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Valuing prevention through economic evaluation: some considerations regarding the choice of discount model for health effects with focus on infectious diseases

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Abstract

In cost-effectiveness analysis, the valuing of costs and health effects over time remains a controversial issue. The debate mostly focuses on whether the discount rates for health and money should be equal and which discounting model and time preferences are most appropriate. In this paper we add to the debate by arguing that the assessment of effectiveness of a preventive intervention may influence the choice of the discounting procedure for health. Health effects in cost-effectiveness analysis are commonly expressed in life-years gained, QALYs gained or lives saved. These denominators are only indirect and partial measures of the effects of a preventive intervention. The actual effect of the intervention is a reduction of the risk of mortality and morbidity in a given period of time. This risk reduction will not always coincide with the moment at which the impact on (quality-adjusted) life-years gained is made (i.e. at risk exposure), for example when preventing chronic disease with an asymptomatic stage. In this paper we show that truly acknowledging the origin of health benefits could have implications for the discounting procedure. We present a discounting model that adequately focuses on the reduction of risk. This model recognises the potential interpretation of risk reduction for infection as an economic good to be acquired with associated mortality reductions as later indirect effects. This implies that our suggested discounting model focuses on the moment(s) of risk reduction. A numerical example illustrates our approach. We discuss the associated potential implications for public health policy and discuss how the effects of the intervention can be additionally corrected for societal preferences.

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... Therefore a large range covering the values reported across country specific guidelines and recommendations has been tested. Meanwhile alternative discounting approaches have been proposed and should be further explored36373839. However, discounting health effects in prevention should be reconsidered as it too heavily and negatively affects the estimated cost-effectiveness results of vaccination programmes when outcomes occur much later than the point of intervention [37,40]. ...
... Meanwhile alternative discounting approaches have been proposed and should be further explored36373839. However, discounting health effects in prevention should be reconsidered as it too heavily and negatively affects the estimated cost-effectiveness results of vaccination programmes when outcomes occur much later than the point of intervention [37,40]. Vaccinating at an earlier age involves a longer waiting period before the health effects of the vaccine become apparent compared with vaccinating at an older age. ...
Article
Mathematical models provide valuable insights into the public health and economic impact of cervical cancer vaccination programmes. An in-depth economic analysis should explore the effects of different vaccine-related factors and vaccination scenarios (independent of screening practices) on health benefits and costs. In this analysis, a Markov cohort model was used to explore the impact of vaccine characteristics (e.g. cross-type protection and waning of immunity) and different vaccination scenarios (e.g. age at vaccination and multiple cohort strategies) on the cost-effectiveness results of cervical cancer vaccination programmes. The analysis was applied across different regions in the world (Chile, Finland, Ireland, Poland and Taiwan) to describe the influence of location-specific conditions. The results indicate that in all the different settings cervical cancer vaccination becomes more cost-effective with broader and sustained vaccine protection, with vaccination at younger ages, and with the inclusion of several cohorts. When other factors were varied, the cost-effectiveness of vaccination was most negatively impacted by increasing the discount rate applied to costs and health effects.
... Key factors for the success of such a targeted vaccination program would certainly be the coverage rate achieved among these autochthonous populations , the possibility to achieve a relatively low price for the vaccination despite the non-universal setting and an enhancement of general notion that preventive programs are worthwhile invest- ments. It is clear that preventive programs benefit from a lowering in discount rate36373839 . In general vaccination and screening programs most often avert diseases which would have occurred in the (far) future. ...
... However, when the former discount rate of 4% is applied HP vaccination is estimated not cost-effective (ICER > D 80,000/LYG) and should not be imple- mented. As indicated above, the literature is accumulating that health should indeed be discounted at a significantly lower discount rate than money [36,39]. Factors contributing to lower time preference for health than for money are the desire to eliminate dread [40], the increasing value of health over time [36] and the potential double discounting of health effects [41] . ...
Article
To estimate the cost-effectiveness of a potential Helicobacter pylori (HP) vaccine for the Dutch situation, we developed a Markov model. Several HP prevalence scenarios were assessed. Additionally, we assessed the impact of the discount rate for health on the outcomes, as this influence can be profound for vaccines. When applying the current discount rate of 1.5% for health, the expected cost-effectiveness of HP vaccination is estimated below the informal Dutch threshold of euro 20,000/LYG when the HP prevalence is assumed > or =20% in the Dutch population. In conclusion, we showed that HP vaccination could possibly be a cost-effective intervention. However, this depends to a large extend on the prevalence of HP in the population. Furthermore, we showed the large impact of the discount rate for health on the cost-effectiveness of a HP vaccination program, illustrative for other vaccination programs.
... Specifically for vaccines, in an attempt to appropriately value the outcomes of evaluations of preventive interventions, it has been proposed that the health outcomes might be discounted from the moment of risk reduction (i.e., averted infections) instead of from the moment that health is actually gained [32,33] . Bos and colleagues argued that in the case of a vaccination program health gains of preventing infections are undervalued because of discounting , in particular for some infectious diseases with a longterm delay between the initial infection and disease development. ...
... For instance, applying these two approaches, but now starting at a 4% discount rate, we find a net present value of 1613 and 1607 QALYs for the proportional and hyperbolic discounting approach, respectively. Notably, in the time-shifted discounting approach [32] , health outcomes of HPV vaccination were discounted at a constant rate only for the period between vaccination and infection, and in the period after infection a zero discount rate was applied. When the stepwise discounting approach was applied, the total number of discounted QALYs were comparable to those obtained at a constant rate of 3%. ...
Article
Discounting has long been a matter of controversy in the field of health economic evaluations. How to weigh future health effects has resulted in ongoing discussions. These discussions are imminently relevant for health care interventions with current costs but future benefits. Different approaches to discount health effects have been proposed. In this study, we estimated the impact of different approaches for discounting health benefits of human papillomavirus (HPV) vaccination. An HPV model was used to estimate the impact of different discounting approaches on the present value of health effects. For the constant discount approaches, we varied the discount rate for health effects ranging from 0% to 4%. Next, the impact of relevant alternative discounting approaches was estimated, including hyperbolic, proportional, stepwise, and time-shifted discounting. The present value of health effects gained through HPV vaccination varied strongly when varying discount rates and approaches. The application of the current Dutch guidelines resulted in a present value of health effects that was eight or two times higher than that produced when using the proportional discounting approach or when using the internationally more common 4% discount rate for health effects, respectively. Obviously, such differences translate into large variations in corresponding incremental cost-effectiveness ratios. The exact discount rate and approach chosen in an economic evaluation importantly impact the projected value of health benefits of HPV vaccination. Investigating alternative discounting approaches in health-economic analysis is important, especially for vaccination programs yielding health effects far into the future. Our study underlines the relevance of ongoing discussions on how and at what rates to discount.
... It is well known from empirical research on time preference that people have a stronger preference for outcomes that manifest in the near future rather than the distant future [36,37]. Two approaches have been proposed for a methodology combining a discount rate for health that is essentially similar to that for money in the short term with a relatively low discount rate farther into the future [38][39][40]. While similar, the proposals differ significantly in terms of their motivation for the approach. ...
... In this method, the time between vaccination and the outcome (e.g., averted mortality) should be treated differently (discounted higher) than the time during which the life-years are gained due to the aforementioned outcome. Bos et al. present a similar approach; however, this method focuses on the initial period from vaccination until averted infection, with a relatively high discount rate for health at the level of monetary discounting and a postinfection period with a lower discount rate for health [39]. Both methods are better illustrated using life-years gained as the outcome rather than QALYs, due to the inherent full dependency of individual life-years on each other within a sequence of life-years gained for one individual. ...
Article
Full-text available
This study reviews the current challenges in the economic evaluation of vaccines with a focus on European countries. In particular, the type of clinical evidence generally available, the impact of discounting for time preference and the use of modeling to derive valid cost-effectiveness assessments are considered. First, the characteristics of evidence for vaccines are discussed, as well as potential difficulties faced when using evidence-based medicine applied to curative drugs to interpret vaccine evidence. Then, discounting is considered and specific examples illustrating issues with different types of discounting are described, taking HPV as the example. Finally, the need for sometimes complex dynamic models for vaccines is explored, and specific types of models are reviewed, keeping into consideration the adage "complex when needed, straightforward if allowed."
... No tocante à taxa de desconto O grande desafio metodológico em relação à medida do denominador da razão custo/efetividade (resultado) de estudos dessa ordem é o relativo ao desconto no efeito. Ainda hoje essa discussão traz aos economistas da saúde um embate sobre o melhor valor para a taxa de desconto e, no caso de benefícios intangíveis como é a saúde, ser ou não pertinente 31,32,33,34,35 . ...
Article
This study aims to contribute to the dissemination of the theoretical foundations for cost-effectiveness and cost-utility analysis. It also provides backing for reflections on the implementation of studies leading to real benefits for both the population and health system management. Taking a historical perspective, and drawing on the work of renowned authors, the study provides an extensive literature review on cost-effectiveness and cost-utility analysis, from the theoretical formulation to the definition of methodological guidelines. The study also highlights the methodological controversies resulting from the diversity of theoretical approaches. As a result, it recommends conducting research on the theoretical foundations, and particularly the position of the extra-welfarists.
... 49,50 Additionally, time preference may exist only to the time until risk exposure, and not the time until health consequences from risk exposure arise (eg, cervical cancer is the health consequence of a much earlier exposure to HPV). 51 Adjustment of the discount procedure to account for these aspects is not current practice, but would substantially improve the estimated cost-eff ectiveness of prevention versus cure. 49,50 Currently, policy makers are presented with very wide cost-eff ectiveness ranges for preventive public-health actions when sensitivity to discounting is illustrated to them. ...
Article
Vaccines have features that require special consideration when assessing their cost-effectiveness. These features are related to herd immunity, quality-of-life losses in young children, parental care and work loss, time preference, uncertainty, eradication, macroeconomics, and tiered pricing. Advisory committees on public funding for vaccines, or for pharmaceuticals in general, should be knowledgable about these special features. We discuss key issues and difficulties in decision making for vaccines against rotavirus, human papillomavirus, varicella-zoster virus, influenza virus, and Streptococcus pneumoniae. We argue that guidelines for economic evaluation should be reconsidered generally to recommend (1) modelling options for the assessment of interventions against infectious diseases; (2) a wider perspective to account for impacts on third parties, if relevant; (3) a wider scope of costs than health-care system costs alone, if appropriate; and (4) alternative discounting techniques to explore social time preference over long periods.
... As is evident from the discussion above many choices in health both at an individual and societal level involve decisions with a trade-off between something now and something later (34). The evaluation of health risk reduction, routine preventive care, and population screening programs include health measures that improve future health (35). ...
Article
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Health promotion often works toward remote goals with a trade-off between costs today and benefits in the future. However, for individuals using a positive discount rate for health outcomes a healthy state many years ahead has such a small value that it is difficult to motivate them to engage in preventive behaviors. The framework of time and risk for analysis can perform a useful role in health education and information where the framing of different features of risk might diminish discounting and increase motivation to change be- havior. Personal versus general risk and perceived control related to preventive programs are discussed. A summary of valuation factors in preventive programs based on literature review is presented: (a) long-term decisions are sensitive to discount rates; (b) discount rates vary by level of uncertainty, individuals, and con- texts; (c) personal risks from adverse health behaviors are judged as smaller than the same risks for people in general; (d) probability discounting is used, if the risk is perceived as controllable; (e) people’s tendency to discount future consequences might be suppressed by lowering the amount of perceived control.
... Discounting has been much debated. [38][39][40] Higher discount rates reduce the apparent cost effectiveness of the technology being examined, whereas lower discount rates give more favourable results. Policy makers need to fully understand which rates are used and their implications. ...
Article
Full-text available
Cervical cancer is a leading cause of death worldwide, and in Ireland it is the ninth most commonly diagnosed cancer in women. Almost 100% of these cancers are caused by human papillomavirus (HPV) infection. Two newly developed vaccines against HPV infection have become available. This study is a cost-utility analysis of the HPV vaccine in Ireland, and it compares the cost-effectiveness profiles of the two vaccines. A cost-utility analysis of the HPV vaccine in Ireland was performed using a Markov model. A cohort of screened and vaccinated women was compared with an unvaccinated screened cohort, and both cohorts were followed over their lifetimes. The model looked at uptake of services related to HPV disease in both cohorts. Outcomes were measured in quality adjusted life years (QALYs). Extensive sensitivity analysis was done. For the base case analysis, the model showed that the incremental cost-effectiveness ratio (ICER) for quadrivalent HPV vaccination would be 25,349 euros/QALY and 30,460 euros/QALY for the bivalent vaccine. The ICER for the quadrivalent vaccine ranged from 2877 euros to 36,548 euros, and for the bivalent from 3399 euros to 45,237 euros. At current prices, the bivalent vaccine would need to be 22% cheaper than the quadrivalent vaccine in order to have equivalent cost effectiveness. HPV vaccination has the potential to be very cost effective in Ireland. The quadrivalent vaccine is more cost effective than the bivalent vaccine.
... According to much of the health economic literature, health effects should be discounted at the same rate as costs, however; some argue that health effects should be discounted at a lower rate than costs [54]. Others have suggested that discounting for vaccines should start from the time of risk reduction rather than the time of intervention [55,56]. ...
Article
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Despite the fact that approximately 70% of Canadian women undergo cervical cancer screening at least once every 3 years, approximately 1,300 women were diagnosed with cervical cancer and approximately 380 died from it in 2008. This study estimates the effectiveness and cost-effectiveness of vaccinating 12-year old Canadian females with an AS04-adjuvanted cervical cancer vaccine. The indirect effect of vaccination, via herd immunity, is also estimated. A 12-health-state 1-year-cycle Markov model was developed to estimate lifetime HPV related events for a cohort of 12-year old females. Annual transition probabilities between health-states were derived from published literature and Canadian population statistics. The model was calibrated using Canadian cancer statistics. From a healthcare perspective, the cost-effectiveness of introducing a vaccine with efficacy against HPV-16/18 and evidence of cross-protection against other oncogenic HPV types was evaluated in a population undergoing current screening practices. The base-case analysis included 70% screening coverage, 75% vaccination coverage, $135/dose for vaccine, and 3% discount rate on future costs and health effects. Conservative herd immunity effects were taken into account by estimated HPV incidence using a mathematical model parameterized by reported age-stratified sexual mixing data. Sensitivity analyses were performed to address parameter uncertainties. Vaccinating 12-year old females (n = 100,000) was estimated to prevent between 390-633 undiscounted cervical cancer cases (reduction of 47%-77%) and 168-275 undiscounted deaths (48%-78%) over their lifetime, depending on whether or not herd immunity and cross-protection against other oncogenic HPV types were included. Vaccination was estimated to cost $18,672-$31,687 per QALY-gained, the lower range representing inclusion of cross-protective efficacy and herd immunity. The cost per QALY-gained was most sensitive to duration of vaccine protection, discount rate, and the correlation between probability of screening and probability of vaccination. In the context of current screening patterns, vaccination of 12-year old Canadian females with an ASO4-ajuvanted cervical cancer vaccine is estimated to significantly reduce cervical cancer and mortality, and is a cost-effective option. However, the economic attractiveness of vaccination is impacted by the vaccine's duration of protection and the discount rate used in the analysis.
... We applied conventional practice [24] to the discounting of health effects. An alternative approach has recently been proposed for preventive interventions [52] in which risk reduction is discounted from the time of intervention, which would lead to more favorable cost-effectiveness ratios. ...
Article
Routine influenza vaccination is currently recommended in several countries for people aged more than 60 or 65 years or with high risk of complications. A lower age threshold of 50 years has been recommended in the United States since 1999. To help policymakers consider whether such a policy should be adopted more widely, we conducted an economic evaluation of lowering the age limit for routine influenza vaccination to 50 years in Brazil, France, Germany, and Italy. The probabilistic model was designed to compare in a single season the costs and clinical outcomes associated with two alternative vaccination policies for persons aged 50 to 64 years: reimbursement only for people at high risk of complications (current policy), and reimbursement for all individuals in this age group (proposed policy). Two perspectives were considered: third-party payer (TPP) and societal. Model inputs were obtained primarily from the published literature and validated through expert opinion. The historical distribution of annual influenza-like illness (ILI) incidence was used to simulate the uncertain incidence in any given season. We estimated gains in unadjusted and quality-adjusted life expectancy, and the cost per quality-adjusted life-year (QALY) gained. Deterministic and probabilistic sensitivity analyses were conducted. Comparing the proposed to the current policy, the estimated mean costs per QALY gained were R$4,100, EURO 13,200, EURO 31,400 and EURO 15,700 for Brazil, France, Germany, and Italy, respectively, from a TPP perspective. From the societal perspective, the age-based policy is predicted to yield net cost savings in Germany and Italy, whereas the cost per QALY decreased to R$2800 for Brazil and EURO 8000 for France. The results were particularly sensitive to the ILI incidence rate, vaccine uptake, influenza fatality rate, and the costs of administering vaccination. Assuming a cost-effectiveness threshold ratio of EURO 50,000 per QALY gained, the probabilities of the new policy being cost-effective were 94% and 95% for France, 72% and near 100% for Germany, and 89% and 99% for Italy, from the TPP and societal perspectives, respectively. Extending routine influenza vaccination to people more than 50 years of age is likely to be cost-effective in all four countries studied.
... In particular, in the absence of discounting health gains at all (a rate of 0%), base-case cost-utility ratios were consistently halved. It is noteworthy that (near) non-discounting of health gains is still advocated and motivated, in particular in the area of infectious diseases vaccines (Bos et al. 2004). The prolonged decision on the reimbursement of the HPV vaccine within the Dutch Drugs Reimbursement System is unique in that it is currently the sole product having so far been denied for the Reimbursement System based on the health economics report. ...
Article
Full-text available
Aim This article seeks to highlight the methodological issues involved in the public health economics of vaccines in the Netherlands and the ensuing implications for immunisation policy. Subjects and methods We review and analyse the role of health economics (and especially cost-effectiveness issues) in the decision-making process of the Dutch (1) Drugs Reimbursement System and (2) National Immunisation Programme. Different types of health-economic analyses are illustrated by the examples of meningococcal C, pneumococcal, and human papilloma virus (HPV) vaccines. Results The role of health economics has recently increased in importance in Dutch public health decision-making concerning vaccines. The choice of vaccine strategy against meningococcus C, the shift in favour of introducing pneumococcal vaccine, and the prolonged decision on the reimbursement for HPV vaccine were all related to the health-economic component in the recommendation process. Conclusion The role of health economics is growing in decision-making regarding the reimbursement of new therapeutic and prophylactic products. Vaccines, like drugs, will have increasingly to prove their cost-effectiveness if manufacturers are to lead their product not only from phases I to IV, but also through to implementation as part of national immunisation policies covered within national reimbursement systems.
... Without discounting, the cost per QALY was halved and target groups need to have a force of infection that is only twice as high in order to become cost-effective. The exact choice of discount rates is an influential factor for economic evaluations of vaccines where the costs are concentrated early in the time period considered and the health benefits can accrue over longer periods [46,47]. ...
... NICE's current position requires it to follow UK Treasury guidance in discounting costs and benefits at the same rate of 3 1/2 per cent. Academic debate over the discounting of benefits nevertheless persists, especially in circumstances of prevention where life years might accrue only in the distant future[64,65]. Some economists have argued that QALYs are logically un-discountable or, if they are discounted, the rate should be lower than that used for costs. ...
Article
Full-text available
The absence of trial evidence makes it impossible to determine whether or not mass screening for lung cancer would be cost effective and, indeed, whether a clinical trial to investigate the problem would be justified. Attempts have been made to resolve this issue by modelling, although the complex models developed to date have required more real-world data than are currently available. Being founded on unsubstantiated assumptions, they have produced estimates with wide confidence intervals and of uncertain relevance to the United Kingdom. I develop a simple, deterministic, model of a screening regimen potentially applicable to the UK. The model includes only a limited number of parameters, for the majority of which, values have already been established in non-trial settings. The component costs of screening are derived from government guidance and from published audits, whilst the values for test parameters are derived from clinical studies. The expected health gains as a result of screening are calculated by combining published survival data for screened and unscreened cohorts with data from Life Tables. When a degree of uncertainty over a parameter value exists, I use a conservative estimate, i.e. one likely to make screening appear less, rather than more, cost effective. The incremental cost effectiveness ratio of a single screen amongst a high-risk male population is calculated to be around pound14,000 per quality-adjusted life year gained. The average cost of this screening regimen per person screened is around pound200. It is possible that, when obtained experimentally in any future trial, parameter values will be found to differ from those previously obtained in non-trial settings. On the basis both of differing assumptions about evaluation conventions and of reasoned speculations as to how test parameters and costs might behave under screening, the model generates cost effectiveness ratios as high as around pound20,000 and as low as around pound7,000. It is evident that eventually being able to identify a cost effective regimen of CT screening for lung cancer in the UK is by no means an unreasonable expectation.
... Pharmacol. 6(1), (2013) Editorial into the future [12][13][14][15]. Building on these methods, other authors have extended the approach from specifying two discount rates for the near and distant futures to a trajectory of discount rates for multiple periods into the future. ...
... No tocante à taxa de desconto O grande desafio metodológico em relação à medida do denominador da razão custo/efetividade (resultado) de estudos dessa ordem é o relativo ao desconto no efeito. Ainda hoje essa discussão traz aos economistas da saúde um embate sobre o melhor valor para a taxa de desconto e, no caso de benefícios intangíveis como é a saúde, ser ou não pertinente 31,32,33,34,35 . ...
Article
Full-text available
Este trabalho tem por finalidade contribuir com a disseminação do conteúdo teórico desta área do conhecimento, assim como oferecer subsídios para reflexões no que tange à consecução de estudos, os quais resultem em reais benefícios para a população e a gestão do sistema de saúde. Para tanto se realizou, sob uma perspectiva histórica e com base no ponto de vista de reconhecidos autores, ampla revisão da literatura que abrangeu desde sua fundamentação teórica até a formalização de guias metodológicos. O estudo ressalta, inclusive, as controvérsias metodológicas conseqüentes da diversidade das abordagens teóricas. E, como decorrência, recomenda a realização de pesquisas sobre a fundamentação teórica, particularmente a abordada pelos extrawelfaristas.This study aims to contribute to the dissemination of the theoretical foundations for cost-effectiveness and cost-utility analysis. It also provides backing for reflections on the implementation of studies leading to real benefits for both the population and health system management. Taking a historical perspective, and drawing on the work of renowned authors, the study provides an extensive literature review on cost-effectiveness and cost-utility analysis, from the theoretical formulation to the definition of methodological guidelines. The study also highlights the methodological controversies resulting from the diversity of theoretical approaches. As a result, it recommends conducting research on the theoretical foundations, and particularly the position of the extra-welfarists.
... Although this recommendation may be less disputed concerning net costs, no such consensus exists regarding health impacts [48] . More recent publications provide strong arguments for not discounting health impacts – or at least to apply near-zero rates – to attach adequate value to future health impacts [49,50] . This tendency to discount LYG at still decreasing rates may, on the one hand, further strengthen the case for universal antenatal HIV testing from an economic perspective . ...
Article
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This paper reviews the pharmacoeconomic aspects of antenatal testing for HIV. HIV is a retrovirus which is transmitted among humans through sexual contact, infected blood or blood products (needle sharing or percutaneous accidents) and from mother to child (vertical transmission). Vertical transmission from the HIV-infected mother can occur in utero during and after delivery, through breastfeeding. Effective interventions available to reduce the risk of vertical transmission include: pharmacotherapy prior, during and after delivery; voluntary caesarean section; and replacing breastfeeding by bottle-feeding [1,2]. The existence of these effective interventions underlies the need to detect yet undiagnosed HIV-infection in pregnancy through antenatal testing. Contemporary pharmacotherapy consists of a combination of three or more antiretroviral drugs, also referred to as highly-active antiretroviral therapy (HAART). For newly detected HIV-infected mothers, the Centers for Disease Control suggests the use of a zidovudine-comprising combination with one other nucleoside analogue reverse transcriptase inhibitor and a protease inhibitor (PI) [3]. As HIV in pregnancy may be asymptomatic, structured antenatal HIV-testing therefore seems to offer an attractive prevention strategy. Two broad types of approaches exist: selective or targeted testing versus universal testing. The availability of effective - but expensive - combination therapies since 1996 has greatly enhanced the importance of pharmacoeconomic assessments in the field of HIV-infection. Treatment of the mother will incur additional costs but will also make any programme more effective. Furthermore, avoiding children becoming infected with HIV will also incur monetary benefits, as children are also being treated with HAART. In summary, the background of antenatal HIV-testing has undergone major changes compared with the early 1990s. This review of the pharmacoeconomics of antenatal HIV-testing followed a systematic approach as it was performed according to prespecified criteria, allowing valid comparisons in methodologies and findings of those studies that have yet been conducted in this area.
... Still, the scientific debate about how to correctly treat future health benefits remains unresolved [18]. The debate revolves around several aspects, including the issue of time-varying discount rates to reflect time preference [19,20] or discounting models in relation to effectiveness measures [21], but the core controversy centres mainly on whether the health benefits of a given intervention should be discounted at a lower rate than the costs or at the same, uniform rate [22,23]. ...
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In the quest for public and private resources, prevention continues to face a difficult challenge in obtaining tangible public and political support. This may be partly because the economic evidence in favour of prevention is often said to be largely missing. The overall aim of this paper is to examine whether economic evidence in favour of prevention does exist, and if so, what its main characteristics, weaknesses and strengths are. We concentrate on the evidence regarding primary prevention that targets cardiovascular disease event or risk reduction. We conducted a systematic literature review of journal articles published during the period 1995-2005, based on a comprehensive key-word based search in generic and specialized electronic databases, accompanied by manual searches of expert databases. The search strategy consisted of combinations of freetext and keywords related to economic evaluation, cardiovascular diseases, and primary preventive interventions of risk assessment or modification. A total of 195 studies fulfilled all of the relevant inclusion criteria. Overall, a significant amount of relevant economic evidence in favour of prevention does exist, despite important remaining gaps. The majority of studies were cost-effectiveness-analyses, expressing benefits as "life years gained", were conducted in a US or UK setting, assessed clinical prevention, mainly drugs targeted at lowering lipid levels, and referred to subjects aged 35-64 years old with at least one risk factor. First, this review has demonstrated the obvious lack of economic evaluations of broader health promotion interventions, when compared to clinical prevention. Second, the clear role for government to engage more actively in the economic evaluation of prevention has become very obvious, namely, to fill the gap left by private industry in terms of the evaluation of broader public health interventions and regarding clinical prevention, in light of the documented relationship between study funding and reporting of favourable results. Third, the value of greater adherence to established guidelines on economic evaluation cannot be emphasised enough. Finally, there appear to be certain methodological features in the practice of economic evaluations that might bias the choice between prevention and cure in favour of the latter.
... • Further research on the, to date rarely applied, approach called time-shifted discounting approach is needed [39,57,115]. ...
... Während sich die meisten internationalen Leitlinien zur gesundheitsökonomischen Evaluation nicht mit den Besonderheiten von Impfungen auseinandersetzen, widmet sich eine Reihe von Übersichtsarbeiten und methodologischen Artikeln explizit dieser Thematik. Einige dieser Beiträge konzentrieren sich auf die Vorstellung einzelner Methoden oder die Lösung spezifischer Probleme[8, 9,85]; andere geben einen Überblick über relevante Aspekte oder formulieren (Best-Practice-)Empfehlungen[3, 4,22,25,45,48,53,63,89]. Der Großteil dieser Artikel versucht die Leser bezüglich der Besonderheiten der gesundheitsökonomischen Evaluation von Impfungen zu sensibilisieren und macht deutlich, dass die Anwendung bestimmter Standards der gesundheitsökonomischen Evaluation bei präventiven Interventionen zu einer Unterschätzung der Kosteneffektivität führen kann. Teilweise kann dieser Unterschätzung mit der Anwendung modifizierter Methoden begegnet werden. ...
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Zielsetzung: Entscheidungsträger in Europa beziehen im Rahmen des Empfehlungs- und Erstattungsprozesses von Impfungen zunehmend Studien zur Kosteneffektivität in ihre Entscheidung mit ein. Der steigende Stellenwert erfordert demzufolge eine kritische Auseinandersetzung mit den in gesundheitsökonomischen Evaluationen von Impfungen angewendeten Methoden. Methodik: Im vorliegenden Beitrag werden die Besonderheiten und Herausforderungen im Zusammenhang mit der gesundheitsökonomischen Evaluation von Impfungen zusammengefasst und anhand von Beispielen veranschaulicht. Ergebnisse: Die Besonderheiten von gesundheitsökonomischen Evaluationen von Impfungen basieren einerseits auf dem präventiven Charakter von Impfungen und andererseits darauf, dass es sich bei impfpräventablen Erkrankungen um Infektionskrankheiten handelt. Daraus resultieren besondere methodische Ansätze, wie etwa alternative Diskontierungsmethoden, die Verwendung dynamischer Modelle, um indirekte Effekte wie Herdenschutz oder Serotypen-Replacement abzubilden, sowie spezielle Evaluationsstrategien. Schlussfolgerung: Die Anwendung konventioneller Standards der gesundheitsökonomischen Evaluation bei Impfungen kann zu einer Fehleinschätzung der Kosteneffektivität führen. Dieser Fehleinschätzung kann teilweise mit der Anwendung modifizierter Methoden begegnet werden. Hinsichtlich einiger Besonderheiten besteht jedoch weiterer Forschungsbedarf.
... Constant rate discounting is supported by the discounted utility model, which states that the utility derived from consumption at a future time t is the same as the utility now multiplied by a discounting factor (1 + r) −t . However, this standard model of discounting has been challenged [4][5][6][7][8][9][10], particularly for the case of vaccines [11][12][13][14][15][16], since they have distinct characteristics not shared by many other health interventions and hence their costeffectiveness can be particularly sensitive to discounting. In light of the importance of discounting to economic evaluations of vaccines, this paper aims to survey the methodological basis and merits of alternatives to standard discounting schemes, as well as to consider how they may apply to vaccination. ...
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Discounting future costs and health benefits usually has a large effect on results of cost-effectiveness evaluations of vaccination because of delays between the initial expenditure in the programme and the health benefits from averting disease. Most guidelines currently recommend discounting both costs and health effects at a positive, constant, common rate back to a common point in time. Published economic evaluations of vaccines mostly apply these recommendations. However, both technical and normative arguments have been presented for discounting health at a different rate to consumption (differential discounting), discounting at a rate that changes over time (non-constant discounting), discounting intra-generational and inter-generational effects at a different rate (two-stage discounting), and discounting the health gains from an intervention to a different discount year from the time of intervention (delayed discounting). These considerations are particularly acute for vaccines, because their effects can occur in a different generation from the one paying for them, and because the time of vaccination, of infection aversion, and of disease aversion usually differ. Using differential, two-stage or delayed discounting in model-based cost-effectiveness evaluations of vaccination raises technical challenges, but mechanisms have been proposed to overcome them. Copyright © 2015. Published by Elsevier Ltd.
... [20 years) according to a majority of experts. • Further research on the, to date rarely applied, approach called time-shifted discounting approach is needed [39,57,115]. • Since discount rates and discount approaches usually have a major impact on results of HEE of vaccines, the variation of these aspects need to be analysed (see Sect. ...
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Background Incremental cost-effectiveness and cost-utility analyses [health economic evaluations (HEEs)] of vaccines are routinely considered in decision making on immunization in various industrialized countries. While guidelines advocating more standardization of such HEEs (mainly for curative drugs) exist, several immunization-specific aspects (e.g. indirect effects or discounting approach) are still a subject of debate within the scientific community. Objective The objective of this study was to develop a consensus framework for HEEs of vaccines to support the development of national guidelines in Europe. Methods A systematic literature review was conducted to identify prevailing issues related to HEEs of vaccines. Furthermore, European experts in the field of health economics and immunization decision making were nominated and asked to select relevant aspects for discussion. Based on this, a workshop was held with these experts. Aspects on ‘mathematical modelling’, ‘health economics’ and ‘decision making’ were debated in group-work sessions (GWS) to formulate recommendations and/or—if applicable—to state ‘pros’ and ‘contras’. Results A total of 13 different aspects were identified for modelling and HEE: model selection, time horizon of models, natural disease history, measures of vaccine-induced protection, duration of vaccine-induced protection, indirect effects apart from herd protection, target population, model calibration and validation, handling uncertainty, discounting, health-related quality of life, cost components, and perspectives. For decision making, there were four aspects regarding the purpose and the integration of HEEs of vaccines in decision making as well as the variation of parameters within uncertainty analyses and the reporting of results from HEEs. For each aspect, background information and an expert consensus were formulated. Conclusions There was consensus that when HEEs are used to prioritize healthcare funding, this should be done in a consistent way across all interventions, including vaccines. However, proper evaluation of vaccines implies using tools that are not commonly used for therapeutic drugs. Due to the complexity of and uncertainties around vaccination, transparency in the documentation of HEEs and during subsequent decision making is essential.
... This makes adequately and sufficiently capturing future benefits more important, as constant and nondifferentiated (between costs and effects) discount rates may result in a greater discounting of benefits relative to costs. Consequently, compared with acute care interventions, pediatric interventions, like other preventive interventions, may be undervalued (Bos et al. 2004;Cairns 2006). In addition, because the biology of children differs from that of adults, interventions developed for and/or tested on adults may have different impacts. ...
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This paper reports the results of a study of time preference amongst the general public in the Grampian region of Scotland. The subjects, who were selected randomly from the electoral roll, were offered a series of intertemporal choices. Their responses were used to calculate private financial time preference rates, social non-monetary time preference rates and social financial time preference rates. The paper investigates the relationship between these three measures of time preference in both the short and the long run. It also explores the effects of individual characteristics, including age, and health, on the implicit discount rates.
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Using a simple societal utility function--giving equal weight to current and future generations-it is concluded that costs need to be discounted on the basis of the expected increase in income and the marginal utility of consumption, and that effects need to be discounted on the basis of the expected increase in health and the marginal utility of health. It is derived that both rates need to be equal when assuming a kind of perfect market, where growth rates are determined by the societal utility function. It is argued that this is an extremely heroic assumption and that different discount rates may be needed. Additionally, the traditional 'inconsistency arguments' of Weinstein and Stason and of Keeler and Cretin are reconsidered. Within the context presented earlier, the first inconsistency only emerges when a growth equilibrium is assumed, reinforcing the arguments put forward before. The Keeler and Cretin paradox is reconsidered by showing that absolutely no paradox emerges when programs are not supposed to stop after a year but are supposed to continue indefinitely. The conclusion is drawn that non-believers in market mechanisms assuring an optimal social policy, need to reconsider the use of their discount rates.
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The discount rate to be applied in health care programmes should be based on the time preference rate for health, and this same rate should be applied to costs as well. Due to the limited tradeability of health, when eliciting its time preference rate, the intertemporal choices must be framed in such a way as to resemble as closely as possible those facing health planners and decision makers.
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Quality-adjusted life years (QALY) utility models are multiattribute utility models of survival duration and health quality. This paper formulates six classes of QALY utility models and axiomatizes these models under expected utility (EU) and rank-dependent utility (RDU) assumptions. The QALY models investigated in this paper include the standard linear QALY model, the power and exponential multiplicative models, and the general multiplicative model. Emphasis is placed on a preference assumption, the zero condition, that greatly simplifies the axiomatizations under EU and RDU assumptions. The RDU axiomatizations of QALY models are generally similar to their EU counterparts, but in some cases, they require modification because linearity in probability is no longer assumed, and rank dependence introduces asymmetries between the domains of better-than-death health states and worse-than-death health states. Copyright 1999 Academic Press.
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The resources available for healthcare are limited compared with demand, if not need, and all healthcare systems, regardless of their financing and organisation, employ mechanisms to ration or prioritise finite healthcare resources. This paper reviews alternative approaches that can be used to allocate healthcare resources. It discusses the problems encountered when allocating healthcare resources according to free market principles. It then proceeds to discuss the advantages and disadvantages of alternative resource allocation approaches that can be applied to public health systems. These include: (i) approaches based on the concept of meeting the needs of the population to maximising its capacity to benefit from interventions; (ii) economic approaches that identify the most efficient allocation of resources with the view of maximising health benefits or other measures of social welfare; (iii) approaches that seek to ration healthcare by age; and (iv) approaches that resolve resource allocation disputes through debate and bargaining. At present, there appears to be no consensus about the relative importance of the potentially conflicting principles that can be used to guide resource allocation decisions. It is concluded that whatever shape tomorrow's health service takes, the requirement to make equitable and efficient use of finite healthcare resources will remain.
Article
Research on sequences of outcomes shows that people care||| about features of an experience, such as improvement or deterioration over||| time, and peak and end levels, which the discounted utility model (DU) assumes||| they do not care about. In contrast to the finding that some attributes are||| weighted more than DU predicts, Kahneman and coauthors have proposed that there||| is one feature of sequences that DU predicts people should care about but that||| people in fact ignore or underweight: duration. In this article, the authors||| extend this line of research by investigating the role of conversational norms||| (H. P. Grice, 1975), and scale-norming (D. Kahneman & T. D. Miller, 1986).||| The impact of these 2 factors are examined in 4 parallel studies that||| manipulate these factors orthogonally. The major finding is that response modes||| that reduce reliance on conversational norms or standard of comparison also||| increase the attention that participants pay to duration.
Article
A search was carried out for economic evaluations of hepatitis B (HBV) vaccination, published between 1994 and 2000. The results of these studies are discussed according to the level of HBV endemicity. The great majority of these evaluations were carried out for industrialized countries, for the most part situated in areas of low to very low HBV endemicity. In countries of very low endemicity economic evaluations have yielded contradictory results, depending on the type of epidemiological model they used. The cost-effectiveness of adding universal to selective vaccination strategies in these countries depends on the selective strategies' ability to sufficiently identify, reach and fully vaccinate persons in various risk groups. In areas of low, intermediate and high endemicity, universal vaccination seems justifiable on the basis of economic evaluation. In general, the accuracy of the models has improved over the years, but still the transparency, completeness and comparability of analyses could improve considerably. By noting this, the suitability of different methodologies for different areas of endemicity and vaccination strategies is discussed. It is recommended that specific guidelines for economic evaluation of the prevention of infectious diseases be developed to guarantee the relevance of and to improve the comparability between studies. Copyright
Article
When health effects can be valued in monetary terms, as in cost-benefit analysis, they should be discounted at the same rate as costs. If health effects are measured in quantities (e.g. quality adjusted life years) as in cost-effectiveness analysis (CEA) and the value of health effects is increasing over time, discounting the volume of health effects at a lower rate than costs is a valid method of taking account of the increase in the future value of health effects. We show that the Keeler-Cretin paradox, often used as an argument against discounting health effects at a lower rate than costs, has no relevance for the choice of discount rate in CEA. We present individualistic and welfare models to argue that the rate of growth of the value of health effects is positive. The welfare model suggests that the value of health grows at a rate dependent on the rate of growth of the value of the direct effect of health on utility, the growth rate of income, the elasticity of the marginal utility of income and the extent to which individuals are insured against the income risks of ill health.
Article
Cost-utility analysis (CUA) is a technique that can potentially be used as a guide to allocating healthcare resources so as to obtain the maximum health benefits possible under a given budget constraint. However, it is not clear that current practice captures societal preferences regarding health benefits. In analyses of healthcare interventions providing survival benefits, the market rate of interest is the sole empirical variable that reflects societal preferences. This approach is based on the assumptions that: (i) healthcare interventions should be ranked using cost-effectiveness (CE) ratios; (ii) the discount rate for costs in CUA should be equal to that used in cost-benefit analysis (CBA); (iii) the discount rate in CBA should be the market rate of interest on long-term government bonds; and (iv) the Keeler-Cretin paradox is applicable to CUA of healthcare interventions, so that the discount rate for benefits in CUA should be set equal to the discount rate for costs. This approach ignores a fundamental difference between CBA and CUA, namely that CUA assumes that a budget constraint has been specified prior to the analysis. It starts with the assumption that a given amount of funds have been withdrawn from the economy to fund healthcare, so there is no opportunity cost to consider. For that reason, the principles on which the choice of discount rate rests differ in the two techniques. Furthermore, use of CE ratios to rank interventions assumes that the budget constraint can be expressed as a single constraint. But healthcare budgets are multiyear budgets that are roughly constant from year to year. A more realistic model would involve multiple constraints and would require linear programming for solution. This can be reduced to a series of single constraints, thereby allowing use of the simpler CE ratio approach, if we assume that the budget being allocated is intended for one cohort at a time, i.e. all people for whom a new funding decision must be made in a given year. In general, we assume that future cohorts will be allotted comparable funding. However, the Keeler-Cretin paradox depends on the assumption that cohorts are competing with each other for resources, and is therefore not applicable to CUA of healthcare. Other approaches are therefore needed to assign utilities to healthcare interventions providing survival benefits. Methods should be developed that allow analyses to reflect a range of philosophical approaches through sensitivity analysis.
Article
In surveys of 3,000 households, we have found that people attach less importance to saving lives in the future than to saving lives today, and less importance to saving older persons than to saving younger persons. For the median respondent, saving six people in 25 years is equivalent to saving one person today, while for a horizon of 100 years, 45 persons must be saved for every person saved today. The age of those saved also matters; however, respondents do not weight lives saved by number of life-years remaining: For the median respondent, saving one 20-year old is equivalent to saving seven 60-year olds. Copyright 1994 by Kluwer Academic Publishers
Article
This paper studies an economic model of the dynamic spread of an infectious disease, contrasting its implications in terms of the occurrence of the disease itself, as well as the effects of public health interventions, with those of mathematical epidemiology. Copyright 1996 by Economics Department of the University of Pennsylvania and the Osaka University Institute of Social and Economic Research Association.
Choice over time New York (NY): Russell Sage Publicationsonal equity: an exploration of the fair innings argument
  • G Loewenstein
Foundation of cost-effectiveness analysis for health and medical practices
  • Mc Weinstein
  • Stason