[Prioritization and health--should maximum-price life years be introduced?].
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Cost-Benefit Analysis↗
Biomedical subjects
Dorte Gyrd-Hansen
Publications and source records attributed to Dorte Gyrd-Hansen.
Graded pairs comparison - does strength of preference matter? Analysis of preferences for specialised nurse home visits for pain management.
In the stated preference method called graded pairs comparisons respondents are asked to rate the intensity of their preference for their preferred alternative in a pairwise comparison of alternatives. Econometricians anticipate that the additional information will improve statistical efficiency compared to the standard DCE format. However, this paper reveals that added information inherent in graded pairs scale does not provide smaller standard deviations for the WTP estimated. Secondly, the ordered-response regression models employing the full range of the graded pairs data tend to overestimate WTP, which presumably is caused by the inherent tendency of the ordered-response models to 'predict to the extremes'.
Adult↗
Willingness-to-pay for a population program aimed at reducing dietary salt in Denmark.
BACKGROUND: High intake of salt increases blood pressure and the risk of cardiovascular disease. Population programs aimed at reducing dietary salt may be cost-effective, but little is known about people's valuation of such programs. METHODS: A random sample (n = 924) of Danish people aged 20-74 was interviewed in-person in year 2000. They were asked how much they would be willing to contribute in additional tax for a population program that would half the intake of salt. The respondents were randomized to presentation of effectiveness format (number-needed-to-treat (NNT), relative risk reduction (RRR), avoided cases of heart attack or increase in longevity). RESULTS: In total, 57% were unwilling to contribute to the program (63%, 51%, 51% and 63% in the NNT-, RRR-, case- and longevity-groups, respectively). The mean willingness-to-pay among the remaining 43% was $30 per person per month. While in Denmark, the annual net program cost would be $148 millions in the most unfavorable scenario, the aggregate willingness-to-pay was $468 millions. CONCLUSIONS: A public health program may be worthwhile even though only a minority of the population is willing to contribute towards it. People's valuation is moderately sensitive to format of the program information.
Adult↗
Ordering effect and price sensitivity in discrete choice experiments: need we worry?
The objective of this paper is to analyse the impact that attribute ordering has on the relative importance of the price attribute. A discrete choice experiment was performed in order to elicit psoriasis patients' preferences for treatment. We tested for ordering effect with respect to the price attribute, and disclosed noticeable higher price sensitivity when the price attribute was placed at the end of the program description. Our results indicate that preferences are context dependent and that heuristics may be used in the choice process. Our result does not, however, suggest that ordering effect is a symptom of lexicographic ordering.
Choice Behavior↗
Investigating patients' preferences for cardiac rehabilitation in Denmark.
OBJECTIVES: The objective of this study was to analyze preferences for activities comprised in comprehensive cardiac rehabilitation programs among former cardiac patients from three different hospitals in Copenhagen County, Denmark. METHODS: A discrete choice experiment was applied to elicit the preferences for the offer of participation in various cardiac rehabilitation program activities: smoking cessation course, physical exercise program, personal meetings with cardiac nurse, group meetings managed by cardiac nurses, and nutritional counseling guidance. The questionnaire was sent to 742 former cardiac patients. We had a response rate of 69 percent. RESULTS: We found that preferences differed with respect to gender and age and that the offer of participation in cardiac rehabilitation activities was not highly valued by older patients, in particular among older men. CONCLUSIONS: The discrete choice experiment proved a valuable instrument for the measurement of preferences for cardiac rehabilitation. The study provides important information on patients' preferences for cardiac rehabilitation for healthcare professionals and decision makers.
Age Factors↗
Benign breast disease and breast cancer.
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Breast Diseases↗
[The future of pharmacogenetics--cost-effectiveness and barriers].
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Cost-Benefit Analysis↗
The impact of population ageing on future Danish drug expenditure.
Population ageing is likely to place an increasing burden on future health care budgets. Several studies, however, have demonstrated that the impact of ageing on future hospital expenditures will be overestimated when not accounting for proximity to death. This is because the greater health care expenditures among the elderly are not only due to age per se but due to the high "costs of dying". Similar studies for pharmaceutical expenditures are scarce. The aim of this study was first to estimate the impact of the ageing Danish population on future total expenditures (public outlays as well as private co-payment) on out-of-hospital prescription drugs, holding everything but demographic changes constant. Second, it was to describe the association between age and drug expenditure among survivors compared to that of decedents, and to evaluate the extent to which drug expenditure is increasing with proximity to death in the last 2 years of life. Taking expenditure during the last year of life and the changes in mortality rates into account, future expenditure of prescription drugs was projected by multiplying the estimated mean annual drug expenditure according to age, gender and survival status by the predicted future number of Danes in each stratum, and subsequently, summing up across all strata. A generalized method was developed to account for expenditure several years prior to death. The projection was based on current drug utilisation from a representative prescription database covering the county of Funen, Denmark, and the most recent Danish population forecast for the period 2003-2030. The total population was projected to increase by 0.8% during the period 2003-2030, while the increase was 58% for people aged 75 years and over. The total drug expenditure was projected to increase by 16.9% during the same period when accounting for proximity to death, while it was 17.9% when this was not done. The projected growth in drug expenditure was not merely due to the drug consumption of the elderly. Moreover, the drug expenditure of elderly decedents was only increasing slightly with proximity to death. We conclude that the ageing of the population per se is likely to increase future expenditure on prescription drugs. This predicted increase, however, is small compared to recently observed increases in drug expenditures. The results of the study indicate that Danish policies aimed at limiting the increase in public drug expenditure should focus on rational pharmacotherapy and on the promotion of prescription of cost-effective pharmaceuticals-rather than targeting the drug use of the elderly or reducing the reimbursement generally.
Adolescent↗
Effects coding in discrete choice experiments.
This paper discusses the inherent problems associated with applying dummy coding when including a fixed comparator in a discrete choice experiment, and seeks to illustrate the misinterpretations that may arise if the analyst is not aware of the problem. This note provides two examples of possible misinterpretations with dummy coding and how it is solved with the use of effects coding.
Choice Behavior↗
International comparison of the definition and the practical application of health technology assessment.
OBJECTIVES: Health Technology Assessment (HTA) is defined as a policy research approach that examines the short- and long-term social consequences of the application or use of technology. Internationally different institutions have translated this definition to local contexts. In Denmark, HTA is comprehensive with focus on four aspects of the problem in question (technology [clinical evidence], economy, patient, and organization). The objective of this study is to study how the application of HTA differs across leading countries and to study the extent to which Danish HTA reports differ from foreign HTAs. METHODS: A sample of 433 HTA reports published in the period 1989--2002 by eleven leading institutions or agencies in Denmark and eight other countries were reviewed. We looked at the characteristics of the HTA with respect to focus on the four main aspects and the manner in which each aspect has been approached. RESULTS: The study shows health technology procedures to be the most common type of health technology assessed in HTAs and literature review to be the most often used method of analysis. Policy recommendations are only present in approximately half of the HTA reports. CONCLUSIONS: In the HTAs one generally sees a great focus on the clinical aspect of health technologies, leaving the economic, the patient-related, and the organizational aspect much more unanalyzed. The Danish HTAs generally have a wider scope than HTAs produced in other countries and tend to focus more frequently on patient-related and organizational dimensions.
Denmark↗
Time-trends in health technology assessments: an analysis of developments in composition of international health technology assessments from 1989 to 2002.
OBJECTIVES: Health Technology Assessment (HTA) as a method for producing evidence in the health-care sector has been used for more than 25 years but has grown in extent during the past years. The objective of this study is to explore a possible evolution in these HTAs, in type of assessed technologies, in type of assessors, and in its methods. METHODS: A structured literature review was conducted of 433 HTA reports from the period 1989 to 2002 by eleven leading HTA institutions worldwide. The review focused on the methodology used, the assessors, and the assessed technologies and was designed to elucidate general time-trends in the practical application of HTA. RESULTS: The study shows that literature reviews are still the most often used method of assessment and accounts for a relatively stable fraction of assessments. The fraction of economic evaluations shows a slightly decreasing trend in contrast to randomized controlled trials and modeling/evaluations, which are applied more frequently. The data also demonstrate a more frequent use of external partners as assessors and a shift between devices and pharmaceuticals as assessed technologies. CONCLUSIONS: The study shows an increase in the number of HTAs but no major developments in assessment methods used and, therefore, no widespread spillover from the development in research methods in general to the field of HTA methodology.
Denmark↗
Cost-effectiveness of alendronate in the prevention of osteoporotic fractures in Danish women.
Pharmacological interventions for osteoporosis may reduce morbidity and mortality, but they incur additional health care costs. The aim was to quantify the additional costs and health benefits of prescribing alendronate 10 mg and calcium/vitamin D daily for 71-year-old women with a fracture risk twice that of the population average in stead of calcium/vitamin D alone. A state transition model based primarily on Scandinavian data was developed. Women were followed from age of 71 years until 100. Alendronate was assumed to reduce the fracture risk by 50%. Health benefits from the interventions were expressed in terms of life years, quality adjusted life years, and fractures avoided. Societal costs were estimated using literature estimates and Danish tariffs. All costs were measured in 2002 Danish Kroner (DKK). Future costs and benefits were discounted at 5% per year. The incremental cost per QALY gained was DKK125,000 while the cost per life year gained was DKK 374,000. The use of alendronate was cost-saving when 1) the treatment was extended to five years, 2) the risk of fracture was four times the population average, 3) the effect of alendronate was assumed to persist for three years after discontinuation of treatment, 4) a greater proportion had severe sequelae after a hip fracture, or 5) the start of therapy was delayed until age of 77 years. In conclusion, the use of alendronate compares well with other well established therapies in terms of cost-effectiveness in older women with high risk of fracture.
Aged↗
Willingness to pay for a QALY: theoretical and methodological issues.
What is a QALY worth in monetary units? This paper presents the main arguments in the literature regarding the obstacles involved in establishing one unique willingness to pay (WTP) estimate for the value of a QALY. To directly translate QALYs into monetary units, and in this manner translate existing and forthcoming cost-effectiveness analyses (CEA) to cost-benefit analyses (CBA), it is necessary that one unique WTP per QALY can be established irrespective of context-specific characteristics such as severity of illness, magnitude of health gain, patient characteristics, etc. Because CEA and CBA are two methods of economic evaluation that are based on two very different normative perceptions of the role of health versus other goods in society, the task of performing a linear translation from QALYs to WTP is theoretically unattainable. CBA is based on the welfarist perception that the welfare associated with health is measured by way of individual preferences for health outcomes relative to other goods in society. In contrast, CEA is based on the extra-welfarist notion, which focuses on maximising health and not welfare, and suppresses any variation across income/social groups in utility derived from improvements in health. Another obstacle to one unique WTP per QALY value is that marginal utility of income is non-constant, and a function of income level and possibly health status. When marginal utility of income varies across individuals as well as contexts, measuring the value of health in monetary units may result in valuations of health increments that are very different from valuations retrieved had another unit of measure been applied. In conclusion, from a theoretical point of view, establishing one unique WTP cannot be attained. Applying one sole WTP per QALY value will entail overriding individual preferences such as diminishing marginal utility of health and potential differences in the value of incremental health across population groups. However, one problem that can, and should, be overcome when seeking to establish a monetary value for a QALY is the problem of variance in the marginal utility of income. The importance of applying the appropriate perspective when formulating WTP questions to ensure that the marginal utility of income of the respondents equals that of the financiers of the costs invested to produce the health gains should not be overlooked.
Cost-Benefit Analysis↗
Cost-effectiveness analysis based on the number-needed-to-treat: common sense or non-sense?
This paper explores and critically discusses some of the methodological limitations of using the number-needed-to-treat (NNT) in economic evaluation. We argue that NNT may be a straightforward measure of benefit when the effect of an intervention is immediate, but that serious problems arise when the effect is delay rather than avoidance of an adverse event. In this case, NNT is not a robust or accurate measure of effect, but will vary considerably and inconsistently over time. This weakness will naturally spill over onto any CEA based on NNT. A literature review demonstrated that CEAs based on NNT were all published within the last five years, and that all studies suffered from important limitations. A major weakness of using NNT is the imposed restrictions on the outcome measure, which can only be strictly uni-dimensional and non-generic. Using NNT in economic evaluations is obtained at a cost in terms of both methodological shortcomings, and a reduced ability for such evaluations to serve as a useful tool in decision making processes. The use of NNT in economic evaluations might be better avoided. To every complicated question, there is a simple, straightforward, easy--and probably wrong answer (Occam's Sledgehammer).
Cost-Benefit Analysis↗
Investigating the social value of health changes.
This survey has demonstrated that the Danish public is concerned with distributional aspects of health gains. They have a strong inclination to give priority to those in a more severe health state provided their expected benefits are large enough to bring them to the health level where their rival patients are without treatment. Results also indicated that the equity argument may not apply with equal force on all health dimensions. Respondents did to some extent trade-off equity for greater health gains. A nouvelle finding is that the valuations of health increments per se seem to be affected by whether questions are framed as individual or social choices. If social decision making is the issue, health gains which involve relieving patients of extreme problems are valued more highly than relief of minor ailments. These discrepancies between individual and social valuations suggest that the use of QALY values elicited from an individual's perspective may not be valid in social decision making.
Adult↗
Conjoint analysis. The cost variable: an Achilles' heel?
This paper seeks to enlighten the readers on the potential complexities involved in including cost variables in conjoint analysis, with the aim of emphasising that interpretation of implicit WTP values should be tackled with caution. To illustrate the potential pitfalls, a large data set from a recent Danish study is applied. The data consists of 1991 interviews in which participants are required to perform three discrete choice tasks regarding choice of hospitals, and three choice tasks involving health-care systems in general. Model comparisons are performed which test the effect of (1) the cost range applied and (2) the effect of including a dummy variable to represent the utility associated with payment per se. A wider cost range including higher payments is associated with lower parameter weights associated with the payment variable, and thus increased WTP values. Including a dummy variable to explain utility associated with payment per se has significant effects on the model incurring some of the other variables to become insignificant, and others to change sign. Results suggest that inclusion of a two-dimensional structure to explain the relationship between cost and utility may avoid erroneous conclusions and give rise to significant changes in implicit WTP estimates.
Attitude to Health↗
Willingness to pay for a QALY.
A willingness to pay (WTP) per quality-adjusted-life year (QALY) of DKK 88,000 was estimated on the basis of elicited preferences for health states. The WTP per QALY estimate presented here differs considerably from that implied in contingent valuation studies, suggesting that WTP for reducing risk of death is based on other preference structures than is ex post WTP for improvements in quality of life. Results further suggest that different preference structures may exist when respondents are faced with WTP questions in which case elimination of minor health problems are associated with negligible utility.
Cost-Benefit Analysis↗
How do individuals apply risk information when choosing among health care interventions?
A sample of 3,201 Danes was subjected to personal interviews in which they were asked to state their preferences for risk-reducing health care interventions based on information on absolute risk reduction (ARR) and relative risk reduction (RRR). The aim of the study was to measure the relative weighting of different types of risk information under various circumstances. The effect of presenting questions, and of explicitly formulating RRR, was analyzed. A preference for increases in RRR was demonstrated. There was a stronger inclination to choose the intervention that offered the highest RRR if RRR was explicitly stated. Individuals with more than 10 years of schooling also demonstrated a preference for increased ARR, but only when facing individually framed choices. In a social choice context, preferences for RRR remained intact, but the magnitude of ARR had no impact on choices. Results imply that social framing may induce a propensity to prefer interventions that target high-risk populations. Those respondents who had received < or = 10 years of schooling demonstrated preferences for RRR but not ARR, and no impact of social framing was observed.
Adult↗