Health Economics Review最新文献

Objectives: Value-based insurance design (VBID) aims to direct consumers' preferences by incentivizing the use of high-value care and discouraging the use of low-value care. However, consumers often have limited knowledge of health insurance and the health insurance system, possibly distorting their preferences. In this study, we aim to investigate the impact of specific information treatments on consumers' preferences for VBID.

Methods: We implemented an information experiment as part of a representative survey on health insurance literacy and preferences for VBID within Switzerland's choice-based health insurance system. Preferences for VBID were measured through a discrete choice experiment. Cross-sectional data on 6,033 respondents aged 26-75 were analyzed using descriptive statistics and mixed logit regressions.

Results: Respondents showed strong preferences for their current health insurance instead of VBID alternatives. A general description of current regulations on cost-sharing, drug disbursement, and monthly premiums significantly increased preferences for VBID (p < 0.01). Pointing respondents specifically to VBID further reduced the opposition against VBID plans. At the same time, there is evidence for anchoring effects in copayments after receiving the information treatments, irrespective of the value of the care.

Conclusions: The results of this study highlight that individuals are susceptible to provided information about health insurance when building their preferences for VBID. One potential explanation is limited health insurance literacy, implying that tailored communication strategies may be needed to improve insurance decision-making.

Jel classification: I11, I13.

Background: The operationalization of universal health insurance in Burkina Faso represents a significant challenge for health coverage. The willingness of households to pay is a crucial aspect of the process. This highlights the necessity of examining the factors that may explain their willingness to pay. The objective of this study is to analyze the determinants of households' willingness to pay for health insurance in Burkina Faso.

Methods: The data used in this study were collected between March and September 2017 in the territory of Burkina Faso, covering six administrative regions. A total of 211 households were surveyed, 71 in urban areas and 140 in rural areas. The Tobit model was employed to analyze the determinants of willingness to pay, with the contingent valuation method used to obtain willingness to pay.

Results: The results of the descriptive analysis indicate that households are willing to pay approximately 7,600 F CFA on average for health insurance. The estimation results demonstrate that income has a positive effect on households' willingness to pay. Additionally, the occupation of the head of household and the insurance reimbursement rate are identified as determinants of willingness to pay.

Conclusion: The findings of this study indicate that income, the rate of repayment and the occupation of the head of household are the primary determinants of willingness to pay. In terms of implications, it is essential to ensure that the rate of protection is high, which could encourage households to pay the premium. Furthermore, the results of the evaluation suggest that interventions to increase household income may be beneficial.

Background: Medicine pricing in the community pharmacy sector in Zimbabwe significantly influences accessibility to health care. In this pilot survey, we investigated how community pharmacies in Zimbabwe apply various mark-up strategies to essential and non-essential medicines, and gathered community pharmacists' perspectives on mark-up regulation.

Methods: Using an adapted methodology endorsed by the World Health Organization and Health Action International for studying medicine prices and availability, we conducted a quantitative cross-sectional pilot survey for 46 medicines (31 essential and 15 non-essential) identified using the Zimbabwe Essential Medicines List and classified according to the Vital, Essential, and Non-essential (VEN) tool. We conducted the pilot survey in 92 community pharmacies in the metropolitan area of Harare, Zimbabwe.

Results: We gathered a total of 92 responses from 167 distributed questionnaires. The most prevalent mark-up strategy was the cost-plus fixed percentage.The median mark-up for all medicines in the community pharmacies was 60% (interquartile range 50- 82%). We found a statistically significant difference in the median mark-up by essentiality of medicines (p < 0.001), essential medicines had a median mark-up price of 62% while non-essential medicines had a mark-up of 56%. Antipsychotics had the highest mark-up at 82%, while anti-neoplastic medicine had the lowest at 36%. Overall, 55% of the community pharmacists did not support mark-up regulation.

Conclusion: Mark-up strategies varied across community pharmacies in the metropolitan area of Harare. Without mark-up regulation, essential medicines remain significantly expensive in Zimbabwe. We recommend mark-up regulation in Zimbabwe's community pharmacy sector and emphasize the effective use of multiple pricing strategies to reduce medicine prices.       .

Background: Access to safe, financial affordable health care is a key factor in reducing health disparities. The malaria is a major public health issue, with significant economic implications in Guinea where the free malaria care services were introduced in 2010. This paper analyzes the costs associated with the care pathway for malaria patients in the Republic of Guinea.

Methods: An analysis of the costs associated with malaria disease was conducted using data from a cross-sectional survey on the determinants of malaria care pathway between December 2022 and March 2023. The data were collected in health facilities and at community health workers. According to the patient's perspective, Time-Driven Activity-Based Costing (TDABC) and micro-costing approaches were used to assess the costs associated with care-seeking, cases management, and income loss.

Results: A total of 3300 patients were recruited in 60 health facilities. The majority were in urban areas (64.8%). One third of the patients were children under five years old. Over half of the patients or caregivers were without formal education, and most households were headed by husbands (78.5%). The median monthly income of the head of households was $116.0. Furthermore, after diagnosis, 25.5% of cases were uncomplicated malaria, 19.2% were complicated, and 52.2% were malaria associated with other diseases. Globally 41% of cases were on their first care pathway. The costs of care-seeking varied according to type of malaria, from $3.5 and $13.5 respectively for uncomplicated and complicated cases. The median direct costs of case management at health facilities were $7.3 (IQR: $4.1,13.3) for uncomplicated and $30.5 (IQR: 15.7, 51.4) for complicated cases. The total costs associated with the global care pathway differed across types of malaria and age groups, with median costs estimated at $17.4 (IQR: 6.7, 34.8) for uncomplicated cases and $43.5 (IQR: $ 19.7, 74.0) for complicated malaria. A delay in appropriate care-seeking accounted for 19% of the costs incurred by malaria patients in Guinea (p < 0.001).

Conclusion: Despite the introduction of free malaria prevention services, malaria patients or their caregivers continue to incur costs and loss of income. An approach to selective, free and affordable flat-rate costs could ensure the financial viability of health facilities and reduce out-of-pocket expenses. The next research will focus on the impact of free selective and flat-rate pricing on out-of-pocket expenses, and the analysis of the perception of the malaria care services by care providers and users.

When decision-makers use economic evaluation to facilitate making decisions about reimbursing whether to reimburse pharmaceuticals within a publicly funded health care system, they may consider whether to prioritise specific patient populations or diseases: e.g., cancer or rare disease. This can be achieved through applying equity weights to outcomes such as QALYs. Decision makers, however, must choose whether equity weights are applied to solely the treatment of a specific disease or to treatments of the patient with the specific disease. Without such clarification, confusion may arise which can hinder the work of those who must make reimbursement recommendations and decisions. This study examines the repercussions of implementation of equity weights. For illustration, two hypothetical case studies relating to a rare disease are considered. The first case study demonstrates that applying equity weights only to the treatment of the rare disease of interest can lead to a patient with that rare disease accruing less benefits at a higher cost to the payer. The second case study demonstrates that if equity weights are applied to the patients who have a specific rare disease, then funding of a treatment for a common disease may be restricted only to those patients for whom treatment is more costly and less effective. As discussions continue with respect to applying equity weights within economic evaluation, it is important that the repercussions outlined are recognised.

Background: Combining Trastuzumab with chemotherapy for HER2-positive gastric cancer shows treatment promise but may raise costs. We aimed to evaluate the cost-effectiveness of combining Trastuzumab with chemotherapy for HER2-positive gastric cancer treatment in Iran.

Methods: We employed a partitioned survival model (PSM) to evaluate the cost-effectiveness of trastuzumab plus chemotherapy versus chemotherapy alone. The PSM framework included three distinct health states: progression-free, post-progression, and death. Clinical data, including overall survival and progression-free survival rates, were derived from the ToGA trial, a randomized controlled study. A bottom-up approach was used to calculate costs by considering drug costs, adverse event management costs and other disease management costs separately for the progression-free and post-progression states. The analysis was conducted from the Iranian healthcare system's perspective, considering direct medical costs. We performed a cost-effectiveness analysis to determine the optimal strategy by comparing the incremental cost-effectiveness ratio (ICER) to Iran's cost-effectiveness threshold, set at one to three times the GDP per capita. Additionally, we conducted sensitivity analyses to assess the robustness of our findings.

Results: Both FOLFOX-based regimens were strongly dominated. In comparison, the CAPOX regimen cost $2,811.11 for 0.75 QALYs. Adding Trastuzumab to CAPOX increased the cost to $6,128 and improved effectiveness to 0.92 QALYs, resulting in an ICER of $19,089.94 per QALY, which is between 2 and 3 times the GDP per capita in 2022.

Conclusion: The addition of trastuzumab to chemotherapy regimens improved clinical outcomes in HER2-positive gastric cancer patients. From an economic perspective, the CAPOX regimen is the most cost-effective option when considering a cost-effectiveness threshold of up to two times Iran's GDP per capita. However, when the threshold increases to three times the GDP per capita, the CAPOX + Trastuzumab regimen becomes the preferred choice. These findings provide valuable insights for healthcare policymakers in Iran.

Background: Palbociclib and Ribociclib are cyclin-dependent kinase 4/6 oral molecular inhibitors that have the potential to improve overall survival (OS), progression-free survival (PFS), and quality of life in patients with metastatic breast cancer (MBC). The objective of this study was to analyze the cost-utility of Palbociclib and Ribociclib in comparison with Letrozole monotherapy as the first-line treatment for hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) MBC patients in Iran.

Methods: A Cost-Utility Analysis (CUA) was conducted using a partitioned survival model (PSM) from the perspective of the Iranian healthcare system. The comparative strategies considered were Palbociclib + Letrozole, Ribociclib + Letrozole, and Letrozole monotherapy. The model was structured with a 1-month cycle length and a 15-year time horizon. Clinical safety, efficacy, and survival data in terms of PFS and OS for Palbociclib + Letrozole and Ribociclib + Letrozole were obtained from the latest updates of the PALOMA-1, 2, and MONALEESA-2 studies, respectively. Direct medical costs, including drug costs, visits, hospitalization, CT scans, bone x-rays, monitoring and laboratory testing, as well as medication side effects, were considered. Uncertainty evaluations were performed through deterministic sensitivity analysis and probabilistic sensitivity analysis. Excel 2016 and TreeAge 2020 were used for all stages of the evaluation.

Results: The base case results indicated that, despite its lower effectiveness, Letrozole monotherapy was the most cost-effective strategy, while Palbociclib + Letrozole and Ribociclib + Letrozole were not cost-effective. The incremental cost-effectiveness ratios (ICERs) for Palbociclib + Letrozole and Ribociclib + Letrozole compared to Letrozole monotherapy were estimated at $137,302 and $120,478 per quality-adjusted life-year (QALY), respectively, which exceeded the target threshold of $4565. Deterministic sensitivity analysis demonstrated that the CUA results were not sensitive to changes in the values of uncertain variables. Probabilistic sensitivity analysis also indicated that Palbociclib + Letrozole and Ribociclib + Letrozole had no chance of being cost-effective based on changes in various parameters and simulations.

Conclusions: Palbociclib and Ribociclib showed significant efficacy in combination with Letrozole, as evidenced by improvements in PFS. However, in the first-line treatment of MBC in Iran, these strategies were not cost-effective compared to Letrozole monotherapy.

Background: Improving access to facility-based delivery care has the potential to reduce maternal and newborn deaths across settings. Yet, the access to a health facility for childbirth remains low especially in low-income settings. To inform evidence-based interventions, more evidence is needed especially accounting for demand- and supply-side factors influencing access to facility-based delivery care. We aimed to fill this knowledge gap using data from Tanzania.

Methods: We used data from a cross-sectional survey (conducted in January 2012) of 150 health facilities, 1494 patients and 2846 households with women who had given births in the last 12 months before the survey across 11 districts in three regions in Tanzania. The main outcome was the place of delivery (giving birth in a health facility or otherwise), while explanatory variables were measured at the individual woman and facility level. Given the hierarchical structure of the data and variance in demand across facilities, we used a multilevel mixed-effect logistic regression to explore the determinants of facility-based delivery care.

Results: Eighty-six percent of 2846 women gave birth in a health facility. Demand for facility-based delivery care was influenced more by demand-side factors (76%) than supply-side factors (24%). On demand-side factors, facility births were more common among women who were educated, Muslim, wealthier, with their first childbirth, and those who had at least four antenatal care visits. On supply-side factors, facility births were more common in facilities offering outreach services, longer consultation times and higher interpersonal quality. In contrast, facilities with longer average waiting times, longer travel times and higher chances of charging delivery fees had few facility births.

Conclusions: Policy responses should aim for strategies to improve demand like health education to raise awareness towards care seeking among less educated groups and those with higher parity, reduce financial barriers to access (including time costs to reach and access care), and policy interventions to enhance interpersonal quality in service provision.

Background: Forecasting patient arrivals to hospital emergency departments is critical to dealing with surges and to efficient planning, management and functioning of hospital emerency departments.

Objective: We explore whether past mean values and past observations are useful to forecast daily patient arrivals in an Emergency Department.

Material and methods: We examine whether an integer-valued generalized autoregressive conditional heteroscedastic (INGARCH) model can yield a better conditional distribution fit and forecast of patient arrivals by using past arrival information and taking into account the dynamics of the volatility of arrivals.

Results: We document that INGARCH models improve both in-sample and out-of-sample forecasts, particularly in the lower and upper quantiles of the distribution of arrivals.

Conclusion: Our results suggest that INGARCH modelling is a useful model for short-term and tactical emergency department planning, e.g., to assign rotas or locate staff for unexpected surges in patient arrivals.

Background: The escalating prevalence of type 2 diabetes (T2DM) poses an unparalleled economic catastrophe to developing countries. Cardiovascular diseases remain the primary source of costs among individuals with T2DM, incurring expenses for medications, hospitalizations, and surgical interventions. Compelling evidence suggests that the risk of cardiovascular outcomes can be reduced by three classes of glucose-lowering therapies (GLT), including SGLT2i, GLP-1A, and pioglitazone. However, an evidence-based and cost-effective protocol is still unavailable for many countries. The objective of the current study is to compare the effectiveness and cost-effectiveness of GLT in individuals with T2DM in Brazil.

Methods: We employed Bayesian Networks to calculate the incremental cost-effectiveness ratios (ICER), expressed in international dollars (Int$) per disease-adjusted life years [DALYs] averted. To determine the effectiveness of GLT, we conducted a systematic review with network meta-analysis (NMA) to provide insights for our model. Additionally, we obtained cardiovascular outcome incidence data from two real-world cohorts comprising 851 and 1337 patients in primary and secondary prevention, respectively. Our cost analysis took into account the perspective of the Brazilian public health system, and all values were converted to Int$.

Results: In the NMA, SGLT2i [HR: 0.81 (95% CI 0.69-0.96)], GLP-1A [HR: 0.79 (95% CI 0.67-0.94)], and pioglitazone [HR: 0.73 (95% CI 0.59-0.91)] demonstrated reduced relative risks of non-fatal cardiovascular events. In the context of primary prevention, pioglitazone yielded 0.2339 DALYs averted, with an ICER of Int$7,082 (95% CI 4,521-10,770) per DALY averted when compared to standard care. SGLT2i and GLP-1A also increased effectiveness, resulting in 0.261 and 0.259 DALYs averted, respectively, but with higher ICERs of Int$12,061 (95% CI: 7,227-18,121) and Int$29,119 (95% CI: 23,811-35,367) per DALY averted. In the secondary prevention scenario, all three classes of treatments were deemed cost-effective at a maximum willingness-to-pay threshold of Int$26,700. Notably, pioglitazone consistently exhibited the highest probability of being cost-effective in both scenarios.

Conclusions: In Brazil, pioglitazone presented a higher probability of being cost-effective both in primary and secondary prevention, followed by SGLT2i and GLP-1A. Our findings support the use of cost-effectiveness models to build optimized and hierarchical therapeutic strategy in the management of T2DM.

Trial registration: CRD42020194415.