Konrad Obermann

Cost-Effectiveness of Anticoagulation in Patients with Nonvalvular Atrial Fibrillation with Edoxaban Compared to Warfarin in Germany

We compared the cost-utility analysis for edoxaban at both doses with that of dabigatran at both doses, rivaroxaban, and apixaban (non vitamin K antagonist oral anticoagulants, NOAC) in a German population. Data of clinical outcome events were taken from edoxabans ENGAGE-AF, dabigatrans RE-LY, rivaroxabans ROCKET, and apixabans ARISTOTLE trials. The base-case analyses of a 65-year-old person with a CHADS2 score >1 gained 0.17 and 0.21 quality-adjusted life years over warfarin for 30 mg od and 60 mg od edoxaban, respectively. The incremental cost-effectiveness ratio was 50.000 and 68.000 euro per quality-adjusted life years for the higher and lower dose of edoxaban (Monte Carlo simulation). These findings were also similar to those for apixaban and more cost-effective than the other NOAC regimens. The current market costs for direct oral anticoagulants are high in relation to the quality of life gained from a German public health care insurance perspective. The willingness-to-pay threshold was lowest for 60 mg edoxaban compared to all direct oral anticoagulants and for 30 mg edoxaban compared to dabigatran and rivaroxaban.

Free health care in Sierra Leone: a mite too optimistic?

1 Department of Health and Ageing. Overview of vaccine regulation and safety monitoring and investigation into adverse events following 2010 seasonal infl uenza vaccination in young children. http://www.tga.gov.au/pdf/ alerts-medicine-seasonal-fl u-101008.pdf (accessed July 11, 2011). 2 Medicines and Healthcare products Regulatory Agency. Monitoring the safety of seasonal infl uenza vaccines in children. https://www. cas.dh.gov.uk/ViewandAcknowledgment/ ViewAlert.aspx?AlertID=101460 (accessed July 11, 2011). with other infl uenza vaccines existed, two spontaneous reports would suggest an under-reporting rate of more than 99%. We consider this highly unlikely in this instance. In the context of the methods and data used, we fully agree that a small increased risk cannot be excluded. However, this strategy was for rapid signal detection, not risk quantifi cation. On the basis of enhanced passive surveillance, we believe that our conclusion that “there remains no indication that other infl uenza vaccines are associated with a large increase in risk of febrile convulsions as seen in Australia” is entirely valid. Owing to historical variability in passive reporting rates, comparison of absolute numbers of passive reports between years is not a robust approach to signal detection. The background incidence data from GPRD were included in our letter to provide some context for the “expected” rate. However, within the text constraints of Correspondence, a full description of the GPRD data was not possible. We calculated the background rate of febrile convulsions in children younger than 5 years within 72 h of vaccination to be 2·91 per 10 000 and 1·45 per 10 000 for seasonal and H1N1 infl uenza vaccines, respectively. We accept that children who received monovalent H1N1 vaccine might be diff erent from those who received the seasonal infl uenza vaccine. However, since the same H1N1 vaccine strain was included in the seasonal vaccines, and to take a more conservative approach to the “expected”, we used the latter background rate. Although the observed-to-expected ratio we presented does not account for underreporting of spontaneous reports, this is acknowledged in our letter and does not aff ect our conclusion. Despite the known limitations of the Yellow Card scheme, it remains a vital early warning system and the health professionals who promptly report their suspicions to us deserve early feedback on the important Authors’ reply Our strategy was to identify rapidly whether infl uenza vaccines used in children in the UK from September, 2010, could potentially cause febrile convulsions at a frequency of one case per 100 doses. This was the risk with CSL infl uenza vaccine seen earlier in Australia. Although Sheila Bird raises issues around how data from the General Practice Research Database (GPRD) are described in our analysis, these points do not detract from the conclusion we have drawn. Variable under-reporting of suspected adverse reactions is an inherent limitation of all passive surveillance systems. We attempted to reduce this under-reporting by proactively writing to all health-care professionals to request reporting of any case of convulsions in temporal association with infl uenza vaccine. With around 70 000 children vaccinated, if a 1% risk of convulsions rate in 2010–11 of febrile convulsions than after H1N1 vaccination. The upper limit would be higher still if the yellow-card rate was at best 10%, as for H1N1 in 2009–10. However, for seasonal infl uenza in 2000–01 to 2009–10, MHRA received only one yellow card when an estimated 344 000 under 5s were vaccinated, for whom the febrile convulsion rate within 72 h was 2·9 per 10 000 and so 100 could have been received. Although laudable to off er reassurance, much more detailed data and explanation were needed. Even in Correspondence, key rates or percentages should not be published without numerators and denominators.

More than figures? Qualitative research in health economics.

When attending last year’s (2011) International Health Economics Association (iHEA) conference in Toronto, we were struck by the notion that almost all papers we listened to used a very similar quantitativemethodology, whereas qualitative methods barely seemed to play a role. This is unfortunate: (Health) economists could effectively integrate combinations of qualitative and quantitative methods into their research toolkit, without having to give up the formal modeling approach they are accustomed to. The population and institutions studied will rarely be identical with the population for which policy recommendations are derived, so that, to the extent that the two differ, the recommendations may only partially hold. However, acquiring knowledge about the compatibility of populations and institutions is a complex task, one that may require the type of data generated by qualitative research.

Lessons for health care reform from the less developed world: the case of the Philippines

International technical and financial cooperation for health-sector reform is usually a one-way street: concepts, tools and experiences are transferred from more to less developed countries. Seldom, if ever, are experiences from less developed countries used to inform discussions on reforms in the developed world. There is, however, a case to be made for considering experiences in less developed countries. We report from the Philippines, a country with high population growth, slow economic development, a still immature democracy and alleged large-scale corruption, which has embarked on a long-term path of health care and health financing reforms. Based on qualitative health-related action research between 2002 and 2005, we have identified three crucial factors for achieving progress on reforms in a challenging political environment: (1) strive for local solutions, (2) make use of available technology and (3) work on the margins towards pragmatic solutions whilst having your ethical goals in mind. Some reflection on these factors might stimulate and inform the debate on how health care reforms could be pursued in developed countries.

Akutes Nierenversagen – Optimierungspotenziale zur Gewährleistung einer verbesserten Versorgungsstruktur

Since 2005 the AKI numbers nearly increased threefold. The prevailing health care structure for AKI-management in Germany possesses major potential for improvement. Despite a clear advantage regarding mortality and renal recovery, the cost-intensive CRRT is the predominant procedure in AKI-therapy. Conversion of 85 % of the CRRT-procedures to a dialysis procedure (IHD/SLED) enables annual savings in AKI-therapy by 7.3 million Euros. A reinvestment can finance a strengthened collaboration with licensed nephrologists to improve therapy quality and availability of RRT-units in local hospitals. The the long term aim is the establishment of national therapy guidelines. Lower consequential costs are crucial incentives.

Data for development in health: a case study and monitoring framework from Kazakhstan

Healthcare reforms are often not coupled with a relevant and appropriate monitoring framework, leaving policymakers and the public without evidence about the implications of such reforms. Kazakhstan has embarked on a large-scale reform of its healthcare system in order to achieve Universal Health Coverage. The health-related 2020 Strategic Development Goals reflect this political ambition. In a case-study approach and on the basis of published and unpublished evidence as well as personal involvement and experience (A) the indicators in the 2020 Strategic Development Goals were assessed and (B) a ‘data-mapping’ exercise was conducted, where the WHO health system framework was used to describe the data available at present in Kazakhstan and comment on the different indicators regarding their usefulness for monitoring the current health-related 2020 Strategic Development Goals in Kazakhstan. It was concluded that the country’s current monitoring framework needs further development to track the progress and outcomes of policy implementation. The application of a modified WHO/World Bank/Global Fund health system monitoring framework was suggested to examine the implications of recent health sector reforms. Lessons drawn from the Kazakhstan experience on tailoring the suggested framework, collecting the data, and using the generated intelligence in policy development and decision-making can serve as a useful example for other middle-income countries, potentially enabling them to fast-track developments in the health sector.

The role of national health insurance for achieving UHC in the Philippines: a mixed methods analysis

ABSTRACT Background: Achieving Universal Health Coverage (UHC) has by now become a key health policy goal in many countries and some form of National Health Insurance (NHI) is often used for this. The Philippines has had more than 50 years’ experience with social health insurance and in 1995 established PhilHealth, the country’s national health insurer. Objectives: Analyzing the role of the Philippine NHI scheme in moving towards UHC, identifying potential avenues for improvement as well as indicating challenges and areas for further development. Methods: This paper is based on a mixed methods approach including extensive literature search, data from PhilHealth and other sources, and key informant interviews with staff at PhilHealth, health care providers, and policy experts at national and international level. Results: Major achievements were the expansion of population coverage using an earmarked revenue source (‘Sin Tax’), the introduction of the no-balance-billing to prevent co-payments, and the Health Facilities Enhancement Program to improve quality. The share of PhilHealth in total health expenditures is still only 14%, managing quality and cost of providers remains insufficient, the benefit coverage does not reflect the country’s burden of disease, and financial protection for PhilHealth members is low. The UHC bill would provide a massive jump forward as all Filipinos would then be automatically enrolled in and thus entitled to the benefits of PhilHealth. Conclusions: For expanding a contribution-based NHI beyond formal employment there needs to be a large increase in budget transfers to cover for citizens unable to contribute. The Philippine UHC bill shifts from the idea of contribution leading to entitlement to the idea of citizenship leading to entitlement and can thus be seen as a paradigmatic change in thinking about NHI. There are three areas that we believe are of key importance in developing further NHI: (i) governance, (ii) financial impact, and (iii) strategic purchasing.

Improving the first-line treatment of febrile illnesses in Ghana: willingness to pay for malaria rapid diagnostic tests at licensed chemical shops in the Kintampo area

BackgroundUse of malaria rapid diagnostic test (mRDT) enhances patient management and reduces costs associated with the inappropriate use of antimalarials. Despite its proven clinical effectiveness, mRDT is not readily available at licensed chemical shops in Ghana. Therefore, in order to improve the use of mRDT, there is the need to understand the willingness to pay for and sell mRDT. This study assessed patients’ willingness to pay and licensed chemical operators’ (LCS) willingness to sell mRDTs.MethodsThe study was a cross-sectional survey conducted in Kintampo North Municipality and Kintampo South District of Ghana. Contingent valuation method using the dichotomous approach was applied to explore patient’s willingness to pay. In-depth interviews (IDIs) were used to obtain information from licensed chemical operators’ willingness to sell.ResultsMajority 161 (97%) of the customers were willing to pay for mRDT while 100% of licensed chemical operators were also willing to sell mRDT. The average lowest amount respondents were willing to pay was Ghana cedis (GH¢) 1.1 (US

Social health insurance in a developing country: The case of the Philippines

0.26) and an average highest amount of GH¢ 2.1 (US

Comparison of cost-effectiveness of anticoagulation with dabigatran, rivaroxaban and apixaban in patients with non-valvular atrial fibrillation across countries

0.49). LCS operators were willing to sell the test kit at an average lowest price of GH¢1 (US