Danielle Brunenberg

Joint recovery programme versus usual care : An economic evaluation of a clinical pathway for joint replacement surgery

Objective:The objective of the present study was to determine the incremental cost-effectiveness of a clinical pathway for patients undergoing joint replacement, the Joint Recovery Programme (JRP), as compared with usual care. The existing care process was revised to contain costs and shorten waiting lists by facilitating patient flows and improve healthcare efficiency. Methods:The study design was a before–after trial. In total, 160 patients undergoing total hip and total knee replacement, aged 28 to 87 years (mean age, 64.4 years), were treated either according to the Joint Recovery Programme (a standardized care process with patient education and rehabilitation in groups) or usual care. Both groups were followed for 1 year. Costs were studied from a societal perspective. Outcomes included functional level (Harris Hip score and American Knee Society score) and generic quality of life (EuroQol). Results:The results indicate that the Joint Recovery Programme resulted in a significant cost saving when compared with usual care mainly as a result of a considerable (>50%) reduction in length of hospital stay. The average cost saving per patient amounted to

Cost-effectiveness acceptability curves and a reluctance to lose.

1261 in the total hip replacement group and

The Impact of Differences in EQ-5D and SF-6D Utility Scores on the Acceptability of Cost-Utility Ratios: Results across Five Trial-Based Cost-Utility Studies

3336 in the total knee replacement group. At the same time, both functional level and quality of life were higher in the JRP group. Conclusions:Clinical pathway dominates usual care and is a highly cost-effective approach to contain costs related to joint replacement surgery without adverse consequences for patients.

Societal effects of hearing aid fitting among the moderately hearing impaired.

Cost-effectiveness acceptability curves (CEACs) are a method used to present uncertainty surrounding incremental cost-effectiveness ratios (ICERs). Construction of the curves relies on the assumption that the willingness to pay (WTP) for health gain is identical to the willingness to accept (WTA) health loss. The objective of this paper is to explore the impact that differences between WTP and WTA health changes have on CEACs.Previous empirical evidence has shown that the relationship between WTP and WTA is not 1: 1. The discrepancy between WTP and WTA for health changes can be expressed as a ratio: the accept/reject ratio (which can vary between 1 and infinity). Depending on this ratio, the area within the southwest quadrant of the cost-effectiveness plane in which any bootstrap cost-effect pairs will be considered to be cost effective will be smaller, resulting in a lower CEAC. We used data from two clinical trials to illustrate that relaxing the 1: 1 WTP/WTA assumption has an impact on the CEACs. Given the difficulty in assessing the accept/reject ratio for every evaluation, we suggest presenting a series of CEACs for a range of values for the accept/reject ratio, including 1 and infinite.Although it is not possible to explain this phenomenon within the extra-welfarist framework, it has been shown empirically that individuals give a higher valuation to the removal of effective therapies than to the introduction of new therapies that are more costly and effective. In cost-effectiveness analyses where uncertainty of the ICER covers the southwest quadrant of the cost-effectiveness plane, the discrepancy between societies’ WTP and WTA should be indicated by drawing multiple CEACs.

Cost Effectiveness of an Adherence-Improving Programme in Hypertensive Patients

OBJECTIVE This article investigates whether differences in utility scores based on the EQ-5D and the SF-6D have impact on the incremental cost-utility ratios in five distinct patient groups. METHODS We used five empirical data sets of trial-based cost-utility studies that included patients with different disease conditions and severity (musculoskeletal disease, cardiovascular pulmonary disease, and psychological disorders) to calculate differences in quality-adjusted life-years (QALYs) based on EQ-5D and SF-6D utility scores. We compared incremental QALYs, incremental cost-utility ratios, and the probability that the incremental cost-utility ratio was acceptable within and across the data sets. RESULTS We observed small differences in incremental QALYs, but large differences in the incremental cost-utility ratios and in the probability that these ratios were acceptable at a given threshold, in the majority of the presented cost-utility analyses. More specifically, in the patient groups with relatively mild health conditions the probability of acceptance of the incremental cost-utility ratio was considerably larger when using the EQ-5D to estimate utility. While in the patient groups with worse health conditions the probability of acceptance of the incremental cost-utility ratio was considerably larger when using the SF-6D to estimate utility. CONCLUSIONS Much of the appeal in using QALYs as measure of effectiveness in economic evaluations is in the comparability across conditions and interventions. The incomparability of the results of cost-utility analyses using different instruments to estimate a single index value for health severely undermines this aspect and reduces the credibility of the use of incremental cost-utility ratios for decision-making.

Changing characteristics of first-time hearing aid applicants in The Netherlands in the past decade

The objective of this study was to evaluate hearing aid fitting from a societal viewpoint, rather than the more traditional patient perspective. The effects of hearing aid fitting on generic quality of life (EuroQol), social functioning (SF36), auditory disability, productivity at paid and unpaid labour, and medical consumption, were assessed in a prospective study among 80 moderately hearingimpaired first-time hearing aid applicants. The study showed that hearing aid fitting solved problems with paid employment, but did not seem to affect unpaid work. Use of medical services remained relatively stable after first-time hearing aid fitting. The Amsterdam Inventory proved to be a useful questionnaire to assess the effects on hearing disability. No effects of hearing aid fitting on generic quality of life could be determined with the EuroQol, while hearing aid fitting did lead to an improvement in one aspect of generic quality of life; namely social functioning. El objetivo de este estudio fue evaluar la adaptación de auxiliares auditivos desde un punto de vista social, más que desde la perspective tradicional del paciente. Los efectos de la adaptación de auxiliares auditivos en la calidad genérica de vida (EuroQWol), funcionamiento social (SF36), discapacidad auditiva, productividad en el trabajo remunerado o no remunerado, además de gastos médicos, fueron evaluados en un estudio prospectivo con 80 pacientes con impedimentos auditivos moderados a quienes se les adaptó por primera vez un auxiliar auditivo. El estudio mostró que la adaptación de auxiliares auditivos resuelve problemas en los empleos remunerados pero no parece afectar el trabajo sin remuneración. El uso de servicios médicos permaneció relativamente estable después de la primera adaptación. El cuestionario Amsterdam probó ser un instrumento útil para evaluar los efectos en la discapacidad auditiva. No se pudieron determinar los efectos de la adaptación de auxiliares auditivos en la calidad genérica de vida por medio del EuroQol, mientras que la adaptación de auxiliares auditivos condicionó la mejoría en un aspecto de la calidad genérica de vida, que es concretamente, el funcionamiento social.

DEVELOPMENT OF A QUESTIONNAIRE TO MEASURE HEARING-RELATED HEALTH STATE PREFERENCES FRAMED IN AN OVERALL HEALTH PERSPECTIVE

BackgroundNon-adherence to antihypertensive drugs is high, and the economic consequences of non-adherence may be substantial. The Medication Events Monitoring System (MEMS), which is a method to improve adherence, has been shown to be a useful tool for the management of adherence problems.ObjectiveTo assess the cost effectiveness of the MEMS compared with usual care in a population of hypertensive patients with poor adherence. The MEMS programme consisted of provision of containers fitted with electronic caps together with adherence training if indicated.MethodsIn a randomised controlled trial, 164 hypertensive patients in the experimental strategy and 89 patients in the usual care strategy were followed for 5 months. Patients who had a systolic blood pressure (SBP) ≥160mm Hg and/or diastolic BP (DBP) ≥95mm Hg despite the use of antihypertensive drugs were eligible. Patients were recruited by a GP, and treatment took place in general practice.In the experimental strategy, electronic monitoring of the intake of antihypertensive drugs was introduced without change of medication. Unsatisfactory adherence was defined as <85% of days with the number of doses taken as prescribed. In the usual care strategy, antihypertensive treatment was intensified by the addition or change of antihypertensive drugs, if necessary, without provision of an electronic monitor.Outcome parameters included the proportion of patients with normalised blood pressure (NBP) at 5 months and QALYs. Costs were quantified from the healthcare and societal perspective. Non-parametric bootstrap simulations were per formed to quantify the uncertainty around the mean estimates and cost-effectiveness acceptability curves were presented. In addition, a number of univariate sensitivity analyses were performed on deterministic variables.ResultsAt 5 months, 3.1% (95% UI [uncertainty interval] −9.7%, +15.8%) more patients had NBP, and 0.003 (95% UI −0.005, +0.010) more QALYs were generated in the experimental strategy. A statistically significant lower percentage of patients had a dose escalation in the experimental strategy. Irrespective of the ceiling ratio for cost effectiveness, the cost-effectiveness probability was between 75% and 80% for the analysis from the healthcare perspective using proportion of patients with NBP as the outcome parameter. For the analysis from the societal perspective using QALYs as the outcome parameter, this probability was between 45% and 51%.ConclusionFor a time horizon of 5 months, a difference in both cost and effect could not be detected between an adherence-improving programme compared with usual care for hypertensive patients. The probability that the adherence-improving programme is cost effective is at best moderate. Moreover, the costeffectiveness result is surrounded with considerable uncertainty and large-scale implementation warrants additional research into the economic consequences of this intervention. Patients may benefit from the use of a MEMS monitor in situations where BP targets are not reached because of suspected non-adherence and both patient and GP are reluctant to increase the dose or number of antihypertensive drugs.

Economic evaluation of duloxetine for the treatment of women with stress urinary incontinence : A markov model comparing pharmacotherapy with pelvic floor muscle training

This study assessed changes in the characteristics of firsttime hearing aid applicants in the past decade. Age, gender, date, type and ear of first hearing aid and audiometry were determined for a sample of 705 firsttime hearing aid applicants. Thirteen cohorts resulted, according to the year of first visit to the dispenser. Differences in age, hearing loss, gender and type and ear of first hearing aid between cohorts were analysed. The mean age of first-time hearing aid users increased from 59.52 years in 1987 to 71.84 years in 1999. The mean pure-tone average hearing loss in the better ear (1, 2 and 4 kHz) decreased from 69.06 dB in 1987 to 51.86 dB in 1999. Relatively more males than females were fitted with hearing aids. Our conclusions are that people are being fitted with hearing aids at older ages and with smaller degrees of hearing loss. Sumario En este estudio se evaluaron los cambios en las características de quienes solicitaron por primera vez auxiliares auditivos (AA) en la década pasada. Se analizaron edad, género, fecha, tipo y oído que usó el primer AA y la audiometría de 705 solicitantes primerizos de AA. Resultaron 13 cohortes de acuerdo con el año de la primera visita al proveedor. Se analizaron diferencias en edad, pérdida auditiva, género y tipo y oído primeramente adaptado y las que hubo entre cohortes. La edad promedio de los usuarios primerizos de AA aumentó de 59,52 an˜os en 1987 a 71.84 en 1999. La media del promedio de pérdida con tonos puros en el mejor oído (1, 2 y 4 kHz) disminuyó de 69,06 en 1987 a 51.86 en 1999. Se adaptaron AA relativamente a más hombres que mujeres. Concluimos que se están adaptando AA a personas de mayor edad y con menores grados de pérdida auditiva.