Applied Health Economics and Health Policy最新文献

Indirect effects refer to the population-level effects of vaccination on vaccinated and unvaccinated individuals, including herd protection, serotype replacement, and age shifts, which can substantially impact the real-world effectiveness of vaccination programs. Despite their importance, most economic evaluations omit indirect effects, likely owing to the complexity of underlying mechanisms, data limitations, and difficulties in disentangling confounding factors. Static models and dynamic transmission models (DTMs) are two common approaches for incorporating indirect effects in economic evaluations. Static models rely on simplified assumptions and readily available data but often overlook the temporal and population-level dynamics of disease transmission. In contrast, DTMs account for complex factors (e.g., population mixing, serotype competition, and long-term epidemiological changes) but require more complex model structure and extensive data. In this article, we illustrate the applications, strengths, and limitations of these two modeling approaches through case studies. We demonstrate how choices of model structure and assumptions, data sources, and parameter estimation methodologies can influence projected epidemiological and economic outcomes, sometimes leading to divergent conclusions. While international guidelines increasingly recognize the importance of including indirect effects in economic evaluations, limited methodological guidance from National Immunization Technical Advisory Groups (NITAGs) and health technology assessment (HTA) bodies continues to hinder consistent implementation. This paper advocates for a collaborative effort among stakeholders to generate high-quality surveillance data and establish guidelines for methodological considerations to model indirect effects. Such efforts will improve the accuracy of epidemiological and economic assessments of vaccination programs and strengthen evidence-based decision-making in public health.

Background: Narrow-spectrum antimicrobials are likely to drive fewer antimicrobial resistances. However, they may be more expensive than broad-spectrum alternatives.

Objective: To determine the preferences of antimicrobial stewardship (AMS) experts regarding antimicrobial choice relative to relevant pharmacological and economic attributes, and how those attributes impact their willingness-to-pay for narrow-spectrum of activity.

Methods: Two discrete choice experiments (DCEs), consisting of six pharmacological and economic attributes, were administered via an online survey to Australian infectious disease physicians, clinical microbiologists and hospital AMS pharmacists. Respondents were asked to complete each DCE from a public hospital perspective, assuming 100 or 1000 patients would be treated each year, respectively. A conditional logit model was used to analyse the DCE data.

Results: 155 respondents participated in one or both DCEs. Antimicrobial price, spectrum of activity, administration route, and public funding significantly affected drug choice in both scenarios (p < 0.001). Whether the antimicrobial was a novel class did not significantly impact choice. As the price of a narrow-spectrum antimicrobial increased, it became less preferred compared to a broad-spectrum cheaper alternative. With all other attributes being equal, participants were willing to pay an additional AU$862 for the narrow-spectrum option (95% CI $726-$998).

Conclusions: While narrow-spectrum antimicrobials are preferred for targeted therapy by health practitioners with AMS expertise, price significantly influenced drug choice. Willingness-to-pay values reflect the knowledge and experience of AMS experts who are best-placed to gauge the opportunity costs of paying more for narrow-spectrum antimicrobials. These findings can inform the quantification of spectrum-value for health-system funding decisions.

Background and objective: Partnerships between health economists and multi-sectoral stakeholders are essential for public health economics research. While most evidence comes from low- and middle-income countries, high-income countries also face challenges in governance, communication and translating complex analyses into policy-relevant insights. This study provides a reflective account of partnership working from a UK academic health economics team engaged in population obesity research, identifying key enablers, barriers and lessons for high-income countries contexts, with comparisons to low- and middle-income countries literature.

Methods: The MacPhee partnership model guided reflections across inputs, activities, outputs and outcomes. Semi-structured interviews with eight research staff and two PhD students captured experiences working with local government, community organisations, practitioners, funders and commercial stakeholders. Transcripts were analysed thematically, mapping initial codes to the MacPhee framework and refining themes to highlight transferable lessons.

Results: Effective partnerships relied on pre-existing relationships, clarity on mutual goals, adaptive communication and flexibility. Trust emerged as both an input and an outcome, requiring sustained investment. Partnerships with weak governance, particularly involving commercial stakeholders, were more likely to falter. Compared with low- and middle-income countries contexts, it was noted that the focus should shift from policymaker capacity building towards equipping health economists with relational, translational and governance skills.

Conclusions: High-income countries partnerships between academic health economists and multi-sectoral stakeholders benefit from explicit attention to governance, trust and communication. These findings support integrating partnership working skills into health economics training and ensuring project design accommodates the time and resources required to build sustainable policy-relevant collaborations.

Background: Cognitive behavioral therapy (CBT) represents an effective psychotherapeutic intervention for patients with depression compared with anti-depressant medications (ADM).

Objective: The aim of this study was to determine the economically justifiable price (EJP), consisting of an average cost of CBT per patient-year for which the intervention is cost effective versus ADM for the treatment of adults with depression in Spain.

Methods: A patient-level microsimulation model was developed to conduct a cost-utility analysis over the patients' lifetime horizon. Patient demographics, epidemiology of depression, health resources consumption and health utilities feeding the model were sourced from the Spanish national health survey. Additional longitudinal inputs were derived from previously published economic analyses in depression. In the base case, the EJP was estimated for several willingness-to-pay (WTP) thresholds, including €0/QALY (dominancy) and €22,000/QALY. Two scenarios were considered presenting CBT as a substitute of ADM and both CBT and ADM combined (CBT/ADM). The robustness of the model and its results were tested using both deterministic and probabilistic sensitivity analyses.

Results: For the scenario of CBT versus ADM, the EJP was estimated at €5236 for a WTP threshold of €22,000/QALY. At an EJP of €549, CBT was a dominant intervention compared with ADM. In the scenario considering CBT/ADM versus ADM, the EJP was €5449, CBT/ADM being dominant at an EJP of €255. Sensitivity analyses demonstrated that the base-case results were robust.

Conclusion: CBT and CBT/ADM achieved incremental health benefits compared with ADM. Under the estimated EJPs, CBT and CBT/ADM could represent a cost effective or dominant intervention for adult patients with depression in Spain.

Background: Quasi-experimental studies of mortality variation and trends among large administrative areas of England in the 2000s and early 2010s have suggested that more deprived populations gain larger mortality benefits from marginal increases in public expenditure on secondary care.

Objective: To identify causal effects of marginal changes in expenditure on mortality variation in 2018 among 32,784 more and less deprived small areas of England, with a mean population of 1700, allowing more fine-grained measurements of deprivation and mortality.

Methods: We used cross-sectional data on secondary-care funding allocated to 195 National Health Service administrative areas in England in 2018/19 and employed a well-established instrumental variable approach based on the "distance from target" component of the funding formula, which generates quasi-exogenous variation in funding based on historical factors unrelated to current need for secondary care.

Results: We found an inverted U-shape pattern of mortality gains by deprivation group, whereby the middle group gained significantly more than others. However, we could not reject the null hypothesis that the two more deprived groups received the same mortality gain as the two less deprived groups. These findings were robust to extensive sensitivity analysis using different levels of analysis, control variables, mortality outcomes, functional forms, first-stage regression specifications, and exclusions, and our preferred specifications all satisfied standard instrumental variable diagnostic tests.

Conclusions: We found that the poor do not always gain more from marginal increases in public expenditure on secondary care and, conversely, might not always bear the largest share of the health opportunity costs of cost-increasing programmes.

Background: Medicines with multiple indications pose efficiency problems for health technology assessment (HTA). Evaluating indications separately may result in years of duplicative evaluation work and ultimately delay patient access. The price of these medicines is also difficult to determine because the value may vary between the different indications.

Objectives: A scoping review was conducted to identify HTA and reimbursement frameworks for evaluating and pricing multi-indication medicines for reimbursement decisions and to explore whether there are elements in these frameworks that would have utility if implemented in jurisdictions with well-established HTA systems.

Methods: PubMed, Embase and Scopus were systematically searched and a targeted search of HTA agency websites was conducted in September 2025. Documents were included in the review if they discussed HTA and reimbursement frameworks concerning multi-indication medicines in high-income countries.

Results: Sixteen frameworks were identified, describing four main approaches: policy (3), pricing (6), HTA evaluation methods (4) and decision-making (3). Policy approaches included implementing conditional listing processes and streamlining the evaluation of multi-indication medicines. Pricing frameworks including indication-based pricing frameworks and volume-based agreements were reported most frequently.

Conclusions: While pricing frameworks are commonly used in high-income countries, they do not help reduce duplication of effort in the evaluation and appraisal of these medicines. Policy change allowing for the streamlined incremental evaluation of each new indication may be helpful, although the methodological characteristics of a streamlined HTA have yet to be defined. Subscription-based approaches to purchasing medicines represent another option. Stakeholder engagement is needed to determine the merit and feasibility of different approaches.

Health technology assessments (HTA) and related decision making by regulators, payers and clinical policymakers (henceforth HTA-DM) are not simply technical processes, but normative ones, shaped by economic, moral, and scientific values. Since these value-laden decisions affect consumers, it is broadly accepted that their values need to be taken into consideration in HTA-DM and that they should be actively engaged in some aspects of these processes. This paper begins by examining current approaches to consumer engagement in HTA-DM. We then identify key challenges inherent in meaningful consumer participation, including procedural obstacles, representation issues, and difficulties in values interpretation. After briefly reviewing existing responses to these challenges, we demonstrate how insights from the philosophy of science-particularly scholarship on values in scientific inquiry-can provide new insights into the challenges of integrating consumers' values into HTA-DM and offer some strategies for more targeted and effective consumer involvement.

Objective: The aim of this study was to update EQ-5D-5L data on health-related quality of life (HRQoL) in the Vietnamese population using the EQ-5D-5L instrument and examine associated sociodemographic and health-related factors.

Method: A cross-sectional online survey was conducted between April and May 2025 among 3550 Vietnamese adults aged 18 years and older across three geographic regions. Participants were recruited through convenience and snowball sampling using online platforms. HRQoL was assessed using the EQ-5D-5L index (derived from the Vietnamese value set) and the EQ-VAS. Descriptive statistics, t-tests, ANOVA, and multivariable Tobit regressions were used.

Results: The mean EQ-5D-5L index score was 0.896 (SD 0.14) and the mean EQ-VAS score was 86.7 (SD 11.8). Significant differences were observed across age groups, employment status, education levels, and chronic disease presence (p < 0.001). Older age, unemployment, low education, and multiple morbidities were independently associated with lower HRQoL scores.

Conclusion: The findings provide updated data for HRQoL in Vietnam, confirming the impact of age, socioeconomic status, and health conditions. These results are useful for healthcare planning, health economic evaluations, and prioritizing public health interventions in Vietnam.