Janneke Kaper

Encouraging smokers to quit : The cost effectiveness of reimbursing the costs of smoking cessation treatment

AbstractBackground: Smoking cessation should be encouraged in order to increase life expectancy and reduce smoking-related healthcare costs. Results of a randomised trial suggested that reimbursing the costs of smoking cessation treatment (SCT) may lead to an increased use of SCT and an increased number of quitters versus no reimbursement. Objective: To assess whether reimbursement for SCT is a cost-effective intervention (from the Dutch societal perspective), we calculated the incremental costs per quitter and extrapolated this outcome to incremental costs per QALY saved versus no reimbursement. Methods: In the reimbursement trial, 1266 Dutch smokers were randomly assigned to the intervention or control group using a randomised double consent design. Reimbursement for SCT was offered to the intervention group for a period of 6 months. No reimbursement was offered to the control group.Prolonged abstinence from smoking was determined 6 months after the end of the reimbursement period. The QALYs gained from quitting were calculated until 80 years of age using data from the US. Costs (year 2002 values) were determined from the societal perspective during the reimbursement period (May–November 2002). Benefits were discounted at 4% per annum. The uncertainty of the incremental cost-effectiveness ratios was estimated using non-parametric boot-strapping. Results: Eighteen participants in the control group (2.8%) and 35 participants in the intervention group (5.5%) successfully quit smoking. The costs per participant were €291 and €322, respectively. If society is willing to pay €1000 or €10 000 for an additional 12-month quitter, the probability that reimbursement for SCT would be cost effective was 50% or 95%, respectively. If society is willing to pay €18 000 for a QALY, the probability that reimbursement for SCT would be cost effective was 95%. However, the external validity of the extrapolation from quitters to QALYs is uncertain and several assumptions had to be made. Conclusion: Reimbursement for SCT may be cost effective if Dutch society is willing to pay €10 000 for an additional quitter or €18 000 for a QALY.

Productivity cost calculations in health economic evaluations: Correcting for compensation mechanisms and multiplier effects

Productivity costs related to paid work are commonly calculated in economic evaluations of health technologies by multiplying the relevant number of work days lost with a wage rate estimate. It has been argued that actual productivity costs may either be lower or higher than current estimates due to compensation mechanisms and/or multiplier effects (related to team dependency and problems with finding good substitutes in cases of absenteeism). Empirical evidence on such mechanisms and their impact on productivity costs is scarce, however. This study aims to increase knowledge on how diminished productivity is compensated within firms. Moreover, it aims to explore how compensation and multiplier effects potentially affect productivity cost estimates. Absenteeism and compensation mechanisms were measured in a randomized trial among Dutch citizens examining the cost-effectiveness of reimbursement for smoking cessation treatment. Multiplier effects were extracted from published literature. Productivity costs were calculated applying the Friction Cost Approach. Regular estimates were subsequently adjusted for (i) compensation during regular working hours, (ii) job dependent multipliers and (iii) both compensation and multiplier effects. A total of 187 respondents included in the trial were useful for inclusion in this study, based on being in paid employment, having experienced absenteeism in the preceding six months and completing the questionnaire on absenteeism and compensation mechanisms. Over half of these respondents stated that their absenteeism was compensated during normal working hours by themselves or colleagues. Only counting productivity costs not compensated in regular working hours reduced the traditional estimate by 57%. Correcting for multiplier effects increased regular estimates by a quarter. Combining both impacts decreased traditional estimates by 29%. To conclude, large amounts of lost production are compensated in normal hours. Productivity costs estimates are strongly influenced by adjustment for compensation mechanisms and multiplier effects. The validity of such adjustments needs further examination, however.

If you try to stop smoking, should we pay for it? The cost-utility of reimbursing smoking cessation support in the Netherlands

BACKGROUND Smoking cessation can be encouraged by reimbursing the costs of smoking cessation support (SCS). The short-term efficiency of reimbursement has been evaluated previously. However, a thorough estimate of the long-term cost-utility is lacking. OBJECTIVES To evaluate long-term effects of reimbursement of SCS. METHODS Results from a randomized controlled trial were extrapolated to long-term outcomes in terms of health care costs and (quality adjusted) life years (QALY) gained, using the Chronic Disease Model. Our first scenario was no reimbursement. In a second scenario, the short-term cessation rates from the trial were extrapolated directly. Sensitivity analyses were based on the trials confidence intervals. In the third scenario the additional use of SCS as found in the trial was combined with cessation rates from international meta-analyses. RESULTS Intervention costs per QALY gained compared to the reference scenario were approximately euro1200 extrapolating the trial effects directly, and euro4200 when combining the trials use of SCS with the cessation rates from the literature. Taking all health care effects into account, even costs in life years gained, resulted in an estimated incremental cost-utility of euro4500 and euro7400, respectively. In both scenarios costs per QALY remained below euro16 000 in sensitivity analyses using a life-time horizon. CONCLUSIONS Extrapolating the higher use of SCS due to reimbursement led to more successful quitters and a gain in life years and QALYs. Accounting for overheads, administration costs and the costs of SCS, these health gains could be obtained at relatively low cost, even when including costs in life years gained. Hence, reimbursement of SCS seems to be cost-effective from a health care perspective.

The cost‐effectiveness of antidepressants for smoking cessation in chronic obstructive pulmonary disease (COPD) patients

OBJECTIVES In healthy smokers, antidepressants can double the odds of cessation. Because of its four times lower costs and comparable efficacy in healthy smokers, nortriptyline appears to be favourable compared to bupropion. We assessed which of both drugs was most effective and cost-effective in stopping smoking after 1 year compared with placebo among smokers at risk or with existing chronic obstructive pulmonary disease (COPD). METHODS A total of 255 participants, aged 30-70 years, received smoking cessation counselling and were assigned bupropion, nortriptyline or placebo randomly for 12 weeks. Prolonged abstinence from smoking was defined as a participants report of no cigarettes from week 4 to week 52, validated by urinary cotinine. Costs were calculated using a societal perspective and uncertainty was assessed using the bootstrap method. RESULTS The prolonged abstinence rate was 20.9% with bupropion, 20.0% with nortriptyline and 13.5% with placebo. The differences between bupropion and placebo [relative risk (RR) = 1.6; 95% confidence interval (CI) 0.8-3.0] and between nortriptyline and placebo (RR = 1.5; 95% CI 0.8-2.9) were not significant. Severity of airway obstruction did not influence abstinence significantly. Societal costs were 1368 euros (2.5th-97.5th percentile 193-5260) with bupropion, 1906 euros (2.5th-97.5th 120-17 761) with nortriptyline and 1212 euros (2.5th-97.5th 96-6602) with placebo. Were society willing to pay more than 2000 euros for a quitter, bupropion was most likely to be cost-effective. CONCLUSIONS Bupropion and nortriptyline seem to be equally effective, but bupropion appears to be more cost-effective when compared to placebo and nortriptyline. This impression holds using only health care costs. As the cost-effectiveness analyses concern some uncertainties, the results should be interpreted with care and future studies are needed to replicate the findings.

Intervenciones de reducción de alérgenos mono y multifacéticas para la prevención del asma en niños con alto riesgo de desarrollo de asma

artículo recibido: 07-12-2010 artículo aprobado para publicación: 07-12-2010 Criterios de selección Los ensayos controlados aleatorios de la reducción de la exposición a alérgenos para la prevención primaria del asma en niños. Las intervenciones fueron multifacéticas (reducen la exposición a los alérgenos, inhalados y alimentarios) o monofacéticas (reducen la exposición a alérgenos inhalados o alimentarios). El seguimiento tenía que ser desde el nacimiento (o durante el embarazo) hasta un mínimo de dos años de edad.