Louis Niessen

Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk

BACKGROUND Cardiovascular disease accounts for much morbidity and mortality in developed countries and is becoming increasingly important in less developed regions. Systolic blood pressure above 115 mm Hg accounts for two-thirds of strokes and almost half of ischaemic heart disease cases, and cholesterol concentrations exceeding 3.8 mmol/L for 18% and 55%, respectively. We report estimates of the population health effects, and costs of selected interventions to reduce the risks associated with high cholesterol concentrations and blood pressure in areas of the world with differing epidemiological profiles. METHODS Effect sizes were derived from systematic reviews or meta-analyses, and the effect on health outcomes projected over time for populations with differing age, sex, and epidemiological profiles. Incidence data from estimates of burden of disease were used in a four-state longitudinal population model to calculate disability-adjusted life years (DALYs) averted and patients treated. Costs were taken from previous publications, or estimated by local experts, in 14 regions. FINDINGS Non-personal health interventions, including government action to stimulate a reduction in the salt content of processed foods, are cost-effective ways to limit cardiovascular disease and could avert over 21 million DALYs per year worldwide. Combination treatment for people whose risk of a cardiovascular event over the next 10 years is above 35% is also cost effective leading to substantial additional health benefits by averting an additional 63 million DALYs per year worldwide. INTERPRETATION The combination of personal and non-personal health interventions evaluated here could lower the global incidence of cardiovascular events by as much as 50%.

Priority setting of health interventions: the need for multi-criteria decision analysis

Priority setting of health interventions is often ad-hoc and resources are not used to an optimal extent. Underlying problem is that multiple criteria play a role and decisions are complex. Interventions may be chosen to maximize general population health, to reduce health inequalities of disadvantaged or vulnerable groups, ad/or to respond to life-threatening situations, all with respect to practical and budgetary constraints. This is the type of problem that policy makers are typically bad at solving rationally, unaided. They tend to use heuristic or intuitive approaches to simplify complexity, and in the process, important information is ignored. Next, policy makers may select interventions for only political motives.This indicates the need for rational and transparent approaches to priority setting. Over the past decades, a number of approaches have been developed, including evidence-based medicine, burden of disease analyses, cost-effectiveness analyses, and equity analyses. However, these approaches concentrate on single criteria only, whereas in reality, policy makers need to make choices taking into account multiple criteria simultaneously. Moreover, they do not cover all criteria that are relevant to policy makers.Therefore, the development of a multi-criteria approach to priority setting is necessary, and this has indeed recently been identified as one of the most important issues in health system research. In other scientific disciplines, multi-criteria decision analysis is well developed, has gained widespread acceptance and is routinely used. This paper presents the main principles of multi-criteria decision analysis. There are only a very few applications to guide resource allocation decisions in health. We call for a shift away from present priority setting tools in health – that tend to focus on single criteria – towards transparent and systematic approaches that take into account all relevant criteria simultaneously.

Substantia nigra projections to the reticular formation, superior colliculus and central gray in the rat, cat and monkey

After horseradish peroxidase injections in different parts of the lower brain stem retrogradely labeled neurons were observed in the substantia nigra, mainly ipsilateral pars reticulata. These findings demonstrate that the substantia nigra projects not only to the striatum and thalamus but also to brain stem areas which give rise to descending spinal projections. These nigral projections to brain stem structures may play an important role in a variety of behaviors and may be involved in clinical syndromes associated with nigral lesions.

Need for differential discounting of costs and health effects in cost effectiveness analyses

The decision of the National Institute for Health and Clinical Excellence to abandon differential discounting of future health is a step backwards and could change funding decisions

The evidence-based approach in health policy and health care delivery

Evidence-based approaches are prominent on the national and international agendas for health policy and health research. It is unclear what the implications of this approach are for the production and distribution of health in populations, given the notion of multiple determinants in health. It is equally unclear what kind of barriers there are to the adoption of evidence-based approaches in health care practice. This paper sketches some developments in the way in which health policy is informed by the results from health research. It summarises evidence-based approaches in health at three impact levels: intersectoral assessment, national health care policy, and evidence-based medicine in everyday practice. Consensus is growing on the role of broad and specific health determinants, including health care, as well as on priority setting based on the burden of diseases. In spite of methodological constraints, there is a demand for intersectoral assessments, especially in health sector reform. Initiators of policy changes in other sectors may be held responsible for providing the evidence related to health. There are limited possibilities for priority setting at the national health care policy level. Hence, there is a decentralisation of responsibilities for resource use. Health care providers are encouraged to assume agency roles for both patients and society and asked to promote and deliver effective and efficient health care. Governments will have to design a national framework to facilitate their organisation and legal framework to enhance evidence-based health policy. Treatment guidelines supported by evidence on effectiveness and efficiency will be one essential element in this process. With the increasing number of advocates for the enhancement of population health in the policy arenas, evidence-based approaches provide the information and some of the tools to help with priority setting.

Prediction of coronary heart disease risk in a general, pre-diabetic, and diabetic population during 10 years of follow-up: accuracy of the Framingham, SCORE, and UKPDS risk functions: The Hoorn Study.

OBJECTIVE To test the validity of the Framingham, Systematic Coronary Risk Evaluation (SCORE), and UK Prospective Diabetes Study (UKPDS) risk function in the prediction of risk of coronary heart disease (CHD) in populations with normal glucose tolerance (NGT), intermediate hyperglycemia, and type 2 diabetes. RESEARCH DESIGN AND METHODS Calibration and discrimination of the three prediction models were tested using prospective data for 1,482 Caucasian men and women, 50–75 years of age, who participated in the Hoorn Study. All analyses were stratified by glucose status. RESULTS During 10 years of follow-up, a total of 197 CHD events, of which 43 were fatal, were observed in this population, with the highest percentage of first CHD events in the diabetic group. The Framingham and UKPDS prediction models overestimated the risk of first CHD event in all glucose tolerance groups. Overall, the prediction models had a low to moderate discriminatory capacity. The SCORE risk function was the best predictor of fatal CHD events in the group with NGT (area under the receiver operating characteristic curve 0.79 [95% CI 0.70–0.87]), whereas the UKPDS performed better in the intermediate hyperglycemia group (0.84 [0.74–0.94]) in the estimation of fatal CHD risk. After exclusion of known diabetic patients, all prediction models had a higher discriminatory ability in the group with diabetes. CONCLUSIONS The use of the Framingham function for prediction of the first CHD event is likely to overestimate an individuals absolute CHD risk. In CHD prevention, application of the SCORE and UKPDS functions might be useful in the absence of a more valid tool.

Multi-criteria decision analysis to prioritize health interventions: capitalizing on first experiences

This paper capitalizes on a first set of experiences on the application of multi-criteria decision analysis (MCDA) in seven low- and middle-income settings. It thereby reacts to a recent paper by Peacock et al., highlighting the potential of MCDA to guide policy makers in highly specific decision-making contexts. We argue that MCDA also has a broader application in setting priorities in health, i.e. to indicate general perceptions on priorities without defining the allocation of resources in a precise fashion. This use of MCDA can have far-reaching and constructive influences on policy formulation.

Patient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysis

Aims  Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost‐effectiveness estimates. This study reports empirical findings on the cost‐effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient‐related and intervention‐related cost.

Comparative impact assessment of child pneumonia interventions

OBJECTIVE To compare the cost-effectiveness of interventions to reduce pneumonia mortality through risk reduction, immunization and case management. METHODS Country-specific pneumonia burden estimates and intervention costs from WHO were used to review estimates of pneumonia risk in children under 5 years of age and the efficacy of interventions (case management, pneumonia-related vaccines, improved nutrition and reduced indoor air pollution from household solid fuels). We calculated health benefits (disability-adjusted life years, DALYs, averted) and intervention costs over a period of 10 years for 40 countries, accounting for 90% of pneumonia child deaths. FINDINGS Solid fuel use contributes 30% (90% confidence interval: 18-44) to the burden of childhood pneumonia. Efficacious community-based treatment, promotion of exclusive breastfeeding, zinc supplementation and Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae immunization through existing programmes showed cost-effectiveness ratios of 10-60 International dollars (I

Stroke trends in an aging population. The Technology Assessment Methods Project Team.

) per DALY in low-income countries and less than I