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Werner B F Brouwer

Publications and source records attributed to Werner B F Brouwer.

At least 19 recordsLinked to original sources
PubMed2007

Unrelated medical care in life years gained and the cost utility of primary prevention: in search of a 'perfect' cost-utility ratio.

An important subject of debate in cost-utility analysis of health care programmes is whether to include costs of unrelated medical care in life years gained. The inclusion of such costs is likely to be of consequence in the case of primary prevention. This paper presents different strategies regarding the inclusion not only of the costs, but also of the health effects of unrelated medical care in economic evaluations. Four different cost-utility ratios are presented and related to the criterion of internal consistency. In addition, the possibility to relate the ratios to a well-posed decision problem is analysed. An example computes the different ratios for smoking cessation interventions in different age groups. Including health care costs of unrelated medical care in life years gained increases cost utility ratios, but excluding unrelated medical costs favours smoking cessation interventions targeted at older smokers over those at younger smokers. We conclude that for primary prevention only a cost utility ratio that includes both the costs and effects of unrelated medical care meets the criterion of internal consistency and is related to a meaningful decision problem. Therefore, this type of cost-utility ratio should be preferred even if the data requirements may be substantial.

Cost-Benefit Analysis↗
PubMed2006

Increasing tobacco taxes: a cheap tool to increase public health.

INTRODUCTION: Several studies have estimated health effects resulting from tobacco tax increases. However, studies on the cost effectiveness of tobacco taxes are scarce. The aim of this study was to estimate the cost effectiveness of tobacco tax increases from a health care perspective, explicitly considering medical costs in life years gained. METHODS: The effects of a tax increase were translated into effects on smoking quit rates. A dynamic population model then projected incidence, prevalence and health care costs of the major chronic diseases conditional on smoking status over time. Comparing to a current practice scenario, the differences in healthcare costs, tax revenues, life years and QALYs from a tobacco tax increase resulting in a price increase of 10% increase were estimated. RESULTS: Including effects on health care costs in life years gained, the tax increase costs about 2500 euro per QALY gained. Only 3% of additional tax revenues are enough to compensate additional health care costs in life years gained. CONCLUSIONS: Even if the health care costs in life years gained are taken into account and even if additional tax revenues do not flow to the health care sector a tax increase is a cost-effective intervention to increase public health from a health care perspective.

Cost-Benefit Analysis↗
PubMed2005

Expectations regarding length and health related quality of life: some empirical findings.

Own expectations regarding length and future quality of life can differ from objective measures such as actuarial life expectancy. If so, this may have implications for health behaviour, seeking medical care and for methods used in health economic research. In this paper, we present evidence on own expectations regarding length and quality of life, using data obtained from a Dutch convenience sample (n=600). Data were obtained through a written questionnaire and a web-based survey. Own expectations regarding future quality of life were obtained by using the EQ-5D descriptive system on which respondents could indicate expected health profiles for the ages 60-90. We find that respondents significantly overestimate life expectancy (by 4.1 years, males 7.0 years and females 1.7 years), but appear to underestimate future quality of life from the age 70 onward. Regression analysis is used to explain individual expectations. Age, current health status and the perception of current lifestyle are especially important explanatory variables of people's own expectations regarding length and quality of life. Average age of death of relatives moreover explains self-estimated life expectancy, whereas self-estimated life expectancy explains expectations regarding quality of life. Given the influence inaccurate expectations may have on actual behaviour, more research on own expectations and their relation with actual behaviour is needed.

Age Factors↗
PubMed2005

Process utility from providing informal care: the benefit of caring.

Though economics is usually outcome-oriented, it is often argued that processes matter as well. Utility is not only derived from outcomes, but also from the way this outcome is accomplished. Providing care on a voluntary basis may especially be associated with such process utility. In this paper, we discuss the process utility from providing informal care. We test the hypothesis that informal caregivers derive utility not only from the outcome of informal care, i.e. that the patient is adequately cared for, but also from the process of providing informal care. We present empirical evidence of process utility on the basis of a large sample of Dutch caregivers (n=950). We measure process utility as the difference in happiness between the current situation in which the care recipient is cared for by the caregiver and the hypothetical situation that someone else takes over the care tasks, all other things equal. Other background characteristics on patient and caregiver characteristics, objective and subjective caregiver burden and quality of life are also presented and related to process utility. Our results show that process utility exists and is substantial and therefore important in the context of informal care. Almost half of the caregivers (48.2%) derive positive utility from informal care and on average happiness would decline if informal care tasks were handed over to someone else. Multivariate regression analysis shows that process utility especially relates to caregiver characteristics (age, gender, general happiness, relation to patient and difficulties in performing daily activities) and subjective caregiver burden, whereas it also depends on the number of hours of care provided (objective burden). These results strengthen the idea of supporting the use of informal care, but also that of keeping a close eye on the position of carers.

Aged↗
PubMed2005

Is silence golden? A test of the incorporation of the effects of ill-health on income and leisure in health state valuations.

The objective of the present study was to evaluate whether people include the effects of ill-health on income and leisure in quality of life valuation when the measure is silent on both. A convenience sample of 20 health professionals had to rate a health status on a visual analogue scale (VAS) without being explicitly asked to consider the effects of ill-health on income and leisure. A majority of respondents (60%) does not consider income effects and 75% does consider the effects on leisure. Explicitly asking respondents to incorporate these effects lowers the valuation. Our results indicate that whatever separation between costs and effects is preferred, using quality of life measures which are silent on income and leisure, leads to either double-counting or ignoring real costs or effects.

Adult↗
PubMed2005

The relationship between productivity and health-related quality of life: an empirical exploration in persons with low back pain.

OBJECTIVE: In economic evaluation of health care programmes normally health-related quality of life is part of measurement of a programme's effectiveness and productivity part of its costs. In this paper the relationship between quality of life and productivity is highlighted and empirically assessed in persons suffering from low back pain. METHODS: A secondary analysis was performed on data from a sample of 483 patients treated for low back pain. Periodically, both quality of life (EQ-5D) and productivity indicators for both paid and unpaid work were measured. Mean EQ-5D scores were compared for groups of patients classified by level of productivity. The relationship between quality of life and productivity was also assessed using Spearman rank correlation coefficients. RESULTS: Mean EQ-5D scores for patients without productivity losses were a half to a full standard deviation higher than for patients with the lowest levels of productivity. The correlation between quality of life and productivity was moderate. CONCLUSION: Lower levels of quality of life were associated with efficiency loss and absenteeism. However, due to the moderate strength of the relation the use of information on quality of life to model productivity costs in case of absence of productivity data was not recommended.

Absenteeism↗
PubMed2005

Acceptability of less than perfect health states.

Health normally deteriorates beyond a certain age. This means, in Amartya Sen's terms, that one's health capabilities decline beyond a certain age, making it more difficult to achieve functionings such as mobility or sexual activity. In this paper, we investigate whether this normal reduction in quality of life also induces less than perfect health states to be considered acceptable at advanced stages of life. In other words, we investigate whether it is considered acceptable that health capabilities decline over time. In this study, we use domain-specific descriptions of health (mostly following the EQ-5D domains) in order to investigate whether the acceptability of less than perfect health states is similar for all types of health losses. Besides a theoretical consideration of this issue, we present some empirical evidence based on the answers of 226 respondents to a web-based survey. The results show that often individuals do indeed consider less than perfect health states acceptable, especially at more advanced stages of life. Mild health problems are more often considered acceptable than severe health problems. The acceptability of health states is related to the quality of life score of these states, i.e., worse states are considered less acceptable. This may have implications for the allocation of scarce health care resources.

Adolescent↗
PubMed2005

The friction-cost method : replacement for nothing and leisure for free?

The friction-cost method has been put forward as an alternative to the human-capital method as it allows more realistic estimates of productivity costs to be calculated for use in economic evaluations. The possibility of replacement of (long-term) absentees is at the heart of the friction-cost method. It recognises that society will restore initial production levels after some period of adaptation, the length of which may depend on the availability of labour and, hence, on unemployment. The friction-cost method has received two main criticisms in the literature: (i) it has no theoretical underpinning; and (ii) it treats leisure time as having no value. We demonstrate in a simple 'theoretical' time-allocation model how time use shifts in the friction-cost method and that leisure is not treated as having no value. Rather, it is considered to be valued in terms of QALYs--as is normally the case in economic evaluation. The time-allocation model also demonstrates that when using the friction-cost or human-capital method the changes in the amount of unpaid work and leisure time need to be valued separately. Unpaid production losses from the previously unemployed may be larger than the gain in unpaid production gain of the absentee, resulting in a societal loss of unpaid work or the sacrifice of leisure in order to make up for lost unpaid work. These changes should be incorporated into economic analyses.

Absenteeism↗
PubMed2005

The relationship between productivity and health-related QOL: an exploration.

In economic evaluation of healthcare programmes both QOL and productivity of patients are aspects to be studied. Normally, the former is part of the measurement of the effectiveness of the programme and the latter is part of the measurement of its costs. In this paper we highlight the relationship between QOL and productivity. Two aspects are discussed: (i) the relationship between perceived productivity and health-state valuations; and (ii) the observed relationship between productivity and QOL. The first aspect relates to the fact that in health-state valuations, respondents may consider income changes and ability to work. While this may have important methodological and practical implications, little empirical evidence exists in this area. The second aspect relates to the fact that the observed productivity of individuals is expected to be related to their health-related QOL. Worse health states are expected to be associated with lower productivity. Again, empirical investigation is lacking; however, this relationship may prove important, for instance in modelling productivity costs with use of information on QOL. This paper explores these relationships between productivity and QOL to stimulate debate and research in this area.

Efficiency↗
PubMed2005

Introducing economic evaluation as a policy tool in Korea: will decision makers get quality information? : a critical review of published Korean economic evaluations.

Interest in the use of economic evaluations in Korea as an aid for healthcare decision makers has been growing rapidly since the financial crisis of the Korean National Health Insurance fund and the separation in 2000 of the roles of prescribing and dispensing drugs. The Korean Health Insurance Review Agency (HIRA) is considering making it mandatory for pharmaceutical companies to submit the results of an economic evaluation when demanding reimbursement of new pharmaceuticals. The usefulness of the results of economic evaluations depends highly on the quality of the studies. The purpose of this paper, therefore, is to provide a critical review of economic evaluations of healthcare technologies published in the Korean context. Our results show that many studies did not meet international standards. Study designs were suboptimal, study perspectives and types were often stated incompletely, time periods were often too short, and outcome measures were often less than ideal. In addition, some articles did not distinguish between measurement and valuation of resource use. Capital, overhead and productivity costs were often omitted. Only half of the studies performed sensitivity analyses. In order to further rationalise resource allocation in the Korean healthcare sector, the quality of the information provided through economic evaluations needs to improve. Developing clear guidelines and educating and training researchers in performing economic evaluations is necessary.

Cost-Benefit Analysis↗
PubMed2004

Burden of caregiving: evidence of objective burden, subjective burden, and quality of life impacts on informal caregivers of patients with rheumatoid arthritis.

OBJECTIVE: To improve understanding of the nature and magnitude of the burden of informal care and also to indicate important areas for improving the current ways in which informal care is investigated. METHODS: Information on objective burden (such as care tasks performed and time investment), subjective burden (using the Caregiver Reaction Assessment instrument and a self-rated burden score), and quality of life (using the EuroQoL instrument) were collected in a postal questionnaire of 153 informal caregivers who provide care for rheumatoid arthritis (RA) patients. RESULTS: Caregivers had been caring for the RA patients on average for >11 years, reflecting the chronic nature of RA. They provide a substantial amount of care (27.4 hours per week) and are moderately strained (24.6 on the self-rated burden scale). Caregivers are relatively healthy on average but caregivers of more severe RA patients are relatively unhealthy, which may indicate health losses due to caregiving. CONCLUSION: Informal care can be burdensome in the context of RA. More information may help assist informal caregivers in caring for RA patients and help to avoid health problems and high subjective burden.

Activities of Daily Living↗
PubMed2004

Economic valuation of informal care. An overview of methods and applications.

Informal care makes up a significant part of the total amount of care provided to care recipients with chronic and terminal diseases. Still, informal care is often neglected in economic evaluations of health care programs. Probably this is related to the fact that the costs of informal care are to an important extent related to time inputs by relatives and friends of care recipients and time is not easy to value. Development of theoretically sound, yet easily applicable valuation methods is therefore important since ignoring the costs of informal care may lead to undesirable shifts between formal and informal care. Moreover, there is increasing evidence that providing informal care may lead to health problems for the caregiver, both in terms of morbidity and mortality. Until now these health effects have not been incorporated in economic evaluations. More attention for the identification and valuation of the full costs and (health) effects of informal care for the informal caregiver seems needed therefore. This contribution presents a critical evaluation of the available methods to incorporate informal care in economic evaluations.

Activities of Daily Living↗
PubMed2004

Decision makers' views on health care objectives and budget constraints: results from a pilot study.

Economic evaluations aim to inform policy makers about the costs and effects of medical interventions to support their decisions on the allocation of health care resources. Decision makers combine information on cost-effectiveness with their preferences and with possible constraints for the allocation of health care resources. That is, decision makers need to specify an optimality criterion and all possible (budget) constraints. Usually this is a more or less implicit process. The aim of our pilot study was to find out whether decision makers consider the objectives and budget constraints we selected for a theoretical model of resource allocation relevant, and to set priorities for these objectives.

Budgets↗
PubMed2004

Discounting in decision making: the consistency argument revisited empirically.

Discounting is one of the prominent topics of debate in health economics. While the standard practice in economic evaluation is to discount costs and effects alike with a 3-5% discount rate, many have raised questions about this practice. The debate sometimes seems trapped in Weinstein and Stason's consistency argument. In this paper, we use a set of health care programs--resembling Weinstein and Stason's hypothetical programs--to test whether appointed societal decision makers are consistent in their preferences over present and future costs and health effects, and whether they discount costs and effects at the same rate. Our results demonstrate these appointed decision makers to be fairly inconsistent on both issues, susceptible to the framing of problems and in part myopic. In other words, our respondents appear to be incapable of providing reasonable and consistent preferences between present and future costs, and health effects for use in economic evaluations. There is some support for the idea that rather than using constant and identical rates for costs and effects, real differences in health endowment over time (the growth rate for health) could serve as a basis for discount rates. Our respondents seem to relate their discount rate for health to their expectations about future life expectancy, but this also is dependent on the elicitation method.

Adolescent↗
PubMed2004

Instruments for assessing the burden of informal caregiving for stroke patients in clinical practice: a comparison of CSI, CRA, SCQ and self-rated burden.

OBJECTIVE: To compare the feasibility, convergent and clinical validity of three commonly used burden scales: Caregiver Strain Index (CSI), Caregiver Reaction Assessment (CRA) and Sense of Competence Questionnaire (SCQ), with a self-developed single question on self-rated burden (SRB). SUBJECTS: Stroke patients receiving support from an informal caregiver (n = 148) and their caregivers were followed up to six months after stroke. INTERVENTION: Feasibility was assessed with several measures of missing values. Convergent validity was assessed on the basis of the correlation patterns between the burden scales, and clinical validity through evaluation of expected associations between levels of burden and explanatory patients' and caregivers' characteristics. RESULTS: Missing values were less often observed on CSI and SRB than SCQ and CRA. Significant correlation coefficients (p < 0.05) could be demonstrated between all burden scales, except for one subscale of CRA. Evidence for clinical validity was strongest for CSI and SRB, based on associations between higher burden scores and patients' disability, and patients' and caregivers' poor level of health-related quality of life (all p < 0.05). CONCLUSIONS: A concise and simple measure would facilitate early detection of caregivers at risk in clinical practice and research. CSI and SRB are more feasible and at least as valid instruments for assessment of caregiver burden in stroke than the longer and more complex SCQ and CRA. SRB could be used for quick screening of caregivers at risk. CSI is indicated for further diagnosis of the burden of informal caregivers.

Aged↗
PubMed2004

Reconciliation of economic concerns and health policy: illustration of an equity adjustment procedure using proportional shortfall.

Economic evaluations have become an important and much used tool in aiding decision makers in deciding on reimbursement or implementation of new healthcare technologies. Nevertheless, the impact of economic evaluations on reimbursement decisions has been modest; results of economic evaluations do not have a good record in predicting funding decisions. This is usually explained in terms of fairness; there is increasing awareness that valuations of QALYs may differ when the QALYs accrue to different patients. The problem, however, is that these equity concerns often remain implicit, and therefore frustrate explicitness and transparency in evidence-based decision making. It has been suggested that a so-called equity adjustment procedure may (partially) solve this problem. Typically this would involve the application of so-called equity weights, which can be used to recalculate the value of QALY gains for different patients. This paper explores such an equity adjustment procedure, using the equity concept of proportional shortfall. Proportional shortfall assumes that measurement of inequalities in health should concentrate on the fraction of QALYs that people lose relative to their remaining life expectancy, and not on the absolute number of QALYs lost or gained. It is the ratio of QALYs lost over the QALYs remaining. This equity concept combines elements of two popular but conflicting notions of equity: fair innings and severity-of-illness. We applied the concept of proportional shortfall to ten conditions and tentatively explored how an equity adjustment procedure using proportional shortfall might affect priority setting. Our equity adjustment procedure lowered the cost-effectiveness threshold when a condition was relatively mild. Because the proportional shortfall caused by the ten conditions differed considerably, the equity-adjustment procedure discriminated strongly between the ten conditions, and this experiment provided a good opportunity to explore the impact of equity adjustment for healthcare reimbursement decisions. In conclusion, our results suggest that equity can be measured and that integration of equity concerns into an economic evaluation improves the fit between economic models and reimbursement decisions. It is recommended that cost-effectiveness driven health policy systems consider equity adjustments.

Cost-Benefit Analysis↗