Dorte Gyrd-Hansen

International comparison of the definition and the practical application of health technology assessment.

OBJECTIVES Health Technology Assessment (HTA) is defined as a policy research approach that examines the short- and long-term social consequences of the application or use of technology. Internationally different institutions have translated this definition to local contexts. In Denmark, HTA is comprehensive with focus on four aspects of the problem in question (technology [clinical evidence], economy, patient, and organization). The objective of this study is to study how the application of HTA differs across leading countries and to study the extent to which Danish HTA reports differ from foreign HTAs. METHODS A sample of 433 HTA reports published in the period 1989--2002 by eleven leading institutions or agencies in Denmark and eight other countries were reviewed. We looked at the characteristics of the HTA with respect to focus on the four main aspects and the manner in which each aspect has been approached. RESULTS The study shows health technology procedures to be the most common type of health technology assessed in HTAs and literature review to be the most often used method of analysis. Policy recommendations are only present in approximately half of the HTA reports. CONCLUSIONS In the HTAs one generally sees a great focus on the clinical aspect of health technologies, leaving the economic, the patient-related, and the organizational aspect much more unanalyzed. The Danish HTAs generally have a wider scope than HTAs produced in other countries and tend to focus more frequently on patient-related and organizational dimensions.

Willingness to pay for a QALY: theoretical and methodological issues.

What is a QALY worth in monetary units? This paper presents the main arguments in the literature regarding the obstacles involved in establishing one unique willingness to pay (WTP) estimate for the value of a QALY.To directly translate QALYs into monetary units, and in this manner translate existing and forthcoming cost-effectiveness analyses (CEA) to cost-benefit analyses (CBA), it is necessary that one unique WTP per QALY can be established irrespective of context-specific characteristics such as severity of illness, magnitude of health gain, patient characteristics, etc. Because CEA and CBA are two methods of economic evaluation that are based on two very different normative perceptions of the role of health versus other goods in society, the task of performing a linear translation from QALYs to WTP is theoretically unattainable.CBA is based on the welfarist perception that the welfare associated with health is measured by way of individual preferences for health outcomes relative to other goods in society. In contrast, CEA is based on the extra-welfarist notion, which focuses on maximising health and not welfare, and suppresses any variation across income/social groups in utility derived from improvements in health. Another obstacle to one unique WTP per QALY value is that marginal utility of income is non-constant, and a function of income level and possibly health status. When marginal utility of income varies across individuals as well as contexts, measuring the value of health in monetary units may result in valuations of health increments that are very different from valuations retrieved had another unit of measure been applied.In conclusion, from a theoretical point of view, establishing one unique WTP cannot be attained. Applying one sole WTP per QALY value will entail overriding individual preferences such as diminishing marginal utility of health and potential differences in the value of incremental health across population groups. However, one problem that can, and should, be overcome when seeking to establish a monetary value for a QALY is the problem of variance in the marginal utility of income. The importance of applying the appropriate perspective when formulating WTP questions to ensure that the marginal utility of income of the respondents equals that of the financiers of the costs invested to produce the health gains should not be overlooked.

Number needed to treat: easily understood and intuitively meaningful? Theoretical considerations and a randomized trial

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.

Colorectal cancer screening: efficiency and effectiveness

The cost-effectiveness of a series of mutually exclusive colorectal cancer screening programmes with varying screening interval and target group are analysed. Costs and effects for 60 possible screening programmes are simulated on the basis of data collected from a randomized trial initiated in 1985 in Funen County, Denmark. The screening test applied is the unhydrated Hemoccult-II. The analysis identifies six efficient programmes with cost-effectiveness estimates ranging from 17000 to 42500 Danish kroner (DKK) per life-year.

Societal views on orphan drugs: cross sectional survey of Norwegians aged 40 to 67

Objective To determine whether a general societal preference for prioritising treatment of rare diseases over common ones exists and could provide a justification for accepting higher cost effectiveness thresholds for orphan drugs. Design Cross sectional survey using a web based questionnaire. Setting Norway. Participants Random sample of 1547 Norwegians aged 40-67. Main outcome measure Choice between funding treatment for a rare disease versus a common disease and how funds should be allocated if it were not possible to treat all patients, for each of two scenarios: identical treatment costs per patient and higher costs for the rare disease. Respondents rated five statements concerning attitudes to equity on a five point Likert scale (5=completely agree). Results For the equal cost scenario, 11.2% (9.6% to 12.8%) of respondents favoured treating the rare disease, 24.9% (21.7% to 26.0%) the common disease, and 64.9% (62.6% to 67.3%) were indifferent. When the rare disease was four times more costly to treat, the results were, respectively, 7.4% (6.1% to 8.7%), 45.3% (42.8% to 47.8%), and 47.3% (44.8% to 49.8%). Rankings for attitude on a Likert scale indicated strong support for the statements “rare disease patients should have the right to treatment even if more expensive” (mean score 4.5, SD 0.86) and “resources should be used to provide the greatest possible health benefits” (3.9, 1.23). Conclusions Despite strong general support for statements expressing a desire for equal treatment rights for patients with rare diseases, there was little evidence that a societal preference for rarity exists if treatment of patients with rare diseases is at the expense of treatment of those with common diseases.

Quality of life in rhinoconjunctivitis assessed with generic and disease specific questionnaires

Background:  Illness as perceived by the allergic patient with asthma and/or rhinoconjunctivitis (RC) can be assessed by measurements of their health‐related quality of life (HRQL). For this purpose the RC Quality of Life Questionnaire (RQLQ) has gained general acceptance; however, as most allergic patients experience symptoms from multiple organs, disease‐specific HRQL measures may be deficient. This study compares a generic and a disease‐specific HRQL instrument in grass and/or mite‐allergic patients.

Increasing participation in cervical cancer screening: Offering a HPV self-test to long-term non-attendees as part of RACOMIP, a Swedish randomized controlled trial

RACOMIP is a population‐based, randomized trial of the effectiveness and cost‐effectiveness of different interventions aimed at increasing participation in a well‐run cervical cancer screening program in western Sweden. In this article, we report results from one intervention, offering non‐attendees a high‐risk human papillomavirus (HPV) self‐test. Comparison was made with standard screening invitation routine or standard routine plus a telephone call. Women (8,800), aged 30–62, were randomly selected among women without a registered Pap smear in the two latest screening rounds. These women were randomized 1:5:5 to one of three arms: 800 were offered a high‐risk HPV self‐test, 4,000 were randomized to a telephone call (reported previously) and 4,000 constituted a control group (standard screening invitation routine). Results were based on intention to treat analysis and cost‐effectiveness was calculated as marginal cost per cancer case prevented. The endpoint was the frequency of testing. The total response rate in the self‐testing arm was 24.5%, significantly higher than in the telephone arm (18%, RR 1.36, 95% CI 1.19–1.57) and the control group (10.6%, RR 2.33, 95% CI 2.00–2.71). All nine women who tested positive for high‐risk HPV attended for a cervical smear and colposcopy. From the health‐care sector perspective, the intervention will most likely lead to no additional cost. Offering a self‐test for HPV as an alternative to Pap smears increases participation among long‐term non‐attendees. Offering various screening options can be a successful method for increasing participation in this group.

The impact of contact with psychiatry on senior medical students’ attitudes toward psychiatry

Objective:  To investigate the attitudes of Danish medical students as to the attractiveness of psychiatry as a career possibility and to asses the impact on such attitudes of actual contact with psychiatry.

Subchronic toxicity of baltic herring oil and its fractions in the rat (III) bone tissue composition and dimension, and ratio of n-6/n-3 fatty acids in serum phospholipids

Pharmacological interventions for osteoporosis may reduce morbidity and mortality, but they incur additional health care costs. The aim was to quantify the additional costs and health benefits of prescribing alendronate 10 mg and calcium/vitamin D daily for 71-year-old women with a fracture risk twice that of the population average in stead of calcium/vitamin D alone. A state transition model based primarily on Scandinavian data was developed. Women were followed from age of 71 years until 100. Alendronate was assumed to reduce the fracture risk by 50%. Health benefits from the interventions were expressed in terms of life years, quality adjusted life years, and fractures avoided. Societal costs were estimated using literature estimates and Danish tariffs. All costs were measured in 2002 Danish Kroner (DKK). Future costs and benefits were discounted at 5% per year. The incremental cost per QALY gained was DKK125,000 while the cost per life year gained was DKK 374,000. The use of alendronate was cost-saving when 1) the treatment was extended to five years, 2) the risk of fracture was four times the population average, 3) the effect of alendronate was assumed to persist for three years after discontinuation of treatment, 4) a greater proportion had severe sequelae after a hip fracture, or 5) the start of therapy was delayed until age of 77 years. In conclusion, the use of alendronate compares well with other well established therapies in terms of cost-effectiveness in older women with high risk of fracture.

Health-Economic Analyses of subcutaneous Specific Immunotherapy for grass pollen and mite allergy

OBJECTIVE To investigate the health and monetary consequences of treating allergy with specific immunotherapy (SIT) compared with symptomatic treatment/standard care among patients with grass pollen or mite allergy. METHODS We performed an economic analysis based on 253 grass- and/or mite allergic patients who started SIT from 1.1.1996 to 1.1.2002 at the Allergy Unit, Aarhus University Hospital and at a specialist practice in Aarhus. Relevant data were collected before, during and after SIT treatment from the national health service based on each patients personal identification number and medical records and from a specifically designed questionnaire. A cost-benefit analysis including direct and indirect costs before, during and after SIT was performed. In addition direct costs were related to the clinical effect (improvement in well-being) in the form of a cost-effectiveness analysis. RESULTS The direct cost per patient/year before SIT (equivalent to standard care) was DKK 2,580. The investment in SIT was DKK 27,545 (in present values) per patient over a 4-year period. After SIT the cost was reduced to DKK 1,072 per patient/year. In the long term, prospective introduction of SIT incurred additional present-value direct costs of DKK 13,676 per patient treated and DKK 2,784 per patient/year of improved well-being. However, when indirect costs were included in the economic evaluation SIT was shown to be net beneficial. CONCLUSION This study reveals that SIT is associated with initial resource investments and subsequent resource savings in the long term compared with standard care. When all consequences are measured in monetary terms, and assuming that sick days are associated with a loss of productivity, this analysis suggests that SIT increases societal welfare. This conclusion also holds if there is no loss of productivity.