Pauline Chauvin

Evaluation of full costs of care for patients with Alzheimer's disease in France: the predominant role of informal care.

OBJECTIVE It is crucial that the cost of Alzheimers disease be evaluated, from a societal perspective, since the number of patients is expected to increase dramatically in the coming decades. This assessment of the full cost of care for community-dwelling patients with Alzheimers disease in France also addresses the factors associated with informal care, its predominant component. DATA AND METHODS From 2009 to 2010, 57 patient/informal caregiver pairs were interviewed using the Resource Utilization in Dementia questionnaire, adapted to provide a micro-costing approach of the overall care process. Both the opportunity cost method and the proxy good method were used to value informal care. Ordinary least square regression was performed to determine factors associated with informal care. RESULTS Average total monthly costs were €2450 with the proxy good method and €3102 with the opportunity cost method. Living with the patient, severity of dementia and hours spent on formal care were significantly associated with informal care time. POLICY IMPLICATIONS Since French allowance cannot cover all formal and informal non-medical costs, the choice for policy makers is either to spend more on formal care or to develop family care by investing in supportive programmes for informal caregivers.

Cost-effectiveness of colorectal cancer screening with computed tomography colonography according to a polyp size threshold for polypectomy.

Objective Computed tomography colonography (CTC) has an acceptable accuracy in detecting colonic lesions, especially for polyps at least 6 mm. The aim of this analysis is to determine the cost-effectiveness of population-based screening for colorectal cancer (CRC) using CTC with a polyp size threshold. Methods The cost-effectiveness ratios of CTC performed at 50, 60 and 70 years old, without (PL strategy) or with (TS strategy) polyp size threshold were compared using a Markov process. Incremental cost-effectiveness ratios (ICER) were calculated per life-years gained (LYG) for a time horizon of 30 years. Results The ICER of PL and TS strategies were 12 042 and 2765 &U20AC;/LYG associated to CRC prevention rates of 37.9 and 36.5%. The ICER of PL and TS strategies dropped to 9687 and 1857 &U20AC;/LYG when advanced adenoma (AA) prevalence increased from 6.9 to 8.6% for male participants and 3.8–4.9% for female participants or to 9482 and 2067 &U20AC;/LYG when adenoma and AA annual recurrence rates dropped to 3.2 and 0.25%. The ICER for PL and TS strategies decreased to 7947 and 954 &U20AC;/LYG or when only two CTC were performed at 50 and 60-years-old. Conversely, the ICER did not significantly change when varying population participation rate or accuracy of CTC. Conclusion CTC with a 6 mm threshold for polypectomy is associated to a substantial cost reduction without significant loss of efficacy. Cost-effectiveness depends more on the AA prevalence or transition rate to CRC than on CTC accuracy or screening compliance.

Cost-effectiveness of colorectal cancer screening with computed tomography colonography or fecal blood tests

Objective To assess the cost-effectiveness of colorectal cancer screening using computed tomography colonography (CTC) and immunological fecal occult blood test (iFOBT). Methods CTC and iFOBT strategies were compared with Nn screening or guaiac FOBT (gFOBT) using Markov modeling. CTC was proposed at 50, 60, and 70 years, whereas gFOBT and iFOBT were performed every 2 years beginning at 50 years until 74 years of age with a 30-year time horizon. We calculated incremental cost-effectiveness ratios and efficiency ratios (ERs). Then, we performed univariate and probabilistic sensitivity analyses. Results With gFOBT as reference, colorectal cancer prevention rate was 18% for CTC and 11% for iFOBT. The incremental cost-effectiveness ratio of CTC and iFOBT were respectively 3204 and 5458&OV0556; per life years gained (LYG), the ER for CTC was 0.22 and the ER for iFOBT was 2.08 colonoscopies per LYG. Cost-effectiveness results were sensitive to CTC cost. In the probabilistic sensitivity analysis, compared with CTC, iFOBT strategy was cost-effective for 84.6% of simulations when we assumed a willingness to pay (WTP) of 20 000&OV0556;/LYG. Conclusion CTC requires substantially less colonoscopies than iFOBT and is cost-effective for low values of WTP. However, iFOBT is the preferred screening strategy for a WTP greater than 6207&OV0556;/LYG.

Are public subsidies effective to reduce emergency care? Evidence from the PLASA study

Elderly people facing dependence are exposed to the financial risk of long lasting care expenditures. This risk is high for people facing cognitive, functional and behavioral problems. In the short-term, dependent elderly people face increased non-medical care expenditures. In the long-term, they face increased medical care expenditures, which are driven by emergency care events such as: emergency hospitalization, emergency medical visits, and emergency institutionalizations. In France, providing public financial assistance has been shown to improve dependent peoples access to non-medical care services. However, the impact of public financial assistance on emergency care use has not been explored yet. Our study aims at determining whether financial assistance on non-medical care provision decreases the probability of emergency care rates using data of 1131 French patients diagnosed with Alzheimers disease, collected between 2003 and 2007. Using instrumental variables to deal with the presence of a potential endogeneity bias, we find that beneficiaries of long-term care subsidies have a significantly lower rate of emergency care than non-beneficiaries. Failing to control for endogeneity problems would lead to misestimate the impact of long-term care subsidies on emergency care rates. Finding that home care subsidies has a protective effect for emergency care confirmed the efficacy of this public policy tool.

Bases théoriques des études coût-efficacité en médecine

RésuméL’objectif de cet article est d’expliciter les fondements des études coût-efficacité, de décrire les indicateurs sur lesquels elles s’appuient, pour montrer leur ancrage dans les décisions collectives en matière de santé publique.AbstractThe objective of this study was to explain foundations of cost-effectiveness analysis and to describe indicators and variables commonly used in public health decisions.