies can be incidence-based or prevalence-based. The adjustment of cost figures for time preferences and the performance of a sensitivity analysis are presented. The standard methodology is applied to diseases in two different areas. The first disease category is dyspepsia, a complaint with a rather somatic background. The second is schizophrenia, a mental syndrome. In performing COI studies in practice, however, researchers are forced to deviate, in many aspects, from the theoretical standards. In this article these choices, and the reasons behind these choices, are explained. Furthermore, we discuss certain problems regarding the reluctance to make a diagnosis regarding certain diseases, the reliability and the validity of the sources used and the absence of certain figures. The value of the information derived from COI studies for policy-making is assessed.

Real world designs in economic evaluation : bridging the gap between clinical research and policy making

AbstractThis paper identifies the information that economic evaluation should provide to adequately inform policy-makers. First, policy-makers need cost-effectiveness information that is both internally and externally valid. The latter aspect is often ignored and refers to the relevance of the results of economic trials to the specific decision-making context of the policy-maker. Second, policy-makers, like purchasers of care, may want assessments of the overall budget and health impacts of adopting an intervention in a disease or treatment area. This requires more of an aggregate analysis than the current approaches to economic evaluation (which are typically individual-orientated).There are 3 main conceptual approaches to economic evaluation: the use of randomised controlled trials (RCTs), observational studies and modelling. The RCT can be considered as the gold standard in economic evaluation because of its high internal validity, but results should be interpreted with caution because of its low external validity. There a number of options to enhance external validity; of these, additional modelling and observational data seem to be the most promising. To address issues at the system level, disease modelling or public health modelling is suggested.A 3-step approach, comprising successive assessment of internal validity, external validity (real world relevance) and net impact at the system level, can enhance the informative value of economic analyses. For example, this approach has been used to assess the informative value to decision-makers of an RCT in benign prostatic hyperplasia. The analysis emphasised the feasibility and importance of additional modelling beyond the results from an RCT-based economic analysis and provided important information of relevance for policy-making.Because of the need to increase the realworld relevance of pharmacoeconomic analyses, there is potentially a large role for modelling in economic evaluation; however, in order to enhance its credibility, more attention should be paid to validity aspects.

Systematic Review of Economic Evaluations of Smoking Cessation: Standardizing the Cost-Effectiveness

Objectives . This study was performed to render cost-effectiveness studies on smoking cessation therapies, utilized until now, more comparable and more useful for medical decision making. Methods . The cost-effectiveness ratios reported by the studies were recalculated using a societal perspective and guidelines for economic evaluation. Results . The costs of individual interventions generally increased as a result of the standardization procedure, whereas the effect size decreased. This resulted in increases in the cost-effectiveness ratios for individual studies ranging from 120% to 5600%. Conclusions . The variation between studies in the percentage increase in cost-effectiveness ratios is huge. This means that not following guidelines when calculating cost-effectiveness ratios can result in large errors. Despite the fact that the standardized cost-effectiveness ratios of smoking interventions were higher than the unstandardized cost-effectiveness ratios, interventions aimed at reducing the prevalence of smoking are cost-effective.

Estimating the Costs of Epilepsy: An International Comparison of Epilepsy Cost Studies

Summary:  Purpose: To compare systematically the national and per capita estimates of the cost of epilepsy in different countries.