Mickael Bech

Comparison of different screening tools (FRAX®, OST, ORAI, OSIRIS, SCORE and age alone) to identify women with increased risk of fracture. A population-based prospective study

PURPOSE To compare the power of FRAX® without bone mineral density (BMD) and simpler screening tools (OST, ORAI, OSIRIS, SCORE and age alone) in predicting fractures. METHODS This study was a prospective, population-based study performed in Denmark comprising 3614 women aged 40-90 years, who returned a questionnaire concerning items on risk factors for osteoporosis. Fracture risk was calculated using the different screening tools (FRAX®, OST, ORAI, OSIRIS and SCORE) for each woman. The women were followed using the Danish National Register registering new major osteoporotic fractures during 3 years, counting only the first fracture per person. Area under the receiver operating characteristic curve (ROC) and statistics and Harrells index were calculated. Agreement between the tools was calculated by kappa statistics. RESULTS A total of 4% of the women experienced a new major osteoporotic fracture during the follow-up period. There were no differences in the area under the curve (AUC) values between FRAX® and the simpler tools; AUC values between 0.703 and 0.722 (p = 0.86). Also, Harrells C values were very similar between the tools. Agreement between the tools was modest. CONCLUSION During 3 years follow-up FRAX® did not perform better in the fracture risk prediction compared with simpler tools such as OST, ORAI, OSIRIS, SCORE or age alone in a screening scenario where BMD was not measured. These findings suggest that simpler models based on fewer risk factors, which would be easier to use in clinical practice by the GP or the patient herself, could just as well as FRAX® be used to identify women with increased risk of fracture. SUMMARY Comparison of FRAX® and simpler screening tools (OST, ORAI, OSIRIS, SCORE) in predicting fractures indicate that FRAX® did not perform better in fracture risk prediction compared with the simpler tools or even age alone in a screening scenario without bone mineral density assessment.

Designing a stated choice experiment: The value of a qualitative process

Abstract Designing a stated or discrete choice experiment (DCE) involves a process of developing, testing and optimizing the experiment questionnaire. This process is important for the success of the experiment and the validity of the results, but it is often not reported thoroughly. In the field of health care, one faces challenges in relation to what makes sense both for the respondent and what has clinical relevance, especially in situations with little evidence and unclear choices, where the decision making process is not clear or informed. This is the case for degenerative spine diseases, where the selection of candidates for surgical rather than non-surgical treatment has been widely discussed and where surgery rates accordingly vary across settings. In the present work, we demonstrated how the qualitative process significantly impacted and guided the design, and it was clear that a less thorough qualitative process would have resulted in a less useable and valid design. To elicit relevant attributes and levels for a DCE, fieldwork in clinical departments in Danish hospitals was performed and has been supplemented by qualitative interviews with patients and doctors. Systematic and thorough qualitative investigation of the decision context relevant attributes and levels and appropriate framing appears valuable in the process of designing a DCE for quantitative pilot testing.

Ageing and health care expenditure in EU-15

The purpose of this paper is to investigate the relationship between ageing and the evolution of health care expenditure per capita in the EU-15 countries. A secondary purpose is to produce estimates that can be used in projections of future health care costs. Explanatory variables include economic, social, demographic and institutional variables as well as variables related to capacity and production technology in the health care sector. The study applies a co-integrated panel data regression approach to derive short-run relationships and furthermore reports long-run relationships between health care expenditure and the explanatory variables. Our findings suggest that there is a positive short-run effect of ageing on health care expenditure, but that the long-run effect of ageing is approximately zero. We find life expectancy to be a more important driver. Although the short-run effect of life expectancy on expenditure is approximately zero, we find that the long-run effect is positive, so that increasing life expectancy leads to a more than proportional, i.e. exponential, increase in health care expenditure.

The influence of economic incentives and regulatory factors on the adoption of treatment technologies: a case study of technologies used to treat heart attacks.

The Technological Change in Health Care Research Network collected unique patient-level data on three procedures for treatment of heart attack patients (catheterization, coronary artery bypass grafts and percutaneous transluminal coronary angioplasty) for 17 countries over a 15-year period to examine the impact of economic and institutional factors on technology adoption. Specific institutional factors are shown to be important to the uptake of these technologies. Health-care systems characterized as public contract systems and reimbursement systems have higher adoption rates than public-integrated health-care systems. Central control of funding of investments is negatively associated with adoption rates and the impact is of the same magnitude as the overall health-care system classification. GDP per capita also has a strong role in initial adoption. The impact of income and institutional characteristics on the utilization rates of the three procedures diminishes over time.

The effect of real-time teleconsultations between hospital-based nurses and patients with severe COPD discharged after an exacerbation

Summary We investigated the effect of daily real-time teleconsultations for one week between hospital-based nurses specialised in respiratory diseases and patients with severe COPD discharged after acute exacerbation. Patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) at two hospitals were recruited at hospital discharge. They were randomly assigned to intervention or control. The telemedicine equipment consisted of a briefcase with built-in computer including a web camera, microphone and measurement equipment. The primary outcome was the mean number of total hospital readmissions within 26 weeks of discharge. A total of 266 patients (mean age 72 years) were allocated to either intervention (n = 132) or control (n = 134). There was no significant difference in the unconditional total mean number of hospital readmissions after 26 weeks: mean 1.4 (SD 2.1) in the intervention group and 1.6 (SD 2.4) in the control group. In a secondary analysis, there was no significant difference between the two groups in mortality, time to readmission, mean number of total hospital readmissions, mean number of readmissions with AECOPD, mean number of total hospital readmission days or mean number of readmission days with AECOPD calculated at 4, 8, 12 and 26 weeks. Thus the addition of one week of teleconsultations between hospital-based nurses and patients with severe COPD discharged after hospitalisation did not significantly reduce readmissions or affect mortality.

Demographic Changes and Aggregate Healthcare Expenditure in Europe

This paper extracts the policy implications from ENEPRI Research Report No. 32, prepared under Work Package VI B of the AHEAD Project (Ageing, Health Status and Determinants of Health Expenditure) for the European Commission. The main purpose of this paper is to investigate the relationship between ageing and aggregate healthcare expenditure in EU countries on a macroeconomic level when including economic and institutional variables.

Fracture risk assessed by Fracture Risk Assessment Tool (FRAX) compared with fracture risk derived from population fracture rates

Purpose: To evaluate the performance of the Swedish version of Fracture Risk Assessment Tool (FRAX)) without bone mass density (BMD) in a Danish population to examine the possibility of applying this version to Danish women. Methods: From the Danish National Register of social security numbers, we randomly selected 5000 women living in the region of Southern Denmark aged 40—90 years to receive a mailed questionnaire concerning risk factors for osteoporosis based on FRAX. The predicted 10-year probability of hip fractures was calculated for each woman returning a complete questionnaire using the Swedish version of FRAX. The observed 10-year hip fracture risk was also calculated for each woman using age-specific hip fracture rates from the National Hospital Discharge Register and National survival tables. Results: A total of 4194 (84%) women responded to the questionnaire and 3636 (73%) gave complete information and were included in the analysis. Using FRAX, the predicted 10-year fracture risk was 7.6%, ranging from 0.3 to 25.0% at the age of 41—50 and 81—90, respectively, while the corresponding observed fracture risk was 7.6%, ranging from 0.4 to 24.0%, respectively and not significantly different from the predicted risk (p = 0.92). Conclusions: The Swedish version of FRAX without BMD is applicable to Danish women.

Exploring spatial patterns in general practice expenditure

The determinants for per capita general practitioner (GP) public expenditure across Danish municipalities are analysed using data from the period 1997–2004. Heterogeneity and dependency across years are controlled for. Spatial spillover effects across municipalities are investigated in order to disclose the spatial dynamics of public GP expenditure. The results reveal substantial heterogeneity and dependency across time, as well as the presence of a significant spatial spillover effect. The effects of determinants are seriously over-estimated if such features are ignored. The spatial coefficient is strongly significant and suggests that there is an indirect effect on expenditure of non-observable variables that are geographically concentrated.

Economic evaluation of empirical antisecretory therapy versus Helicobacter pylori test for management of dyspepsia: a randomized trial in primary care

OBJECTIVES An economic evaluation was performed of empirical antisecretory therapy versus test for Helicobacter pylori in the management of dyspepsia patients presenting in primary care. METHODS A randomized trial in 106 general practices in the County of Funen, Denmark, was designed to include prospective collection of clinical outcome measures and resource utilization data. Dyspepsia patients (n = 722) presenting in general practice with more than 2 weeks of epigastric pain or discomfort were managed according to one of three initial management strategies: (i) empirical antisecretory therapy, (ii) testing for Helicobacter pylori, or (iii) empirical antisecretory therapy, followed by Helicobacter pylori testing if symptoms improved. Cost-effectiveness and incremental cost-effectiveness ratios of the strategies were determined. RESULTS The mean proportion of days without dyspeptic symptoms during the 1-year follow-up was 0.59 in the group treated with empirical antisecretory therapy, 0.57 in the H. pylori test-and-eradicate group, and 0.53 in the combination group. After 1 year, 23 percent, 26 percent, and 22 percent, respectively, were symptom-free. Applying the proportion of days without dyspeptic symptoms, the cost-effectiveness for empirical treatment, H. pylori test and the combination were 12,131 Danish kroner (DKK), 9,576 DKK, and 7,301 DKK, respectively. The incremental cost-effectiveness going from the combination strategy to empirical antisecretory treatment or H. pylori test alone was 54,783 DKK and 39,700 DKK per additional proportion of days without dyspeptic symptoms. CONCLUSIONS Empirical antisecretory therapy confers a small insignificant benefit but costs more than strategies based on test for H. pylori and is probably not a cost-effective strategy for the management of dyspepsia in primary care.

Public pharmaceutical expenditure: identification of spatial effects

The aim of the present study is to analyse the spatio-temporal dynamics underlying Spanish pharmaceutical expenditure increases. We suggest alternative ways to resolve the problem of identifying exogenous and endogenous spatial spillover in a seemingly unrelated regression framework, while parametric instability is captured using linear time trends in the coefficients. The results highlight the need of considering these dynamic aspects in the pharmaceutical expenditure analysis.