Losartan reduces the burden and cost of ESRD: public health implications from the RENAAL study for the European Union.
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Type 2 diabetes is the leading cause of end-stage renal disease (ESRD) in most industrialized countries in Europe. The RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan) Study evaluated the renal protective effects of losartan versus placebo on a background of non-ACE-I/non-AIIA conventional antihypertensive therapy in 1513 patients with type 2 diabetes and nephropathy. Losartan reduced the incidence of doubling of serum creatinine, end-stage renal disease (ESRD), or death by 16% (P=0.022) and reduced the risk of progression to ESRD, defined as the initiation of dialysis or transplantation, by 29% (P=0.002). We set out to estimate the potential effect of losartan on the burden and costs associated with ESRD over 3.5 years in the European Union (EU). The risk reduction in new cases of ESRD was calculated by combining type 2 diabetes population estimates for the EU with the percent absolute risk reduction of ESRD in patients treated with losartan as observed in RENAAL. The number of days each patient experienced ESRD was defined as the length of time from onset of ESRD until the minimum of death or 3.5 years. ESRD-free person-years avoided with losartan treatment were calculated by combining the population estimate with the ESRD days avoided divided by number of days in a year. ESRD costs from Germany were used to approximate the potential cost savings from reduced time with ESRD and fewer ESRD cases on a EU wide basis. There are approximately 700,000 diagnosed type 2 diabetes patients with proteinuria (urine albumin/creatinine >or=300 mg/g) in the EU. The addition of losartan to the treatment regimen of these patients is expected to lead to a reduction of 44,100 cases of ESRD, 64,400 fewer person-years with ESRD, and reduce ESRD-related costs by euro 2.6 billion over 3.5 years based on RENAAL data. Treatment with losartan not only reduced the incidence of ESRD, but also can result in substantial cost savings in the European Union. (+info)
When do developing countries adopt managed care policies and technologies? Part I: Policies, experience, and a framework of preconditions.
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OBJECTIVE: For developing countries with constrained economic resources, managed care holds out the promise of being able to control healthcare costs and reduce unnecessary utilization. However, little empirical evidence has been gathered about when managed care techniques can be applied to these countries and no framework considers the macroeconomic context. We propose a straightforward method to evaluate the economic and policy environment of a developing country to assess when managed care might be introduced. STUDY DESIGN AND METHODS: Analysis of available developing country health system and healthcare spending data, review of the available literature, and authors' experience evaluating healthcare reforms in developing countries. RESULTS: Many countries have implemented managed care techniques, which are driven by policy efforts to increase quality or to control costs. Successful implementation of managed care, however, appears to depend on five major preconditions. One precondition is an adequately developed formal wage sector in which patients have a sufficient ability to pay for healthcare services. Another is an adequate labor supply of trained professionals to support managed care administration, foster competition, and use available information technology. CONCLUSIONS: Although managed care encompasses a range of incentives and arrangements, implementation in developing countries appears to depend on attaining macroeconomic preconditions. (+info)
When do developing countries adopt managed care policies and technologies? Part II: Infrastructure, techniques, and reform strategies.
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OBJECTIVES: To specify the essential infrastructure elements required to implement managed care techniques successfully in a developing country, once the necessary macroeconomic preconditions for managed care have been met. Also, to describe how managed care techniques can be integrated into health system reform strategies. STUDY DESIGN AND METHODS: Analysis of available developing country health system and healthcare spending data, review of the available literature, and authors' experience evaluating healthcare reform in developing countries. RESULTS: Successful managed care relationships among payers, providers, and patients rely on several essential infrastructure elements: enabling legislation; regulatory mechanisms to administratively correct health and insurance market failures; enforceable contracts; and formal groups or associations of providers. Once these infrastructure elements are in place, a developing country government can consider implementing 1 or more managed care techniques, including payment strategies, demand-side techniques, and utilization management. CONCLUSIONS: Governments in many developing countries can take deliberate steps to accelerate the evolution of certain macroeconomic preconditions--human capital and information systems--and essential infrastructure elements necessary to support managed care techniques. They may then choose to experiment carefully with implementing specific managed care techniques, with consideration given to how the managed care techniques can promote primary care. (+info)
Inside the sausage factory: improving estimates of the effects of health insurance expansion proposals.
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The fate of a proposal to expand health insurance is influenced by predictions of the proposal's effects on the number of newly insured and the cost of new coverage. Estimates vary widely, for reasons that are often hard to discern and evaluate. This article describes and compares the frameworks and parameters used for insurance modeling. It examines conventions and controversies surrounding a series of modeling parameters: how individuals respond to a change in the price of coverage, the extent of participation in a new plan by those already privately insured, firms' behavior, and the value of public versus private coverage. The article also suggests ways of making models more transparent and proposes "reference case" guidelines for modelers so that consumers can compare modeling results. (+info)
Cost-effectiveness in Canada of intravenous proton pump inhibitors for all patients presenting with acute upper gastrointestinal bleeding.
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BACKGROUND: The administration of proton pump inhibitors intravenously after endoscopic treatment of peptic ulcers significantly reduces the recurrence of bleeding. AIM: To evaluate the incremental cost-effectiveness in Canada of intravenous proton pump inhibitor before endoscopic therapy to patients presenting with acute upper gastrointestinal bleeding, compared with endoscopic treatment alone. METHODS: From a third-party payer perspective, we modelled the costs and effectiveness over 60 days of the two approaches using decision analysis. The probabilities of various outcomes, such as re-bleeding and the need for surgery, were taken from the published literature. We included the costs of intravenous proton pump inhibitor, therapeutic endoscopy, surgical procedures and hospitalizations, all expressed in 2001 Canadian dollars. RESULTS: In a hypothetical cohort of 1000 patients, the intravenous proton pump inhibitor approach resulted in mean savings of 20,700 Canadian dollars with 37 re-bleeding episodes averted. The investigation of uncertainty resulted in a likelihood of intravenous proton pump inhibitor being cost-effective of at least 0.73. CONCLUSION: It is common in Canada to administer intravenous proton pump inhibitors to patients with upper gastrointestinal bleeding even before endoscopic confirmation of bleeding peptic ulcers. Our results suggest that this approach has a high likelihood of being cost-effective. (+info)
Cost-effectiveness of diagnostic imaging work-up and treatment for patients with intermittent claudication in The Netherlands.
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OBJECTIVE: to determine the societal cost-effectiveness of various management strategies, including both the diagnostic imaging work-up and treatment, for patients with intermittent claudication in The Netherlands. METHODS: a decision-analytic model was used and included probability and quality of life data available from the literature. A cost-analysis was performed in a university setting in The Netherlands. Imaging work-up options included magnetic resonance angiography (MRA), color-guided duplex ultrasound, or intraarterial digital subtraction angiography (DSA) and treatment options were percutaneous transluminal angioplasty with selective stent placement if feasible or bypass surgery. Management strategies were defined as combinations of imaging work-up and treatment options. A conservative strategy with no imaging work-up and walking exercises was considered as reference. Main outcome measures were quality-adjusted life years (QALYs), lifetime costs (euro), and incremental cost-effectiveness (CE) ratios. The base-case analysis evaluated 60-year-old men with severe unilateral intermittent claudication of at least one year duration. RESULTS: the range in QALYs and costs across management strategies that considered angioplasty as only treatment option was small (maximum difference: 0.0033 QALYs and 451 euros). Similarly, the range was small across management strategies that considered angioplasty if feasible otherwise bypass surgery (maximum difference: 0.0033 QALYs and 280 euros). MRA in combination with angioplasty (6.1487 QALYs and 8556 euros) had a CE ratio of 20,000 euros/QALY relative to the conservative strategy. The most effective strategy was DSA in combination with angioplasty if feasible otherwise bypass surgery (6.2254 QALYs and 18,583 euros) which had a CE ratio of 131,000 euros/QALY relative to MRA in combination with angioplasty. CONCLUSION: the results suggest that the imaging work-up with non-invasive imaging modalities can replace DSA for the work-up of patients with intermittent claudication without a substantial loss in effectiveness and a minimal cost-reduction. Management strategies including angioplasty are cost-effective in the Netherlands but although strategies including bypass surgery are more effective, their incremental costs are very high. (+info)
Future savings from measles eradication in industrialized countries.
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Estimates are made of monetary savings associated with measles eradication in seven industrialized countries. Three scenarios were studied: First, changing from the present two-dose measles-mumps-rubella (MMR) immunization schedule to one-dose of MMR; second, the use of an MMR and mumps-rubella schedule; or third, continuing the present schedule. Results show that the largest savings (US $623 million) would be achieved by changing to a one-dose MMR schedule with an assumption of a 3% discount rate and measles eradication in 2010. The smallest overall savings would result from option 3, by use of a 5% discount rate and the assumption that measles eradication occurs in 2020 ($10 million). These savings are less than previously estimated for the United States, partly because of the assumption that measles vaccines will continue to be delivered in response to possible bioterrorism threats. (+info)
Economic weights for feed intake in the growing pig derived from a growth model and an economic model.
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Economic weights are obtained for feed intake using a growth model and an economic model. The underlying concept of the growth model is the linear plateau model. Parameters of this model are the marginal ratio (MR) of extra fat and extra protein deposition with increasing feed intake (FI) and the maximum protein deposition (Pd(max)). The optimum feed intake (FI0) is defined as the minimum feed intake that meets energy requirements for Pd(max). The effect of varying FI and MR on performance traits was determined. An increase in FI results in a larger increase in growth rate with lower MR. For a given MR, feed conversion ratio is lowest when FI equals FI0. Lean meat percentage (LMP) is largest for a low MR in combination with a low FI. The decrease in LMP with higher FI islargest when FI exceeds FI0. Economic weights for FI, MR and Pd(max) depend on FI in relation to FI0. Economic weights for FI are positive when FI is less than FI0 and negative when FI is larger than FI0. The MR has only then a negative economic weight, when FI is below FI0. Economic weights of FI and MR have a larger magnitude with lower MR and lower Fl. In contrast, economic weights for growth rate and FI derived from the economic model only change in magnitude and not in sign with different levels of these traits. The economic model always puts a negative economic weight on FI since it expresses profit due to a decrease in FI with constant growth rate and LMP. This holds the risk of continuous decrease in FI in pig breeding programs. In contrast, the use of growth models for genetic improvement allows direct selection for an optimum feed intake which maximizes feed efficiency in combination with maximum lean meat growth. It is concluded that recording procedures have to be adapted to collect the data necessary to implement growth models in practical pig breeding applications. (+info)