Imre Bon cz1,2 · Csa ba Dózsa3 · Zoltán Kaló4 · Lás zló Nagy5 · Bar bara Borc sek3 ·

Ágnes Brandt müller6 · József Betle hem7 · An dor Sebestyén8 · Lás zló Gulác si6 1 De part ment of Health Pol i cy, Na tion al Health In sur ance Fund Ad min is tra tion (OEP),

Bu dapest, Hun gary2 In sti tute of Di ag nos tics and Man age ment, Fac ul ty of Health Sci ences, Uni ver si ty of Pécs,

Pécs, Hun gary3 Min istry of Health, Bu dapest, Hun gary 4 No var tis, Bu dapest, Hun gary5 MSD, Bu dapest, Hun gary6 De part ment of Pub lic Pol i cy and Man age ment, Unit of Health Eco nomics

and Health Tech nol o gy As sess ment, Corv i nus Uni ver si ty Bu dapest, Hun gary7 In sti tute of Nurs ing and Clin i cal Sci ences, Fac ul ty of Health Sci ences, Uni ver si ty of Pécs,

Pécs, Hun gary8 Coun ty Baranya Health In sur ance Fund Ad min is tra tion, Pécs, Hun gary

De vel op ment of health eco nomics in Hun gary be tween 1990–2006

Ab stract

The aim of this pa per is to give an over-

view on the de vel op ment, cur rent sta tus

and fu ture chal lenges of health eco nomics

in Hun gary. We iden ti fied the ma jor chal-

lenges dur ing the de vel op ment of health

eco nomics in Hun gary. The great est chal-

lenge that health eco nomics faced in the

ear ly and mid-1990s was the lack of well-

qual i fied pro fes sion als be cause in Cen tral

and East ern Eu ro pean coun tries there had

not been any rel e vant train ings be fore. It

was the next ma jor chal lenge for the Hun-

gar i an health care fi nanc ing sys tem to in-

te grate the re sults from health eco nomics

stud ies into the de ci sion mak ing pro cess-

es of pub lic ad min is tra tion, through the

de vel op ment of the le gal frame work and

in sti tu tion al i sa tion health eco nomics.

Hope ful ly, the de vel op ment of health eco-

nomics in Hun gary over the last 15 years

will con tin ue, which is great ly stim u lat-

ed by host ing the 6th Eu ro pean Con fer-

ence on Health Eco nomics in Bu dapest

in 2006.

Key words

Health eco nomics · Health care

fi nanc ing · Health in sur ance ·

Health ser vices re search · Hun gary

With ref er ence to the 6th Eu ro pean Con-

fer ence on Health Eco nomics we would

like to take the op por tu ni ty to in form you

of the de vel op ment, cur rent sta tus and

fu ture chal lenges of health eco nomics in

Hun gary.

1. Her itage of so cial ism and look ing for the right way

Af ter World War II, for mer so cial ist coun-

tries in Cen tral and East ern Eu rope (CEE)

adopt ed the Se mashko health care mod el

and fol lowed it un til the po lit i cal chang es

in 1990. Sim i lar ly to oth er fields, the so cial-

ist health care sys tem lacked cost sen si tiv-

i ty and health eco nom ic con sid er a tions

were of lit tle im por tance in de ci sion mak-

ing pro cess es.

Fol low ing the po lit i cal chang es, just

like sev er al CEE coun tries, Hun gary re-

turned to the Bis mar ck ian sol i dar i ty-ba-

sed so cial se cu ri ty sys tem [1]. Re form ing

the health care sys tem the pur chas er-pro-

vider split has been in tro duced. In Hun-

gary the Na tion al Health In sur ance Fund

Ad min is tra tion (Orszá gos Egészség biz-

tosítási Pénztár, OEP), the or ga ni sa tion

soli tar i ly re spon si ble for health care fi nanc-

ing was es tab lished in 1993.

The great est chal lenge that health

eco nomics faced in the ear ly and mid-

1990s was the lack of well-qual i fied pro-

fes sion als be cause in CEE coun tries the-

re had not been any rel e vant train ings be-

fore. Dur ing the de vel op ment of a corps

of pro fes sion als in the ’90s, in an anal o-

gous man ner to the way that wan der ing

Mag yars con duct ed raids in West Eu rope

from the Carpathi an ba sin, sev er al young

re searchers were at tend ing rep utable uni-

ver si ties of West Eu rope and North Amer-

i ca ob tain ing the M.Sc. de gree in health

eco nomics and re lat ed fields (health ser-

vices re search, health tech nol o gy as sess-

Eur J Health Econom 2006 · [Suppl 1] 7:4–6

DOI 10.1007/s10198-006-0364-z

© Springer Medizin Verlag 2005

S4 | Eur J Health Econom Suppl 1 · 2006

ment, health care man age ment). Stu dents

learn ing abroad were pro vid ed grants and

schol ar ships by the Hun gar i an gov ern-

ments, in ter na tion al or gan i sa tions, e.g.

the World Bank, foun da tions, e.g. Soros

Foun da tion, the British Coun cil as well as

for eign uni ver si ties.

By the mil len ni um these ef forts blos-

somed into a corps of high ly-trained Hun-

gar i an ex perts with in ter na tion al ly ac-

knowl edged qual i fi ca tion and ex pe ri ence.

It was a painful les son of this pro cess that

many young col leagues failed to re turn to

Hun gary and took a job abroad. Fur ther-

more, most of those who re turned have

been em ployed in the pri vate sec tor and

not in the pub lic sec tor.

2. In sti tu tion al de vel op ment in high er ed u ca tion of health eco nomics

In Hun gary uni ver si ty ed u ca tion was

launched in 1367, when King Louise the

Great found ed the first uni ver si ty of the

coun try in Pécs upon the con sent of Pope

Ur ban V. In spite of the aca dem ic de vel op-

ment over cen turies there re mained sev er-

al gaps in the train ing of sev er al mod ern

spe cial i ties. Be sides in sti tu tions of tra di-

tion al med i cal ed u ca tion those of pub lic

health train ing and health care man age-

ment train ing were mis sing. In or der to

plug these gaps the Health Ser vices Man-

age ment Train ing Cen tre of the Sem mel-

weis Uni ver si ty and the School of Pub-

lic Health of the Uni ver si ty of De bre cen

were found ed in the mid 1990s with the

spon sor ship of the World Bank [2]. Both

schools spe cialise in post grad u ate stud ies

lead ing to the M.Sc. de gree.

In 1997, a four year B.Sc. pro gramme

was ini ti at ed in health in sur ance at the Uni-

ver si ty of Pécs aimed to train spe cial ists

for health in sur ance ad min is tra tion and fi-

nanc ing. Over the re cent years fa cil i ties for

launch ing the M.Sc pro gramme have also

been cre at ed.

At Corv i nus Uni ver si ty of Bu dapest,

De part ment of Pub lic Pol i cy and Man age-

ment the aca dem ic pro gramme of health

eco nomics start ed in 1997. As part of the

de part ment the Unit of Health Eco nomics

and Health Tech nol o gy As sess ment was

formed in 2001 cur rent ly made up by 6 re-

searchers and teach ers. (http://hecon.uni-

corv i nus.hu). Fourth and fifth year stu-

dents study 4 sub jects in the health ca-

re block: Health Pol i cy and Fi nanc ing,

Health Eco nomics, Health Tech nol o gy

As sess ment and Qual i ty Im prove ment in

Health Care. The PhD cours es in health

eco nomics and health tech nol o gy as sess-

ment are at tend ed by 11 PhD stu dents

from Corv i nus Uni ver si ty, Sem mel weis

Uni ver si ty and oth er uni ver si ties.

The Unit of Health Eco nomics and

Health Tech nol o gy As sess ment has been

the mem ber of IN AH TA (In ter na tion al

Net work of Agen cies in Health Tech nol o-

gy As sess ment) since 2001 un der the na-

me Hun HTA.

3. The pro fes sion al as so ci a tion of health economists in Hun gary

The Hun gar i an Health Eco nomics As so-

ci a tion (Mag yar Egészség-gaz daság tani

Tár saság, META) was found ed in 2003

and has a cur rent mem ber ship of ca. 100.

It holds month ly as sem blies on a reg u lar

ba sis where pre sen ta tions are made on dif-

fer ent ar eas of health eco nomics fol lowed

by dis cus sions.

4. The im pact of health eco nomics on de ci sion mak ing in pub lic ad min is tra tion

It was a ma jor chal lenge for the Hun gar i an

health care fi nanc ing sys tem to in te grate

the re sults of health eco nomics into the de-

ci sion mak ing pro cess es of pub lic ad min is-

tra tion [3]. In 2002, the Min istry of Health

re leased guide lines for con duct ing health

eco nom ic anal y ses [4]. These guide lines

de ter mine the method olog i cal is sues of

health eco nom ic eval u a tions.

In 2004, the Na tion al In sti tute for

Strate gic Health Re search (Egészségü gyi

Straté giai Ku tatóin tézet, ESKI) was es tab-

lished, which as sists with de ci sion mak ing

in four ma jor ar eas of health pol i cy and

fi nanc ing: med i cal in for mat ics and in for-

ma tion pol i cy, health eco nomics, health

ser vices re search and health tech nol o gy

as sess ment. As a re sult of this de vel op-

ment Hun gary has moved to wards in tro-

duc ing the ‘Fourth Hur dle’ for phar ma ceu-

Table 1 Major scientific meetings in Hungary in the field of health economics

Date Topic Pre sen ter Or ga ni sa tion

2002.09.09. Cov er age pol i cy is sues Da vid Ban ta TNO, Lei den, Nether lands

2002.10.08. Health eco nomics guide lines Mike Drum mond Uni ver si ty of York, UK

2003.03.31. Eco nomics in pub lic health Niek Klazin ga Uni ver si ty of Ams ter dam, Nether lands

2003.09.29. Re source al lo ca tion Frans Rut ten Eras mus Uni ver si ty Rot ter dam,

Nether lands

2003.11.21. Man aged care Tom Get zen Tem ple Uni ver si ty, Philadel phia, USA

2004.04.21. Fis cal de cen tral iza tion Guillem López-Casas no vas Uni ver si ty Pom peu Fab ra, Cat alo nia, Spain

2005.09.24 The EU RON HEED data-base Liv io Garat ti ni Mario Ne gri In sti tute, Mi lan, Italy

2005.02.02 A dis cus sion on the re forms of in sti tu tion al

mech a nism for health in East Eu rope

János Ko r nai Har vard Uni ver si ty, Col legium Bu dapest,

Cen tral Eu ro pean Uni ver si ty

2005.04.25 Cost ing guide line Mark Koop man schap Eras mus Uni ver si ty Rot ter dam, iMTA,

The Nether lands

2006.03.20 Cov er age pol i cy in the NHS and in Hun gary Ron Ake hurst School of Health and Re lat ed Re search,

The Uni ver si ty of Sheffield, UK

Eur J Health Econom Suppl 1 · 2006 | S5

ti cals. This de vel op ment is well sup port ed

by the Act No. CLIV of 1997 on Health,

which clear ly states among the ba sic prin-

ci ples (Ti tle 2. para graph 2 point 5) that

health care ser vices have to be ev i dence

based and cost-ef fec tive.

On May 1, 2004, Hun gary joined the

Eu ro pean Union, hence it was nec es sary

to adopt the EU Trans paren cy Di rec tive.

Due to the in tro duc tion of the Trans paren-

cy Di rec tive de ci sions on pric ing and re-

im burse ment of drugs are made in ac cor-

dance with the reg u la tions and prac tice

of the EU [5]. Ac com pa ny ing the Na tion-

al Health In sur ance Fund Ad min is tra tion

(OEP), the Tech nol o gy Ap praisal Com mit-

tee (Tech noló gia Értékelő Bi zottság, TÉB)

has been set up to pre pare de ci sions on re-

im burse ment ap pli ca tions.

The ap pli ca tion of health eco nom ic re-

sults for de ci sion mak ing in pub lic ad min-

is tra tion trig gered an en hanced in ter na-

tion al co op er a tion over the re cent years.

OEP in co op er a tion with Corv i nus Uni ver-

si ty or gan ised nu mer ous con fer ences and

sym posia with the par tic i pa tion of in ter na-

tion al ly rep utable au thor i ties. The events

fea tured pre sen ters and top ics as fol lows

(. Table 1).

We here by thank our col leagues list ed

above for their co op er a tion and con tri bu-

tion to the de vel op ment of Hun gar i an

health eco nomics.

5. Cur rent chal lenges and fu ture op tions

Re cent ly health eco nomics top ics list ed

be low were of the high est pri or i ty in Hun-

gary: drug re im burse ment and health ca-

re fi nanc ing [6, 7,8], in for mal pay ment [9,

10, 11, 12], qual i ty as sur ance in health ca-

re [13, 14, 15, 16], health tech nol o gy as sess-

ment [17], re nal re place ment [18, 19, 20],

na tion wide or ga nized breast, co lo rec tal

and cer vi cal screen ing pro grammes [21,

22, 23], qual i ty of life [24, 25], hip frac tures

[26, 27, 28], health ser vices re search [29, 30,

31, 32].

Cur rent chal lenges in Hun gary are

sim i lar to those of in ter na tion al prac tice.

Health eco nomics is ca pa ble of pro vid ing

con sid er able help with re source al lo ca tion

de ci sions where by fi nanc ing de ci sions can

be based upon sci en tif ic re sults. This is es-

pe cial ly im por tant in coun tries of eco nom-

ic en vi ron ment sim i lar to that in Hun gary

where the lack of re sources im pos es se ri-

ous hur dles for ra tio nal de ci sion mak ing.

Hope ful ly, the de vel op ment of health eco-

nomics in Hun gary over the last 15 years

will con tin ue, which is great ly stim u lat ed

by host ing ECHE 2006.

Cor re spond ing au thorImre Bon cz

Na tion al Health In sur ance Fund Ad min is tra tion (OEP)1139 Bu dapest, Váci út 73/A. Hun garyE-mail: bon cz.i@oep.hu

Ref er ences

1. Deppe HU, Oreskovic S (2006) Back to Eu rope:

Back to Bis marck? Int J Health Serv 26(4):777-802

2. Bon cz I (2005) An overview of the Hun gar i an

health care. Hos pi tal 7(3):41-42

3. Gu lac si L, Bon cz I, Drum mond M (2004) Is sues for

coun tries con sid er ing in tro duc ing the “fourth hur-

dle”: The case of Hun gary. Int J Tech nol As sess

Health Care 20:337-341

4. Szende A, Mo gy orosy Z, Muszbek N, et al. (2002)

Method olog i cal guide lines for con duct ing eco-

nom ic eval u a tion of health care in ter ven tions in

Hun gary: a Hun gar i an pro pos al for meth o dol o gy

stan dards. Eur J Health Econom 3:196-202

5. Dozsa C, Borc sek B, Bon cz I, et al. (2005) Ex pe ri-

ences of Adop tion of the Di rec tive 89/105/EEC

of the Coun cil of the Eu ro pean Com mu ni ties on

Trans paren cy in Hun gary. Ital ian Jour nal of Pub lic

Health 3(S1):139

6. Gu lac si L, Da vid T, Dozsa C (2002) Pric ing and re im-

burse ment of drugs and med i cal de vices in Hun-

gary. Eur J Health Econom 3(4):271-278

7. Bon cz I, Nagy J, Sebestyen A, Ko rosi L (2004) Fi-

nanc ing of health care ser vices in Hun gary. Eur J

Health Econom 5(3):252-258

8. Szende A, Mo gy orosy Z. (2004) Health care provi-

der pay ment mech a nisms in the new EU mem bers

of Cen tral Eu rope and the Baltic states. Cur rent re-

forms, in cen tives, and chal lenges. Eur J Health Eco-

nom 5(3):259-62

9. Gaal P, Bel li PC, Mc Kee M, Szoc s ka M (2006) In for-

mal pay ments for health care: def i ni tions, dis tinc-

tions, and dilem mas. J Health Polit Pol i cy Law

31(2):251-93

10. Gaal P, Eve tovits T, Mc Kee M (2006) In for mal pay-

ment for health care: Ev i dence from Hun gary.

Health Pol i cy 77(1):86-102

11. Gaal P, Mc Kee M (2005) Fee-for-ser vice or do na-

tion? Hun gar i an per spec tives on in for mal pay-

ment for health care. Soc Sci Med 60(7):1445-57

12. Szende A, Cu ly er AJ (2006) The in equity of in for-

mal pay ments for health care: the case of Hun gary.

Health Pol i cy 75(3):262-71

13. Gu lac si L (2001) Hun gar i an health care in tran si-

tion; Stud ies on the im prove ment of the ef fec tive-

ness of health care in Hun gary by im ple ment ing

qual i ty as sur ance. Uni ver si ty of Ams ter dam.

14. Ban ta D, Gu lac si L (2001) The need for cost-ef-

fec tive qual i ty im prove ment in ter ven tions. Eu ro-

health 6(5):27-28.

15. Gu lac si L, Ko vacs A, Janes ki J (1994) Qual i ty As-

sur ance in Hun gar i an Hos pi tals: A New Fo cus for

Man age ment De vel op ment. J Health Adm Educ

12(4):551-559

16. Gu lac si L (1999) Mo ti vat ed for im prove ment. Int J

Qual Health Care 11(2):174-176

17. Gu lac si L (2001) Health tech nol o gy as sess ment in

Cen tral and East ern Eu rope. Eu ro health 7(1)3-5

18. Kalo Z, Jaray J, Nagy J (2001) Eco nom ic eval u a tion

of kid ney trans plan ta tion ver sus he mo di al y sis in

pa tients with end-stage re nal dis ease in Hun gary.

Prog Trans plant 11(3):188-93

19. Kalo Z (2003) Eco nom ic as pects of re nal trans plan-

ta tion. Trans plant Proc 35(3):1223-6

20. Mo gy orosy Z, Muc si I, Ro si vall L (2003) Re nal re-

place ment ther a py in Hun gary: the decade of tran-

si tion. Nephrol Dial Trans plant 18:1066–1071.

21. Bon cz I (2006) Pre ven tion of cer vi cal can cer in low-

re source set tings. JAMA 295(11):1248.

22. Bon cz I, Sebestyén A, Döbrőssy L, Ottó S (2006)

The role of im mu no chem i cal test ing for co lo rec tal

can cer. Lan cet On col 7(5):363-364.

23. Bon cz I, Sebestyen A, Hof fer G et al. (2006) Cost

im pli ca tions of the first year of the Hun gar i an na-

tion wide breast can cer screen ing pro gramme. EJC

Suppl 4(2):56-57

24. Lo vas K, Kalo Z, McKen na SP, Whal ley D, Pen tek M,

Gen ti G (2003) Es tab lish ing a stan dard for pa tient-

com plet ed in stru ment adap ta tions in East ern Eu-

rope: ex pe ri ence with the Not ting ham Health Pro-

file in Hun gary. Health Pol i cy 63(1):49-61

25. Szende A, Lei dy NK, Re vic ki D (2005) Health-re lat-

ed qual i ty of life and oth er pa tient-re port ed out-

comes in the Eu ro pean cen tral ized drug reg u la to ry

pro cess: a re view of guid ance doc u ments and per-

formed au tho riza tions of me dic i nal prod ucts 1995

to 2003. Val ue Health 8(5):534-48

26. Sebestyen A, Bon cz I, Da vid T, Toth F, Nyarady J

(2005) To tal in sur ance cost of treat ment of hip frac-

tures ac cord ing to the load sta bil i ty of dif fer ent sur-

gi cal meth ods. Val ue in Health 8(6): A219

27. Sebestyen A, Bon cz I, Borz sei L, Nyarady J (2005)

DRG-based cost anal y sis of fe mur neck frac tures in

pa tients with and with out com pli ca tions us ing the

Hun gar i an HBCs sys tem. Eur Surg Res 37(S1):18

28. Sebestyen A, Bon cz I, Dozsa C, Toth F, Nyarady J

(2004) Anal y sis of fe mur neck frac ture in Hun gary

from pro fes sion al, pub lic health and health eco-

nomics point of view. Eur J Trau ma 30(S1):174

29. Szoc s ka MK, Rethe lyi JM, Nor mand C (2005) Man-

ag ing health care re form in Hun gary: chal lenges

and op por tu ni ties. BMJ 331(7510):231-3

30. Gu lac si L, Bon cz I, Ko vacs A (2004) The im pacts of

the EU en large ment on the Hun gar i an Health care

sys tem. Ti jd schrift voor Gezond hei dsweten schap-

pen 82(5):281-284

31. Bon cz I, Sebestyen A (2006) Com pen sa tion for vac-

cine in ju ry in Hun gary. Lan cet 367(9517):1144

32. Borc sek B, Bon cz I, Dozsa C, Nagy J, Resze gi C

(2005) A. The Sys tem at ic lit er a ture re view of the

gam ma knife. Ital ian Jour nal of Pub lic Health

3(S1):178

S6 | Eur J Health Econom Suppl 1 · 2006

Oral presentations

0161

Cost-eff ec tive of screen ing for co lo rec tal can cerAas E. (Uni ver si ty of Oslo, Nor way)

In many Eu ro pean coun tries screen ing for co lo rec tal can cer is in tro-duced with out a prop er ev i dence of cost-ef fec tive ness. In this pa per we pres ent a cost-ef fec tive ness anal y sis of screen ing for co lo rec tal can cer with two unique fea tures: A com pre hen sive dataset is col lect ed from a Nor we gian ran dom ized tri al of screen ing with sig moi dos co py, and un cer tain ty is ex plic it ly mod elled as a Par tial ly Ob served Markov De ci-sion Pro cess. Four ques tions are ex am ined:What is the im pact on cost of screen ing of in clud ing avoid ed treat ment costs and pro duc tion gains?What is the cost of screen ing per life year gained?What is the mar gin al cost per life year gained of in clud ing a fae cal oc cult blood test (FOBT)?What is the cost per life year gained ac cord ing to Dukes’ stag es?Data at the lev el of each in di vid u al in clude in for ma tion about tri al costs, use of health care ser vices, labour mar ket par tic i pa tion, trav el ex pens-es, in ci dences of can cer with stage de scrip tion, time of death and so cio-eco nom ic vari ables as in come, ed u ca tion, age, and gen der. The ro bust-ness of the re sults is test ed with prob a bilis tic sen si tiv i ty anal y ses. Pre lim-i nary re sults show that the cost per life year gained from sig moi dos co py is favourable com pared with oth er pre ven tive health mea sures, while an ad di tion al FOBT is not.

0355

Chal lenges of Es to ni an health sys tem due to mo bil i ty of health pro fes sion alsAaviksoo A. (PRAX IS Cen tre for Pol i cy Stud ies Pol i cy Pro gramme, Es to nia, Tallinn)Votilderk A., Kallaste E., Jesse M.

Cur rent pa per de scribes chal lenges and pol i cy re spons es that mo bil-i ty of health pro fes sion als has posed on Es to nia, a new EU mem ber. Our anal y sis is based on sev er al sur veys of health pro fes sion als and our own stud ies con duct ed be tween 2003 and 2005.years have wit nessed in creased em i gra tion of Es to ni an doc tors, res i dents and nurs es to Scan-di na vian coun tries, which is main ly driv en by very large wage dif fer en-tials and ex pec ta tions for bet ter work ing con di tions abroad. An ac tive re cruit ment by re cip i ent coun tries has played a very im por tant role in fa cil i tat ing em i gra tion.of Es to ni an health pro fes sion als is al ready hav-ing a sig nif i cant im pact on Es to ni an health sys tem, caus ing short age of nurs es and doc tors in some fields.pol i cy re ac tion of Es to ni an gov ern-ment to these prob lems has been to in crease salaries of health pro fes sion-als by 30-40% in 2005. On the oth er side of the pol i cy mea sures are lon-ger wait ing lists for health ser vices, and high er gov ern ment fund ing for ed u ca tion of health pro fes sion als. In the pa per we dis cuss whether these pol i cy mea sures have had sub stan tial im pact on the chal lenges of Es to ni-an health sys tem and what might be the fu ture op tions.

0061Ex plor ing State De pen dent Re port ing Bias in Self-As sessed Health in a Sub-Sa ha ran Pop u la tion Abe gunde D. (World Health Or ga ni za tion, Gen e va, Switzer land,)Lam bo E.S., Akande T.M.

A num ber of stud ies, main ly from de vel oped coun tries, have il lus trat-ed the chal lenges in cross-pop u la tion com pa ra bil i ty of re spons es to Self As sessed Health (SAH) ques tions across in di vid u als who dif fer in terms of so cio-eco nom ic, de mo graph ic, cul tur al fac tors and health ex pe-ri ence. This is be cause of re sponse het ero ge ne ity, which re sults from re sponse cat e go ry shift or “true” health ef fects. A chal lenge is iso lat ing the “true” health ef fects from re port ing be hav iour, par tic u lar ly in a mul-ti cul tur al pop u la tion with de vel op ing coun try de mo graph ics. Us ing house hold health sur vey data from Nige ria, a typ i cal Sub-Sa ha ran coun-try, we ex plored state de pen dent re port ing bias across in di vid u als’; cul-tur al back grounds, house hold wealth, lev el of ed u ca tion, age and gen-der, and com pared the re sults with sim i lar stud ies from de vel oped coun-tries. By con di tion ing the SAH re sponse on ob serv able health vari able (mor bid i ty ex pe ri ence) and oth er in di vid u al char ac ter is tics, our re sults showed that re port ing het ero ge ne ity was more preva lent in our data com pared to stud ies from de vel oped coun tries. We found ev i dence for in dex and thresh old shift for cul tur al groups, house hold wealth, ed u ca-tion, age and gen der. Dis tinc tive ly, re port ing het ero ge ne ity was dem on-stra ted even across house hold wealth and ed u ca tion al lev el in our data un like in stud ies from de vel oped coun tries. We con clude that in di vid u-al char ac ter is tics in flu ence re port ing be hav iour dif fer ent ly in our data. The find ings have im pli ca tions for sam ple size in fu ture stud ies. To com-pare SAH re spons es across sub groups, re sponse be hav iour should first be con trolled for and re sults of stud ies us ing SAH should be cau tious ly in ter pret ed for oth er coun tries, par tic u lar ly in sub-Sa ha ran Africa.

0579

Test ing the Pre dic tive Va lid i ty of TTO and SGAbel lan J.M. (De part ment of Eco nomics, Eras mus Uni ver si ty, Rot ter dam, The Nether lands)Ble ichrodt H.

A well-known prob lem in health util i ty mea sure ment is that the main meth ods yield sys tem at i cal ly dif fer ent re sults. Ble ichrodt & Jo han nes-son (1997) found ev i dence that among the main meth ods, the time trade-off is most con sis tent with in di vid u al pref er ences. Their meth-od used only rank ing data, how ev er, and was en tire ly framed in terms of cer tain ty. Be sides, in re cent year ad vances in the SG have been pro-posed that have im proved the de scrip tive ac cu ra cy of SG mea sure ments. In par tic u lar, al low ing that peo ple be have ac cord ing to prospect the o-ry, cur rent ly the main de scrip tive the o ry of de ci sion un der risk, has re moved many in con sis ten cies in SG mea sure ment. This pa per pre sents a new com par i son be tween TTO and SG mea sure ments both un der cer-tain ty and un der risk and both based on rank ing and based on choice data. We find that when all health out comes are cer tain the TTO still out per forms the SG. For risky health out comes, how ev er, the SG per-forms bet ter than the TTO, es pe cial ly when we cor rect the SG for the de vi a tions from ex pect ed util i ty that are mod elled by prospect the o ry. This pat tern holds both for rank ing and for choice data.

0549

The Val ue of Hu man Life in Hun garyAdor ján R. (Min istry of Fi nance, Bu dapest, Hun gary)

The main ob jec tive of my work was to de ter mine the val ue of sta tis ti cal hu man life in Hun gary. For this eval u a tion I used a con sen su al meth-od of the so called labour mar ket ap proach. I car ried out ten dif fer ent re gres sion mod el spec i fi ca tions on a sam ple of 1287 el e ments that rep-

Eur J Health Econom 2006 · [Suppl 1] 7:7–104

DOI 10.1007/s10198-006-0368-8

© Springer Medizin Verlag 2005

Eur J Health Econom Suppl 1 · 2006 | S7

0083

De ter min ing the at tributes of in for mal careAl-Jan abi H. (Uni ver si ty of Bris tol, Bris tol, Unit ed King dom)Coast J., Fly nn T.

Health economists could make more use of the qual i ta tive re search that al ready ex ists in health care to aid ex per i men tal de sign for stat ed pref er-ence dis crete choice mod elling. Meta-eth nog ra phy is a tech nique to syn-the sise qual i ta tive re search, and bears sim i lar i ties to quan ti ta tive meta-anal y sis. Meta-eth nog ra phy was ap plied to cre ate at tributes for in for mal care. First, a lit er a ture search was con duct ed for qual i ta tive re search on in for mal care. Sec ond, the stud ies iden ti fied were pur po sive ly re duced to a man age able list for syn the sis. Third, the find ings of the stud ies were anal y sed, con trast ed and fi nal ly com bined. Through this pro cess themes were de vel oped to ex plain the ex pe ri ence of in for mal care. From these over ar ch ing themes a list of in for mal care at tributes will be pre-sent ed. These at tributes will cov er re ciproc i ty, bur den, respite, ac tiv i ty and con trol. Meta-eth nog ra phy has sev er al ad van tages over oth er qual i-ta tive meth ods of cre at ing at tributes. It can be used to de vel op an un der-stand ing of a top ic be yond that of a stan dard lit er a ture re view, but it can also be quick er and more com pre hen sive than con duct ing pri ma ry re search to ob tain at tributes.

0167

In come-re lat ed in equal i ty in phy si cian ser vice use among old er peo ple in 10 Eu ro pean coun triesAllin S. (Lon don School of Eco nomics Health and So cial Care, Lon don, UK)Masse ria C.

Us ing a unique, com pre hen sive dataset across 10 Eu ro pean coun tries, Sur vey on Health Age ing and Re tire ment in Eu rope (SHARE), this study mea sures the lev el of in come-re lat ed in equal i ty in phy si cian (GP and spe cial ist) ser vice use among those over age 60. The prob a bil i ty of a vis it to the GP and spe cial ist (in the past 12 months) was pre dict ed us ing mul ti var i ate lo gis tic re gres sion mod els. In come-re lat ed hor i zon-tal in equity in dices were cal cu lat ed ac cord ing to the in di rect stan dard-iza tion ap proach. Over all, in all ten coun tries in ves ti gat ed, the prob a-bil i ty of GP vis it ap pears large ly eq ui table while spe cial ist ser vice use ap pears pro-rich. Only in the Nether lands and Swe den is there ev i dence of a pro-rich in equity in the prob a bil i ty of a GP vis it. Af ter ad just ing for dif fer ences in need across the in come dis tri bu tion, the dis tri bu tion of spe cial ist care favours the high in come groups in eight out of ten coun-tries. The im por tance of fi nan cial bar ri ers to ac cess (e.g. user charges) and more com pre hen sive mea sure ments of wealth are dis cussed.

0213

Es ti mat ing smok ing ces sa tion re lapse rates for pol i cy eval u a tionAmaya-Amaya M. (Health eco nomics re search unit of ap plied health sci ences uni ver si ty of Ab erdeen, UK)Goode A., Lud brook A.

With in the UK gov ern ment’s To bac co Con trol pol i cy, smok ing ces sa tion in ter ven tions have been dem on stra ted to be ef fec tive and cost-ef fec tive at the in di vid u al lev el. How ev er, for the pur pos es of pol i cy eval u a tion, what is re quired is an es ti mate of the ex pect ed ef fec tive ness, at a pop u la-tion lev el, of dif fer ent com po nents of the strat e gy. The im pact of smok-ing ces sa tion ser vices on prev a lence de pends not only on the lev els of ac tiv i ty and short term quit rates but also on un der stand ing how many of these quit ters will re turn to smok ing. Es ti mates pro duced for a re view of the ef fec tive ness and cost-ef fec tive ness of smok ing ces sa tion in ter ven-tions are based on a life time re lapse rate of 40%, with a range of 30% -50%. This pa per ex plores the use of the British House hold Pan el Sur vey

re sent ed the full-time em ployed adult pop u la tion. Dif fer ent forms of in come as the de pen dent vari able and var i ous bun dles of ex plana to ry vari ables were used. In come was sig nif i cant ly in flu enced in a pos i tive di rec tion by ed u ca tion lev el, gen der, whether white col lar work er or not, res i dence (in Bu dapest or coun try side towns), age, the size of the com-pa ny, in de pen dence, and num ber of chil dren. The na tion al i ty of the com pa ny had a neg a tive ef fect. The best mod els pro duced the range HUF 78-393 mil lion (in year 1998) for the most prob a ble in ter val of the val ue of a sta tis ti cal hu man life, with HUF 250 mil lion be ing the most prob a ble val ue. This re sult can el e men ta ry con tribute to pub lic pol i cy de ci sions about a state in vest ment or ac tion, where risk of loos-ing or gain ing hu man life is ex ist ing and com par i son be tween the costs and the ben e fits is need ed. How ev er, in this as pect Hun gary has lot to do in the near fu ture.

0261

Health ex pen di ture un der de mo graph ic un cer tain tyAhn N. (FEDEA, Madrid, Spain,)

Pre vi ous pro jec tions of health ex pen di ture have been usu al ly car ried out by com bin ing con stant age-sex spe cif ic health ex pen di ture with de ter-min is tic pop u la tion pro jec tion. How ev er, it has been shown that pop u-la tion size and struc ture in the fu ture is high ly un cer tain and most pro-jec tions turned out wrong. We im prove upon the ex ist ing lit er a ture by in cor po rat ing un cer tain ties in pop u la tion pro jec tion. Ac cord ing to the me di an pro jec tion, na tion al health ex pen di ture will in crease by 2 to 5 per cent age points as a share of GDP dur ing the pe ri od 2004-2050. How-ev er, de mo graph ic un cer tain ty will en tail sub stan tial un cer tain ties in the fu ture health ex pen di ture. By 80% con fi dence in ter val, health ex pen-di ture in 2050 as the share of GDP will range from 9.5 to 12% in Bel-gium, from 9 to 15% in Fin land, from 11.2 to 13.1% in Ger many, from 11.2 to 12.5% in The Nether lands, and from 6.4 to 7% in Spain. This pro-jec tion as sumes con stant real age-spe cif ic per-cap i ta health ex pen di ture. On the oth er hand, some pro jec tions car ried out un der even a slight ly high er growth rate of per-cap i ta health ex pen di ture rel a tive to that of per-cap i ta GDP would in crease sub stan tial ly the share of health ex pen-di ture in GDP in the me di um and long term.

0375

Ad verse Se lec tion and op ti mal health in sur ance con tractsAlary D. (Uni ver sité Par is Dauphine, Par is, France)Bien F.

This pa per in ves ti gates the im pact of ad verse se lec tion on health in sur-ance con tracts. We use a bi-di men sion al util i ty func tion (wealth and health sta tus) to take into ac count the link be tween health sta tus loss and the in dem ni ty. Health sta tus loss can in crease or de crease mar gin al util i ty of wealth and then mod i fy op ti mal con tracts. We show that when over-in sur ance is not for bid den by in sti tu tion al con straint, first best in dem-ni ties are larg er than pe cu niary loss if the mar gin al util i ty of wealth is de creas ing in health oth er wise the in dem ni ty is low er than the pe cu niary loss es. The first part of this re sult pro vides an ex pla na tion for dis abil i ty pen sion in health in sur ance con tracts. The in tu ition is that ill ness re duce health sta tus and then in creas es (de creas es) the mar gin al util i ty of wealth in the bad state of na ture when mar gin al util i ty is de creas ing (in creas ing) in health. Next, we give suf fi cient con di tions such that first best con tracts are op ti mal with asym met ric in for ma tion. In deed high risks pre fer high-er (resp. low er) in dem ni ty than low risks when mar gin al util i ty of wealth is de creas ing in health (resp. in creas ing).

S8 | Eur J Health Econom Suppl 1 · 2006

(BHPS) data to in ves ti gate the de ter mi nants of smok ing ces sa tion path-ways and tra jec to ries. The du ra tion up to a re lapse af ter quit ting is rep-re sent ed with sev er al mod els for the haz ard func tion, in clud ing para-met ric and semi-para met ric spec i fi ca tions. Non-para met ric anal y sis is also car ried out. Sta tis ti cal tests are used to choose the best spec i fi ca tion. Ul ti mate ly this re search should pro duce more ro bust es ti mates for the UK of the long-term re lapse rates for those who quit smok ing

0165

Cog ni tive Abil i ty and Scale Bias in the Con tin gent Val u a tion Meth odAn der s son H. (Swedish Na tion al Road & Trans port Re search In sti tute, Sol na, Swe den)Svens son M.

In this study we in ves ti gate whether or not the scale bias found in con-tin gent val u a tion (CVM) stud ies on mor tal i ty risk re duc tions is a re sult of cog ni tive con straints among re spon dents. Scale bias refers to a re jec-tion of near-pro por tion al i ty be tween the re spon dents’ will ing ness to pay (WTP) for a risk re duc tion and the size of the risk re duc tion, a nec-es sary (but not suf fi cient) con di tion for the es ti mates to be con sid ered valid mea sures of the mar gin al WTP. This study is the first, to our best knowl edge, which in ves ti gates the re la tion ship be tween cog ni tive abil-i ty and near-pro por tion al i ty be tween WTP and the mag ni tude of risk re duc tions. In the study 200 Swedish stu dents par tic i pat ed in an ex per i-ment where their cog ni tive abil i ty was test ed be fore they took part in a CVM-study where they were asked about their WTP to re duce bus-mor-tal i ty risk. In or der to avoid an chor ing ef fects the open-end ed CVM for-mat is used. The re sults im ply that that the de vi a tion from pro por tion al-i ty is less among those re spon dents with high er cog ni tive abil i ty.

0256

The mis sion is re mis sion – health eco nom ic con se quences of achiev ing re mis sion in an ti de pres sant treat ment of de pres sion An dlin-Soboc ki P. (Stock holm Health Eco nomics, Stock holm, Swe den)Ek man M., Jöns son B.

Ob jec tives. There has been an in creased ar gu men ta tion over the past decade sug gest ing full re mis sion to be the pri ma ry goal of the ini tial phase of ther a py. There are how ev er few stud ies in ves ti gat ing the health eco nom ic con se quences of at tain ing re mis sion in phar ma co log i cal treat-ment of de pres sion in clin i cal prac tice. The aim of this study was to de ter mine what ex plains re mis sion in de pressed pa tients in Swedish pri-ma ry care and to in ves ti gate its im pact on cost and health-re lat ed qual i-ty-of-life.. The study was de signed as a nat u ral is tic lon gi tu di nal sur vey of pa tients with de pres sion in pri ma ry care set ting. Data on pa tients’ so cio-de mo graph ics, dai ly ac tiv i ty, health care re source use, qual i ty-of-life (EQ-5D) were col lect ed us ing ques tion naires com plet ed dur ing out pa tient GP vis it for a fol low-up pe ri od of ap prox i mate ly 6 months. Pa tient re cruit ment and data col lec tion were per formed at about 65 pri-ma ry care cen tres in Swe den and 447 pa tients were en rolled. Dis ease sever i ty was as sessed with the Clin i cal Glob al Im pres sion Sever i ty scale (CGI-S). Cox re gres sion anal y sis was used to an a lyse what fac tors in flu-ence the time to achieve re mis sion.. 53% of the pa tients achieved re mis-sion at end of fol low-up. Re mit ting pa tients had on av er age 7 out pa tient care vis its less per year than non-re mit ting pa tients (p<0.0001), and sub-stan tial ly few er sick-leave days 56 days per year (p=0.029). Re mit ting pa tients had a sig nif i cant ly low er to tal year ly cost of SEK 50 000, com-pared to non-re mit ting pa tients. The health-re lat ed qual i ty-of-life was 0.24 high er in re mit ting pa tients (p<0.0001). Severe ly de pressed pa tients had a 70% low er chance of achiev ing re mis sion quick ly than pa tients with milder cas es of de pres sion (p<0.0001).. Re mis sion has a sub stan tial health eco nom ic im pact and we have shown both sta tis ti cal ly sig nif i cant

re duc tions in cost as well as im proved qual i ty-of-life. This study has con-vinc ing ev i dence for the im por tance of aim ing for full re mis sion in the treat ment of de pres sion, and hence in di cat ing that an tide pres sants that rapid ly lead to re mis sion may be cost ef fec tive.words

0257

Re source-use and costs as so ci at ed with de pres sive pa tients in the pri ma ry care An dlin-Soboc ki P. (Stock holm Health Eco nomics, Stock holm, Swe den)Ek man M., Jöns son B.

Back ground. Ac cord ing to the WHO, de pres sion is the fourth lead ing cause of dis abil i ty world wide, which makes it im por tant to pro vide ef fec tive treat ment against the dis ease. De spite the clin i cal and eco nom-ic im por tance of de pres sion, re source uti li za tion and cost in clin i cal prac tice is not well doc u ment ed. The aim of this study was to in ves ti-gate med i cal re source con sump tion, pro duc tiv i ty loss and costs as so ci-at ed with pa tients treat ed with an tide pres sants for de pres sion in pri ma-ry care. 65 Swedish pri ma ry care prac ti tion ers re cruit ed 447 pa tients to this nat u ral is tic lon gi tu di nal ob ser va tion al study. Pa tients over 18 years with de pres sive symp toms, and who ini ti at ed a new an ti de pres-sant ther a py were in clud ed in the study. Data on pa tients’ so cio-de mo-graph ics, dai ly ac tiv i ty and qual i ty-of-life (EQ-5D) were col lect ed us ing ques tion naires com plet ed dur ing out pa tient GP vis it for a fol low-up pe ri od of ap prox i mate ly 6 months. Dis ease sever i ty was as sessed with the Clin i cal Glob al Im pres sion of Sever i ty (CGI-S). Re gres sion anal y-sis was used in or der to in ves ti gate the de ter mi nants of cost in de pres-sion.. Based on a com plete sam ple of 398 pa tients, the to tal an nu al cost per pa tient was es ti mat ed at SEK 102 000 (SEK 92 000-113 000) in 2005 prices. Di rect costs were es ti mat ed at SEK 36 000, con sti tut ing 35% of the to tal an nu al cost per pa tient. Among di rect costs, the cost for med-i cal vis its was the largest sin gle cost item, rep re sent ing about 18%. The costs for an tide pres sants rep re sent ed only 4% of the to tal costs. The in di-rect costs, i.e. pro duc tiv i ty loss due to lost work ing time, were es ti mat-ed at SEK 67 000 per pa tient (SEK 57 000-76 000), or 65% of the to tal an nu al costs per pa tient. No de mo graph ic vari ables were sig nif i cant ly as so ci at ed with cost of de pres sion. Di rect and in di rect costs were how-ev er cor re lat ed pos i tive ly with achieve ment of clin i cal re mis sion. The pres ence of sick-leave dur ing fol low-up was more over as so ci at ed with 82% high er costs. The bur den of de pres sion to so ci ety is high, both in terms of di rect treat ments costs and in di rect costs for sick ness ab sence and ear ly re tire ment. Be cause of the high in di rect cost per pa tient, there seems to be a par tic u lar need for ther a pies that have the po ten tial to re duce ab sen teeism and ear ly re tire ment. words de pres sion, pri ma ry care, cost, cost-of-ill ness.

0087

Un re solved is sues and chal lenges in effi cien cy mea sure mentAn drew S. (Cen tre for Health Eco nomics, York, Unit ed King dom)

Sto chas tic fron tier anal y sis (SFA) and data en vel op ment anal y sis (DEA) have be come pop u lar tech niques for mea sur ing or gan i sa tion al ef fi cien-cy. Some key is sues re quire fur ther con sid er a tion be fore these tech-niques are fit for the pur pos es of reg u la tion. State ments about rel a tive or gan i sa tion al ef fi cien cy can not be made un less the or gan i sa tions be ing com pared pur sue a com mon set of ob jec tives to which a uni form set of weights is at tached. The ap pro pri ate ness of the an a lyt i cal mod el can-not be eval u at ed us ing stan dard test ing pro ce dures, be cause the aim of ef fi cien cy anal y sis is to ex tract in di vid u al rather than av er age ef fects. The eval u a tive task is more de mand ing the more com plex the pro duc-tion pro cess and the more het er og e nous the en vi ron men tal con straints each or ga ni sa tion faces. The his tor i cal con text in which or gan i sa tions are lo cat ed can rarely be ful ly ap pre ci at ed by the an a lyst, and this lack

Eur J Health Econom Suppl 1 · 2006 | S9

of knowl edge places con straints on mod el con struc tion and in ter pre ta-tion. Fur ther de vel op ment is re quired be fore ei ther SFA or and DEA are able to meet these chal lenges. An al ter na tive ap proach is il lus trat-ed that al lows anal y sis of or gan i sa tions that pur sue mul ti ple ob jec tives, of fers greater flex i bil i ty in mod el con struc tion, and is ame na ble to stan-dard sta tis ti cal test ing.

0596

Ex pen di ture con trol un der DRG-based fi nanc ing in the En glish NHSAn drew S. (Cen tre for Health Eco nomics, York, Unit ed King dom)

Glob al ex pen di ture con trol has be come a ma jor chal lenge in the En glish NHS fol low ing the in tro duc tion of DRG-based fund ing (so-called Pay-ment by Re sults, PbR). Pri ma ry Care Trusts (PCTs) – who are re spon-si ble for the com mis sion ing of care on be half of their res i dent pop u la-tions – face in creased fi nan cial risk for two rea sons. First, un der PbR they are un able to ne go ti ate low er prices, hav ing to pay the set na tion-al prices. Sec ond, they have less con trol over vol ume, be cause pa tients have greater choice about where and when they are treat ed. This makes it dif fi cult to spec i fy vol umes in ad vance with their con trac tu al part ners. We ex plore the abil i ty of PCTs to man age de mand so as to en sure that their bud get al lo ca tions are not ex ceed ed. We ex am ine the in stru ments avail able to PCTs to in flu ence the de ci sions of (1) gen er al prac ti tion ers who in flu ence the lev el of de mand by virtue of their treat ment and re fer-ral de ci sions; and (2) providers, par tic u lar ly hos pi tal con sul tants, who in flu ence the ex tent to which de mand is con vert ed into ac tiv i ty by their ad mis sion and treat ment de ci sions. We con clude that these in stru ments are in suf fi cient ly pow ered to man age ex pen di ture, and that re fine ment of the pay ment sys tem is re quired.

0367

Price Reg u la tion and Com pe ti tion in Jap a nese Phar ma ceu ti cal Mar ket-A Case of Anti-in fec tiveAne gawa T. (Keio Uni ver si ty, Grad u ate School of Busi ness Ad min is tra tion, Yoko hama, Japan)

This pa per stud ies Jap a nese phar ma ceu ti cal price reg u la tion us ing data on pop u lar anti-in fec tive prod ucts be tween 1990 and 2002. The gov-ern ment reg u lates the of fi cial price of prod ucts for the Na tion al Health In sur ance re im burse ment, while it leaves the whole sale price to mar-ket com pe ti tion. To eval u ate the pol i cy, this study fo cus es on the role of “price dif fer ence ra tio” and the ef fects of prod uct pro files in clud ing “dose form”, “prod uct age”, “strength”, “pack age vol ume”. Prod ucts with high er strength, high er vol ume pack age, and co-pro mot ed prod uct are found to have high er. One per cent in crease in the raised de mand by 3 per cent in our sam ple, which ef fect has be come even larg er late ly. This is due to the fact that phar ma ceu ti cal sup pli ers tend to low er the whole-sale price of the “high er strength” and “larg er vol ume pack age” of “cap-sule & tab let” prod ucts. Al though the gov ern ment ap plies the uni form pric ing rule to all prod ucts, pric ing of the whole sale price and de mand for prod ucts vary with prod uct pro files. Sup pli ers can in crease de mand by low er ing the whole sale prices of prod ucts of the cap sule and tab let form, larg er pack age, and/or high er strength. The reg u la tors are ad vised to take the prod ucts pro files into con sid er a tion to im ple ment price reg-u la tion.

0211

De mand man age ment when con sumers are not ex pect ed util i ty max i miz ersAnia A. B. (Uni ver si ty of Vi en na of Eco nomics, Vi en na, Aus tria)

De mand man age ment is the stan dard way to al le vi ate the moral haz-ard prob lem in her ent to health in sur ance mar kets. Con sumers’; use of health ser vices is dis ci plined through de ductibles and co-pay ments. This is done un der the as sump tion that con sumers ful fill the ax ioms un der ly ing ex pect ed util i ty the o ry. Ex ten sive ex per i men tal lit er a ture sug gests that con sumers tend to over weight un like ly and to un der es-ti mate like ly events. More over, their at ti tudes to wards risk de pend on whether the out come in volves gains or loss es. This be hav ior does not con form to stan dard ex pect ed util i ty the o ry. Al ter na tives that would ex plain those anoma lies have been pro posed by rank-de pen dent util i-ty and prospect the o ry. In the pres ent pa per we re view in sur ance be hav-ior and the con se quences of de mand man age ment when con sumers are af fect ed by be hav ioral anoma lies of the type de scribed above. We show that (1) due to prob a bil i ty dis tor tion alone, even risk averse con sumers may leave like ly con tin gen cies unin sured, in de pen dent of how big the loss is; (2) op ti mistic con sumers, who tend to un der es ti mate the prob a-bil i ty of se vere ill ness, will buy more in sur ance for mild than for se vere ill ness es; and (3) for op ti mistic con sumers, the prob lem of moral haz ard is al le vi at ed, i.e. they may in deed pre fer par tial to full in sur ance.

0343

Am bu la to ry au tol o gous trans plantLe Cor roller So ri ano AG. (IN SERM, Mar seille, France)Fauch er C., Maran inchi D., Blaise D. and Moat ti JP.

We pres ent the first ran dom is ed study com par ing out pa tient ver sus stan-dard hos pi tal i sa tion fol low up af ter au tol o gous pe riph er al blood stem cell trans plan ta tion for can cer pa tients. End point of the study was the to tal num ber of days spent in hos pi tal (vis its in out pa tient clin ic + hos-pi tal iza tion) dur ing the study pe ri od (from graft up to day60). Qual i-ty of life (QLQ-C30), anx i ety (Spiel berg er’s State-Trait Anx i ety), symp-toms, sat is fac tion with the treat ment (spe cif ic) and cost min i miza tion (in clud ing in di rect costs) were mea sured. 131 pa tients have been ran-dom ized (66 out pa tient & 65 stan dard). Out pa tient pa tients spent few er days in hos pi tal. 26 of them were not dis charged at day 0 for non-med-i cal rea sons (no care giv er or re fusal) and 10 pa tients for med i cal rea-sons. Only 30 pa tients were dis charged at day 0. Qual i ty of life re sults were in fa vor of con ven tion al hos pi tal iza tion for phys i cal ca pac i ty, pain and fa tigue (P=0.05). We con clud ed that out pa tient au to graft is fea si-ble in a rou tine prac tice from the med i cal and hos pi tal points of view. It ap peared not de sir able for the pa tient’s point of view. The anx i ety /sat is fac tion eval u a tion (cur rent ly on go ing) will com plete this as ser tion. The eco nom ic anal y sis will de ter mine the pu ta tive ben e fit of the am bu-la to ry de sign from sev er al points of view (pa tients, health care sys tem and col lec tiv i ty).

0364

What Med i cal Con di tions Most ly Drive Hos pi tal Costs in Can a da Be tween 1998-1999 and 2003-2004?Ariste R. (Cana di an In sti tute for Health In for ma tion (CIHI), Ot tawa, On tario, Can a da)Glus sich A., Panait D.

New med i cal tech nolo gies could drive both com po nents of spend ing, which are price and quan ti ty. There are some con di tions re lat ed to med-i cal treat ments known to un der go sub stan tial tech no log i cal chang es. We as sume that hos pi tal spend ing for such con di tions grow faster than spend ing for con di tions with less in no va tive treat ments. We would like

S10 | Eur J Health Econom Suppl 1 · 2006

to know whether em pir i cal ev i dence sup ports this hy poth e sis. Ob jec-tive of this study is to cal cu late the growth in hos pi tal spend ing by cat e-go ry of di ag no sis and to de ter mine which com po nent of costs is main ly re spon si ble for driv ing hos pi tal costs. Start by es ti mat ing the lev el and change in nom i nal hos pi tal spend ing for the fis cal years 1998 and 2003 for twen ty of the ICD-10-CA chap ters (broad cat e gories) and about six-ty cat e gories of di ag no sis. We use a bot tom-up ap proach, mean ing the cost of a giv en con di tion is es ti mat ed with mi cro-lev el data. The cost data are ob tained from the data bases of Cana di an provinces with ma jor cost ing ini tia tives un der way. Ad just ments for co-mor bidi ties were made us ing re gres sion anal y sis. Num ber of cas es is ob tained from the Hos pi tal Dis charge Ab stract Database. Av er age spend ing is es ti mat ed as the prod uct of av er age cost by the num ber of cas es. We then de com-pose spend ing growth into price growth and quan ti ty growth. Pre lim i-nary re sults sug gest that for spe cif ic con di tions, ris ing num ber of cas es, rather than ris ing cost per case, was main ly re spon si ble for the spend ing growth; which is in line with some in ter na tion al stud ies.

0040

Risk Equal i sa tion and Com pe ti tion in Vol un tary Health In sur ance Mar ketsArm strong J. (Vol un tary Health In sur ance Board, Dub lin, Ire land)

Com mu ni ty rat ing has long been a cor ner stone of the Irish pri vate health in sur ance mar ket. In 1996, fol low ing un der the Third Non-Life In sur ance Di rec tive, a risk equal i sa tion sys tem was in tro duced in gov ern-ment reg u la tion. Its aim is to pre vent cream skim ming and thus pro tect the com mu ni ty rat ing sys tem that op er ates while still en abling a com-pet i tive health in sur ance mar ket.num ber of mod i fi ca tions to the 1996 scheme have been made. How ev er, ef fec tive ly the same ba sis for equal i-sa tion op er ates now as orig i nal ly. This is dif fer ent than the ba sis for the mech a nisms that op er ate in oth er coun tries such as Bel gium, Ger many, Is rael, the Nether lands and Switzer land. How ev er, no trans fer have, of yet, been made be tween in sur ers and the cen tral fund due to both le gal and im ple men ta tion is sues.first pur pose of this study is to re view the his to ry, struc ture and like ly ef fec tive ness of the risk equal i sa tion sys-tem in Ire land. The sec ond ob jec tive is to con sid er, first, the like ly con-se quences for the com pet i tive health in sur ance mar ket of the ab sence of trans fers and, sec ond, the con se quences should trans fers com mence. It will con clude that, with this ab sence, there is clear ev i dence that mar-ket out comes con sis tent with cream-skim ming have arisen and that this has led to high er pre mi ums for some in sured per sons than would oth-er wise have been re quired. Fur ther more, it will con clude that eco nom i-cal ly ef fec tive com pe ti tion can only oc cur in the Irish health in sur ance mar ket with risk equal i sa tion.

0212

Com mu ni ty Rat ing in Com pet i tive Health In sur ance Mar ketsArm strong J. (Vol un tary Health In sur ance Board, Dub lin, Ire land)

Com mu ni ty rat ing is in creas ing ly used as a tool to en sure that health in sur ance is af ford able to ev ery one re gard less to their risk pro file. How-ev er, it is a term that is not al ways eas i ly un der stood by pol i cy mak ers in the con text of a com pet i tive health in sur ance mar ket with mul ti ple ben e fit pack ages. In this ar ti cle it is ar gued that there are, in fact, many dif fer ent meth ods that could be used to de ter mine the ap pro pri ate com-mu ni ty rat ed pre mi um in such mar kets. Each meth od leads to dif fer-ences in re spect of pre mi um flex i bil i ty, eq ui ty and mar ket sta bil i ty. Fur-ther more, the fea si bil i ty of in tro duc ing com mu ni ty rat ing in mar kets where risk rat ing al ready ap plies is re viewed. Fi nal ly, the reg u la to ry el e-ments that are nec es sary un der the var i ous forms of com mu ni ty rat ing are ex am ined. Of par tic u lar rel e vance will be risk equal i sa tion and the dif fer ent ap proach es that could be used un der each form of com mu ni ty

rat ing will be con sid ered.pa per will build on ex ist ing work in this area. Cost data is used from an in sur er op er at ing in the Irish health in sur-ance mar ket to de ter mine the ap pro pri ate com mu ni ty rat ed pre mi um lev els that should be charged un der the pos si ble al ter nate com mu ni ty rat ing def i ni tions. It shows that us ing the same data hav ing the al ter-nate def i ni tions may have a con sid er able ef fect of the cost of the con tri-bu tions for a con tribut ing en ti ty – be it the State or mem ber. This can lead to a sig nif i cant op por tu ni ty cost for the con trib u tor.is con clud ed that while there are many dif fer ent meth ods of ap ply ing com mu ni ty rat-ing each one has dif fer ent con se quences is terms of eq ui ty and ef fi cien-cy in clud ing, in par tic u lar, min imis ing the risk of ad verse se lec tion.rat-ing is in creas ing ly used as a tool to en sure that health in sur ance is af ford-able to ev ery one re gard less to their risk pro file. How ev er, it is a term that is not al ways eas i ly un der stood by pol i cy mak ers in the con text of a com-pet i tive health in sur ance mar ket with mul ti ple ben e fit pack ages. In this ar ti cle it is ar gued that there are, in fact, many dif fer ent meth ods that could be used to de ter mine the ap pro pri ate com mu ni ty rat ed pre mi um in such mar kets. Each meth od leads to dif fer ences in re spect of pre mi-um flex i bil i ty, eq ui ty and mar ket sta bil i ty. Fur ther more, the fea si bil i ty of in tro duc ing com mu ni ty rat ing in mar kets where risk rat ing al ready ap plies is re viewed. Fi nal ly, the reg u la to ry el e ments that are nec es sary un der the var i ous forms of com mu ni ty rat ing are ex am ined. Of par tic u-lar rel e vance will be risk equal i sa tion and the dif fer ent ap proach es that could be used un der each form of com mu ni ty rat ing will be con sid ered.pa per will build on ex ist ing work in this area. Cost data is used from an in sur er op er at ing in the Irish health in sur ance mar ket to de ter mine the ap pro pri ate com mu ni ty rat ed pre mi um lev els that should be charged un der the pos si ble al ter nate com mu ni ty rat ing def i ni tions. It shows that us ing the same data hav ing the al ter nate def i ni tions may have a con sid-er able ef fect of the cost of the con tri bu tions for a con tribut ing en ti ty – be it the State or not. This can lead to a sig nif i cant op por tu ni ty cost for the con trib u tor. It is con clud ed that while there are many dif fer ent meth-ods of ap ply ing com mu ni ty rat ing each one has dif fer ent con se quences is terms of eq ui ty and ef fi cien cy in clud ing, in par tic u lar, min imis ing the risk of ad verse se lec tion.

0476

Are the old wealthy health i er?Ask ild sen J. E. (De part ment of Eco nomics, Uni ver si ty of Bergen, Nor way)Gras dal A.

Usu al ly in equal i ties in health sta tus are as so ci at ed with in come and oth-er so cio eco nom ic vari ables. For el der ly peo ple, in par tic u lar re tired re ceiv ing pen sions, in come dis per sion is like ly to be much less than for younger co horts. On the oth er hand, wealth sta tus may vary more among se niors. It is not ob vi ous whether dif fer ences in wealth are caused by health con di tion, or whether wealthy peo ple are in a bet ter po si tion to main tain good health. In this pa per we ex plore the as so ci a-tions be tween wealth of old er peo ple com pared to younger peo ple, and their self re port ed health sta tus, us ing 6 waves of the Nor we gian Stan-dard of Liv ing Sur vey (SLS). Data from SLS are matched with data from the in come and wealth reg is ters at Sta tis tics Nor way, pro vid ing in for-ma tion on in come, trans fers in clud ing pen sions, and fi nan cial as sets for all in di vid u als in the sur vey. We use a fixed ef fect mod el to es ti mate the ef fect of lagged health on net fi nan cial as sets of three age groups, 25–45, 46–67 and 68+.

Eur J Health Econom Suppl 1 · 2006 | S11

0166

The cost-eff ec tive ness of tele med i cine for pre-clin i cal traffi c ac ci dent emer gen cy res cueAu er bach H. (In sti tute of Pa thol o gy, Ber lin, Ger many)Schreyögg J.

Ob jec tive: Since the Eu ro pean Com mis sion set a goal of re duc ing the num ber of road ac ci dent deaths across the EU by 2010 to one half, the use of tele med i cine for pre-clin i cal traf fic ac ci dent emer gen cy res cue is very high on the agen da. This study as sess es the cost-ef fec tive ness of two equip ment ver sions of a telemed i cal de vice for pre-clin i cal traf fic ac ci dent emer gen cy res cues in Ger many com pared at base line as sump-tions. Meth ods: Cost-ef fec tive ness anal y sis with multi-way sen si tiv i ty-anal y-sis is per formed from a so ci etal per spec tive. Costs re sult ing from per-son al in ju ry, wast ed jour neys and er ro neous dis patch ing of res cue ser-vices are based on data from the Ger man Fed er al High way Re search In sti tute. The ef fects (life years gained) are based on prob a bil i ties for re duc ing ther a py-free in ter vals and im prove ments in first-aid pro vid-ed by layper sons de rived from two lo gis tic re gres sion mod els, based on data from the GI DAS database. Re sults: The cost-ef fec tive ness ra tio of the ver sion “Au to mat ic Ac ci dent Alert” (€ 247,977 per life year gained) would be slight ly high er than of the full equip ment ver sion (€ 239,524 per life year gained). De creas ing costs of de vices would dis pro por tion ate ly re duce to tal costs and rapid mar ket pen e tra tion would large ly in crease the cost-ef fec tive ness ra tio of both de vices.Con clu sion: The net costs per life year gained in the ap pli ca tion of the two ver sions of the telemed i cal de vice are very high. The im ple men ta-tion of the de vices seems only re al is tic as part of a larg er Eu ro pean co-or di nat ed ini tia tive.

0323

The eff ects of ref er ence pric ing on ex-fac to ry prices of Rx drugs in Ger man so cial health in sur ance: A pan el data ap proachAu gurzky B. (RWI Es sen, Ger many)Göhlmann, Greß, Wasem

This pa per ex am ines ef fects of ref er ence pric ing for pre scrip tion drugs in Ger man so cial health in sur ance based on econo met ric pan el data meth ods. We an a lyse the ef fect on ex-fac to ry prices and on mar ket en tries as well as ex its. More over, we in ves ti gate whether man u fac tur-ers adapt prices of their prod ucts not sub ject to ref er ence pric ing as a con se quence of chang es in ref er ence prices of their prod ucts sub ject to ref er ence pric ing. We use a large pan el data set of near ly all Ger man pre-scrip tion drugs on a month ly ba sis be tween Jan uary 2002 and July 2005. Al to geth er, the data com prise more than 1.5 mil lion ob ser va tions. They pro vide in for ma tion on ex-fac to ry prices, ref er ence prices, man u fac tur-ers, mar ket shares of the prod ucts, type of pre scrip tion drug, and mar-ket en tries and ex its. Our re sults show that there is no full price ad just-ment A 1%-change in ref er ence prices leads to a 0.2%-change in mar ket prices. Price ad just ment is fast, it only takes two months. Fur ther more, the first in tro duc tion of a ref er ence price re duces mar ket prices of the af fect ed prod ucts by ap prox i mate ly 6%. Fi nal ly, we ob serve a sig nif i cant time ef fect which is pos i tive in the mar ket with out ref er ence prices and neg a tive in that with ref er ence prices.

0303

Crit i cal re view of the eco nom ic eval u a tion stud ies in Ko reaBae EY. (Health In sur ance Re view Agen cy, Seoul, Ko rea/south/)

Ob jec tives: This study aims to re view the eco nom ic eval u a tion stud ies un der tak en in Ko rea ac cord ing to draft guide lines of Health In sur ance Re view Agen cy (HIRA), Ko rea Meth ods: All data bases re lat ed to health ser vice re search in Ko rea were searched, and any CEA or CUA stud ies pub lished by Septem ber 1. 2004 were screened. As a re sult, 34 stud ies were fi nal ly iden ti fied and re viewed. Re sults: Most of stud ies re viewed com plied HIRA guide lines in gen er-al, but some points need to be ad dressed to as sure the qual i ty of in for ma-tion. First, many stud ies were based on the data sources of weak ev i dence like case se ries stud ies. Some stud ies (8 out of 34) es ti mat ed the ef fect from the meta-anal y sis of pub lished stud ies, but none of them used the lo cal ly col lect ed clin i cal data. Un cer tain ty also was not con sid ered suf fi-cient ly. 16 out of 34 stud ies did not con duct sen si tiv i ty anal y sis, and most re searchers did not pay at ten tion to the un cer tain ty of qual i ty weight. Con clu sions: Eco nom ic eval u a tion stud ies un der tak en in Ko rea have not aimed to be used in de ci sion-mak ing pro cess un til now, which seems to be the rea son why many stud ies have not pre sent ed enough in for ma tion need ed in re im burse ment de ci sion. HIRA guide lines are ex pect ed to im prove the qual i ty of eco nom ic eval u a tion stud ies.

0587

The Im pact of Pay roll Tax es for Fund ing Health Care in New EU Mem ber States Baeza C. (World Bank)Lan gen brun ner J.

Most new mem ber states rely upon high pay roll tax es of 10-18 per cent for fund ing health ser vices. At the same time, coun tries face dou ble dig it un em ploy ment and sig nif i cant in for mal economies. The pa per looks at im pacts of this la bor tax on health rev enues and the econ o my as a whole, and con sid ers oth er op tions for fund ing of health care ser vices. Three coun tries are uti lized as case stud ies: Hun gary, Poland, and Slo vakia.

0346

NICE ways of mak ing health care de ci sionsBak er R. (Uni ver si ty of New cas tle upon Tyne, UK)Don ald son C., Shack ley P., Rob in son A., Smith R., Ma son H.

Na tion al In sti tute for Health and Clin i cal Ex cel lence (NICE) is sue guid-ance for the rest of the Na tion al Health Ser vice in Eng land and Wales about the pri or i ty to be giv en to new, and ex ist ing, health tech nolo gies. To date the fo cus of NICE eco nom ic eval u a tions has been cal cu la tion of the cost per qual i ty ad just ed life year (QALY) pro duced by health in ter-ven tions. How ev er, there may be con sid er a tions oth er than just max-imis ing the num ber of QALYs that the pub lic val ue and, fur ther, these may dif fer from the con sid er a tions of health pol i cy mak ers. This study there fore elicit ed the views of a sam ple of the gen er al pub lic and a sam-ple of pol i cy mak ers faced with mak ing pri ori ti sa tion de ci sions, us ing Q meth o dol o gy. This meth o dol o gy com bines qual i ta tive and quan ti ta tive tech niques to in ves ti gate sub jec tive opin ion. A set of state ments ex press-ing views about pri or i ty set ting was gen er at ed us ing fo cus groups. Mem-bers of the gen er al pub lic and health ser vice pol i cy mak ers then com plet-ed ‘card sorts’ (known as ‘Q sorts’) of these state ments, rank ing them from ‘most agree’ to ‘most dis agree’. A form of fac tor anal y sis is used to iden ti fy com mon and dif fer en ti at ing pat terns in re spon dents’ Q sorts. This pa per re ports the find ings of this anal y sis and the im pli ca tions for health care pri or i ty set ting.

S12 | Eur J Health Econom Suppl 1 · 2006

0011

In for mal Pay ment in Hun gary Health Care Sys temBalázs P. (De part ment of Pub lic Health, Sem mel weis Uni ver si ty, Bu dapest, Hun gary)

Hun gary has a state run manda to ry so cial se cu ri ty sys tem with uni ver sal cov er age for the health care ex pens es. In come lev els of doc tors con tract-ed to the so cial health in sur ance are tra di tion al ly very low com pared to oth er pro fes sions in this coun try, or re lat ed to the propor tions of cor re-spond ing in come groups in the de vel oped in dus tri al coun tries. Nine out of ten pri ma ry care doc tors are now in the pri vate sec tor, but the own-er ship does not play any im por tant role, for prac ti cal ly all ser vices, let alone the den tal ones, are re im bursed by the sin gle pub lic fund of so cial health in sur ance. In the spe cialised care pub lic in sti tu tions with salaried doc tors re pres ent an over whelm ing ma jor i ty of the out pa tient and in pa-tient sec tor. pri vate fi nanc ing paid most ly in cash and with out any pri-vate in sur ance cov er age came about in den tist ry and cos met ic sur gery. Spe cial com fort ser vices in hos pi tals may be or dered also by the pa tients on so cial health in sur ance. But, some ser vices, typ i cal ly the home vis its of fam i ly doc tors, are cov ered only on the provider’s de ci sion jus ti fied by the se vere ill state of the pa tient. Be sides the le gal ized wait ing lists, there are short ages in supply and work force bring ing about the in vis i ble wait-ing lists reg is tered only in the pock ets of pub lic em ploy ee doc tors, who re pres ent their so-called own pa tients in the pub lic hos pi tals. Choos ing the doc tor with all sub se quent wish es must be paid for, but these are legal-ly non-ex ist ing ser vices in the pub lic fa cil i ties.the four decades of so cial-ist econ o my, in or der to mask this pri vate busi ness (services men tioned above in clu sive the op tion al home vis its) Hun gary de vel oped an ex cep-tion al sys tem. The pa tients were only thank ful for a ser vice be yond all le gal def i ni tions and paid “thanks giv ing” mon ey to the doc tor. On this ter mi nol o gy, the rit u al flair of trans ac tion is and was the ide o log i cal back-bone to jus ti fy this in come since the mid dle of the 20th century. the fall of Com mu nism, the prob lem and its ter mi nol o gy re mained with us in Hungary. But, there is no need any more for in for mal bar gain ing and metaphoric lan guage between the gov ern ment and the med i cal pro fes-sion. The real mar ket econ o my does not tol erate an un reg u lat ed mix-up of pub lic and pri vate fi nanc ing. Solv ing this prob lem, Hun gary must find the ap pro pri ate mea sures to con vert the pri vate pur chas ing pow er trapped now in the “thanks giv ing” ide ol o gy with out do ing any harm to the pub lic in ter ests of the health care sys tem.

0067

Den tists’ mi gra tion in the Eu ro pean Union and eco nom ic area (part 2) Hun gar i an den tist’s pat terns of mi gra tionBalázs P. (Sem mel weis Uni ver si ty, Bu dapest, Hun gary)

With in the glob al mi gra tion of physi cians, in ter nal mi gra tion in the Eu ro pean Union and Eco nom ic Area (EU/EEA) is a spe cif ic prob lem. In this de vel oped part of the world, rela-tive ly small dif fer ences may gen-er ate con sid er able re gion al shifts in both the num bers and pro fes sion al train ing of the health care work force. More over, the lat est EU-en large-ment in May 2004 opened the doors to a one-way mi gra tion of physi-cians out of the for mer so-called so cial ist Cen tral and East ern Eu ro-pean (CEE) coun tries. In the Czech Re pub lic, Es to nia, Hun gary, Latvia, Lithua nia, Poland, Slo vakia, and Slove nia, there are many fac tors in flu-enc ing the move ment of work force to ward the old mem ber states. So cio-eco nom i cal ly, it has been due to a sig nif i cant ly low er lev el of do mes tic in come. For so cio-cul tur al rea-sons, the ma jor i ty of doc tors from the CEE ap pear to have sought em ploy ment in the UK or in the Ger man-speak ing coun tries. Un for tu nate ly, for the time be ing there are no sci-en-tif ic and sta tis ti cal ly ver i fi able, com plex eval u a tions at EU/EEA-lev-el of this mi gra tion. Ob tain ing ad e quate in for ma tion re quires a spe cif-ic meth o dol o gy and in ter ac tive data bas es.or der to pro pose a fea si ble fu ture mod el, the au thors have re strict ed their anal y sis to den tists, a rel a-

tive ly small group of the health care com mu ni ty. More over, in den tist ry, as op posed to the main ly pub licly fi nanced oth er branch es of health ser-vice, there is a con sid-er able con tri bu tion from pri vate fi nanc ing. This fact may en hance the so cio-eco nom ic driv ing forces be hind pro fes sion-al mi gra tion. The pres ent Hun gar i an study, and its U.K. coun ter part, are the first to shed light on den tal mi gra tion at na tion al and EU/EEAlevels. In 2004, Hun gary had 10,2 mil lion in hab i tants and 5670 den tists, of whom 2487 worked in the pub lic fi nanced pri ma ry den tal care. The re main ing 2738 (in clud ed uni ver si ty staff mem-bers who run pri vate prac tices) worked in the pri vate sec tor. Pro por tion of im mi grant den-tists was found to be rel a tive ly high (7,81%). came main ly from large Hun gar i an eth nic mi nori ties in two neigh bour ing coun tries (Ru ma nia and Ukraine). Based on pro fes sion al reg is tra tion, the au thors anal y sed mi gra tion, in land mi gra tional at ti tudes of do mes tic provider and re-mi gra tion of im mi grants. Be cause of a lack of re li able data, the loss of do mes tic den tists’ to the work force was cal cu lat ed on a co hort-anal y sis of den tists who grad u at ed from 1970 to 2005. The re sult ing data show, that there has been a rel a tive ly low in ter na tion al em mi gra tion by Hun-gar i an den tists. In ter nal mi gra tion of den tists has also been very low. Its driv ing fac tor ap pears to have been a con-sider able de mand for pri-vate den tal care in the West ern part of the coun try.au thors con clude that in fu ture in or der to mon i tor the mi gra tion of health care work ers (and sub se quent ly plan ro fes sion al train ing and ser vice ca pac i ties with-in the EU/EEA) it will be nec es sary to es tab lish a com pat i ble na tion al and EU-wide sys tem of reg is tra tion and no ti fi ca tion. The den tal work-force would be an ide al group in which to pi lot this sys tem.

0410

Ex pect ed lon gev i ty and smok ing in ItalyBalia S. (Uni ver si ty of York, UK)

This pa per in ves ti gates lon gev i ty, health, smok ing be hav iour and so cio-eco nom ic char ac ter is tics among the el der ly us ing Ital ian data from the ear ly (2004) re lease of the Sur vey of Health, Age ing and Re tire ment in Eu rope (SHARE). In di vid u al life time util i ty is max i mized at some op ti-mal de mand for health, where fu ture util i ty and hence the de ci sion-mak ing pro cess de pend upon the prob a bil i ty of sur vival. Health sta tus and the risk of mor tal i ty are af fect ed by lifestyle and health in vest ment de ci sions such as smok ing, and sub jec tive mea sures of life ex pect an-cy have been shown to be pow er ful pre dic tors of ac tu al mor tal i ty. The SHARE data pro vides a nu mer i cal mea sure for this, which is in ter nal-ly con sis tent and ap pro pri ate ly co vary ing with risk fac tors and oth er so cio-eco nom ic vari ables. We use sub jec tive sur vival prob a bil i ty as a proxy for mor tal i ty in a struc tur al equa tions mod el, where the sur vival prob a bil i ty is ex plained by past in di vid u al char ac ter is tics, health sta tus, health-re lat ed be haviours and un ob serv able char ac ter is tics. This mo ti-vates a re cur sive mod el for sub jec tive mor tal i ty, self-as sessed health and smok ing du ra tion that in cludes both ob serv able and un ob serv able fac-tors. Un ob serv able in di vid u al het ero ge ne ity is con sid ered by es ti mat-ing a mix ture mod el via the EM al go rithm, which al lows di vi sion of the un der ly ing pop u la tion ac cord ing to dif fer ent class es and es ti ma tion of class mem ber ship prob a bil i ties. Smok ing du ra tion is shown to have a strong im pact on the prob a bil i ty of sur vival and un ob serv able frailty ex plains the het ero ge ne ity in the pop u la tion.

0337

Ex chang ing knowl edge – us ing eco nom ic prin ci ples in pri or i ty set ting prac tice Bate A. (Cen tre for Health Ser vices Re search, Uni ver si ty of New cas tle upon Tyne)Don ald son C., Murtagh M., Ruta D.

Health care re sources are scarce and, thus, health or gan i sa tions have to make choic es about how best to meet ob jec tives. Eco nomics, as the ‘sci-

Eur J Health Econom Suppl 1 · 2006 | S13

ence of scarci ty’, found ed on the prin ci ple of op por tu ni ty cost, should pro vide the the o ry and so lu tions to help these or gan i sa tions un der take this dif fi cult task. In the UK, the use of eco nomics to in form pri or i ty set-ting is ev i dent at the na tion al lev el with bod ies such as the Na tion al In sti-tute for Health and Clin i cal Ex cel lence (NICE) us ing health eco nom-ic in for ma tion to in form their de ci sion-mak ing. How ev er, eco nomics is less well de vel oped in the con text of lo cal de ci sion-mak ing, and re searchers are ques tion ing the use ful ness of pro mot ing health eco nom-ic meth ods, es pe cial ly cost-ef fec tive ness and cost-util i ty anal y sis, for pri-or i ty set ting at this lev el. In this pre sen ta tion we dis cuss an al ter na tive ap proach to de vel op ing the use of eco nomics with in lo cal health care or gan i sa tions. Us ing par tic i pa to ry ac tion re search (PAR) we worked with a lo cal UK NHS com mis sion ing or ga ni sa tion in the North-East of Eng land to in te grate eco nom ic prin ci ples into the cur rent de ci sion-mak ing man age ment pro cess to cre ate a more sys tem at ic frame work for pri ori ti sa tion. Ob ser va tion, doc u men ta tion of meet ings, and fo cus groups were used to iden ti fy the bar ri ers and fa cil i ta tors to adop tion of the frame work; as sess how the frame work is in ter pret ed and re con-struct ed by its users; and eval u ate the use ful ness of the frame work from their per spec tives. We pres ent the re sults from one case study and ex am-ine the po ten tial for the fur ther de vel op ment of eco nom ic sys tem at ic frame works by iden ti fy ing how they can be in formed by, and in form ‘real-world’ de ci sion-mak ing.

0611

De vel op ment of a na tion-wide qual i ty in di ca tor sys tem in Hun garyBe licza E. (Na tion al Health In sur ance Fund, Bu dapest, Hun gary)Takács E., Bon cz I.

The Hun gar i an Na tion al Health In sur ance Fund Ad min is tra tion (NHI FA) launched a pro gram to eval u ate and as sess the qual i ty of Hun-gar i an health care providers in 2002. In Hun gary health care is fi nanced through so cial in sur ance fund, which is han dled by the NHI FA as a cen-tral or gan of pub lic ad min is tra tion. For the in di ca tor de vel op ment the NHI FA’s work ing group uses the ad min is tra tive data, which are re port-ed by health care providers con tract ed with NHI FA. The NHI FA is the only health in sur ance com pa ny of the com pul so ry so cial health in sur-ance in Hun gary. The ad min is tra tive data base con tains among oth ers the in sur ance iden ti fi ca tion num ber, sex, date of birth, ZIP code, date of treat ment, di ag noses and in ter ven tions re lat ed to treat ed pa tients on ev ery pa tient vis it. The qual i ty in di ca tor pro gram aims at the ac count-abil i ty of health care ser vices, the en cour age ment and sup port of qual i-ty im prove ment pro jects and the qual i ty im prove ment of ad min is tra tive data. The in di ca tors are cal cu lat ed at na tion al and hos pi tal lev el. The providers are grouped and com pared ac cord ing to their pa tient mix es. At the ini tial stage of the in di ca tor pro gram the health care providers are not named but in di cat ed with code num ber. Nev er the less, the providers know their code num ber, so they are able to com pare their own re sults to oth er providers. Ac cord ing to our ex pe ri ence the fol low ing ad van-tages and dis ad van tages of the use of ad min is tra tive data can be de ter-mined. As the data base is avail able, it is cheap com pared to oth er pos si-ble data col lec tion al ter na tives. It is di rect ly ac ces si ble, in cludes all hos pi-tal cas es and makes the con tin u ous de vel op ment of the in di ca tor sys tem pos si ble. We can con nect the data about the pro vi sions of a giv en pa tient even among more providers. Fur ther ad van tage is that we can take some risk fac tors into ac count due to de tailed data. There is also an op por tu-ni ty to an a lyse the trend of in di ca tor val ues as de tailed data have been re port ed to NHI FA for more than 10 years. One of the biggest dis ad van-tages is that the pri ma ry data col lec tion ob jec tive, that is to get in for ma-tion for fi nanc ing, makes the data bi ased. The lack of some nec es sary risk fac tors lim its the pos si ble anal y ses. Un for tu nate ly, we have less data for pro cess in di ca tor than for the less in ter pretable out come in di ca tors. The pub li ca tion of the first in di ca tors trig gered an in ten sive me dia re ac-tion, which re sult ed in a more ac tive par tic i pa tion of the ex pert or gan i sa-

tions. They re alised they should sug gest some re fine ment of the screen-ing cri te ria of in volv ing cas es and hos pi tal group ing by a dif fer ent meth-o dol o gy. One les son for us is that we should put more em pha sis on com-mu ni ca tion with pro fes sion al or gan i sa tions to make the pro gram ac cept-able for them.

0178

An Al ter na tive Ap proach to Es ti mat ing Med i cal Costs: The Case of Bariatric Sur geryBaner jee R. (Mayo Foun da tion, Rochester, USA)Shah N.

Ra tio nale: Tra di tion al cost ac count ing data are not al ways a good mea-sure of re source costs for eco nom ic eval u a tions in health care be cause the fixed com po nent of to tal costs is large. Since price is like ly to be a ma jor fac tor de ter min ing the de mand for dis cre tionary med i cal pro ce-dures that re quire high out-of-pock et pay ments, we eval u ate firm be hav-ior us ing stan dard eco nom ic the o ry.Ob jec tives: We es ti mate a cost func tion for Bariatric sur gery with out us ing tra di tion al cost data. Meth o dol o gy: We as sume the mar ket for Bariatric sur gery is im per-fect ly com pet i tive and that med i cal in sti tu tions are prof it max i miz ers. We es ti mate the cost func tion for Bariatric sur gery us ing data on price, quan ti ty and in sti tu tion al fea tures with data from the Na tion al In pa-tient Sam ple for 2003. We de rive our mea sure of price from the re port-ed ex pect ed pay er source.Re sults: Pre lim i nary anal y sis re veals a mild ly pos i tive ly sloped mar gin-al cost curve. This is ro bust to a va ri ety of lin ear spec i fi ca tions. We find an in verse mar gin al cost elas tic i ty of 0.14.Con clu sions: Ris ing mar gin al costs may be ev i dence of ca pac i ty con-straints. Typ i cal ly, U-shaped mar gin al costs are con sid ered ev i dence of large fixed costs or pos i tive ex ter nal i ties. These are like ly to be ob served in time-se ries data for an in di vid u al firm or in a pan el of firms. Our on-go ing anal y sis uses pan el data from 1998-2003 to fur ther study these fac tors.

0511

The eff ects of own er ship struc ture chang es in the Hun gar i an health provider sec torBaranyi L. (Min istry of Health, Bu dapest, Hun gary)Mi hal icza P., Lelkes I.,

The ef fect of the own er ship struc ture of a health provider on the health care de liv ery has been dis cussed sev er al times. There is no the o ret i cal or em pir i cal con sen sus in the lit er a ture whether the pub lic or the pri-vate own er ship is bet ter for pro vid ing health care ser vices. It is a quite new phe nom e non in Hun gary that the lo cal gov ern ments – which are the own ers of health care fa cil i ty most ly – as sign a pri vate com pa ny to pro vide health care ser vices. The com pa ny may use the pub lic fa cil i ty and will be re spon si ble for de liv er ing health care in the ter ri to ry of the lo cal gov ern ment. This so lu tion is not wide ly used to day and only short term ex pe ri ences are avail able we are go ing to try to eval u ate them. The aim is not to make a clear state ment which form of own er ship is su pe ri-or but to com pare them ac cord ing to the method olo gies de vel oped in the lit er a ture. Our ex pec ta tion is that sev er al use ful lessons will be learnt from the Hun gar i an case.

S14 | Eur J Health Econom Suppl 1 · 2006

0469

Com pe ti tion among Health Plans: A Two-Sid ed Ap proachBardey D. (Uni ver si ty of Rosario (Bo go ta) and Gre maq Uni ver si ty of Toulouse 1, Bo go ta, Colom bia)Ro chet JC.

In this pa per, we use a two-sid ed ap proach to mod elize com pe ti tion be tween Health Plans. In deed, Health Plans com pete on pol i cy hold ers’ mar ket but also on physi cians’ mar ket in or der to at tract them in their net works of care. Our pa per re veals some in ter est ing net works’ ef fects that oc cur in a com pet i tive health in sur ance mar ket. Health Plans pro-vid ing a high di ver si ty of physi cians at tract, in av er age, pol i cy hold ers’ char ac ter ized by a high er risk. Ac cord ing to the mode of re mu ner a tion used, our two-sid ed ap proach shows how the Health Plans sup ply ing a high er di ver si ty of physi cians can sur pris ing ly ben e fit from this risk seg-men ta tion ef fect to ob tain more im por tant dis counts and re al ize high-er prof its in equi lib ri um.

0128

Clin i cal, and So cio-De mografi c Vari ables as Pre dic tors of Ser vices Us age and Costs in the Men tal Health Sec torBar rel la A. (Uni ver si ty of Rome Tor Ver ga ta, Rome, Italy)Po lac sek A., Ric ci R., Span donaro F.

In the 80s the Ital ian Men tal Health sec tor has wit nessed the clo sure of Men tal Home and re or ga ni za tion of psy chi at ric ser vices into a Men tal Health De part ment (MHD) in clud ing com mu ni ty ser vices, short and long term care, and hos pi tals psy chi at ric ser vice.sec tor is cur rent ly char-ac ter ized by Lack of ser vices stan dard iza tion High pres ence of chron ic pa tients, with oc ca sion al acute episodes re quir ing care with vari able in ten sityA pay ment sys tem fi nanc ing DRG for hos pi tal units and pro-vid ing rates for com mu ni ty ser vices, both crit i cized in lit er a ture.stud ies demon strate that so cio-de mo graph ic fac tors and di ag no sis are im por-tant in ser vices us age pre dic tion. They also em pha size that costs vari-a tion blurs the re la tion be tween pa tient at tributes and ser vices us age, hin der ing the de vel op ment of a sys tem of per spec tive fi nanc ing based on needs es ti ma tion.This pro ject aims to de fine a mod el of Prospec tive Fi nanc ing Sys tem for the MHDs, by clas si fy ing pa tients through the HoN OS scale, in te grat ed by di ag no sis and so cio-de mo graph ic fac tors.this pur pose, a 3-years re search has been car ried out. The sur vey, which col lects data on 2.600 pa tients, has ap plied both a mul ti ple re gres sion and an anal y sis of mul ti ple cor re spon dences, to char ac ter ize pa tients’ pro files grouped ac cord ing to com mon char ac ter is tics.

0484

Moral haz ard and the de mand for health ser vices: a match ing es ti ma tor ap proachBar ros P. (Uni ver si dade Nova de Lis boa, Por tu gal)Mach a do M., Galdeano A.S.

In this pa per we es ti mate the im pact of health in sur ance cov er age be yond Na tion al Health In sur ance on the de mand for sev er al health ser vices. Tra di tion al ly, the lit er a ture has tried to deal with the en do-gene ity of the pri vate (ex tra) in sur ance de ci sion by find ing in stru men-tal vari ables. It is hard to think, how ev er, of any vari able that a pri ori would be a good in stru ment and, there fore, we take a dif fer ent ap proach. We con cen trate on the most com mon health in sur ance plan in the Por-tuguese Health Sur vey, (ADSE), which is giv en to all civ il ser vants and their de pen dants. We ar gue that this in sur ance is ex og e nous for most peo ple i.e. not cor re lat ed with their health sta tus. Un der this iden ti fy-ing as sump tion we es ti mate the im pact of hav ing ADSE cov er age on three dif fer ent health ser vices us ing a match ing es ti ma tor tech nique.

The mea sures of de mand for health ser vices are num ber of vis its, num-ber of blood and urine tests, and the prob a bil i ty of vis it ing a den tist. Pre lim i nary re sults show large pos i tive ef fects of ADSE for num ber of vis its and tests among the young (18 to 30 years old) but only for tests are these ef fects sta tis ti cal ly sig nif i cant ly dif fer ent from zero. The mag-ni tude of the ef fects re pres ent 21.8 and 30 per cent of the av er age num-ber of vis its and tests for the young. On the con trary, we find no ev i-dence of moral haz ard on the prob a bil i ty of vis it ing a den tist. Fi nal ly, we ar gue that there is ev i dence of a pos i tive cu mu la tive ef fect of ADSE on health over the years.

0092

Con trac tu al de sign and pub lic-pri vate partern ships for hos pi talsBar ros P. (Uni ver si dade Nova de Lis boa, Por tu gal)Gi ralt X.M.

The Por tuguese Gov ern ment has re cent ly an nounced the launch ing of pub lic pri vatepro gramme to build new hos pi tals. Such part ner ships have, the des ig na tion of PFI – Pri vate Fi nance Ini tia tives – been al ready usedthe UK. The nov el ty of the Por tuguese PFI lies in that both in fras truc-ture and the clin i cal ac tiv i ties man age ment will be award ed to a pri vate. This makes a sig nif i cant de par ture from PFIs in oth er coun tries, where on-ly the in fra struc ture con struc tion is giv en to the pri vate agent. A care ful eco nom ic anal y sis of the prop er ties of this op tion shed light on po ten tial prob lems to be ex pect ed, and pro vide guide lines forde sign of pub lic-pri-vate part ner ships in gen er al. It is also clear that it co or di na tion is sues that do not arise in the tra di tion al pub lic-pri vate, and there fore one needs to check whether usu al pre scrip tions fromthe o ry do still hold.Por tuguese PFI will force the cre ation of two en ti ties, one in charge of con struc tion, the oth er with re spon si bil i ty of clin i cal op er a tions.share hold er struc ture of the win ning par ties in each con tract is ex pect ed toto a con sid er able ex tent. The con tract for in fra struc ture con struc tion have a du ra tion of 30 years, while the con tract for clin i cal ser vices man age mentbe of 10 years, re new able twice. A con straint pres ent in the Por tuguese pro gramme, by de sign, is that the same core con sor tium will take both con tracts in a first phase, though in de pen dent ju ridic en ti ties will be in charge of each con tract (de spite the ex is tence of a sub stan tial over lap in share hold ers iden ti ties), though not nec es sar i ly iden ti cal.im ple men ta tion of this pub-lic-pri vate part ner ship pro gram de mands acon tract de sign, and the def-i ni tion of what is in clud ed in the con tract ofen ti ty and what re mains to be in clud ed in the con tract to to the oth er one. Some ac tiv i ties are clear ly one side or the oth er. How ev er, there are oth ers that can con ceiv-ably be in cludedany of the two pri vate par ties. These are, es sen tial ly, the soft fa cil i ties, like ser vices, cater ing, and the like.def i ni tion of bound aries may have a sig nif i cant im pact on thep ri vate eco nom ic agents are will ing to take, and it con sti tutes part of con tract de sign prob lem for the Gov-ern ment. The qual i ty of these ser vices be eas i ly ob served by the en ti ty in charge of clin i cal ac tiv i ties, though itwell be non-con tractible in the sense that it can not fig ure in the con tracts by the Gov ern ment.qual i ty of these soft fa cil i ties may not be con tractible in all rel e vant, the con trac-tu al de sign must pro vide the prop er in cen tives. One in stru ment to the Gov ern ment is the choice of the en ti ty that will man age fa cil i ties.sim pli fy mat ters, we take a crude view of soft fa cil i ties man age ment. The fa cil i ties can be in clud ed in the con tract of clin i cal ac tiv i ties man age ment. Al ter-na tive ly, they can be in clud ed in thestruc ture in sti tu tion, be ing di rect ly paid by the Gov ern ment. In the first op tion, the clin i cal ac tiv i ties man-age ment has to con tract with the soft fa cil i ties provider its in put. An oth-er op tion would be the clin i cal ac tiv i ties man age ment to pro vide di rect ly the soft fa cil i ties ser vices, a sit u a tion we term ver ti cal in te gra tion.sys tems are lin ear on costs, which con forms well with ob served prac tice. More-over, con tracts for in fra struc ture con struc tion (and main te nance) and for clin i cal man age ment must spec i fy in full all eco nom ic trans ac tions be tween the and the Gov ern ment.fo cus on the ex ter nal ef fects of hav ing two con tracts, one for soft fa cil i ties ser vices pro vi sion the oth er for clin i-

Eur J Health Econom Suppl 1 · 2006 | S15

cal ser vices man age ment. For that pur pose, we from the usu al asym met-ric in for ma tion prob lems. Thus, our ap proach isto the lit er a ture on suf fi-cient ver ti cal re straints than on op ti mal con tracts.com ple ments the in for-ma tion-based con tract ing anal y sis.turns out that first-best choic es can be achieved un der each regime (not sur pris ing, as we as sumed away the usu al in for ma tion al prob lems), with def i ni tion of the pay ment rule. par-tic u lar, we want to ad dress here the op ti mal con tract de sign un der the as sump tion that qual i ty de ci sions in soft fa cil i ties can be ob served by the en ti ty in charge of clin i cal ac tiv i ties but not by the Gov ern ment. Clin i-cal ac tiv i ties pro vide their own in put, which com bined with in fra-struc-ture and soft fa cil i ties qual i ty, pro duces treat ment to pa tients.can look at this is sue from sev er al per spec tives. The more gen er al one is to take it as a di rect ap pli ca tion of as set spec i fic i ty the o ries, with in the the o ry of the firm (Hart, 1993), and ask whether, or not, there is a mo tive for in te-gra tion of soft fa cil i ties into the clin i cal ac tiv i ties man age ment en ti ty. At a gen er al lev el, this takes us to the dis cus sion of which par ty makes the more de ci sive spe cif ic-in vest ment and which one is the more sen si tive to the award ing of con trol rights.this line, it seems rea son able to ar gue that clin i cal ac tiv i ties should lead the pro cess of ver ti cal in te gra tion, as its mar gin al con tri bu tion and sen si tiv i ty of as set-spe cif ic in vest ment is pre sum ably greater than that of soft-fa cil i ties man age ment. straight for-ward ar gu ment, how ev er, is only part of the sto ry as the ex is tence of a pay er to both en ti ties pro vid ing ser vices and the de sign of the pay ment sched ules in tro duce some fur ther struc ture into the mod el, and com ple-men tar i ties be tween in puts may play a de ci sive role.re cent mod el of Jelo-vac and Ma cho-Stadler (2002) looks pre cise ly at the is sue of cen tral iza-tion and de cen tral iza tion in the con text of health care pro vi sion. Their pri ma ry ex am ple uses hos pi tals and physi cians as the rel e vant agents. De cen tral iza tion in their set ting means that an en ti ty con tract ed by the pay er will also set the con tract to a sec ond en ti ty. Cen tral iza tion means the pay er of fers di rect ly con tracts to both physi cians and hos pi tals.terms of our prob lem, the agents will be the man agers of clin i cal ac tiv i ties and the man agers of soft fa cil i ties. The Gov ern ment may set the con tracts to both (cen tral iza tion) or al low for the man ag er of clin i cal ac tiv i ties to set the con tract for the soft-fa cil i ties man ag er (de cen tral iza tion). Ac cord ing to the re sults of Jelo vac and Ma cho-Stadler (2002), and as sum ing the con-tri bu tion of clin i cal ac tiv i ties to the health of pa tients to be more im por-tant than that of soft fa cil i ties, we fall again in an ar gu ment in fa vor of in clud ing soft-fa cil i ties man age ment with in the clin i cal ac tiv i ties con-tract, and then let the man agers of clin i cal ac tiv i ties hire and or ga nize the soft fa cil i ties in put. How ev er, the set ting of of Jelo vac and Ma cho-Stadler (2002) leaves out a cou ple of el e ments that we be lieve to be also rel e vant to in clude first, the ap pli ca tion of lin ear pay ment sched ules, and, sec ond, al low ing for pa tients wel fare to be a con cern to providers as well, which takes us to a ver sion of the mod el of El lis and McGuire (1986).

0091

An as sess ment of the em pir i cal va lid i ty of the EQ-5D, SF-6D and Eu ro Qol VAS in a sam ple of the gen er al pop u la tionBar ton G. (Uni ver si ty of Not ting ham, Unit ed King dom)Sach TH., Av ery AJ., Jenk in son C., Do her ty M., Muir KR.

Ob jec tive: To as sess the em pir i cal va lid i ty of three health re lat ed qual i-ty of life (HRQL) mea sures: the EQ-5D, SF-6D and Eu ro Qol vi su al an a-logue scale (VAS). Meth ods: In for ma tion on six per son al char ac ter is tics (age, gen der, eth-nic i ty, smok ing sta tus, body mass in dex (BMI), oc cu pa tion al skill lev-el), ten health con di tions (back pain, hip pain, knee pain, heart dis ease, stroke, asth ma, can cer, di a be tes, rheu ma toid ar thri tis and os teo ar thri-tis) and HRQL was re quest ed from 2770 pa tients aged ≥45 years in one gen er al prac tice. Lin ear re gres sion anal y sis was used to as sess the re la-tion ship be tween each of the three HRQL mea sures (EQ-5D, SF-6D, VAS) and six teen ex plana to ry vari ables (the six per son al char ac ter is tics and ten health con di tions).

Re sults: In creas ing age, worse BMI, low er oc cu pa tion al skill lev el, back pain, hip pain, knee pain, heart dis ease, rheu ma toid ar thri tis, and os teo-ar thri tis were as so ci at ed with a sig nif i cant loss in HRQL (on the EQ-5D, SF-6D, and VAS). As were hav ing smoked reg u lar ly and di a be tes (EQ-5D and VAS), stroke (EQ-5D and SF-6D), asth ma (SF-6D and VAS) and can cer (VAS). Con clu sion: The EQ-5D, SF-6D and VAS were able to de tect the in de-pen dent loss in HRQL as so ci at ed with many dif fer ent per son al char ac-ter is tics and health con di tions.

0246

Ap pli ca tion of lo cal search meth ods in cost-eff ec tive ness anal y sisBar ton P. (Health Eco nomics Fa cil i ty of Birm ing ham, Unit ed King dom)Joban pu tra P., Bryan S., Burls A.

Rheu ma toid ar thri tis (RA) is a chron ic con di tion for which a large num ber of dis ease-mod i fy ing anti-rheu mat ic drugs (DMARDs) are avail able. Typ-i cal ly DMARDs will be stopped af ter a time for var i ous rea sons. Thus the ap pro pri ate long-term strat e gy re quires the use of a se quence of DMARDs. Any pos si ble se quence is in prin ci ple a can di date for cost-ef fec tive ness anal-y sis. With 11 com mon ly used DMARDs to con sid er, there are a to tal of near ly 40 mil lion pos si ble se quences of DMARDs, and over 100 mil lion se quences if sub sets are to be con sid ered as well. It is clear ly not pos si ble to test all these se quences. of DMARDs are com pared us ing the Birm ing-ham Rheu ma toid Ar thri tis Mod el (BRAM). The BRAM al lows re al is tic dis-tri bu tions to be used for the time spent on any DMARD, and the ef fects of a DMARD may de pend on a pa tient’s pre vi ous his to ry. The mod el works by gen er at ing a large num ber of vir tu al pa tient his to ries from which pop u-la tion mean costs and QALYs are es ti mat ed. This work il lus trates the use of lo cal search meth ods from op er a tional re search, in clud ing sim u lat ed an neal ing and ge net ic al go rithms, to find the op ti mum se quence in a com-pu ta tion al ly fea si ble way. The sto chas tic na tures of the mod el and search al go rithms are made to work to geth er.

0499

Age-re lat ed pub lic ex pen di ture pro jec tions for the EU 25 Mem ber StatesBar tozs P. (Eu ro pean Com mis sion, DG Eco nom ic and Fi nan cial Aff airs, Labour Mar kets, Tax a tion and Qual i ty of Pub lic Fi nances, Brus sels, Bel gium)

Part of the or gan ised ses sion by the Eu ro pean Com mis sion: Pol i cy choic-es for Eu rope- age ing and sus tain abil i ty: “Through the Age ing Work ing Group of the Eco nom ic Pol i cy Com mit tee data has been gath ered from all EU Mem ber States and new pro jec tions are cal cu lat ed for the in creas-es in pub lic ex pen di tures re lat ed to de mo graph ic chang es. Dif fer ent sce-nar ios have been cal cu lat ed and sen si tiv i ty anal y sis has been con duct-ed on dif fer ent as sump tions. The pro jec tions sug gest that most of the in crease in pub lic spend ing due to pure ly de mo graph ic ef fects would be re lat ed to pen sions, health care and long-term care. There are vari a-tions be tween the Mem ber States and be tween the im pacts of the dif fer-ent com po nents of the pro jec tions”

0389

The Ex tent and the Depth of Drug Cov er age in Can a daBasu K. (Mi crosim u la tion Mod elling and Data Anal y sis Di vi sion, Ap plied Re search and Anal y sis Di rec torate, Health Can a da, Ot tawa, Can a da)Gup ta A.

Ob jec tives: study 1) the ex tent and pat terns of pre scrip tion drug cov-er age in Can a da and 2) the so cio-eco nom ic anal y sis of out-of-pock et drug ex pens es.

S16 | Eur J Health Econom Suppl 1 · 2006

Data: We syn the sized data from di verse sources such as Sur vey of House-hold Spend ing, Sur vey of Labour and In come Dy nam ics, and Cana di an Com mu ni ty Health Sur vey. The re sul tant mi cro database con tains in di-vid u al/fam i ly drug cov er age in for ma tion along with a di ver si ty of so cio-eco nom ic char ac ter is tics. Meth o dol o gy: The ex tent of drug cov er age is es ti mat ed by us ing a lo gis-tic re gres sion mod el with drug cov er age (yes/no) as de pen dent vari able and in di vid u al age, sex, in come, ru ral/ur ban, ed u ca tion, mar i tal sta tus, source of in come, em ploy ment sta tus (full-time/part-time), and provin-cial dum mies as in de pen dent vari ables. Out-of-pock et drug ex pense is es ti mat ed us ing a to bit mod el. This mod el uses out-of-pock et drug ex pen di ture as a pro por tion of in come as a de pen dent vari able and age, sex, ru ral/ur ban, and the types of cov er age as in de pen dent vari ables. Re sults: Com pared to On tario, house holds in all oth er provinces have high er out-of-pock et drug ex pens es. House holds in Prince Ed ward Is land, Que bec, Saskatchewan, and Al ber ta have rel a tive ly high bur den. Males have low er bur den than fe males, pre sum ably, be cause fe males have rel a tive ly high er drug con sump tion. Com pared to house holds not cov ered by a drug plan, house holds cov ered by pri vate plans have a low-er rel a tive bur den while those cov ered by pub lic non-pre mi um plans have a high er rel a tive bur den.

0140

Time trends and spa tial spill-over eff ects in the Span ish pub lic phar ma ceu ti cal ex pen di turesBech M. (Uni ver si ty of South ern Den mark, Odense C, Den mark)Lau rid sen J., López F., Sánchez M.M.

Phar ma ceu ti cal ex pen di ture in Spain is main ly fund ed by the Span ish Na tion al Health Sys tem, how ev er, reg u la tion of the Span ish drug mar-ket has pro vid ed very sparse cost-con tain ment in cen tives for both con-sumers and providers. Phar ma ceu ti cal ex pen di ture as a share of to tal health care ex pen di ture has steadi ly in creased from 18% in the mid 1990s to above 23% in the late 1990s. The fo cus of this study is to de ter-mine the dy nam ics across provinces and time caus ing phar ma ceu ti cal ex pen di ture to in crease. A re gres sion mod el for per cap i ta pub lic phar-ma ceu ti cal ex pen di ture is an a lyzed, based on small-area data from the fifty Span ish provinces, ob served an nu al ly for the pe ri od 1996-2003. Ad just ment for re sid u al cor re la tion across time pe ri ods and re sid u al vari ance in sta bil i ty is shown to be es sen tial for prop er in fer ence re gard-ing ef fects of ex og e nous de ter mi nants. Pres ence of para met ric in sta bil-i ty is dem on stra ted and found to be main ly cap tured us ing in creas ing or de creas ing lin ear time trends in the co ef fi cients. Fi nal ly, it is re vealed that con trol for en dog e nous spa tial spillover is high ly im por tant in or der to ob tain prop er con clu sions re gard ing the ef fects of de ter mi nants of phar ma ceu ti cal ex pen di ture. The study thus adds to pre vi ous knowl-edge and mod elling prac tice by demon strat ing the fal la cy of sim pler tra di tion al ap proach es alike OLS and fur ther stress es the ne ces si ty of, not only ad just ing for each of the above fea tures, but in te grat ing them into a uni fied frame work when anal y ses are based on small-area health care data.

0119

A Gen er al Mod el of In sur er Be hav ior to de rive op ti mal Risk Ad just ment Pol i cy in a Com pet i tive So cial Health In sur ance Mar ketBeck K. (CSS In sur ance, Lucerne, Switzer land)

There is plen ty of lit er a ture about risk ad just ment in a com pet i tive so cial health in sur ance mar ket fo cus ing more and more on the ac tu ar i-al as pects of the prob lem – for ex am ple op ti miz ing the R2 of the for mu-la, op ti mal es ti mat ing tech niques, avail abil i ty of data etc.: say ing com pa-ra bly lit tle about the prob lem of op ti mal reg u la tion. This is par tic u lar ly

puz zling as the fear of over reg u la tion is one of the ma jor is sues in the cur rent po lit i cal dis cus sions in Ger many and Switzer land. The pre dom i-nant ques tion is how to iden ti fy the op ti mal risk ad just ment-reg u la tion and how to pre vent pos si ble over reg u la tion. pa per pre sents a sim ple, the-o ret i cal mod el, based on in sur er’s trade off be tween cost con tain ment ac tiv i ties and risk se lec tion in or der to deal with the reg u la tion prob-lem in a pos i tive man ner. Over-, un der-, und op ti mal reg u la tion can be de scribed. Al though the mod el is quite gen er al, it is pos si ble to de rive prac ti cal and un am bigu ous pol i cy rec om men da tions con di tion al on the giv en sit u a tion in the health in sur er mar ket. This im plies the ne ces si ty for mon i tor ing the mar ket. de scrip tion of a sta tis ti cal frame work need-ed to mon i tor mar ket ac tiv i ties is de scribed and il lus trat ed with em pir-i cal ex am ples from Switzer land. The pa per also com pares the de rived pol i cy im pli ca tions with the ac tu al dis cus sion in Ger many, Switzer land and the Nether lands. With out the need to re fer to nor ma tive dif fer ences the rec om men da tions of the mod el cor re spond with the dif fer ent po lit-i cal de bates in the three coun tries. This shows that the mod el pro duces prac ti cal and ap pli ca ble guide lines for pol i cy mak ers, con front ed with the is sue of risk ad just ment reg u la tion.

0024

Cost Shar ing in Health In sur anceBeck er K. (Uni ver si ty of Zurich, SOI, Zurich, Switzer land)Zweifel P.

Health in sur ance is po ten tial ly sub ject to risk se lec tion, i.e. ad verse se lec tion on the part of con sumers and cream skim ming on the part of in sur ers. Ad verse se lec tion mod els pre dict that com pet i tive health in sur ers can es chew high-risk in di vid u als by of fer ing con tracts with low de ductibles or co pay ment rates, while at tract ing low-risk in di vid u-als with high er co pay ments, re sult ing in a sep a rat ing equi lib ri um. This con tri bu tion seeks to de ter mine whether in com pet i tive Swiss so cial health in sur ance poli cies with de ductibles in ex cess of the le gal min i-mum do in deed serve as an in stru ment of risk se lec tion. In a dis crete choice ex per i ment, ef fect ed in 2003, some 1,000 in di vid u als were giv en the hy po thet i cal choice of al ter na tive in sur ance con tracts that dif fered both in terms of de ductibles and co pay ments and in ben e fits cov ered. Re sults sug gest that in di vid u als with out med i cal ser vices dur ing the past six months, tend ed to se lect a pol i cy with a high de ductible. Com-pen sa tion de mand ed for vol un tar i ly ac cept ing an in crease in the an nu-al de ductible also varies with so cioe co nom ic char ac ter is tics and in creas-es with the cur rent lev el of de ductible, as pre dict ed by the o ry and con-sti tut ing ev i dence in fa vor of the risk se lec tion hy poth e sis. The ex per i-ment al lows to com pute nec es sary pre mi um re duc tions and pro vides guid ance for the pric ing pol i cy of in sur ers when of fer ing dif fer en ti at-ed prod ucts.

0109

Car dio vas cu lar Tech nol o gy vari abil i ty of use in Spain dur ing the pe ri od 2000-2004 at the Span ish NHSBe laza J. (Madrid, Spain)

In tro duc tion and ob jec tives: In Spain there are 17 Au ton o mous Re gions that have the re spon si bil i ty of Health ser vices pro vid ing and fund ing through dev o lu tion of a % of the in come tax as well as through the use of spe cif ic tax es on al co hol, etc…The role of the Cen tral NHS is ba si cal ly one of co-or di na tion, ap proval of new drugs and health de vices, price fix ing for phar ma ceu ti cals as well as rec om men da tions on health pol i cy through dif fer ent mech a nisms such as what is called an in te gral health plan for an spe cif ic dis ease such as CVs or can cer by set ting the stan dards or care to be ap plied and re sources and prac tices to be in cor po rat ed at the Na tion al lev el by each Au ton o my. Be ing Spain a coun try that in the last ten years 1993-2003 ded i cat ed a fixed per cent age of the GNP to pub lic med i cine at the ex pense only of

Eur J Health Econom Suppl 1 · 2006 | S17

the in crease of the pri vate in sur ance, we could ask our selves if the dif-fer ence of 1-2% of the GNP in vest ed in the mar ket would not af fect the de gree of tech nol o gy dif fu sion at the lev el of the Au tonomies as also the health ex pen di ture per cap i ta shows, big vari a tions be tween them. In a study done by FENIN in Spain re view ing the 2004 health bud gets for sev er al Au tonomies there was an av er age 6% ded i cat ed to health tech-nolo gies (in clud ing all kind of prod ucts, im plants, med i cal de vices and heavy equip ment in vest ment) what in the EU COMED 2003 pro file was es ti mat ed in 75€ per cap i ta : 25% be low UK and Italy, 50% be low France and 70% be low Ger many.This pre lim i nary anal y sis should make as think on the pos si ble ex is-tence of vari a tions at the lev el of use of high tech nolo gies, where the de gree of ex per tise and re sources need ed is big and there fore re quires an in vest ment in fa cil i ties and hu man re sources as well as ex per tise. Due to the fact that CV dis eases are the main rea son of mor tal i ty in Eu rope and at the OEDC by rep re sent ing be tween 30–50% of the to tal mor tal i ty, we have de cid ed to study the vari abil i ty of use of three CV tech nolo gies used in the treat ment of these dis eases: ICP (in tra-cor o-nary pro ce dures to treat blocked ar te ries.), ICD (im plantable de fib ril la-tors to treat ma lig nant ar ry th mias that hap pen in pa tients main ly af ter an MI) and CRT (car di ac resyn chro niza tion de vices to treat Heart Fail-ure pa tients to im prove his qual i ty and de crease its mor tal i ty).Ma te ri al and meth ods: We have re viewed the data on the use and im plant of three tech nolo gies (ICP.ICD and CRT) in the pe ri od 2000–2004 by ac cu mu lat ing the data from all hos pi tals be long ing to each Au ton o mous re gion and di vid ing this val ue by the pop u la tion in or der to get an in di ca tor per mil lion of habi tants. To mea sure the vari abil-i ty we have cal cu lat ed the VR (vari abil i ty ra tio or ra tio be tween the high er and low er val ues) and the Non Weighed Co ef fi cient of vari a-tion (CV, cal cu lat ed as the ra tio be tween the stan dard de vi a tion and the mean val ues). The re sults for the year 2004 are the fol low ing: ICP (1.97, 0.23), ICD (4.5, 0.33), CRT(10.6, 0.64) and in clud ing the anal y-sis for the im plant of pace mak ers a tech nol o gy old er than 40 years PM (1.97, 0.23).This means that the most sta ble tech nol o gy is ICP and that the vari abil i ty is high er for the ICD and spe cial ly for the CRT (5 years life tech nol o gy).In or der to study the sit u a tion on the year 2004 we used an econo met ric mod el in clud ing of fer vari ables (Health ex pen di ture per cap i ta, Gross Re gion al prod uct per cap i ta, No. of cen ters per mil lion) and de mand vari ables (% of pop u la tion over 40+ and over 65+ years old mor tal i ty, in ci dence and prev a lence of dis eases)Re sults: The best ex plana to ry vari ables were the Gross Re gion al Prod-uct and the No. of cen ters per mil lion at each re gion (of fer vari ables) while the de mand vari ables re lat ed with the bur den of dis ease had a very low ex plana to ry pow er.In the case of HF and the use of CRT the mod el in clud ed just the No. of cen ters and the % of pop u la tion of 40+years al though in this case the co ef fi cient was neg a tive, what can be ex plained by the fact that this ther-a py is dif fus ing ear li er in the more rich re gions that are not nec es sar i-ly those with high er prev a lence of HF. The to tal vari abil i ty ex plained is al most 65%, F = 15, p=0.00042 and both vari ables be ing quite sig nif i-cant with a p <0.01. A more de tailed anal y sis will be pre sent ed with mod-els found for each tech nol o gy.Con clu sion: The vari abil i ty is low er for the ICP and high er for ICDs and CRT. The dif fu sion of rather young tech nolo gies is fa cil i tat ed by the rich ness of each re gion as the ex pe ri ence and fa cil i ties can be more eas-i ly ac quired that in the oth ers. For all tech nolo gies, even for very sta ble ones such as PM, there ex ist a me di um to high vari abil i ty of use that cre-ates for the pa tient a sit u a tion of lack of eq ui ty at the SNS lev el. In Spain the lev el of use of these three tech nolo gies is well be low the EU-15 av er-age even tak ing into ac count the low er in ci dence of Isch emic Dis eases in our coun try. An econo met ric mod elling for 2004 re in forces the pre-dom i nant role of the Re gion rich ness as an ex pla na tion of the vari abil i-ty. This tech nolo gies are also un der -pre scribed com pared with sim i lar Eu ro pean coun tries, ac cord ing to cur rent clin i cal guide lines, but what it is worst, with the ex is tence of an un ac cept able lev el of in equity (2:1, 4.5 : 1 or 11 : 1) ac cord ing to where the pa tient lives.

0528

Hun gar i an cost-util i ty anal y sis of anas tro zole vs tam ox i fen in post meno paus al wom en with ear ly breast can cer (EBC)Bene dict A. (MED TAP In sti tute at UBC, Bu dapest, Hun gary)

Ob jec tives: In the ATAC tri al, anas tro zole pro duced sig nif i cant ly lon-ger dis ease-free sur vival and time to re cur rence com pared with tam ox i-fen in post meno paus al wom en with hor mone re cep tor-pos i tive (HR+) EBCafter 5 years of treat ment. A cost-util i ty anal y sis of anas tro zole com-pared with tam ox i fen was un der tak en in Hun gar i an set ting for re im-burse ment sub mis sion. Meth ods: A Markov mod el based on pa tient-lev el tri al data was used to pro ject 5-year out comes from the ATAC tri al to 25 years. Re source util-i sa tion data were ob tained from Hun gar i an data bases of the Na tion al In sur ance Fund. Unit costs (in 2004HUF) were ob tained from Hun gar-i an DRGs and out pa tient fee sched ules. Util i ty scores from a UK study in post meno paus al EBC wom en were in cor po rat ed. Costs and ben e fits were dis count ed at 5%. In cre men tal cost ef fec tive ness ra tios (ICERs), 95% CIs, and ac cept abil i ty curves were cal cu lat ed. Re sults: The ICER for anas tro zole com pared with tam ox i fen at 25 years was HUF 4.77 mn/QALY (CI: HUF 2.38-15.1 mn). Re sults were sen si-tive to the cost of meta stat ic treat ment and the as sump tions about the du ra tion of treat ment ben e fit. Con clu sions: Com pared to a cost-ef fec tive ness thresh old of ¬20,000, of ten quot ed in coun tries of the EU zone, anas tro zole pro vides a cost-ef fec tive al ter na tive to ge ner ic tam ox i fen for pri ma ry ad ju vant treat-ment of post meno paus al wom en with HR+ EBC.

0207

Na tion al med i cal guide lines and pri or i ty set ting in Swe denBerggren F. (Na tion al Board of Health and Wel fare, Stock holm, Swe den)Kärvinge C.

The aim of the health care sec tor is to pro vide good health on equal terms for the en tire pop u la tion. The work with na tion al guide lines pro vide ev i-dence based rank ing by pri ori tis ing in ter ven tions linked to a spe cif ic con-di tion. An eth i cal plat form con sist ing of hu man val ue, need and sol i dar i-ty and cost-ef fi cien cy pro vide the foun da tion of the pri or i ty set ting. Three groups work to geth er with a core team to pro vide a guide line that ranks in ter ven tions for spec i fied in di ca tions from 1 to 10. The groups con sist of a med i cal sci en tif ic group, a health eco nomics group and a pri or i ty-set-ting group. These groups pro vide the core group with ev i dence-based doc-u men ta tion where the core group de liv ers a pri or i ty set ting league ta ble. Im ple men ta tion is eval u at ed through stud ies of clin i cal prac tice. Guide-lines for stroke, asth ma and COPD, heart dis eases and ve nous throm bo-em bo lism have been pub lished. Guide lines for de pres sion, de men tia and can cer (breast can cer, co lo rec tal can cer and pros tate can cer) are un der way. This form of na tion al guide lines pro vides the pos si bil i ty to draw con-clu sion con cern ing al lo ca tion and re al lo ca tion of re sources and have been well re ceived by the coun ty coun cils that pro vides the health care. The heart dis ease and stroke guide lines are the first set of guide lines that have base line in ves ti ga tions on clin i cal prac tice com plet ed.

0396

Ad mis sion rates or length of stay: What is more im por tant for cost-con tain ment poli cies?Bernal-Del ga do E. (In sti tute for Heath Sci ences, Aragon, Spain)Peiró-Moreno S., Ri dao-López M.

Back ground: From a pop u la tion-based per spec tive, hos pi tal ex pen di-ture could be con sid ered as a func tion of ad mis sion rates, hos pi tal iza tion

S18 | Eur J Health Econom Suppl 1 · 2006

costs and cost of ad verse events. Cost-con tain ment poli cies fo cus pret ty much on hos pi tal iza tion costs (DRGs as stan dard), but small area vari a-tion stud ies sug gest ad mis sion rates con tain ment as a bet ter op tion. Meth ods Pop u la tion: We se lect ed 2002 her nia re pair and chole cis tec to-my hos pi tal ad mis sions per formed in 95 health care ar eas (from 10 Span-ish re gions). Main out come: pro ce dure-spe cif ic ex pen di ture per in hab i-tant and year; Pre dict ing vari ables: pro ce dure-spe cif ic ad mis sion rates per 10,000 in hab i tants, length of stay (LOS), per cent age of pro ce dures us ing am bu la to ry sur gery, la paro scop ic tech nique, per cent age of emer-gen cy read mis sions 30 days af ter dis charge. Anal y sis: Pear son co ef fi-cients to de ter mine sig nif i cant cor re la tions, and mul ti ple lin eal re gres-sion were used. Re sults: Ad mis sion rates ex plained 84% (her nia re pair) and 62% (chole-cis tec to my) of ex pen di ture vari ance. No oth er vari ables were sig nif i cant in her nia. How ev er, chole cis tec to my ex pen di tures were also ex plained by LOS (14%), read mis sions (8%) and per cent age of am bu la to ry sur-gery (5%). When mul ti ple re gres sion was used, ad mis sion rates, LOS and read mis sions were sig nif i cant, ex plain ing about 97% of ex pen di ture vari ance, both in her nia re pair and chole cis tec to my. Con clu sions: Ad mis sion rates were found the most im por tant fac tor ex plain ing ex pen di ture per habi tant. Cost-con tain ment poli cies should be re ori ent ed and fo cused on ad mis sion rates man age ment in stead of LOS man age ment.

0023

How does ac cess to cap i tal im pact hos pi tal fi nan cial and op er at ing per for mance?Ber net P. (Flori da At lantic Uni ver si ty, Flori da, US)Hsuan F.

Non prof it hos pi tals in the U.S. raise cap i tal pri mar i ly through bond is sues. On one hand, this cap i tal can be in vest ed in new plant and equip-ment that can im prove op er at ing ef fi cien cy, which may fur ther be re flect ed in im proved fi nan cial re sults. On the oth er hand, the ad di tion-al bur den of debt re pay ment may force the hos pi tal to make cuts that ul ti mate ly hin der per for mance. This study ex plores this re la tion ship through an anal y sis of all not-for-prof it hos pi tal bond is sues be tween 1993 and 2002. Key mea sures of fi nan cial and op er at ing per for mance are mea sured both be fore and af ter each bond is sue to de ter mine if ra tios im prove as a re sult of the new in fu sion of cap i tal. This study has the added ben e fit of be ing able to ac count for self-se lec tion bias, as the same per for mance da tum is col lect ed for hos pi tals that choose to not is sue debt. Re sults will also in di cate those hos pi tal char ac ter is tics that im prove the odds for suc cess af ter debt has been is sued. This study may bet ter in form fa cil i ty fund ing de ci sions to help in sure that in vest ments are made where they will be most ef fec tive.

0248

Choice of para met ric dis tri bu tions in de ci sion an a lyt ic mod els and ex pect ed val ue of per fect in for ma tionBischof M. (In sti tute for Clin i cal Epi de mi ol o gy, Uni ver si ty Hos pi tal Basel, Switzer land)Sen di P.

Back ground: Prob a bilis tic sen si tiv i ty anal y sis (PSA) al lows us to ad dress sec ond or der un cer tain ty in de ci sion an a lyt ic mod els. This usu al ly en tails the choice of prob a bil i ty dis tri bu tions for rel e vant in put pa ram e ters in a cost-ef fec tive ness mod el. It is un clear how the use of dif-fer ent al ter na tive para met ric dis tri bu tions may in flu ence the re sults. We ex am ined the im pact of us ing dif fer ent dis tri bu tions for ma jor mod el pa ram e ters on the ex pect ed val ue of per fect in for ma tion (EVPI), which is a means of sum ma riz ing un cer tain ty in a mon e tary way.Meth ods: A prob a bilis tic Markov mod el for the anal y sis of the cost-ef fec tive ness of pre ven tive treat ments for os teo po ro sis was used and dif-

fer ent para met ric dis tri bu tions were ap plied to those groups of pa ram e-ters with the high est ex pect ed val ue of sam ple in for ma tion (EVSI) (treat-ment ef fect: log nor mal, nor mal; qual i ty of life: beta, gam ma, trun cat ed nor mal; costs: gam ma, nor mal). The over all EVPI was cal cu lat ed for dif-fer ent com bi na tions of in put dis tri bu tions. Re sults: The EVPI may vary by more than 50% de pend ing on the choice of in put dis tri bu tion in our mod el. Con clu sion: The choice of para met ric dis tri bu tions can sub stan tial ly af fect over all un cer tain ty as re flect ed by the EVPI. Pre sent ing the re sults for a va ri ety of dif fer ent para met ric dis tri bu tions can help to ad dress this is sue.

0360

Pro duc tiv i ty in Psy chi at ric Out-pa tient Treat mentBjörn gaar J. (SIN TEF Health Re search, Trond heim, Nor way)Mag nussen J.

There has been a de mand for a pro duc tiv i ty in crease in Nor we gian out-pa tient clin ics. This de mand has how ev er been crit i cized for not con-sid er ing pos si ble neg a tive side-ef fects, such as re duced qual i ty in treat-ment. pa per rais es three re search ques tions. To what ex tent are dif fer-ences in pro duc tiv i ty be tween ther a pists a func tion of in di vid u al char-ac ter is tics, such as for mal qual i fi ca tions and ex pe ri ence? To what ex tent are dif fer ences in pro duc tiv i ty caused by char ac ter is tics of the psy chi at-ric team, such as team func tion, size and pro fes sion al com po si tion. Are pro duc tiv i ty dif fer ences as so ci at ed with dif fer ences in av er age lev els of pa tients’ ex pe ri ences in the teams? Data were col lect ed from two sep a-rate sources. Data on time spent on dif fer ent ac tiv i ties in all Nor we gian adult out pa tient clin ics and teams were col lect ed by reg is tra tion forms for a pe ri od of two weeks in Septem ber 2004. The ma te ri al con sists of 90 out pa tient clin ics, from 180 teams and con sists of 1700 ther a pists. In ad di tion we have data on ex pe ri ences/sat is fac tion from 6 677 pa tients who re ceived treat ment in out-pa tient clin ics and teams in Septem ber 2004 is mea sures us ing data en vel op ment anal y sis. In puts are mea sured as num ber of hours spent on pa tient re lat ed ac tiv i ty by type of pro fes-sion and ex pe ri ence. Out puts are mea sured as num ber of con cul ta tions and an in dex of qual i ty which is con truct ed from the pa tient sat is fac-tion data.

0171

Eco nom ic Eval u a tion of Val sar tan in Pa tients with Chron ic Heart Fail ure: Re sults From the Val-HeFT Study Adapt ed to the Nether landsCor nelis B. (Uni ver si ty of Gronin gen, De part ment of So cial Phar ma cy, Phar ma coepi demi ol o gy and Phar ma co ther a py, Gronin gen Uni ver si ty In sti tute for Drug Ex plo ra tion (GUIDE), Gronin gen, the Nether lands)Groot M., Jas mi na J.I., Boom G., Post ma M.J.

Back ground: The Val-HeFT-study was a multi na tion al ran dom ized tri-al, in which a to tal of 5010 pa tients with NYHA class II to IV heart fail-ure were as signed to val sar tan or pla ce bo (added to back ground ther a-py). Val sar tan re duced heart fail ure hos pi tal iza tions sig nif i cant ly.Ob jec tives: To con duct an eval u a tion on the eco nom ic im pact of val-sar tan based on Val-HeFT in clud ing sub group anal y ses fol low ing val-sar tan’s re cent reg is tra tion for CHF in Eu rope.Meth ods: Re source-use was based on data col lect ed dur ing Val-HeFT. These were mul ti plied by Dutch cost es ti mates and cat e go rized in costs for hos pi tal iza tions, in pa tient and out pa tient ser vices, am bu lance trans-porta tion, death out side the hos pi tal, and out pa tient car dio vas cu lar med i ca tions (1999 price-lev el; 3% dis count rate).Re sults: Mean pa tients’ fol low-up was 23 months and costs for hos pi tal-iza tions were €617 low er among val sar tan pa tients. Mean to tal costs for val sar tan and con trols were €8,810 and €8,441 re spec tive ly, re sult ing in in cre men tal costs of €368. In pa tients re ceiv ing an ACE-in hib i tor but

Eur J Health Econom Suppl 1 · 2006 | S19

no beta-block er these in cre men tal costs were even low er, €171. There was an over all re duc tion in costs of €1,311 in pa tients not re ceiv ing an ACE-in hib i tor at base line.Con clu sions: Val sar tan pro vides clin i cal ben e fits at mod est costs in the Nether lands. Sub group anal y ses show that val sar tan ther a py is cost-sav-ing and in creas es sur vival for pa tients not re ceiv ing ACE-in hibitors.

0380

How much are we spend ing to treat dis eases?Bo hi gas L. (Barcelona, Spain)Gis bert R., Brosa F., De la Puente ML

Health care pub lic bud gets tend to fo cus in re sources (i.e. per son nel, goods and ser vices) or ser vices (hos pi tal, pri ma ry care, etc.) but they do not ex plain which dis eases the pub lic health care sys tems try to pre-vent or treat. This pa per pre sents the re sults of an a lyz ing in which dis-eases the pub lic Cata lan health care bud get is spent. The meth o dol o gy used is the one of dis ease cost ing, but tak ing in ac count the whole pub lic bud get. The dis ease unit is the ICD9 main cat e gories. The re sults help to il lu mi nate pol i cy mak ers and plan ners of Catalun ya about the pri or i-ties im plied in the bud getary sys tem.

0313

In tro duc tion of health eco nomics into de ci sion mak ing on pub lic health in ter ven tionsBon cz I. (Na tion al Health In sur ance Fund Ad min is tra tion (OEP), Bu dapest, Hun gary)Sebestyén A., Betle hem J., Oláh A., Dózsa Cs., Gulác si L.

Pur pose of this pol i cy pa per is to give an overview on the in tro duc-tion of health eco nomics into de ci sion mak ing on or ga nized na tion wide screen ing pro grammes. Meth ods: We anal y sed the avail able ev i dences in the Hun gar i an set ting on the de ci sion mak ing pro cess on breast, cer-vi cal and co lo rec tal screen ing. Re sults: Af ter in ter na tion al sci en tif ic ev i-dences were crit i cal ly re viewed, pi lot screen ing pro grammes were in tro-duced in Hun gary in all the 3 can cer type. Health eco nomics (cost-ef fec-tive ness) anal y sis was con duct ed for breast, cer vi cal and co lo rec tal can-cer and the re sults mea sured by the cost per life years saved were ac cept-able from fi nan cial point of view. Bud get-im pact anal y sis was pre pared also. Fi nal ly, in na tion wide or ga nized screen ing pro grammes wom en be tween the age of 45-65 are in vit ed by per son al let ter for mam mog ra-phy breast screen ing with 2 years screen ing in ter val; wom en be tween the ages of 25-65 are in vit ed by a per son al let ter for cer vi cal screen ing, with a 3 years screen ing in ter val. The de ci sion on turn ing the co lo rec tal can cer screen ing pi lot into a na tion wide pro gramme is still pend ing; cur-rent ly per sons be tween 45-65 are in vit ed with a 2 years screen ing in ter-val. Con clu sions: The im ple men ta tion of na tion wide or ga nized can cer screen ing pro grammes was based on care ful eval u a tion of med i cal ev i-dences and health eco nomics anal y sis.

0514

Im pact of il le gal pay ments on the health care fa cil i ty struc ture in Hun garyBon dar E. (Min istry of Health, Bu dapest, Hun gary)Baranyi L.

De spite the to tal i tar i an pow er struc ture of the so ci ety at large, the “planned char ac ter” of health sys tems of our re gion the de vel op ment of the fa cil i ty net work was out of con trol of of fi cial pol i cy mak ers due to a hid den and un con trol lable in for mal in cen tive pen e trat ing al most all seg ments of the de liv ery struc ture. This is the “gra tu ity” pay ment. This fenomenon can be dis cussed by dif fer ent (eth i cal, jus tice etc) points of

view, but it is im por tant to an a lyse it from the point of view of im pact on the de liv ery struc ture. The parts of health sys tem (pro fes sions, type of care, ge o graph i cal, etc) where pa tients were will ing and able to be “grate-ful” are typ i cal ly bet ter de vel oped (staffed, equipped), than oth er seg-ments. Where short age ex pe ri enced in the num ber of grate ful pa tients, the staff is small er than re quired and providers are not keen on de vel op-ing ser vices. This il le gal in cen tive is re cent ly com ple ment ed by an oth-er type of il le gal pay ment, the pro mo tion of pro duc ers and dis trib u tors. By and large gra tu ity is about dis crim i na tion, the pro mo tion is an in cen-tive to widen the pa tients cured re gard less of their so cial po si tion. Both im pacts can be es ti mat ed in or der to make a pol i cy rec om men da tion.

0036

Are health in sur ers able to chan nel pa tients to wards pre ferred providers? An em pir i cal studyBoo nen L. (Eras mus Uni ver si ty, Rot ter dam, Nether lands)Schut FT.

Aim: This pa per in ves ti gates the ef fects of var i ous in cen tive mech a-nisms em ployed by health in sur ers to chan nel con sumers to wards pre-ferred phar ma cies. Meth od: Us ing two datasets on in di vid u al choice of phar ma cy from two dif fer ent Dutch health in sur ers (N≈45,466), we ex am ine the im pact of fi nan cial and non-fi nan cial in cen tives on provider choice for dif fer ent types of con sumers. We es ti mate a log it mod el of phar ma cy choice in which the var i ous in cen tives to vis it a pre ferred phar ma cy, dis tance (as a proxy for time price) and con sumer char ac ter is tics are the most im por-tant ex plana to ry vari ables.Re sults: Con sumer choice of phar ma cy ap pears to be quite sen si tive to the fi nan cial in cen tives, while the non-fi nan cial in cen tives ap pear to be a less ef fec tive chan nelling de vice. The main driv er of con sumer choice, how ev er, ap pears to be the dis tance from the home ad dress to wards the phar ma cy.Con clu sion: The re sults show that, even though rel a tive ly few con-sumers switched to a pre ferred phar ma cy, (fi nan cial) in cen tives have a sig nif i cant ef fect on con sumer choice of phar ma cy. Dis tance ap pears to play a dom i nant role in the choice of phar ma cy by con sumers. Par tic-u lar ly in non-ur ban re gions, this may lim it the op por tu ni ties for health in sur ers to chan nel their sub scribers to pre ferred phar ma cies.

0498

Striv ing af ter the gen er al ex ten sion of the trans par ent cov er age pol i cy sys tem – trans for ma tion of cov er age sys tem over med i cal de vicesBorc sek B. (Min istry of Health, Bu dapest, Hun gary)Dózsa Cs., Bon cz I., Nagy J., Daub n er M., Rup nik E., Ilku L, Lakatosné Kovács A.

Back ground: The rapid suc ces sion of health tech nolo gies press es fi-nancers to eval u ate con stant ly which health tech nolo gies are to be sub si-dized, which aren’t. In or der to man age this dif fi cul ty in Hun gary the Na-tion al Health In sur ance Fund Ad min is tra tion(NHI FA) and the Min istry of Health(MOH) have de vel oped a com plex cov er age pol i cy sys tem. Ob jec tives: The main ob jec tives are re al iz ing cost-ef fec tive health care through eco nom ic eval u a tions and HTAs, mak ing de ci sions in the in ter-ests of the pa tients, and max i miz ing the so cial ben e fits. Meth o dol o gy: At first the cov er age pol i cy sys tem of phar ma ceu ti cals has been de vel oped, be cause in con se quence of the EU ac ces sion Hun-gary had to adapt the trans paren cy di rec tive in the re im burse ment pol i-cy. The fu ture aim was the gen er al ex ten sion of the trans par ent cov er age pol i cy sys tem for the med i cal de vices and med i cal pro ce dures. Find ings: The MOH and the NHI FA have been very keen on ex tend ing the pre dictable, trans par ent re im burse ment pro cess over oth er health

S20 | Eur J Health Econom Suppl 1 · 2006

tech nolo gies as med i cal de vices, di ag nos tic and sur gi cal tech nolo gies ap ply ing the ex pe ri ences about the cur rent sys tem on the phar ma ceu ti-cal re im burse ment be cause only a com pre hen sive cov er age pol i cy can en sure that cost-ef fec tive ness be a ma jor as pect of the de ci sion mak-ing pro cess on whether some thing should be fund ed or not. The le gal frame work and the pro ce dure – which are un der de vel op ment – are based on the meth ods and ex pe ri ences of the phar ma ceu ti cal cov er-age sys tem but dif fer ent ap proach es have been tak en into con sid er a-tion be cause of the spe cif ic na ture of these types of tech nolo gies. We would like to demon strate the ex pe ri ences of the cod i fi ca tion pro cess, the change-over stage and the fur ther aims pre sent ing some con sid er-able cas es(eg. DES) on this top ic.

0352

Ad verse se lec tion and risk equal iza tion in the ital ian in sur ance mar ketsBor gia P. (CEIS SANI TA, Rome, Italy)Doglia M.

Fore word prob lem to fi nan cial cov er health ex pens es rep re sents a sub-ject of cen tral im por tance not only for the dis tri bu tion of re sources with-in the pub lic health sec tor, but also for the of fer of ser vices stem ming from it. The pri vate health sec tor con tributes to the in crease of op por-tu ni ties for treat ment and it of ten rep re sents a more flex i ble al ter na tive to the sat is fac tion of in di vid u al pref er ences., data bank and method ol o-gyaim of the pa per is to an a lyse the eco nom ic health risk of an in sured sam ple. This has been ob tained by a mul ti var i ate anal y sis and re gres-sion on data col lec tion com ing from Bank of Italy, Na tion al In sti tute for Sta tis tics, De part ment of Health and Ital ian As so ci a tion of In sur-ers. In par tic u lar the con sump tion be haviours, the in come bal ances and their de mo graph ic and pro fes sion al char ac ter is tics have been ob served.health ex pens es are main ly sus tained di rect ly by con sumers while only a re sid u al part of it is guar an teed through a vol un tary health in sur ance.in sur ance con tributes to an im prove ment of ac cess op por tu ni ties in treat ment ser vices. How ev er its de vel op ment is still lim it ed.study shows as ad verse se lec tion rep re sents one of the main ob sta cles for a fu ture in te gra tive health in sur ance de vel op ment and sug gests some in ter ven-tions for risk equal iza tion.

0079

Cost-eff ec tive ness of a dis ease man age ment pro gram for ma jor de pres sion in el der ly pri ma ry care pa tientsBosmans J. (EMGO-In sti tu ut, Ams ter dam, The Nether lands)Brui jne M., Hout H., Mar wi jk H., Beek man A., Bouter L., Stal man W., Tul der M.

Back ground: Ma jor de pres sion is a com mon dis or der in old er adults and is as so ci at ed with in creased health care costs. De pres sion of ten re mains un rec og nized and un der treat ed in old er adults, es pe cial ly in pri ma ry care.Ob jec tive: To eval u ate the cost-ef fec tive ness of a dis ease man age ment pro gram for ma jor de pres sion in el der ly pri ma ry care pa tients com-pared with usu al care.De sign: Eco nom ic eval u a tion along side a clus ter ran dom ized con-trolled tri al.Meth ods: Clin i cal out come mea sures were sever i ty of de pres sion, re cov-ery from de pres sion and qual i ty of life. Re source use was mea sured over a 12 month pe ri od us ing in ter views and was sub se quent ly val ued us ing cost prices. Con fi dence in ter vals around cost dif fer ences and the un cer tain ty sur round ing the cost-ef fec tive ness es ti mates were es ti mat-ed us ing boot strap ping.Re sults: There were no sig nif i cant dif fer ences in clin i cal out comes be tween the in ter ven tion and usu al care group. Mean to tal costs were €1784 in the in ter ven tion and €1898 in the usu al care group. The dif fer-

ence was not sta tis ti cal ly sig nif i cant (mean dif fer ence –€114, 95% CI –€1003; €933). Cost-ef fec tive ness planes in di cat ed that there were no sig-nif i cant dif fer ences in cost-ef fec tive ness be tween the two groups.Con clu sion: This dis ease man age ment pro gram for ma jor de pres sion in el der ly pri ma ry care pa tients had no sig nif i cant ef fects on clin i cal out-comes, costs and cost-ef fec tive ness. There fore, con tin u ing usu al care is rec om mend ed.

0556

Fourth hur dle in Hun gary – lat est de vel op ments and fu ture chal lengesBrandt muller A. (Cen ter for Pub lic Aff airs Stud ies, Bu dapest, Hun gary)Karpati K., Bon cz I., Gu lac si L.

Ra tio nale: The fourth hur dle is a live ques tion in the Hun gar i an health care sys tem. The pur suit of a more pru dent health ser vice pro vi sion, bud get con straints and the new reg u la tion in tro duc ing the fourth hur-dle in the phar ma ceu ti cal mar ket en cour age a new way of think ing. The Hun gar i an health eco nom ic guide line was de vel oped on the ground of in ter na tion al coun ter parts and was is sued in the of fi cial gazette of the Min istry of Health in 2001. Af ter join ing the EU and with the pro mul-ga tion of the new leg is la tion its rec om men da tions are sup posed to be fol lowed in health eco nom ic anal y ses.Ob jec tives: The study aimed to in ves ti gate the re cent phar ma ceu ti cal cov er age de ci sions and the op por tu ni ties for de vel op ment some years af ter the is sue of the Hun gar i an health eco nom ic guide line.Meth ods: We in ves ti gat ed the dos sier of 25 in no va tive drugs sub mit ted re cent ly, to see if ba sic in for ma tion are avail able for de ci sion-mak ers.Re sults: There are en cour ag ing de vel op ments in reg u la tion and in sti tu-tion al iza tion: a new HTA in sti tuiton and de ci sion pro cess es were es tab-lished. How ev er, co heren cy and trans paren cy of cov er age de ci sions, and the use of eco nom ic ev i dences are still to be im proved. Anal y sis of 25 dossiers showed that de ci sions are pri mar i ly ground ed on clin i cal ef fec-tive ness and im por tance for pub lic health. The size of the tar get pop u-la tion, bud get im pact and Hun gar i an cost-ef fec tive ness ev i dence are rarely avail able, how ev er in ter na tion al clin i cal ev i dences and HTAs are pre sent ed. The biggest chal lenges are to elim i nate the con sid er able short-age of Hun gar i an data, and to pro mote the trans fer abil i ty of in ter na tion-al anal y ses.

0314

Ref er ence pric ing of phar ma ceu ti calsBrekke K.R. (Nor we gian School of Eco nomics and Busi ness Ad min is tra-tion, De part ment of Eco nomics, Bergen, Nor way)König bauer I., Straume O.R.

We con sid er a ther a peu tic mar ket with po ten tial ly three phar ma ceu ti-cal firms. Two of the firms of fer hor i zon tal ly dif fer en ti at ed brand-name drugs. One of the brand-name drugs is a new treat ment un der patent pro tec tion that will be in tro duced, if the prof its are suf fi cient to cov er the en try costs. The oth er brand-name drug has al ready lost its patent and faces com pe ti tion from a third firm of fer ing a ge ner ic ver sion per-ceived to be of low er qual i ty. This mod el al lows us to com pare ge ner ic ref er ence pric ing (GRP), ther a peu tic ref er ence pric ing (TRP), and no ref er ence pric ing (NRP). We show that com pe ti tion is strongest un der TRP, re sult ing in the low est drug prices (and med i cal ex pen di tures). How ev er, TRP also pro vides the low est prof its to the patent-hold ing firm, mak ing en try of the new drug treat ment least like ly. Sur pris ing-ly, we find that GRP dis torts drug choic es most, ex pos ing pa tients to high er health risks.

Eur J Health Econom Suppl 1 · 2006 | S21

0125

The short age of or gansBrey er F. (Uni ver si ty of Kon stanz, Ger many)Kliemt H.

In Ger many, as in oth er Eu ro pean coun tries, there is a se vere short age of do nor or gans. In par tic u lar with kid neys, the an nu al num ber of new en tries to the wait ing list ex ceeds the num ber of trans plan ta tions by more than 1,000, and hun dreds of pa tients on the wait ing list die ev ery year. Fur ther more, while 2 out of 3 Ger mans de clare their “prin ci pal will-ing ness” to do nate their or gans af ter death, only 12 per cent pos sess a do nor card. The pa per is or ga nized in three parts. Part 1 pro vides es ti-mates of the an nu al de mand and the po ten tial sup ply of do nor or gans. Part 2 iden ti fies rea sons why the ac tu al sup ply re mains far be low po ten-tial sup ply. Em pha sis is placed on in suf fi cient re im burse ment for hos-pi tals and lack ing in cen tives for po ten tial or gan donors. Part 3 is de vot-ed to an anal y sis of pos si ble reme dies. The con tro ver sial lit er a ture on a num ber of rad i cal re forms (such as the pre sumed con sent mod el, re ciproc i ty in or gan al lo ca tion and pay ments to liv ing kid ney donors) are dis cussed in de tail. The au thors con clude that the or gan short age is due not to a law of na ture but to in ap pro pri ate so cial in sti tu tions.

0074

Pa tients’ pref er ences for health care sys tem re forms in Hun garyAkkazie va B. (Uni ver si ty of Hei del berg, Ger many)Gu lac si L., Brandt muller A., Pen tek M., Bridg es J.

Re cent ly, there is a grow ing fo cus on pa tients’ opin ions/pref er ences to de vel op a bet ter ev i dence base for health care poli cies. The ob jec tive of the study is to un der stand pa tient pref er ences for health care re forms in Hun gary as a means of in form ing the fu ture health care pol i cy. A con-joint anal y sis was de signed and ad min is tered to the study pop u la tion with in rheu ma tol o gy out-pa tient cen tre in Flór Fer enc Coun ty Hos pi-tal, Hun gary. At tributes and at tribute lev els were de vel oped on the ba sis of key in for mant in ter views and lit er a ture re view. A mixed ef fects lin ear prob a bil i ty mod el was es ti mat ed, hold ing all re spon dent char ac ter is tics con stant and cor rect ing for clus ter ing. Con joint Anal y sis ques tion naires were dis tribut ed by a phy si cian to the pa tients in a clin ic and ad di tion al-ly mailed by post. Re gres sion re sults (R2=56.8%) in di cat ed that pa tients pre ferred a health sys tem that was not to be cost con strained (P=0.003), one that was based on sol i dar i ty (P=<0.001) and one where pa tients were em pow ered (P=0.024). Fur ther, they would choose a sys tem with no choice over provider to avoid pay ing a co-pay ment (P=0.005). This study demon strates that pa tients have clear pref er ence over health care sys tem’s pol i cy so that the stat ed pref er ence meth ods, such as con joint anal y sis, could be used to de vel op ev i dence based health care pol i cy.

0562

Cost-eff ec tive ness as sess ment of in fl ix imab ther a py in Hun gary – ad ap ta tion of a Swedish rheu ma toid ar thri tis studyBrod szky V. (Corv i nus Uni ver si ty of Bu dapest, Hun gary)Má jer I., Pén tek M., Ko belt G., Gulác si L.

Ob jec tives: Sev er al stud ies have shown the cost-ef fec tive ness of in flix-imab, an ef fec tive but cost ly new bi o log i cal drug in rheu ma toid ar thri tis (RA). Hun gary is fac ing the dif fi cul ties of in tro duc ing the “fourth hur-dle” once cost-ef fec tive ness anal y sis is a de mand be fore re im burse ment but re sources are lim it ed for health tech nol o gy as sess ments. The aim of our study was to as sess the cost-ef fec tive ness of in flix imab in RA in Hun-gary us ing coun try-spe cif ic eco nom ic and health sta tus data and clin i-cal re sults of a Swedish fol low up study. Our anal y sis should serve first

ex per i men tal re sults of the method olog i cal is sues emerg ing with the ad ap ta tion of in ter na tion al cost-ef fec tive ness mod els into a new Eu ro-pean Union mem ber state.Ma te ri als and meth ods: The anal y sis was based on our pre vi ous cost-of-ill ness study in volv ing 255 RA pa tients in Hun gary, which has es tab-lished the costs, dis ease ac tiv i ty and health sta tus on dif fer ent dis ease sever i ty lev els. Pa tients who are can di dates for bi o log ic ther a py and cor-re spond to the sam ple of the Swedish study were se lect ed. We es ti mat ed the util i ty gain of 1 year in flix imab treat ment in the Hun gar i an pa tients us ing the re sults of the clin i cal study, with sen si tiv i ty anal y sis for three dif fer ent as sump tions. To as sess the mar gin al costs of in flix imab ther a-py we con sid ered the tran si tions of pa tients be tween dif fer ent dis abil i-ty lev els and the con se quent cost-sav ings, in volv ing treat ment costs of in flix imab ther a py in Hun gary. The time ho ri zon of the anal y sis was 1 year. Both di rect and fric tion cost meth ods and hu man-cap i tal ap proach were used.Re sults: 43 pa tients were el i gi ble for the cri te ria. The mean util i ty gain (QALY) was 0,338-0,372 ac cord ing to the var i ous as sump tions. Cost-sav ing af ter 1 year in flix imab ther a py was 155 EUR (only di rect costs), 380 EUR (fric tion cost meth od) and 544 EUR (hu man cap i tal ap proach). The in cre men tal cost-ef fec tive ness was es ti mat ed as 25833–189570 EUR/QALYCon clu sion: Our re sults of fer ba sic pre lim i nary data on the cost-ef fec-tive ness of in flix imab in Hun gar i an RA tar get pop u la tion. Though our study has lim i ta tions, our re sults re flect that it is with in the gen er al ly ac cept ed thresh old also in Hun gary. Our study con firmed that col lab o-ra tion be tween health tech nol o gy as sess ment units and har mo niza tion of the meth ods used might speed up and give a pos i tive spin to the com-pre hen sive im ple men ta tion of “fourth hur dle” in the EU.

0243

A dol lar is a dol lar is a dol larBrouw er W. (De part ment of Health Pol i cy & Man age ment Uni ver si ty Rot ter dam, Nether lands)Exel NJA., Bal tussen R., Rut ten FFH.

It is nor mal ly stat ed that an eco nom ic eval u a tion should take the so ci-etal per spec tive and that this im plies the in cor po ra tion of all costs and ef fects, re gard less of where these oc cur. How ev er, this broad per spec-tive may be in con flict with the nar row er per spec tive of the health care de ci sion mak ers we are try ing to aid. We ar gue that not all costs have to be con sid ered equal ly im por tant for health care de ci sion mak ing and that there is a dis crep an cy be tween the eco nom i cal ly pre ferred so ci etal per spec tive and the aim of aid ing health care de ci sion mak ers. This is re lat ed to the the o ry of lo cal op ti mal i ty. Three rea sons why some costs may be con sid ered more im por tant for health care de ci sion mak-ers than oth ers are (i) rel e vance, (ii) eq ui ty and (iii) re spon si bil i ty. sug-gest that it may be use ful to adopt a two-per spec tive ap proach as a stan-dard, pre sent ing one cost-ef fec tive ness ra tio fol low ing a strict health care per spec tive and one fol low ing the com mon so ci etal per spec tive. The health care per spec tive may as sist the health care pol i cy mak er bet-ter in achiev ing health care goals, while the so ci etal per spec tive in di-cates whether the lo cal op ti mal i ty of the nar row health care per spec-tive is also in line with so ci etal op ti mal i ty. More re search on ac tu al de ci-sions should pro vide more in sight into the rel a tive weights at tached to dif fer ent types of costs.

0445

Pro vid ing In for mal care, what does it mean? W.Brouw er (De part ment of Health Pol i cy & Man age ment Uni ver si ty Rot ter dam, Nether lands)

In this pre sen ta tion, we pro vide an overview of all rel e vant con cepts re lat ed to in for mal care. The fol low ing is sues will be pre sent ed, both

S22 | Eur J Health Econom Suppl 1 · 2006

the o ret i cal ly as em pir i cal ly: ap pro pri ate mea sure ment of in for mal care tasks per formed, mea sure ment of time in vest ed, op por tu ni ties sac ri-ficed due to pro vid ing in for mal care, mea sure ment of the psy cho log i-cal bur den of care giv ing, iden ti fy ing and mea sur ing the pro cess util i-ty of pro vid ing in for mal care, the qual i ty of life of the care giv er. The au thors pres ent many em pir i cal re sults for in for mal care givers pro vid-ing care for var i ous pa tient groups.

0142

The Em pir i cal Re la tion ship be tween Com mu ni ty So cial Cap i tal and the De mand for CigarettesBrown T. (Uni ver si ty of Cal i for nia at Berke ley, USA)Scheffl er R.M., Suky ong S., Reed M.

We show that com mu ni ty so cial cap i tal is in verse ly and strong ly re lat ed to the num ber of cigarettes that smok ers con sume. We do not find com-mu ni ty so cial cap i tal to be re lat ed to the de ci sion to par tic i pate in smok-ing for adults. Us ing a new val i dat ed mea sure of com mu ni ty so cial cap-i tal, the Petris So cial Cap i tal In dex and three years (1998–2000) of U.S. data on 38,807 adults, we es ti mate a two-part de mand mod el in cor po-rat ing the fol low ing con trols com mu ni ty-lev el fixed ef fects, price in clud-ing ex cise tax es, fam i ly in come, a smug gling in di ca tor, non smok ing reg-u la tions, ed u ca tion, mar i tal sta tus, sex, age, and race/eth nic i ty.

0032

Macroe co nom ic Con di tions, Mor tal i ty and HealthBuch mueller T. (Uni ver si ty of Cal i for nia, Irvine, USA)Grignon M., Ju sot F., Per ronnin M.

In con trast to the con ven tion al be lief that health de te ri o rates dur ing eco-nom ic down turns, a grow ing body of re search sug gests that mor tal i ty and mor bid i ty de cline when the econ o my tem porar i ly weak ens. Since most stud ies in this area use data from the U.S., it is not clear whether this re la-tion ship holds in oth er coun tries or is an ar ti fact of the unique fea tures of the U.S. health care sys tem and so cial safe ty net. This pa per ex tends the lit-er a ture by us ing ag gre gate and in di vid u al-lev el data from France to in ves-ti gate the re la tion ship be tween macroe co nom ic con di tions and health out-comes. The ag gre gate anal y sis is based on data on mor tal i ty and un em-ploy ment rates from each of France’s 95 dé parte mentes for the 1982-2004 pe ri od. In ad di tion to ex am in ing the re la tion ship be tween over all mor tal i-ty and un em ploy ment, we con duct sep a rate anal y ses by source of mor tal i-ty. The in di vid u al-lev el data come from the Enqu&ecirc;te sur la San té et la Pro tec tion So ciale (ESPS), a sur vey of the French pop u la tion that has been con duct ed bi en ni al ly since 1988. The ESPS pro vides de tailed in for-ma tion on health sta tus, health be hav iors and the uti li za tion of med i cal care. We re late sev er al health out comes to lo cal eco nom ic con di tions, con-trol ling for in di vid u al de mo graph ic and so cioe co nom ic char ac ter is tics, gen er al time trends and area fixed ef fects.

0174

Health fi nanc ing in high in come coun tries: lessons for coun tries in tran si tion Busse R. (De part ment for Health Care Man age ment, Ber lin Uni ver si ty of Tech nol o gy, Ber lin, Ger many)Schreyögg J.

Ob jec tives: The aim of this study is to re view ev i dence on health fi nanc-ing ar range ments in high in come coun tries over the last 30 years and to iden ti fy and eval u ate key pol i cy lessons from this ex pe ri ence for low and mid dle in come coun tries. Meth o dol o gy: The pre sent ed re view is based on a con cep tu al frame-work of health fi nanc ing “func tions”. Coun tries have been grouped for

com par a tive eval u a tive pur pos es into three groups, based on the main mech a nism of fi nanc ing health care. De ci sions on cov er age and ben e-fit en ti tle ments as well as var i ous func tions of health care fi nanc ing (i.e. col lect ing, pool ing and pur chas ing) of 25 high in come coun tries are de scribed and an a lyzed.Re sults: The pool ing func tion is most es sen tial in or der to pro vide cov-er age to as many in di vid u als as pos si ble, thus re duc ing their fi nan cial risk be ing the prin ci pal aim of pub lic health fi nanc ing. Pri vate health in sur ance, med i cal sav ings ac counts and oth er forms of pri vate re source col lec tion can only be sup ple men tary mod els for in creas ing uni ver sal cov er age. The evo lu tion of health fi nanc ing schemes to wards uni ver sal cov er age was pret ty sim i lar in the in clud ed coun tries. Next to the pre-con di tion of eco nom ic growth, the most es sen tial lessons are to ini ti-ate pi lots for vol un tary health in sur ance, to fos ter the abil i ty to ad min-is trate, to en sure po lit i cal com mit ment to ex pand pop u la tion cov er age, to com bine ex pan sion of pop u la tion cov er age with risk-pool ing and to en sure eval u a tion of prod ucts and ser vices at each stage.

0441

What is in the health care bas ket, who de cides and what cri te ria are tak en into ac count? Rein hard B. (De part ment for Health Care Man age ment, Ber lin Uni ver si ty of Tech nol o gy, Ger many)

Ob jec tives: The ob jec tive is to iden ti fy and an a lyse a frame work for health bas kets, the tax on o my of ben e fit cat a logues for health care ser-vices and the cri te ria for the in- or ex clu sion of ben e fits in nine EU mem-ber states (Den mark, France, Ger many, Hun gary, Italy, the Nether lands, Poland, Spain and Unit ed King dom). Meth ods: An open ques tion naire was de vel oped, fol low ing the frame work of func tion al cat e gories of the OECD’s “Sys tem of Health Ac counts”. Re searchers in each coun try were asked to iden ti fy the de ci-sion-mak ing pro cess es on the ben e fit bas ket as a whole in their coun try and to pro vide a de tailed de scrip tion of the ex ist ing ben e fit cat a logues for each func tion al cat e go ry, the ac tors in volved in de ci sion-mak ing and the de ci sion cri te ria.Re sults: It turns out that the ex plic it ness of ben e fit cat a logues varies large ly be tween the coun tries. In the ab sence of ex plic it ly de fined ben e-fit cat a logues, in- and out pa tient re mu ner a tion schemes have de-fac to the char ac ter of de-fac to ben e fit cat a logues. The cri te ria for the in- or ex clu sion into ben e fit cat a logues are of ten not trans par ent and (cost)-ef fec tive ness is only ap plied for cer tain sec tors. Con clu sion: An EU-wide har mon i sa tion of ben e fit bas kets does not seem re al is tic in short or me di um term as the vari a tion of cri te ria and the tax onomies of ben e fit cat a logues are large but not in sur mount able. There may be scope for a Eu ro pean core bas ket.

0225

Test ing lin ear re stric tions in the anal y sis of data from dis crete choice ex per i mentsCairns J. (Health Ser vices Re search Unit, Pub lic Health and Pol i cy, Lon don School of Hy giene and Trop i cal Med i cine, Lon don, UK)

A com mon meth od of an a lys ing dis crete choice data is by use of dif-fer ence mod els, where the dif fer ence in at tribute lev els be tween two op tions are en tered as in de pen dent vari ables. The im plic it as sump-tion is usu al ly that there is a lin ear re la tion ship be tween dif fer ences in at tribute lev els and the strength of pref er ence for one op tion over an oth er. In cas es where the at tribute is not mea sured con tin u ous ly one an a lyt i cal op tion is to mea sure the dif fer ences in lev els. This im pos es the re stric tion that the dif fer ence be tween lev el i and lev el i+1 has the same sig nif i cance as the dif fer ence be tween lev el i+1 and lev el i+2. This might be a rea son able ap prox i ma tion in some cir cum stances but par tic-

Eur J Health Econom Suppl 1 · 2006 | S23

u lar ly when the at tribute is mea sured or di nal ly rather than on an in ter-val scale this should be test ed rather than as sumed. Even for dif fer ences mea sured on an in ter val scale the as sump tion of lin ear i ty may not be valid and should be test ed. This pa per shows how the re stric tion can be test ed and il lus trates the im pli ca tions of al ter na tive as sump tions us ing two datasets, one on pref er ences over den tal res to ra tions, and the oth-er con cern ing as sess ments of health risk by divers and oth er off shore work ers.

0173

Med i cal tourism and its im pli ca tions for the sin gle mar ketCar rera P. (Uni ver si ty of Hei del berg – Med i cal School, Hei del berg, Ger many)Bridg es J.

Faced with long wait ing lists and the high cost of pri vate treat ment, pa tients from de vel oped coun tries are seek ing treat ment abroad. This has led to the rise of med i cal tourism as a growth in dus try for de vel op-ing coun tries and, with in the EU, among new EU mem ber states not least be cause of EU reg u la tions and low er prices. To be sure how ev er, even Ger many and France are in creas ing ly pro vid ing med i cal ser vices to Eu ro pean and in ter na tion al pa tients. Un for tu nate ly, giv en the pauci-ty of for mal lit er a ture and con cep tu al im pre ci sion, bet ter un der stand ing of med i cal tourism is hin dered. We of fer a sys tem at ic lit er a ture re view of the term “tourism” in the con text of health care us ing the Med line database. Based on the re view, we de fined med i cal tourism as the or ga-nized trav el out side one’s nat u ral health care ju ris dic tion for the res-to ra tion of the in di vid u al’s well-be ing in mind and body. Build ing on this def i ni tion, we pro vide an overview of the med i cal tourism mar-ket in Eu rope, map ping out the di rec tion of trade be tween health care sys tems par tic u lar ly the main play ers in the pro vi sion of med i cal care. Is sues such as the push fac tors driv ing pa tients to seek health care out-side of their sys tems and the im pact of the rise of med i cal tourism are like wise ex plored.

0308

The ‘ACE’ Ap proach to Pri or i ty Set ting in Aus tralia: Back ground and Progress To Date Carter R. (Uni ver si ty of Mel bourne, Aus tralia)Vos T.

While the im por tance and need for pri or i ty set ting in the health sec tor is clear ly es tab lished, the cen tral ques tion of how pri or i ty set ting is to be achieved re mains con test ed. In this talk the gen e sis and ap pli ca tion of an in no va tive Aus tralian ap proach to pri or i ty set ting (called “ACE” – As sess ing Cost Ef fec tive ness) is pre sent ed.The start ing point for ACE was the de vel op ment of a check list on what con sti tutes an “ide al” ap proach to pri or i ty set ting. The check list in cor po-rates guid ance from eco nom ic the o ry, from em pir i cal ex pe ri ence, from eth ics and so cial jus tice and from the more prag mat ic needs of de ci sion-mak ers. The “ACE Ap proach” is in no va tive in its close at ten tion to tech-ni cal rigour (in the eco nom ic and epi demi o log i cal anal y ses), bal anced by a con cern for “due pro cess” and in clu sion of broad er con sid er a tions through a sec ond-stage fil ter anal y sis. The fil ters in clude ‘eq ui ty’; ‘ac cept-abil i ty to stake hold ers’; and ‘fea si bil i ty of im ple men ta tion’.The ACE ap proach has now been tri aled in four stud ies in Aus tralia (in can cer; men tal health; heart dis ease; and obe si ty pre ven tion) fund-ed by gov ern ment or through the com pet i tive grant pro cess. A fur ther ma jor study has com menced on the pre ven tion of non-com mu ni ca ble dis ease. In a com pan ion talk, the ACE: Obe si ty study will be pre sent-ed in more de tail.

0359

Ex plain ing in come-re lat ed in equal i ties in health care util i sa tion in Eng land, Scot land and WalesCastel li A. (Cen tre for Health Eco nomics, York, UK)

De cen tral i sa tion of the health care sec tor has been a pop u lar pol i cy re form in the last decade. The ef fects of this re form are nei ther thor ough-ly in ves ti gat ed nor com plete ly un der stood. On the one hand, de cen tral i-sa tion of the health care sec tor can jeop ar dise eq ui ty if in di vid u als who are “equal” in ev ery re spect but the ju ris dic tion in which they hap pen to live are treat ed dif fer ent ly than they would be in a more cen tralised struc ture. On the oth er hand, how ev er, it may be ben e fi cial to lo cal ju ris-dic tions as these will be able to tai lor the pro duc tion and pro vi sion of health care goods and ser vices to lo cal needs and pref er ences. First, we in ves ti gate how the de cen tral i sa tion of the health care sec tor af fects eq ui-ty in health care util i sa tion with in a de cen tralised sys tem, us ing the con-stituent coun tries of Great Britain as a case study. Data are tak en from the Gen er al House hold Sur vey from 1995/96. The util i sa tion of pri ma-ry and sec ond ary care is prox ied by GP vis its, out pa tient vis its and in pa-tient stays. Sec ond ly, we an a lyse the de ter mi nants of in come-re lat ed in equal i ties in health care use ob served in Eng land, Scot land and Wales be fore the dev o lu tion re form and how these have been af fect ed by the re form it self through a de com po si tion ap proach.

0085

A new ap proach to mea sur ing health sys tem out puts and pro duc tiv i tyAdri an na C. (Cen tre for Health Eco nomics, York, UKnit ed King dom)Daw son D., Grav elle H., O’Ma ho ny M., Street A., Weale M., Ja cobs R., Mar tin S., Stevens P., Stokes L.

The pro duc tiv i ty of the health sys tem should cap ture the valu able things that the health sys tem pro duces. This is not straight for ward be cause of dif fi cul ties in defin ing health care out puts and of at tach ing val ues to the out puts. We pro pose two new meth ods for mea sur ing out put growth. An ‘ide al’ val ue weight ed out put in dex has two fun da men tal fea tures. First, the val ue at tached to each out put re flects its rel a tive con tri bu tion to health out comes and, sec ond, the val ue of oth er im por tant char ac-ter is tics of health care, such as the pro cess of care de liv ery, can be read-i ly in cor po rat ed. Com pre hen sive cal cu la tion of this in dex is cur rent ly un fea si ble be cause of a lack of health out come data. In the mean time an ‘in ter im’ cost weight ed out put in dex is pro posed, which in cor po rates qual i ty ad just ments. We cal cu late the ‘ide al’ in dex for a lim it ed set of ‘spec i men’ ac tiv i ties, for which data on health out comes are avail able, and the ‘in ter im’ in dex for the En glish NHS from 1999/99 to 2003/04. This in ter im in dex is com bined with a mea sure of in put growth to as sess to tal fac tor pro duc tiv i ty growth over the pe ri od.

0409

The de ter mi nants of re gion al health ex pen di ture in a de cen tral ized sys temCav a lieri M. (Uni ver si ty of Cata nia, De part ment of Eco nomics and Quan ti ta tive Meth ods (DEMQ), Cata nia, Italy)Guc cio C.

In lat est years there has been a grow ing in ter est on fac tors ex plain ing health ex pen di ture at a re gion al lev el. The ex ist ing lit er a ture on the de ter mi nants of health ex pen di ture has fol lowed two dif fer ent ap proach-es. Pi o neer ing stud ies have fo cused on cross coun try health ex pen di-ture anal y ses but were not able to ap pro pri ate ly deal with the prob lem of coun try het ere o gene ity. Most re cent ly, few pa pers have re strict ed the anal y sis to sin gle coun tries with ei ther a fed er al sys tem (e.g. Can a da and Switzer land) or mul ti ple higly au ton o mous ju ris dic tions (e.g. Spain). In

S24 | Eur J Health Econom Suppl 1 · 2006

the case of Italy, even though the health sys tem was ini tial ly de signed as a cen tral ized one, the gov ern ment has pro gres sive ly un der tak en a de cen tral iza tion pro cess up to the point of mod i fy ing the Con sti tu tion in or der to ap point re gions with ex clu sive health care re spon si bil i ties. In this pa per, we anal ize data on re gion al per cap i ta health care ex pen di-ture (in real terms) for the pe ri od 1990-2003. The ob jec tive is to de ter-mine the ef fects of dif fer ent vari ables and to eval u ate the re sult ing im pli-ca tions for the de sign of a fi nan cial perequa tion mod el to be used in a fu ture fed er al sys tem.

0518

How Eq ui table is the Fi nanc ing of Health Care? The Case of MalaysiaChai P.Y. (Uni ver si ty of Not ting ham, UK)Whynes D.K., Sach T.H.

In tro duc tion: Eq ui ty is one of the cri te ri ons for as sess ing the per for-mance of health fi nanc ing sys tems. As a tax-fi nanced coun try, the Malaysian gov ern ment con tribute sub stan tial ly to wards fi nanc ing the health care ser vices. Even though both pub lic and pri vate sec tors con-tribute to the sys tem, ul ti mate ly, house holds bear the fi nan cial costs of health care ser vices.Ob jec tive: This study aims to com pre hen sive ly as sess the eq ui ty of health care fi nanc ing in Malaysia. It fo cus es on house holds’ pay ment for health care, in or der to de ter mine the dis tri bu tion of fi nan cial bur-den across house holds with dif fer ent abil i ty to pay. Meth ods: The data used was the House hold Ex pen di ture Sur vey Malaysia 1998/99. Four ap proach es are em ployed, i. The pro por tion ap proach, ii. The tab u la tion ap proach, iii. Con cen tra tion curves and iv. The Kak wani’s pro gres siv i ty in dex.Re sults: Re sults showed that Malaysia’s health fi nanc ing sys tem was slight ly pro gres sive, with a Kak wani’s pro gres siv i ty in dex of 0.0897. Such re sults are the off set ting ef fect from, i. Mild ly pro gres sive out-of-pock et pay ments (0.0093), ii. Pro gres sive pri vate in sur ance (0.2293), iii. Pro gres sive con tri bu tions to EPF and SOC SO (0.1194), iv. Re gres sive in di rect tax es (-0.1863), and v. Pro gres sive di rect tax es (0.3827).Con clu sions: The Malaysian ex pe ri ence has shown that the par al lel ex is-tence of pub lic and pri vate health care ser vices and in di vid u al’s health seek ing be hav iour pro duce a mild ly pro gres sive fi nanc ing sys tem.

0081

Fis cal sus tain abil i ty and the health fi nanc ing sys tems of South-East ern Eu ropeChakraborty S. (The World Bank, Wash ing ton DC, USA)Boskovic T.

The coun tries of South-east ern Eu rope (SEE) (Bosnia and Herze gov-ina, Croa t ia, FYR Mace do nia and Ser bia and Mon tene gro) are look ing to wards EU ac ces sion. Fis cal dis ci pline and ex pen di ture man age ment are key is sues. Pub lic spend ing on health is al ready high in these coun-tries. The SEE coun tries face the prospect of ag ing pop u la tions and grow ing de mand for bet ter qual i ty health ser vices. These fac tors are like ly to fuel the growth of pub lic spend ing on health. This means that SEE coun tries have to adopt health fi nanc ing stra te gies that cre ate fis cal sus tain abil i ty while pro mot ing qual i ty and ac cess. The study an a lyzes the un der ly ing de ter mi nants of the pat terns of health fi nanc ing and ex pen di tures in SEE coun tries and im pli ca tions for re forms. The study is based on an anal y sis of sec ond ary data (WHO Health for All database, World De vel op ment In di ca tors, gov ern ment data).The find ings are: (i) there is lit tle scope for in creas ing pub lic spend ing on health (ii) pub lic re sources are not fo cused on cost-ef fec tive health in ter ven tions and pub lic goods and mer it goods, (iii) health care in sti-tu tions have low pro duc tiv i ty, (iv) in a con text where un em ploy ment is high and there is tax eva sion, de pend ing on pay roll tax es is cre at ing fis-

cal sus tain abil i ty con cerns, (v) phar ma ceu ti cal ex pen di tures are a key cost driv er. Based on these find ings, the study pre sents pol i cy op tions for re forms.

0428

De vel op ment Phar ma cy-based Risk Ad just ment Mod elChang R.E. (Grad u ate In sti tute of Health Care Or ga ni za tion Ad min is tra tion, Col lege of Pub lic Health, Na tion al Tai wan Uni ver si ty, Taipei, Tai wan)Lai C.L., Hsieh M.F.

Di ag no sis-based ad justers and pre scribed drugs ad justers have at tract ed the re search at ten tion for their rich clin i cal mes sage. Re view ing med i cal ex pense struc ture in Tai wan, one-third of out pa tient med i cal ex pense is spent on pre scrip tion drugs, and chron ic dis ease pre scrip tions ac count for the main por tion in drug ex pens es. This study in tends to re fine di ag-nos tic risk ad justers with pre scrip tion in for ma tion to im prove the pre-dictabil i ty of risk ad just ment mod els in Tai wan. With de tailed en roll-ment data, med i cal ex pense data, and di ag nos tic and pre scrip tion data of con tract ed in sti tu tion in 2000 and 2001, the pre dictabil i ties of var i-ous risk ad justers were an a lyzed. The re sults show that more clin i cal in for ma tion im proves the pre dictabil i ty. Us ing pre scrip tion in for ma tion to re fine di ag no sis-based risk ad justers by split ting it into re fined cost groups can im prove the risk ad just ment mod el not only in r-squares but also pre dic tive ra tio of spe cif ic chron ic dis ease group, which can be of help to re duce risk se lec tion.

0586

Fis cal Sus tain abil i ty in Health in New EU Mem ber StatesMukesh C. (World Bank)

While GDP growth in new mem ber states is ro bust, the health sec tors con tin ue to roll up debt. Against this back drop, coun tries are also fac-ing ag ing pop u la tions, growth in med i cal tech nolo gies, and ris ing con-sumer ex pec ta tions. The pa per ex am ines trends and looks at im pacts of var i ous op tions to make ex pen di tures more sus tain able.

0421

High er Health state and health con sump tion for 50+ VPH in sured in Eu rope?Chevrou-Séver ac H. (IEMS (In sti tute of Health Eco nomics and Man age ment), Uni ver si ty of Lau sanne, Switzer land)Lufkin T., Hu gue nin J.

Back ground: In al most all Eu ro pean coun tries health cov er age or health in sur ance is com pul so ry for al most all peo ple, ir re spec tive of the type of health in sur ance scheme (Bev erid gian, Bis mar ck ian or pri vate com pul-so ry). As de fined by OECD (2004), VPHI could be of three cat e gories: du pli cate, sup ple men tary or com ple men ta ry. In the SHARE coun tries, the VPHI of fers are di rect ly linked to the health base line sys tem.Aim: We fo cus on the im pact on health sta tus of hav ing a VPHI, com-pared to the base line in sur ance scheme among peo ple aged 50 years old or more, from the Sur vey on Health, Ag ing and Re tire ment in Eu rope (SHARE).. Giv en the di ver si ty of health sys tems de scribed above and giv en that the SHARE dataset in cludes ques tions on the types of health care (HC) in sured by VPHI, it is pos si ble to spec i fy, by coun try, the dif-fer ent VPHI cov er age most ly cho sen by re spon dents. We then an a lyse the im pact of hav ing a VPHI on in di vid u al health sta-tus in each coun try. We ex pect that this ef fect tran sits also through high-er health care con sump tion. Do dif fer ences in health care con sump tion be tween peo ple hav ing a VPHI and peo ple not hav ing one ex ist? Do these dif fer ences have an im pact on health sta tus?

Eur J Health Econom Suppl 1 · 2006 | S25

How ev er, in the case of VPHI, we should first take ad verse se lec tion into ac count. It is de pends on ex pect ed health sta tus and HC con sump tion. More over, health states and health con sump tion are linked, and hav ing a VPHI could af fect health care uti li za tion and health sta tus. Know ing that health care con sump tion and health sta tus could also be si mul ta neous-ly de ter mined and/or en dog e nous, we an a lyse the im pact of VPHI on health sta tus thanks to a switch ing mod el with si mul ta ne ous equa tions. Meth o dol o gy: We tack le the ad verse se lec tion is sue with a Roy switch-ing mod el (Mad dala, 1983), with en dog e nous switch ing. The choice of hav ing a VPHI is gen er al ly made at younger ages. Hence forth, this de ci-sion de pends on past ex pect ed health state and/or health con sump tion, in for ma tion which is not ob served to day. This is sue could be cir cum-vent ed in the case of lon gi tu di nal data. In stead of this in for ma tion, we only ob serve a re al iza tion of this la tent vari able in the 1st wave of the SHARE data: the fact of be ing pri vate ly in sured to day. The VPHI par tic i pa tion cri te ri on will de ter mine if the ob served out-come is the one in the regime with VPHI, or in the regime with out. No tice that, in our spec i fi ca tion, the out come is com posed of two vari-ables: HC con sump tion and health sta tus.More over, self-per ceived health is also a la tent vari able. The re sponse de pends on a per son al ap praisal of one’s own health which is not ob serv-able. Hence forth, the Roy mod el is ful ly ap pro pri ate. First ly, the VPHI par tic i pa tion equa tion is es ti mat ed by a pro bit mod el. Sec ond ly, we es ti-mate two si mul ta ne ous equa tion sys tems. Both sys tems are com posed of one lin ear equa tion for health care con sump tion and one pro bit spec-i fi ca tion for self-per ceived health (SPH). The es ti ma tion of each sys tem is made through full in for ma tion max i-mum like li hood (FIML) es ti ma tion (Hu gue nin, 2004). This es ti ma tion meth od al lows to test first ly for en do gene ity be tween vari ables and, sec-ond ly, for si mul tane ity. Pre lim i nary re sults: Up to now, we have fo cused on three coun tries: Aus tria, Den mark and Italy. The first one has a Bis mar ck ian health sys-tem and the last two have a Bev erid gian one. Gen er al ly, be cause of the cross-sec tion al fea ture of the SHARE dataset, es ti mat ing ad verse se lec-tion ef fect is chal leng ing. More over, in the case of VPHI, in sur ers can deny or lim it cov er age be cause of pre-ex ist ing health con di tions. In Den mark, peo ple are most ly pri vate ly in sured for di rect and wider ac cess to GP and spe cial ists. First of all, in Den mark, there is no si mul-tane ity be tween HC con sump tion and SPH. Sec ond ly, SPH doesn’t have any im pact on HC con sump tion for VPH in sured and non VPH in sured. HC con sump tion is main ly de ter mined by ob jec tive health mea-sures. Con trary to our ex pec ta tion, HC con sump tion af fects SPH only for non VPH in sured peo ple.In Aus tria, peo ple are main ly pri vate ly in sured for ex tend ed or full hos-pi tal cov er age. This is con firmed by our pro bit es ti ma tion of VPHI par-tic i pa tion. Here again, we do not de tect si mul tane ity be tween HC con-sump tion and SPH. In both regimes, HC con sump tion is high ly sig nif i-cant in ex plain ing SPH. It is also the case in both regimes for the im pact of ob jec tive health mea sures on HC con sump tion and SPH. Here again, SPH does not ex plain HC con sump tion. In Italy, the rea sons to take a VPHI are more mixed. It can be for du pli-cate care, sup ple men tary or com ple men ta ry cov er age. More over, peo-ple can have an in di vid u al or a fam i ly con tract, and be in sured through their em ploy er or not. Fur ther more the OECD fig ures for pri vate in sur-ance are much high er than in the SHARE sam ple. It seems plau si ble that in sur ers refuse to in sure el der ly peo ple due to risk se lec tion. In both regimes, SPH is not af fect ed by HC con sump tion. For non pri vate-ly in sured peo ple, so cio-eco nom ic sta tus and chron ic dis eases in flu ence HC con sump tion. For pri vate ly in sured 50+ Ital ians, our spec i fi ca tion is less pow er ful in ex plain ing HC con sump tion. Our mod el prob a bly suf fers from the fact that we were forced to pool the dif fer ent rea sons for tak ing a VPHI.Ex ten sions: At this point, we are in the pro cess of pur su ing the anal y-sis for the re main ing SHARE coun tries. More over, we plan to ex tend the mod el to take HC qual i ty and ac cess into ac count. We also wish to an a lyse the Eu ro pean coun tries con junct ly, tak ing into ac count the dif-fer ences in base line health sys tem and also in pri vate health in sur ance.

Such a glob al ap proach is rel e vant in try ing to de ter mine if there are com mon fea tures across Eu rope.

0547

Is there a need for cen ters of ex cel lence in Greece?Christodoulou I. (Med i cal School, Dem o cri tus Uni ver si ty of Thrace, Thes sa loni ki, Greece)Pogo ni dis Chr., Xen o dox i dou E., Dri mala

AIM of this study is to ex am ine the opin ion of physi cians about the need for Cen ters of Med i cal Ex cel lence in Greece.Ma te ri al and meth ods: A ques tion naire was dis tribut ed in 85 physi-cians, 35 spe cial ists and 50 trainees. An swers were tak en from 9 dif fer-ent hos pi tals in Greece.Re sults: Many physi cians (69%) be lieve that sur gi cal op er a tions of ad vanced dif fi cul ty can be ex e cut ed in any Hos pi tal since “good name of sur geons and of Sur gi cal De part ments” de pends on them (25%). In a per cent age of 33%, doc tors con sid er that ther a py in a Cen ter of Ex cel lence is of ten not need ed, while the rest be lieve that only too old pa tients and pa tients with ad vanced ma lig nan cies might lose the chance of ad vanced med i cal ther a py.Cur rent ther a peu tic in ter ven tions held in Cen ters of Ex cel lence are most ly “over ther a py” ac cord ing to the 65%.In to tal, physi cians are not op po site to the idea of na tion al in sti tu tions of Ex cel lence (100%).Al most all trainees but only half of the spe cial ists wish to work in a Cen ter of Ex cel lence, even cir cum stan tial ly.Con clu sions: Cen ters of Ex cel lence of fer ad vanced health ser vices to the pub lic but have a spe cial role in the Na tion al Sys tem of Health. If Na tion al Health In sti tutes of Ex cel lence are es tab lished in Greece, they would at tract many physi cians, es pe cial ly the younger ones.

0070

Eco nom ic Re sources and Child HealthChung W. (Na tion al Uni ver si ty of Sin ga pore, Sin ga pore)

We use data from the In done sian Fam i ly Life Sur vey (IFLS) to ex am-ine the re la tion ship be tween child health and house hold eco nom ic re sources, and find that eco nom ic re sources as mea sured by equiv al ized ex pen di ture have a sta tis ti cal ly sig nif i cant pos i tive ef fect on child health. We make ad di tion al use of the data (where ex ten sive data on chil dren’s nu tri tion, house hold san i ta tion, the uti li za tion of med i cal care, and fam-i ly health sta tus are avail able) to as sess the mech a nisms through which eco nom ic re sources may af fect child health. We find ev i dence that eco-nom ic re sources have a siz able and sig nif i cant ef fect on these po ten tial in ter me di ary fac tors, and that they part ly ex plain the pro tec tive role of eco nom ic re sources in child health.

0412

Ex plana to ry fac tors of the in equal i ties in the util i sa tion of health care in SpainClavero A. (Uni ver si ty of Mála ga. Ap plied Eco nomics (Sta tis tics and Econo met rics), Mála ga, Es panol)González-Al va rez, Luz M.

This in ves ti ga tion tries to de com pose the de gree of in equal i ty in the health care util i sa tion into the con tri bu tions of some ex plana to ry fac-tors by Oax a ca ap proach. Due to the dif fer ent char ac ter is tics of the vis its to gen er al prac ti tio ner and to spe cial ists is re quired a sep a rate anal y sis for each med i cal care.Eu ro pean Com mu ni ty House hold Pan el (ECHP) has been the se lect ed in for ma tion source be cause it con tains in for ma tion about the util i sa tion of the afore said ser vices and about the gen er al health sit u a tion and so cio-eco nom ic char ac ter is tics. Oth er ad van tages of the ECHP are the mon i tor ing of a giv en sam ple of in di-

S26 | Eur J Health Econom Suppl 1 · 2006

vid u als over time, and thus per mit to mea sure the im pact of the pre vi-ous use on cur rent use. Oax a ca de com po si tion fo cus es on the gap in the util i sa tion be tween two groups pub lic and pub lic-pri vate in sur ance cov-er age. This gap can be at tributable to dif fer ences in the ex plana to ry fac-tors and to dif fer ences in the ef fects of each fac tor on the health care util-i sa tion of the two groups. The re sults sug gest that there are not greater gaps in GP vis its, but the gap in the prob a bil i ty of a vis it to spe cial ist is ex plained by the dif fer ences in in come and ed u ca tion and the elas tic i ty of util i sa tion re spect to the pre vi ous use.

0004

Phar ma ceu ti cal ex pen di ture, Health Care Ex pen di ture and GDPClemente J. (Zaragoza Uni ver si ty, Zaragoza, Spain)Mar cuel lo C., Mon ta&ntilde;es A.

AB STRACT ex pen di ture is one of the main com po nents of Health Care Ex pen di ture. In 1998, phar ma ceu ti cal ex pen di ture made up about 13% of to tal Health Care Ex pen di ture in Swe den and 11% in the Unit ed States. The evo lu tion of phar ma ceu ti cal ex pen di ture in re la tion to Gross Do mes tic Prod uct has marked ly in creased since the 1980, al though some coun tries have re cent ly man aged to re verse this ten den cy. The evo lu tion of Health Care Ex pen di ture has been anal y sed in nu mer ous stud ies and re sults have con firmed the ex is tence of a long-term re la tion-ship be tween Health Care Ex pen di ture and Gross Do mes tic Prod uct (GDP). Nev er the less, this re la tion ship is not a sta ble one as there is no com mon ly ap plied in ter na tion al norm and dif fer ing in come-elas tic i ties by groups of coun tries can be ob served (Clemente et al. 2004). In this study, we an a lyse the long-term re la tion ship be tween ag gre gate Health Care Ex pen di ture, Gross Do mes tic Prod uct and the ef fect of phar ma ceu-ti cal ex pen di ture on that re la tion ship.

0311

Do peers lifestyles in fl u ence obe si ty in ado les cents?Clí ma co M.I. (IS CAC-Coim bra Poly tech nic In sti tute, Coim bra, Por tu gal)Bar ros P.P., Lourenço Ó.

Frame work: Obe si ty is an im por tant prob lem of pub lic health, which is of ten ini ti at ed by un healthy be haviours dur ing ad o les cence. Food habits among young peo ple are gen er al ly in flu enced by their peers, the so-called “peer pres sure”, as well as oth er haz ardous con sump tions such as al co hol, to bac co and drugs. In this work, obe si ty is viewed as a house-hold pro duced good, and self-im age and so cial in ter ac tions are like ly to play a key role in de ter min ing ad o les cent weight.Ob jec tives: The main ob jec tive of this pa per is to iden ti fy the risk fac tors which may ex plain obe si ty/over weight among the group of ado les cents, ac cord ing to the Body Mass-for-age, a med i cal cri te ri on al ter na tive to the BMI adapt ed to ado les cents. More over, it aims to draw at ten tion to the di men sion of the prob lem in a risk group com posed of po ten tial fu ture obese adults, with all the as so ci at ed health costs. Par tic u lar at ten-tion is paid to the po ten tial in flu ence of the peer pres sure ef fect on obe si-ty, since con sump tion de ci sions are af fect ed by age peers. Meth o dol o gy and data: A re cur sive si mul ta ne ous equa tion mod el, in volv ing two bi na-ry choice vari ables, has been de vel oped, in cor po rat ing the im por tance of peer ef fects and to con trol its po ten tial en dog e nous na ture. Con trol vari-ables in clude age, gen der, school per for mance, fam i ly co he sion, friend-ship co he sion, so cial and eco nom i cal fam i ly lev el, food habits, sports prac tice, and con sump tion of ad dic tive sub stances. The data used are from a Por tuguese sur vey on the health of ado les cents made in 2002. The uni verse of this sur vey is com posed of stu dents in the 6th, 8th and 10th years of sec ond ary ed u ca tion, with ages be tween 11 and 25 years old.Con clu sions: The key find ing is that peer ef fects play a sig nif i cant role in the prob a bil i ty of obe si ty. Di et ing and cor po ral self-im age are also im por tant de ter mi nants of obe si ty.

0538

Casemix in Bel giumClo son M.C. (Uni ver si ty of Bel gium)

APRDRGs are ac tu al ly used for the fi nanc ing of the day of stay for all acute hos pi tals (45% of hos pi tal fi nanc ing) in Bel gium and are pro gres-sive ly used in the fi nanc ing of the med i cal ser vices and drugs. Prospec-tive pay ment is based on mean length of stay or lump sum by ad mis-sion ac cord ing to APRDRGs and lev els of sever i ty. A re search has been made on the im pact of the im ple men ta tion of a prospec tive pay ment of the days of stay in 1995 in Bel gium on a data base in clud ing all acute hos pi tals from 1991 to 1998.In sum ma ry, there were a small de crease in length of stay, a large in crease in sever i ty, a sharp in crease in read-mis sion, an in crease in growth of to tal ex pen di tures, a slow down in the de cline of mor tal i ty rates, a risk of se lec tion and of “by pass” of the re form. It can favour ad verse se lec tion and im pair ac ces si bil i ty to care if some fac tors (so cial, sever i ty...) are not tak en into ac count. It should be made clear that such re form needs to be as glob al as pos si ble to avoid cost shift ing and ad verse se lec tion. As it is of ten the case in the health care sec tor, in tro duc tion of ef fi cien cy in cen tives has to be hard ly pub-lic reg u lat ed in or der not to pro duce ad verse ef fect. It is im pos si ble to take into ac count all fac tors hav ing an im pact on the treat ment and the costs of each pa tient. This is the rea son why APRDRGs are not a good tool for a fi nanc ing by pa tient or ad mis sion but is only a good tool for the cal i bra tion of a glob al bud get for the hos pi tal. This al lows a bet ter share of risk across pa tients and across APRDRGs. Mix fi nanc ing sys-tem (par tial prospec tive and par tial ret ro spec tive) is an oth er way to share risk be tween fi nanc ing au thor i ties and hos pi tals: ret ro spec tive spe cial pay ment for out liers, fi nanc ing for spe cif ic func tions (emer gen-cy care, re search, teach ing...), ex clu sion of some patholo gies or ex pen-di tures from the prospec tive pay ment sys tem (psy chi a try, new drugs...) can be used. In Bel gium, thanks to the fee for ser vices sys tem, it is also pos si ble to share by act or by drugs the risk be tween fi nanc ing au thor i-ties and hos pi tal. It is al ready done for clin i cal bi ol o gy and will be done for drugs, prospec tive pay ment ac cord ing to AP DRG can be ap plied only on 50% or 70% of the fees. The com ple men ta ry per cent age con tin-ues to be fi nanced by act or drugs. This sys tem al lows main tain ing the in for ma tion sys tem linked to re source re al ly used that can be very use-ful to eval u ate qual i ty of care, cost shift ing.

0439

The Eff ects of In di vid u al and Child Ill ness on Work Ab sence De ci sionsCoomer N. (North Car oli na State Uni ver si ty, Raleigh, USA)

This pa per ex am ines the ef fects of per son al and child ill ness on ab sence de ci sions of par ents. Ab sen teeism is shown in the lit er a ture to have sig-nif i cant ef fects for both firms and house holds. Loss es in work time lead to costs in the form of de creas es in pro duc tiv i ty, in creas es in la bor costs and de creas es in house hold in come. This re search ex plores the ab sen-teeism de ci sions of em ployed par ents in an ef fort to bet ter un der stand be hav ior that may con tribute to ab sen teeism. The the o ret i cal frame-work mod els the de ci sion to miss work when ei ther the in di vid u al is ill, the child is ill or both are ill. The avail abil i ty of child care and sick leave pro vi sions im pact the in di vid u al’s ab sence de ci sion. Struc tur al es ti-ma tion will al low for the in tro duc tion of new poli cies re lat ing to ab sen-teeism and their eval u a tion.

Eur J Health Econom Suppl 1 · 2006 | S27

0045

The Eff ect of Tax es and Bans on Pas sive Smok ingCor naglia F. (Uni ver si ty Col lege Lon don, UK)Adda J.

This pa per eval u ates the ef fect of ex cise tax es and bans on smok ing in pub lic places on the ex po sure to to bac co smoke of non-smok ers. We di rect ly quan ti fy pas sive smok ing us ing data on co ti nine lev els- a me tab-o lite of nic o tine- mea sured in non smok ers. Ex ploit ing state and time vari a tion across US states, we reach two im por tant con clu sions. First, ex cise tax es have a sig nif i cant ef fect on pas sive smok ing. Sec ond, smok-ing bans have on av er age no ef fects on non smok ers, be cause we show that bans can have con trast ing ef fects. In par tic u lar, while bans in pub-lic trans porta tion or in schools de crease the ex po sure of non smok ers, bans in recre ation al pub lic places can in fact per verse ly in crease their ex po sure by dis plac ing smok ers to pri vate places where they con tam i-nate non smok ers.

0449

A com par a tive anal y sis of pric ing and re im burse ment for in-patent drugs in 7 EU coun triesCor na go D. (Mario Ne gri In sti tute, Mi lan, Italy)Com padri P., Garat ti ni L.

This com par a tive study anal y ses pric ing and re im burse ment poli cies for in-patent drugs in sev en Eu ro pean coun tries (Bel gium, France, Ger-many, Italy, the Nether lands, Spain, and the Unit ed King dom), con duct-ed ac cord ing to a com mon meth o dol o gy in each coun try. Gen er al in sti-tu tion al frame work, mar ket ac cess, pric ing, re im burse ment and cost con-tain ment mea sures adopt ed by each do mes tic mar ket were con sid ered. The anal y sis im plied two phas es (i) re view ing the lit er a ture on the sub-ject in na tion al and in ter na tion al jour nals, and (ii) in ter view ing a se lect-ed ex pert pan el of key play ers in each coun try (com posed of at least one civ il ser vant, one phar ma ceu ti cal man ag er, and one health economist). The anal y sis showed a gen er al trend to in tro duce short-term mea sures to con tain phar ma ceu ti cal ex pen di tures, which seem to be hard to con-trol in al most all coun tries anal y sed. How ev er, we still found a wide het-ero ge ne ity in the gen er al ap proach es adopt ed by each coun try for pric-ing and re im burse ment pro ce dures, prob a bly be cause of do mes tic and his tor i cal is sues.

0406

Ge ner ic mar ket pen e tra tion and cross-coun try com pe ti tion in EU-5, Can a da and the Unit ed States phar-ma ceu ti cals mar ketCos ta Font J. (Lon don School of Eco nomics, Health and So cial Care, Lon don, UK)Kanavos P.

Lit tle ev i dence is known on the de ter mi nants of gener ics pen e tra tion in coun tries sub ject to sig nif i cant mar ket reg u la tion. This pa per em pir i-cal ly ex am ines the ex tent the de ter mi nants of ge ner ic en try in dif fer ent Eu ro pean and North Amer i can coun tries us ing IMS data from 2000-2005. On the oth er hand, we scru ti nise the ex tent to which gener ics pen-e tra tion ex plains cross-coun try price dif fer ences in dif fer ent coun tries. In ter est ing ly we find that coun try size and coun try spe cif ic fixed ef fects ex plain most sig nif i cant fac tors in ex plain ing mar ket pen e tra tion rather than cross-coun try price dif fer ences.

0039

Pru dence and health care risksCourbage C. (The Gen e va As so ci a tion, Gen e va, Switzer land)

Pru dence is a com mon as sump tion in risk and in sur ance eco nomics. Pru dence can be de fined ei ther through a pre cau tion ary sav ing mo tive (Kim ball, 1990) or in terms of pref er ence to wards risks (Eeck houdt and Schles ing er, 2005). Pru dence has been es tab lished in4

0123

Fac tors in fl u enc ing the evo lu tion of new drugs prices be tween 2000 and 2005 in Por tu galCrisos to mo S. (Cen tre for Phar ma coepi demi o log ic Re search, Lis boa, Por tu gal)Zil da M.

Ob jec tives: To char ac ter ize drugs with prices first ap proved in 2000; to an a lyse prices evo lu tion till 2005 and to in ves ti gate its re la tion with some char ac ter is tics of the price reg u la tion mech a nisms in place in Por tu gal.Meth ods: Data on new drugs (re im bursed and non-ge ner ic) and their prices were col lect ed from of fi cial sources. Due to skewed dis tri bu tion of rel a tive price chang es non para met ric sta tis tics were used. To in ves ti-gate the ef fect of oth er vari ables (and its in ter ac tions) on rel a tive price chang es the gen er al lin ear mod el (GLM) was used.Re sults: For the 528 drugs un der anal y sis, low er rel a tive price chang es, be tween 2000 and 2005, were found for drugs with pro vi sion al price ap provals, drugs in clud ed in the re im burse ment sys tem, drugs with more re cent re im burse ment ap proval and drugs re im bursed un der spe-cial re im burse ment schemes (all p<0.05). The mod el ac counts for 77.5% of the vari ance in the rel a tive price chang es, with price ap proval (pro vi-sion al/de fin i tive) hav ing the great est in flu ence (p<0.05).Con clu sion: Cur rent price reg u la tion mech a nisms seem to have con-tribut ed to con trol drugs prices. In par tic u lar, pro vi sion al prices show a sig nif i cant ly greater re duc tion com pared to non-pro vi sion al prices, sug-gest ing cur rent mech a nisms work to cor rect pro vi sion al prices in the post-ap proval pe ri od, ac cord ing to the cor re spond ing prices in the ref-er ence coun tries (Spain, France and Italy).

0241

Health Eco nomics & Health Pol i cyCromwell J. (Re search Tri an gle In sti tute, Waltham, Mas sachusetts, USA)

The U.S. Congress en act ed a mora to ri um on phy si cian-owned hos pi tals spe cial iz ing in car di ac or mi nor sur gery on the grounds of un fair com-pe ti tion. Spe cial ty hos pi tal growth ex plod ed in the U.S. in re sponse to pay er over pay ments by the fed er al gov ern ment. The mora to ri um en act-ed by Congress, how ev er, was found to be an in ef fi cient, un tar get ed so lu tion by un nec es sar i ly lim it ing com pe ti tion. Ar gu ments against phy-si cian own er ship were found to be anti-com pet i tive and re lied on crit i-cisms pre vi ous ly lodged against for-prof it acute hos pi tals; name ly, avoid-ing severe ly ill pa tients and the unin sured. Phy si cian own er ship per cent-ages were gen er al ly small and not drivers of lu cra tive re fer rals. Congress re scind ed the anti-com pet i tive mora to ri um in fa vor of more fun da men-tal price cor rec tions based, in part, on our rec om men da tions. The U.S. gov ern ment is ag gres sive ly im ple ment ing many pay-for-per for mance demon stra tions that tie pay ments to health care im prove ments. Many dif fer ent pay ment schemes, def i ni tions of out comes, and eval u a tion de signs are be ing test ed. Health economists, like our selves, have been de sign ing ex per i ments and eval u at ing provider and pa tient re spons es to new fi nan cial in cen tives tied to pay ments. Our study re views the stra-te gies, strengths, and weak ness es be hind the dif fer ent ap proach es. Pay-for-per for mance is the Holy Grail of both health economists and pol i cy mak ers, but may be tech ni cal ly im pos si ble to achieve.

S28 | Eur J Health Econom Suppl 1 · 2006

0325

Sur vival Mod els For Cost DataDario G. (De part ment of Pub lic Health and Mi cro bi ol o gy, Uni ver si ty of Turin, Tori no, Italy)Pagano E., Petrin co M., Desideri A., Bigi R., Gre gori D.

Sur vival mod els fail in ac count ing for non pro por tion al i ty in the cost-ac cu mu la tion pro cess. In case of no cen sor ing, the log-gam ma GLM mod el seems to be a ro bust al ter na tive (Basu, et al. 2004). We pro pose the ad di tive Aalen mod el as a valid al ter na tive, al low ing to ob tain a rea-son able fit of the cost-ac cu mu la tion pro cess, main tain ing the ad di tiv i ty of the ef fects, and ob tain ing ad di tion al in for ma tion as com pared to oth-er mod els.Gam ma re gres sion with log link and the Aalen ad di tive mod-el were fit ted to a se ries of Monte Car lo data sim u la tions (four cost dis-tri bu tions: two Log nor mal and two Gam ma; sev en sam ple sizes; 1000 Monte Car lo ex per i ments). Then, the Aalen mod el has been ap plied to the data of the COSTA MI tri al.bias for the Aalen mod el is about 10% for the log-nor mal gen er at ed data and al most neg li gi ble for the Gam-ma case, show ing a con ser va tive cov er age also for small sam ples. the COSTA MI case, the Aalen mod el al lowed the eval u a tion of each co vari-ate ef fect also at ex treme ob served costs.a non-cen sor ing frame work the Aalen ad di tive mod el per forms well and can be a rea son able al ter-na tive to the stan dard Gam ma re gres sion mod els. Still, it of fers ad di-tion al in for ma tion about the re la tion ships be tween costs and spe cif ic co vari ates.

0383

Mea sur ing rel a tives’ QALY-weights for us age in health eco nom ic eval u a tionsDavid son T. (Linköping Uni ver si ty -De part ment of Health and So ci ety, Linköping, Swe den)Kre vers B., Lev in L.Å.

Aims of the study: The ob jec tive of this study was to es ti mate the val ue of the ef fects on rel a tives due to a fam i ly mem ber’s ill ness for us age in health eco nom ic eval u a tions.Meth ods: Data used in this study is from the Swedish part of the EU RO-FAM CARE study, in where rel a tives car ing for an el der at least 4 h per week have been in ter viewed in six Eu ro pean coun tries. We in tro duce a new term, R-QALY-weights, which is the in flu ence on the rel a tives’ QALY-weights due to a fam i ly mem ber’s health state. We cre at ed R-QALY-weights in two ways. First by sub tract ing a pop u la tion based QALY-weight from the QALY-weight for the rel a tive, cre at ed from EQ-5D. In the sec ond meth od of cre at ing R-QALY-weights we asked the re spon dents to as sess their an swers in EQ-5D as sum ing that the el der’s health was so good that he or she would not be in need of care.Re sults: The re sults in di cate that R-QALY-weights oc cur when the re spon dents as sessed their own R-QALY-weights but not for the whole sam ple when we com pared with the gen er al pop u la tion based weights. How ev er, also in the lat ter case, R-QALY-weights could be found in two sub groups: wom en be low 80 years old and care givers whose sit u a tion is de scribed as bur den some.

0583

Health in Ar genti na: di ag no sis and risks in re la tion to MDOs?Puente C., (Min istry of Health, Ar genti na)

The fol low ing up and the anal y sis of the Mil le ni um De vel o ment Ob jec-tives in a com plete per spec tive has di rect ed our coun try to in sti tu tion-al ize the var i ous ac tions and the iso lat ed ini tia tives un der the con trol of an of fi cial in sti tu tion. This in no vat ed task has of fi cial ly start ed in 2004, by the named So cial Pol i cy Co or di na tion Na tion al Coun cil, as

the in sti tu tion al co or di na tor which in cludes a team work formed by tech ni cians of all Min istries: Ed u ca tion, Tech nol o gy and Sci ence; So cial De vel op ment; Pro duc tion and Econ o my; Fed er al Plan ning; Ser vices and Pub lic In vest ment; En vi ron ment and Health; Work, Em ploy ment and So cial Se cu ri ty; and the Cen sus and Sta tis tics Na tion al In sti tute. Specif i cal ly, the fol lowin up of the more di rect ed ob jec tives re lat ed to Health is un der the re spon s abil i ty of the Min istry of En vi ron ment and Health. The ob jec tive of this pre sen ta tion refers to how the fol low ing up of MDOs in health field in Ar genti na is work ing and what the main prob lems which should be dealt to achieve the goals es tab lished are. Ar genti na has in cor po rat ed in its in ter na tion al com mit ment with the MDOs cer tain ob jec tives, goals and ad di tion al in di ca tors to adapt to the coun try`s ne ces si ty and re al i ty. In terms of health, some goals and in di-ca tors were in clud ed to the fol low ing up of the pres ent ob jec tives. This pre sen ta tion shows the pres ent re sults of some in di ca tors, the chang es of these ob jec tives and goals in ac tions and pro grams of con crete ex e cu-tion, and the chal lenges for the fu ture in achiev ing the MDOs.

0233

Is a catch-up hep a ti tis B vac ci na tion cam paign in high-risk adults cost-eff ec tive?De Wit G.A. (Nat. Inst. of Pub lic Health, Cen tre for Pre ven tion and Health Ser vices Re search, Bilthoven, The Nether lands)Kret zschmar M., Man gen M.-J.J.

Back ground: Cur rent hep a ti tis B (HBV) pre ven tion poli cies in the Nether lands in clude screen ing of preg nant wom en and vac ci na tion of chil dren from en dem ic pop u la tions. In ad di tion, a 4 year vac ci na tion cam paign in high-risk adults (sex u al risk groups and hard-drug users) was ini ti at ed in 2002.Aim: To de ter mine the cost-ef fec tive ness of this catch-up vac ci na tion cam paign in high-risk adults at na tion al lev el.Meth ods: A dy nam ic mod el to es ti mate fu ture in ci dence of HBV in the pop u la tion was de vel oped. This mod el de scribes hor i zon tal, ver ti cal and sex u al trans mis sion of HBV. Also, an eco nom ic mod el es ti mat ing di rect health care costs, life years lost and qual i ty of life con se quences of HBV in fec tion was con struct ed. Ac tu al cam paign data on num ber of per sons reached, com pli ance and pro gram costs, in clud ing out reach ac tiv i ties, were used.Re sults: It is es ti mat ed that this 4-year vac ci na tion cam paign re sults in 3000–5000 in fec tions pre vent ed in the Nether lands. Cost per per son re ceiv-ing at least one vac ci na tion are € 170. In the base-case anal y sis, cost per life-year gained and cost per QALY are € 9,400 and € 7,600, re spec tive ly.Con clu sion: This 4 year catch-up cam paign was cost-ef fec tive at a na tion-al lev el. The cost-ef fec tive ness of con tin u a tion of the pro gramme de pends heav i ly on the amount and cost of (more ex pen sive) out reach ac tiv i ties.

0330

Im pact of phar ma ceu ti cal fi rms stra te gies on French physi cians: an tide pres sants pre scrip tionDesquins B. (IEMS, Lau sanne,)Pro topopes cu C., Decol logny A., Hol ly A., Rochaix L.

Ra tio nale some coun tries such as France, physi cians’ in for ma tion re gard-ing the ef fi ca cy of new drugs is main ly pro vid ed by phar ma ceu ti cal com-pa nies who in vest heav i ly in pro mo tion al cam paigns. There is a grow ing con cern that bi ased in for ma tion (not true) dif fused by these cam paigns af fect GPs’ choice of drug. To an a lyse such po ten tial bi as es, we fo cus on the pre scrip tion of an tide pres sants for two rea sons. The first is re lat ed to the fact that in this par tic u lar mar ket, firms have en gaged in heavy prod-uct dif fer en ti a tion stra te gies, while the ac tu al ther a peu tic ef fi cien cy of these var i ous an tide pres sants is judged com pa ra ble by med i cal ex perts. The sec ond is re lat ed to the im por tant un cer tain ty that sur rounds de pres-sion di ag no sis and how it may af fect physi cians’ choice of drug.this pa per,

Eur J Health Econom Suppl 1 · 2006 | S29

we ex am ine the im pact of the phar ma ceu ti cal firms’ pro mo tion al cam-paigns and GPs’ risk aver sion on an tide pres sants’ ini tial i sa tions. use an at tribute mod el and en tro py in dex to eval u ate these im pacts.data cov ers an ti de pres sant ini tial i sa tions by 500 GPs prac tis ing in the PACA re gion in France.and Con clu sion sto this pa per, GP’s aren’t pa tients’ per fect agents since they can’t dis so ci ate the true of bi ased in for ma tion. This ob ser va tion is par tic u lar ly true for physi cians who have risk aver sion. This pa per high lights also the im pact of pro mo tion al spend ing en gaged by drug com pa nies on French GPs an tide pres sants’ pre scrip tion.

0209

Mod elling wait ing times for elec tive sur geryDi mak ou S. (City Uni ver si ty, Lon don, Unit ed King dom)Parkin D., De vlin N., Ap ple by J.

Wait ing is an im por tant means by which health care is ra tioned in the UK NHS. Wait ing times for elec tive sur gery are a key pol i cy and po lit i-cal con cern. The prin ci pal pol i cy re sponse has been to in tro duce wait-ing time tar gets against which per for mance is mea sured and re ward-ed.wait ing times fall, in ter est has grown in ques tions such as how have in cen tives as so ci at ed with tar gets af fect ed man age ri al and clin i cal be hav-iour? How are tar gets met: and how have they af fect ed the dis tri bu tions of wait ing times? Are they met by in creased through put or by im proved man age ment prac tice? Are wait ing times cut down as a whole, or do long waits re place short waits? And more im por tant ly, what fac tors de ter mine first the de ci sion to place a pa tient on list for sur gery and sec ond the thresh old of pa tients on a wait ing list at any giv en time? We will in ves ti gate these ques tions us ing time-to-event anal y sis ap plied to NHS wait ing time data.join ing a wait ing list is not a sto chas tic event, this pa per de vel ops a mod el of wait ing lists where they are re gard ed as un der the con trol of hos pi tals and clin i cians and may be ma nip u lat ed to re spond to in ter nal and ex ter nal sup ply con di tions in clud ing hos pi-tal ca pac i ty and per for mance re quire ments.

0038

Health Fi nanc ing in Brazil in the con text of mac ro-eco nom ic ad just mentDomínguez Ugá M.A. (Es co la Na cional de Saude Públi ca, FIOCRU, Rio de Janeiro, Brazil)

This pa per anal y ses health care fi nanc ing in Brazil con sid er ing two dif-fer ent con texts)The con sti tu tion al re form of 1988, which cre at ed the new Brazil ian So cial Se cu ri ty Sys tem (which in cludes Health Sec tor) and struc tured a fi nanc ing sys tem ac cord ing to its prin ci ples;) The con-text of macroe co nom ic ad just ment, ini ti at ed in the nineties, which in tro-duced many dis tor tions to the orig i nal fi nanc ing mod el, and re sult ed in the need to cre ate a spe cif ic tax to fi nance the Brazil ian health sys tem.fi nal sec tion of this pa per deals with eq ui ty as pects of health fi nanc ing in Brazil, con sid er ing its dis tri bu tion be tween pub lic and pri vate sec tor, the com po si tion of pub lic fi nanc ing (con sid er ing the di rect and in di rect tax es) and the dis tri bu tion of its bur den be tween the dif fer ent in come class es.pre sen ta tion re sults from a re search de vel oped by the au thor at the Na tion al School of Pub lic Health (Es co la Na cional de Saúde Públi-ca / FIOCRUZ), con clud ed on March 2005.

0117

Health care to ir reg u lar im mi grants in the Ital ian NHSDo nia Sofi o A. (Uni ver si ty of Rome Tor Ver ga ta, Roma, Italy)De Gae tano A.

Ir reg u lar im mi gra tion is a wide range phe nom e non es pe cial ly in a coun-try like Italy that has al ways been both a longed for goal for job seek ers

and a tran sit ground to oth er coun tries.if is im pos si ble to mon i tor a phe-nom e non which is out of con trol by def i ni tion, a com par i son be tween the val ues re lat ed to fi nanc ing health care for ir reg u lar im mi grants and the num ber of reg u lar iza tions fol low ing up in these years in duces some con sid er a tions. It ap pears that be tween the year pri or to each mea sure and the fol low ing year, the need of re sources for fi nanc ing pro vi sion of health care to im mi grants varies re mark ably ow ing to the de crease in il le gal im mi grants. On the con trary, ob serv ing the amount of fund ing over sev er al years a con stant trend is ev i dent. This ev i dence leads us to de duce that the above fund ing is not es tab lished on the ba sis of real data nec es sary to ad e quate plan ning and al lo ca tion of re sources. The re sult emerg ing from this anal y sis is that an ef fec tive in for ma tion sys-tem con tin u al ly up dat ed be comes a nec es sary in stru ment to help politi-cians to al lo cate re sources prop er ly, such as to grant health pro tec tion to this spe cial cat e go ry of for eign ers, while on the oth er hand pre vent-ing waste of mon ey due to par tial knowl edge of the phe nom e non “il le-gal im mi grants”.

0127

Does Cost-Shar ing Aff ect Com pli ance?Dor A. (Case West ern Re serve Uni ver si ty, Cleve land, Ohio, USA)En ci nosa W.

This pa per de parts from pre vi ous work on in sur ance and uti li za tion of pre scrip tion drugs in two im por tant re spects. First, bor row ing for the med i cal lit er a ture, we fo cus on pa tient com pli ance (ad her ence to a pre scrip tion drug reg i men) rather than ex pen di tures on pre scrip tion drugs, more com mon ly found in eco nom ic stud ies. This al lows us to iden ti fy un am bigu ous ly be hav ioral re spons es to cost shar ing (non-com-pli ance), there by avoid ing the dif fi cul ty of sep a rat ing price and quan ti ty in ex pen di ture mea sures. Sec ond, rather than con sid er ing only lev els of cost shar ing, we go fur ther by con sid er ing the o ret i cal ly and em pir i cal-ly in cen tives in two main cost-shar ing regimes Flat co pay ment, name-ly a fixed dol lar amount paid out-of-pock et, and “vari able” co pay ment, as per cent of full price (we re fer to this as coin sur ance). We de vel op a sim ple mod el that dif fer en ti ates be tween the two cost-shar ing regimes, us ing prop er ties of the mean-vari ance util i ty func tion. Com par a tive stat-ics show that cost-shar ing re duces com pli ance. More im por tant ly, we show that pa tient com pli ance should be low er un der coin sur ance than un der co pay ments due to un cer tain ty in cost-shar ing. In ad di tion, we de rive ex plic it func tion al forms for the com pli ance de ci sion that dif fer be tween the two regimes and can be es ti mat ed sep a rate ly, us ing a large pri vate in sur ance claims database, we track pa tients over a one year pe ri-od (2000) to see whether they com plied con tin u ous ly, in ter mit tent ly, or not at all to a pre scribed reg i men of med i ca tions. We fo cus on the ex am-ple of di a be tes (Type II), a com mon chron ic con di tion that re quires per-ma nent and con tin u ous use of in su lin-en hanc ing med i ca tions, and dis-ease leads to se vere com pli ca tions when in ap pro pri ate ly treat ed.es ti ma-tion sam ple con sists of 20,494 in di vid u als in the co pay ment regime, and 6,563 in di vid u al in the coin sur ance regimes. To geth er, these in di vid u als be longed to 11 firms, with a to tal of 30 phar ma cy ben e fit plans. With-in each in sur ance regime we es ti mate or dered log it mod els for full com-pli ance, par tial com pli ance, and non-com pli ance with firm, plan, and drug fixed ef fects elas tic i ties can not be ob tained di rect ly from such dis-crete-choice mod els, we per formed a num ber of sim u la tions to com pare cost-shar ing ef fects in the two mod els. Re sults are con sis tent with pred-i ca tions gen er at ed by the the o ret i cal mod el. In the coin sur ance mod-el, an in crease in the coin sur ance rate from 20% to 75% re sult ed in the share of per sons who nev er com ply to in crease by 9.9%, and re duced the share of ful ly com pli ant per sons by 24.6%. In the co pay ment mod-el, a com pa ra ble in crease in the co pay ment from $6 to $10 re sult ed in a 6.2% in crease in the share of non-com pli ers, and a con com i tant 9% re duc tion in the share of full com pli ers. Sim i lar re sults hold when the lev el of cost-shar ing is held con stant across regimes.non-com pli ance re duces ex pen di tures on pre scrip tion drugs it may also lead to in creas-

S30 | Eur J Health Econom Suppl 1 · 2006

es in in di rect med i cal costs due to avertable com pli ca tions (spillover ef fects). Us ing avail able ag gre gate es ti mates of the cost of di a bet ic com-pli ca tions, we cal cu late that the net ef fect of a $6-$10 in crease in co pay-ment would have the di rect ef fect of re duc ing na tion al drug spend ing for di a be tes by about $250 mil lion. (We will also pres ent pre lim i nary es ti mates of in di rect costs ob tained from link ing our data to hos pi tal records for pa tients in the sam ple). For now, the re sults sug gest that both pri vate pay ers and pub lic pay ers may be able to im prove com pli-ance and re duce over all med i cal costs by switch ing from coin sur ance to co pay ments in pre scrip tion drug plans. In ter est ing ly, the soon-to-be-im ple ment ed Medi care pre scrip tion drug ben e fit is based on coin sur-ance (ex clud ing the so-called dough nut hole), where as ctive co pay ment meth od, sug gest ing room for bud get-neu tral im prove ments. In com par-i son, flat co pays are the nom in most EU coun tries.

0269

A Cross-Na tion al Study of In cen tives and Fi nanc ing in Tech nol o gy-In ten sive Modal i ties of CareDor A. (Case West ern Re serve Uni ver si ty, Cleve land, Ohio, USA)Pauly M.

Chron ic Kid ney Dis ease (CKD) is a de bil i tat ing med i cal con di tion lead-ing to or gan fail ure, re quir ing in ten sive and cost ly treat ments such as di al y sis and trans plan ta tion. Due to fac tors such as the ag ing of the pop-u la tion and ris ing obe si ty rates there has been a alarm ing in crease in the in the prev a lence and in ci dence of CKD in all high-in come coun-tries. While pay ment in cen tives to providers have gone through a phase of ex per i men ta tion and change in re cent years, it is not clear how dif fer-ent ap proach es in var i ous coun tries im pact ed out comes and the de liv ery of care. To ad dress this, we con duct ed the In ter na tion al Study of Health-Care Or ga ni za tion and Fi nanc ing (ISH COF).Un der ISH COF, a se ries of sur veys were ad min is tered to coun try in ves ti ga tors in all DOPPS (Di al-y sis Out comes and Prac tice Pat terns Study) coun tries in 2004 and 2005 on var i ous as pects of the CKD fi nanc ing. Coun tries in clud ed are Aus-tralia, Bel gium, Can a da, France, Ger many, Italy, Japan, New Zealand, Spain, Swe den, U.K, and USA.pre lim i nary anal y sis sug gests a re mark-able de gree of sim i lar i ty be tween ISH COF coun tries in the or ga ni za tion of CKD pro grams, with a mix of pri vate and pub lic providers, so cial in sur ance, and low co pays for pa tients. In all coun tries gov ern ment is the ul ti mate pay er (in clud ing the U.S., un der Medi care), and in sev er-al coun tries CKD is ad min is tered sep a rate ly from the rest of the sys-tem. How ev er, there are sig nif i cant vari a tions in the way pay ments to providers are de ter mined, rang ing from fee-for-ser vice at gov ern ment-set prices, to ne go ti at ed prices un der glob al bud gets, to full cap i ta tion. Sig nif i cant vari a tions ex ist in the cost and to tal pay ment of he mo di al y-sis (the main mo dal i ty to treat CKD) and in phy si cian in comes, par tic-u lar ly for Nephrol o gists (CKD spe cial ists) even with in the Eu ro pean zone. sam ple sizes do not al low for mul ti var i ate anal y sis, bi vari ate anal-y sis sug gests that neph rol o gist in comes and the cost of di al y sis are dom-i nant fac tors in ex plain ing CKD ex pen di tures per cap i ta (R2 = 0.11 and 0.18 re spec tive ly); pri ma ry-care phy si cian in comes and the share of pa tients with trans plan ta tion have no sig nif i cant ef fect. Oth er fac tors such as “in ten si ty” of di al y sis (dos age) are fair ly con stant across coun-tries. Pay ments and costs for di al y sis pay ments are mod er ate ly cor re lat-ed with pay ments match ing costs in the U.S., Ger many, and Bel gium, ex ceed ing costs in Spain and New Zealand, and be low costs in Italy and Aus tralia. We do not char ac ter ize the pric ing in the lat ter coun tries as ‘in ef fi cient’ since it can be shown that op ti mal so cial prices for main te-nance ser vices must in cor po rate the net gain from avert ed com pli ca-tions. like per cap i ta ex pen di tures, mor tal i ty rates from CKD vary sub-stan tial ly across coun tries, rang ing from 19% in the U.S., to 8% in Japan, with the me di an found in Italy at 11%. We are cur rent ly in the pro cess of ob tain ing age-ad just ed and risk-ad just ed mor tal i ty rates per coun try, which will al low us to ex am ine the im pact of pay ment rules sys tem ‘gen-eros i ty’ and oth er sys tem vari ables on mea sur able out comes. These sets of re sults will be added to our pre sen ta tion.

0371

The in fl u ence of sup ple men tary health in sur ance on switch ing be hav iourDor mont B. (Uni ver sité Par is-Dauphine, Par is, France)Ge off ard P-Y., Lami raud K.

This pa per fo cus es on the switch ing be hav iour of sick ness fund en rollees in Switzer land. Though the reg u la tion pro motes com pe ti tion be tween funds, there are large pre mi um vari a tions with in can tons. This re veals some in er tia among con sumers. We in ves ti gate one pos si ble bar ri er to switch ing be hav iour the in flu ence of sup ple men tary in sur ance on the choice for ba sic in sur ance. Though there is a clear-cut reg u la to ry sep-a ra tion be tween ba sic and sup ple men tary in sur ance, it turns out that most en rollees take up ba sic and sup ple men tary in sur ance with the same fund. We as sume that in sur ers can risk ad just in di rect ly if they some how tie the con di tions of a sup ple men tary con tract to the pos ses-sion of a ba sic con tract at the same fund.de vel op a the o ret i cal mod el that cap tures some im por tant el e ments of the mar ket. The fo cus is on the in ter ac tion be tween hold ing a sup ple men tary con tract and choos-ing a health plan. We then es ti mate a si mul ta ne ous equa tion mod el of this joint de ci sion. We use ad min stra tive in for ma tion and sur vey data (n=2152 en rollees) on health plan choice. We show that hold ing a sup-ple men tary con tract de creas es the propen si ty to switch. Our re sults sug-gest that the reg u la tion of the sup ple men tary health in sur ance mar ket should in te grate the ef fects it may have on the ba sic in sur ance mar ket.

0555

Turn ing the uni form DRG base-rate into a vol ume-con trol con tract in the Hun gar i an DRG sys temDózsa Cs. (Min istry of Health, Bu dapest, Hun gary)Nagy J., Sebestyén A., Kövi R.., Borc sek B., Bon cz I.

The aim of this pol i cy pa per is to an a lyse the pro cess of the de vel op ment of uni form DRG base-rate and turn ing it into a vol ume-con trol con tract. Data and meth ods: The Hun gar i an DRG sys tem was in tro duced in Hun-gary in 1993 re plac ing the for mer glob al bud get ap proach of hos pi tal fi nanc ing. Our data de rive from the fi nan cial database of the Hun gar i-an Na tion al Health In sur ance Fund Ad min is tra tion, cov er ing the pe ri-od 1993-2004. Re sults: From 1993 un til March 1997 the Hun gar i an hos-pi tals were clas si fied into dif fer ent groups (coun ty-, city hos pi tals, uni-ver si ties, na tion al med i cal in sti tutes), and each group had its own DRG base-rate. Be tween March 1997 and Jan uary 1998 the DRG base-rate of dif fer ent hos pi tal groups had been clos ing up and in Febru ary 1998 we achieved a na tion wide uni form base-rate. In ad di tion to the DRG sys-tem, a vol ume-con trol con tract has been added in 2004 as a ceil ing for hos pi tal per for mance. This vol ume-con trol re sult ed in a float ing DRG base-rate, al though not na tion al but hos pi tal lev el. Con clu sions: The ac tiv i ty based fi nanc ing of hos pi tals through the DRG sys tem re sult-ed in high er per for mance there fore high er health in sur ance ex pen di-tures. The vol ume-con trol con tract pro vides an ar ti fi cial ceil ing over in creased hos pi tal per for mance.

0495

EF PIA HTA Key Prin ci ples: An Aca dem ic Per spec tiveDrum mond M. (Cen tre for Health Eco nomics, Uni ver si ty of York, UK)

This pre sen ta tion fo cus es on three of the key prin ci ples. First, should eval u a tions al low new data to be con sid ered? The data avail able at prod-uct launch are sel dom suf fi cient for a thor ough as sess ment of cost-ef fec-tive ness. There fore, sys tems need to be put in place to gath er ad di tion-al data post-launch and to con sid er these in de ci sions about the ap pro-pri ate use of health tech nolo gies. Sec ond ly, is flex i bil i ty re quired in han-dling the un cer tain ty around new tech nolo gies? Giv en that lit tle will be

Eur J Health Econom Suppl 1 · 2006 | S31

known about the full ther a peu tic val ue of new prod ucts un til there is ex pe ri ence of real-world use, man u fac tur ers and pay ers need to de vel-op a flex i ble ap proach to han dling this un cer tain ty. As new data be come avail able, chang es should be made in the re im burse ment of the tech nol o-gy in a time ly and ef fi cient fash ion. The ex is tence of such a sys tem may make the ini tial re im burse ment de ci sion less pro tract ed, since both pay-ers and man u fac tur ers would know that chang es could be made lat er. Third ly, should as sess ments take place at the na tion al lev el? Be cause a num ber of fac tors, like ly to af fect cost-ef fec tive ness, vary from one ju ris dic tion to an oth er, the most ap pro pri ate place for health tech nol o-gy as sess ments is the na tion al, rather than in ter na tion al, lev el. In most coun tries suf fi cient re sources should be avail able to con duct eval u a-tions to a rea son ably high stan dard.

0550

Ev i dence based pol i cy mak ing – Val ue of sta tis ti cal lifeDzi wors ki W. (Eu ro pean Com mis sion, DG Health and Con sumer Pro tec tion, Unit 2, Strat e gy and anal y sis, Brus sels, Bel gium)

The pre sen ta tion will be a part of the or gan ised ses sion by the Eu ro-pean Com mis sion: Pol i cy choic es for Eu rope- age ing and sus tain abil i ty. “The adop tion of a Eu ro pean Com mis sion pol i cy pro pos al is main ly a po lit i cal de ci sion that be longs to the Col lege of Com mis sion ers, not to of fi cials or tech ni cal ex perts. Ide al ly how ev er, such a de ci sion should be based in ev ery case on sound anal y sis fed by the best data avail able. Im pact as sess ment (IA) meth o dol o gy de vel oped by the Eu ro pean Com-mis sion is a key tool in this re spect. Im ple men ta tion of Bet ter Reg u la-tion prin ci ples like IA meth o dol o gy, through pro vi sion of a care ful and com pre hen sive anal y sis of like ly so cial, eco nom ic and en vi ron men tal im pacts, both di rect and in di rect, con tributes to meet ing the spe cif ic com mit ments of the Lis bon and Sus tain able De vel op ment Stra te gies. It im proves the qual i ty of pol i cy pro pos als and above all ex plains why an ac tion is nec es sary and that the pro posed re sponse is an ap pro pri ate choice or, con verse ly, demon strates why no ac tion at EU lev el should be tak en. DG Health and Con sumer Pro tec tion has iden ti fied that it can best con tribute to the needs of health i er cit i zens and more con fi-dent con sumers by pro duc ing pro pos als whose ben e fi cial im pacts can clear ly be ex plained and jus ti fied. Nonethe less, ev i dence based pol i cy mak ing in health area re quires how ev er high in volve ment of ex ter nal ex perts, es pe cial ly economists. De vel op ment of tools use ful in pol i cy mak ing, like Val ue of Sta tis ti cal Life or spe cif ic Health Im pact As sess-ment method olo gies is how ev er es sen tial. Thus the eco nom ic anal y sis could be last ing ly in cor po rat ed into pol i cy mak ing to the ben e fit of EU cit i zens.”

0068

Den tists Mi gra tion pat terns in the Eu ro pean Union and Eco nom ic Area (part 1) Overview and im mi gra tion of den tists to the Unit ed King domEaton K. (East man Den tal In sti tute, Uni ver si ty Col lege Lon don, Unit ed King dom)Balázs P.

One of the key prin ci ples of the Eu ro pean Union is that all work ers, in clud ing health work ers, who are cit i zens of any of the 29 mem ber states of Eu ro pean Union and Eco nom ic Area (EU/EEA) and who ob tained their trade/pro fes sion al qual i fi ca tion, may work any where with in the EU/EEA. It can there fore be sug gest ed that work force plan ning should be come a Pan-EU/EEA is sue as an over or un der sup ply is both so cial ly and eco nom i cal ly un de sir able. At pres ent, as far as health care work ers are con cerned, there ap pear to be few re li able data. As an ex am ple of the prob lem, this pre sen ta tion and the one that fol lows will high light the cur-rent de fi cien cies in the data for num bers of den tists in the EU/EEA. Data on im mi gra tion pat terns of den tists to the Unit ed King dom (UK)and den-

tists’ pat terns of mi gra tion in Hun gary will be pre sent ed and dis cussed. In 2004, over 360,000 den tists were reg is tered in the 29 EU/EEA mem-ber states. How ev er, reg is tra tion pro ce dures vary from mem ber state to mem ber state and in many mem ber states den tists re main on the reg is-ter af ter they have re tired or em i grat ed. In a re cent sur vey of EU/EEA reg is tra tion bod ies, 11 were un able to pro vide any data for the num bers of den tists who had im mi grat ed to their states. Of the EU/EEA mem-ber states who re port ed data, the great est num ber of im mi grant den tists were to be found in the UK (7236 out of a to tal of 33,314 reg is tered den-tists). An anal y sis of im mi gra tion pat terns re vealed that 4606 den tists were im mi grants to the UK from oth er EU/EEA mem ber states and that 2630 came from oth er non-EU/EEA coun tries. The great est num bers came from South Africa (1474) and Swe den (1454). In three of the last sev en years the num ber of new reg is trants from out side the UK has been greater than the num ber grad u at ing from UK den tal schools. Over the past 15 years there have been dis cern able trends in the pat terns of im mi-gra tion of den tists to the U K, which can be as so ci at ed with eco nom ic and po lit i cal fac tors in the coun tries of or i gin of the den tists con cerned. In 2005, the great est num ber of im mi grant den tists to the UK came from Poland and In dia. The lat ter are re quired to pass the In ter na tion al Qual-i fy ing Ex am i na tion be fore they can be reg is tered for prac tice in the UK. It can be con clud ed that al though the im mi gra tion of den tists to the UK has ben e fit ed this coun try’s econ o my, there may be moral ob jec tions to re cruit ing den tists (and oth er health care work ers) from eco nom i cal ly less well de vel oped coun tries.

0007

In di vid u al So cioe co nom ic Eff ects on the De mand for Health Care Ser vices in Eu ro pean Union Coun triesEconomou A. (Uni ver si ty of Mace do nia, Eco nomics Dept., Thes sa loni ki, Greece)Niko laou A.., Theo dos siou I.

The pur pose of this study is to shed light on the in di vid u al so cio-eco-nom ic sta tus (SES) and de mo graph ic de ter mi nants of the de mand for health care in a cross-com par i son study of nine E.U. coun tries. The ex ist ing lit er a ture, both at the the o ret i cal and the em pir i cal lev el, ver i-fies the ex is tence of a SES gra di ent on the de mand for health care. The pres ent study gives spe cial em pha sis on the ef fects of in di vid u al em ploy-ment char ac ter is tics on al ter na tive in di ca tors of health care de mand, an is sue that re quires fur ther at ten tion by ap plied re search. The ev i dence sup ports the ex is tence of a SES gra di ent based on em ploy ment char ac-ter is tics on the de mand for health care, dif fer en ti at ed with re spect to the type of health care ex am ined and the in sti tu tion al and en vi ron men-tal set tings of the coun tries utilised in the study.

0098

Cost eff ec tive ness of in tra ve nous throm bol y sis with rt-PA with in 3 hours win dow fol low ing acute isch emic strokeEh lers L. (Aarhus Uni ver si ty Hos pi tal, HTA Unit, Aarhus, Den mark)An der sen G., Clausen LB., Bech M., Kjoslashl by M.

In tro duc tion: The aim of this study was to as sess the cost-ef fec tive ness of treat ment of acute isch emic stroke with in 3 hours win dow us ing in tra-ve nous throm bol y sis with rt-PA com pared to con ser va tive treat ment.Ma te ri al and meth ods: A health eco nom ic mod el was de signed to cal-cu late the mar gin al cost-ef fec tive ness ra tios for time spans of 1, 2 and 30 years. Ef fect data were ex tract ed from a meta anal y sis of six large-scale ran dom is ed and pla ce bo-con trolled stud ies of throm bo lyt ic ther a-py with rt-PA. Cost data were ex tract ed from a pi lot study of throm bol-y sis treat ment at the Aarhus Hos pi tal and from pub lished lit er a ture. Re sults: The cal cu lat ed cost-ef fec tive ness ra tio af ter the first year was US$/QALY 46 460. Af ter the sec ond year com pu ta tion of the cost-ef fec-

S32 | Eur J Health Econom Suppl 1 · 2006

tive ness ra tio showed that throm bol y sis was both less ex pen sive and bet-ter (dom i nance), but the re sult was sen si tive to chang es in sev er al vari-ables. In the long term (30 years), throm bol y sis was a dom i nant strat e-gy giv en the mod el premis es.Dis cus sion: The short term re sults showed that throm bol y sis costs ex ceed ed tra di tion al cost thresh olds rec om mend ed upon in tro duc tion of new med i cal tech nolo gies. The long-term com pu ta tions showed po ten tial ly large-scale health eco nom ic cost sav ings, but these cal cu la-tions are un cer tain. The anal y sis con cludes that the em pir i cal data need-ed for lon gi tu di nal com pu ta tion are cur rent ly not avail able.

0283

Phar ma ceu ti cal in no va tion, age ing pop u la tion and health care ex pen di turesEisen R. (Jo hann Wolf gang Goethe-Uni ver si ty, School of Eco nomics and Busi ness and In sti tute of Eu ro pean Health Pol i cy and So cial Law, Frank furt am Main, Ger many)Il gin Y.

Phar ma ceu ti cal in no va tion, age ing pop u la tion and health care ex pen di-tures should an age ing pop u la tion be a prob lem? Some times it is ar gued that age ing pop u la tion in her ent ly caus es high fu ture health care ex pen-di tures then con trol ling health care ex pen di tures ap pears rea son able. Sev er al stud ies fore cast ing health care spend ing pre dict con tin u ous in creas ing ex pens es due to at least three dif fer ent fac tors age ing, tech ni-cal progress, and in creas ing prices. Here we look in par tic u lar at phar ma-ceu ti cal in no va tions. Whether the ef fect of phar ma ceu ti cal in no va tions are cost driv ing or cost low er ing to health care ex pen di tures will be anal-y sed and eval u at ed with re gard to their cur rent im pact. Ar gu ing as for to tal health ex pen di tures that the cor re spond ing prox im i ty to death is in te grant not the age then this prox im i ty would be the cru cial el e ment for ris ing ex pens es. Still in old er age co horts there are as sum able more peo ple in their last life span. There fore in this pe ri od it is im por tant to de ter mine whether more and more treat ments or phar ma ceu ti cals are ap plied as a vain er at tempt to avert death which in con se quence caus es dis pro por tion ate high phar ma ceu ti cal and/or health care ex pen di tures or whether the ex pect an cy of life is in creas ing by med i cal progress or by a more heal thy way of liv ing. The at tempt to sketch the sit u a tion in di-cates that there must be a kind of mul ti plica tive and in ter de pen dent re la-tion ship be tween in flu enc ing fac tors such as phar ma ceu ti cal ex pen di-tures, med i cal progress, age ing struc ture or health-re lat ed ab sen teeism. The in ter de pen dent re la tion ship could be found ed on the Sisy phus Syn-drome, ar gu ing that med i cal progress caus es an in creased lon gev i ty and this in crease in turn leads to an am pli fied al lo ca tion of re sources of health care and there fore ris ing ex pen di tures. Or it could be found ed on the mul ti mor bid i ty of old er pa tients. The suc cess ful med i cal com bat of one dis ease would in crease lon gev i ty with out mak ing them health i er but in duc ing the next dis ease to be med i cat ed.

0076

Treat ment of di a be tes is es sen tial for pre serv ing qual i ty of life and main tain ing pro duc tiv i tyEm neus M. (Novo Nordisk, Bagsvaeli grd, Den mark)Bjoslashrk S., Chris tiansen T., Green A.

A so cio eco nom ic as sess ment of di a be tes in Den mark (year 2001) is pre sent ed. No treat ment of di a be tes leads to se ri ous dis abil i ties and pre ma ture death. Based on epi demi o log i cal ev i dence, a de mo graph ic mod el for di a be tes in the years 1900-2002 has been es tab lished, pro-vid ing es ti mates of the num ber of pa tient-years lived with di a be tes as cur rent ly (CS); in a worst sce nario (WS) with no treat ment op tions; im proved sce nario (IMS) with im proved treat ment; ide al sce nario (IS) where di a be tes is free of ex ces sive risk of com pli ca tions and mor tal i ty. Cur rent costs have been es ti mat ed from pub lic reg is ters and of fi cial sta-

tis tics, and clin i cal ly based es ti mates are struc tured in health care and non-health care re sources, pa tients’ time and in for mal care givers’ time. Ef fects have been quan ti fied as pa tient-years, qual i ty-ad just ed pa tient-years and in come by work ing in clud ing house hold pro duc tion. Cur rent-ly (2001) more than 153.000 peo ple live with di a be tes. IMS showed 16.000 life-years gained com pared to cur rent treat ment with the gain in pro duc tive life-years larg er than the num ber of life years. 20-35% of the cur rent to tal costs is re lat ed to health care; the rest is cost of nurs ing of peo ple with ir re vers ible com pli ca tions. Im proved treat ment could re duce costs to 60% of cur rent lev el due low er non health care cost and less peo ple with sev er com pli ca tions.

0453

Op ti mal pre ven tion and sav ing: in di vid u al de ci sions and pub lic pol i cyEt ner J. (GAINS, Uni ver si ty of Maine and EU RE Qua, Par is)Jel e va M.

The aim of this pa per is to an a lyze op ti mal de ci sions of pre ven tion and sav ing of in di vid u als fac ing a long term health risk in volv ing ex pens es not cov ered by in sur ance poli cies. In a first part we study the in ter ac-tions be tween the two de ci sions (sav ing and pre ven tion) and their de ter-mi nants. In the sec ond part of the pa per, we as sume that pre ven tion gen er ates pos i tive ex ter nal i ties and de ter mine the op ti mal pub lic pol i-cy in stru ments in this con text. More pre cise ly, we con sid er in di vid u als whose util i ty func tion de pends both on con sump tion and health and who face a health risk. In case of dis ease, in di vid u als face ex pens es that in volve on one side a min i mal treat ment costs, cov ered by in sur ance and on the oth er side ad di tion al costs (high er qual i ty treat ment, home care etc.) not cov ered by in sur-ance and thus paid by the in di vid u al him self. To man age health risk, in di vid u als have two pos si bil i ties: in vest in pri ma ry pre ven tion, in or der to re duce the prob a bil i ty of the dis ease and/or save, in or der to face the costs of the dis ease that are not cov ered by in sur ance. We prove that the im pact of wealth and in ter est rate on pre ven tion and sav ing de ci sions strong ly de pends on the per ceived sub sti tutabil i ty be tween health and wealth. When pre ven tion gen er ates pos i tive ex ter nal i ties (as vac cine for in fec tious dis eases for in stance) as ex pect ed, we prove that in di vid-u als’ op ti mal lev els of pre ven tion are low er than the so cial ly op ti mal ones. This gives room for pub lic in ter ven tion in or der to re store op ti mal-i ty. The in stru ment that we an a lyze con sists in sub si diz ing pre ven tion ex pens es and fi nanc ing these sub si dies by a tax on sav ing ben e fits.

0089

Risk Based Guar an teed Re newa bil i ty in Com pet i tive So cial Health In sur anceEu g ster P. (So cioe co nom ic In sti tute, Uni ver si ty of Zurich, Switzer land)Zweifel P.

With out ma jor change in the pre mi um, guar an teed re newa bil i ty (GR), i.e. the uni lat er al com mit ment of an in sur er to ex tend the life of a con-tract, is an im por tant fea ture of com pet i tive health in sur ance that has re ceived not much at ten tion in the lit er a ture. As an ex cep tion, Pauly, Kuh n reuther and Hirth (1995) have pro vid ed a the o ret i cal anal y sis of GR. Their work forms the point of de par ture for the pres ent con tri bu-tion, which seeks to de ter mine the de gree to which GR is jeop ar dized in a com pet i tive so cial health in sur ance sys tem that im pos es uni form pre mi ums. This dan ger is re flect ed by the dis crep an cy be tween a risk-based pre mi um and the reg u lat ed con tri bu tion. Us ing data from one of the largest Swiss so cial health in sur ers in di vid u al risk-based shad ow pre-mi ums are cal cu lat ed on the stan dard con tract with min i mal de ductible. This al lows for es ti ma tion of an up per bound of a GR-com pat i ble pre mi-um. These pre mi ums are then com pared with those es ti mat ed for the U.S. in di vid u al in sur ance mar ket by Pauly and Her ring (2003).

Eur J Health Econom Suppl 1 · 2006 | S33

0260

Sav ings in the Hun gar i an man aged care pi lot pro gramme be tween 1999-2004Falusi Zs. (Na tion al Health In sur ance Fund Ad min is tra tion (OEP), De part-ment of Health Pol i cy, Bu dapest, Hun gary)Bon cz I., Nagy B., Sebestyén A., Kóti T., Dózsa Cs.

Back ground and aim: In 1999 a new man aged care pi lot pro gramme was in tro duced in Hun gary. Nowa days 16 or ga niz ers (Man aged Care Or ga-ni za tions, MCOs) take the re spon si bil i ty of man ag ing health care for a pop u la tion of 2,300,000, which is 23 % of the to tal Hun gar i an pop u la-tion. The aim of the study to cal cu late the sav ings re al ized in the man-aged care pi lot pro gramme. Data and meth ods: Data de rive from the fi nan cial database of the Hun-gar i an Na tion al Health In sur ance Fund Ad min is tra tion, cov er ing the pe ri od 1999-2004. We cal cu lat ed the sav ings as the dif fer ence be tween the risk ad just ed cap i ta tion of MCOs and their ex pen di ture. Re sults: The to tal sav ings of the pro gramme were as fol lows: 3,56 % (1999), 10,40 % (2000), 6,54 (2001), 8,73 % (2002), 3,42 % (2003), 4,01 % (2004). The sav ing of the in di vid u al MCOs var ied be tween 0-17,94 %. The sav ing mea sured by the % of ex pen di tures was the high est in chron-ic and acute in-pa tient care, med i cal de vices’ re im burse ment, while mea-sur ing by nom i nal mon e tary val ue it was the high est in acute in-pa tient care, drug bud get and out-pa tient care. Con clu sions: Al though the Hun gar i an man aged care pi lot pro gramme led to a cost sav ing, there is a hard de bate on the fur ther de vel op ment of this pi lot pro gramme.

0481

Val ue of Treat ment – Re sults of an Event Study on the For ma tion of Al liances in the Eu ro pean Bio tech nol o gy In dus try Farag H. (Eu ro pean Busi ness School, Oestrich-Winkel, Ger many)

Pri or re search has of ten used the bio tech nol o gy in dus try as set ting for an a lys ing col lab o ra tive ac tiv i ty. How ev er, most re searchers have re stric-tive ly fo cussed their work on gen er al fac tors as ex plana to ry vari ables for the val ue cre at ed through al li ance for ma tion, in clud ing al li ance di rec-tion, firm re source en dow ments, and func tion al ar eas of col lab o ra tion. In the con text of the Eu ro pean bio tech nol o gy in dus try, the pres ent study ex tends this line of re search by ex plic it ly con sid er ing in dus try-spe cif ic de ter mi nants of val ue cre ation. Specif i cal ly, it ad dress es the val ue as so ci-at ed with dif fer ent in di ca tions (i.e. ar eas of treat ment), tech nolo gies used, as well as stag es of clin i cal de vel op ment. The pres ent re search re lies on ad vanced event-study method olo gies ac count ing for the in dus try-lev el drivers of bio tech nol o gy firms’ stock prices. In line with cur rent econo-met ric prac tices, cross-sec tion al anal y ses use ran dom-ef fects pan el data mod els. The find ings doc u ment sub stan tial over all re turns to al li ance ac tiv i ty. Col lab o ra tive ben e fits sig nif i cant ly vary de pend ing on the un der-ly ing tech nolo gies and tar get ed med i cal ar eas of treat ment, with high-pro file, high-sales in di ca tions and ad vanced stage pro jects ex pe ri enc ing the high est re turns. Fur ther more, the anal y sis iden ti fies two al ter na tive stra te gies of col lab o ra tive val ue cre ation: Firms may ei ther work to wards ‘high val ue’ trans ac tions or pur sue mul ti ple small er agree ments.

0071

The eco nom ic con se quences of good qual i ty of lab o ra to ry testsFauli S. (The Nor we gian Med i cal As so ci a tion, Oslo, Nor way)Thue G.

Ob jec tive: To de vel op a meth od for eval u a tion of the eco nom ic con se-quences of qual i ty im prov ing mea sures of lab o ra to ry anal y ses.

De sign: He li cobac ter Py lori (H. py lori) tests are used to il lus trate a meth od. A de ci sion mod el is de signed to com pare ex pect ed costs and out comes of three H. py lori tests with dif fer ent an a lyt i cal qual i ty. In for-ma tion from our data and med i cal lit er a ture are used to de ter mine prob-a bil i ties of clin i cal events. A cost-ef fec tive ness anal y sis is done from a so ci etal per spec tive. Fi nal ly we use a prob a bilis tic sen si tiv i ty anal y sis (PSA) to mod el the de ci sion un cer tain ty.Main re sults: In a 100 days pe ri od, tests with high ac cu rate qual i ty (high sen si tiv i ty and spec i fic i ty) dom i nate tests of less ac cu ra cy. The cost of the qual i ty im prove ment pro gramme is mi nor com pared to the po ten-tial of cost-re duc tions. Of the two tests with sim i lar ac cu ra cy the test with high est sen si tiv i ty was sig nif i cant ly more cost ef fec tive than the test with high est spec i fic i ty when the will ing ness to pay for each heal-thy day was more than €18.4.Con clu sions: We have de vel oped a meth od that can be used to eval u ate the eco nom ic con se quences of qual i ty im prov ing mea sures of lab o ra to-ry anal y ses. This study demon strates that even small im prove ments in qual i ty may be cost-ef fec tive.

0510

The eco nom ic con se quences of ill health in South-east ern Eu ropeFavaro D. (Uni ver si ty of Pado va De part ment of Eco nomics, Pado va, Italy)Suhrcke M.

The pur pose of the pres ent study is to pro vide em pir i cal ev i dence on the im pact of adult ill health in South-east ern Eu rope (SEE). We as sess quan-ti ta tive ly the eco nom ic im pact of ill health in SEE both from a macroe co-nom ic and mi croe co nom ic per spec tive. On the mac ro lev el we pro ject the like ly im pact of im proved health on fu ture eco nom ic growth based on a growth re gres sion frame work, and con di tion al on var i ous, plau si-ble fu ture mor tal i ty rate sce nar ios. On the mi cro lev el, we eval u ate the ef fect of ill-health on oc cu pa tion al sta tus, pro duc tiv i ty, earn ings, hours of work and ear ly re tire ment we es ti mate sev er al econo met ric mod els, con trol ling for the en do gene ity of dif fer ent mea sures of health, us ing pri mar i ly the World Bank‘s LSMS datasets (esp. from Al ba nia, Bosnia & Herze gov ina, Bul gar ia, Koso vo). Re sults strong ly con firm the neg a tive im pact of ill health on both the in di vid u al and the mac ro lev el. De pend-ing on the coun try, ill health seems to have a neg a tive ef fect on the prob-a bil i ty of be ing em ployed, on the wage rate, on wages and on hours of work. On the mac ro lev el we find that re duc ing the adult dis ease bur-den in a sus tained man ner would pro duce sub stan tial eco nom ic ben e-fits for the econ o my.

0381

Costs Anal y sis of Breast Can cer Screen ing in Italy Fe deri ci A. (Agen cy for Pub lic Health (ASP) Lazio, Rome, Italy)Bor gia P., Guas tic chi G., Ric cia r di A., Palaz zo F., Rat ti M., Men ni ni F.S.

The pres ent work anal y ses the costs of Breast Can cer screen ing pro-gramme to de fine a new fi nan cial sys tem based on real costs.the screen-ing pro gram into dif fer ent pro cess es (lev els) and ac tiv i ties (costs cen-ters) re lat ed with dis ease man age ment, the Cen ter of Tech nol o gy As sess-ment in Pub lic Health (CTAph) has col lect ed data in five Lo cal Health Units (LHU) of Lazio Re gion. The whole to tal costs are re spec tive ly € 1,557,183 for LHU 1 which screened 26,080 wom en (39,7% of in volved pop u la tion) € 1,998,142 for LHU 2 which screened 39,485 wom en (62,1% of in volved pop u la tion), € 691,811 for LHU 3 which screened 9,919 wom en (14,5% of in volved pop u la tion), € 345,595 for LHU 4 which screened 6,839 wom en (55,5% of in volved pop u la tion) and € 745,289 for LHU 5 which screened 15,453 wom en (63,7% of in volved pop u la tion).the new fee sys tem the CTAph pro pos es to fi nance the ef fec-tive ac tiv i ties of each lev el. It re quires to up grate the only one fee per in vit ed wom an with three dif fer ent fees based on screened per sons in

S34 | Eur J Health Econom Suppl 1 · 2006

each lev el. In this way the pro duc tiv i ty of each costs cen ter is prop er-ly re mu ner at ed; as well it’s pos si ble to re duce the waste of the fi nan cial re sources.

0373

Cost-eff ec tive ness of in ter ven tions to re duce to bac co smok ing. An ap pli ca tion of the RIVM Chron ic Dis ease Mod elFeen stra T. (In sti tute for Pub lic Health and the En vi ron ment, RIVM, Bilthoven, Nether lands)Baal P., Hoogen veen R., Vi j gen S., Be mel mans W.

Smok ing is re lat ed to sub stan tial mor bid i ty and mor tal i ty. This study as sessed the cost-ef fec tive ness of eight in ter ven tions to en hance smok-ing ces sa tion in adults, name ly to bac co tax es, mass me dia cam paigns, min i mal coun sel ing, struc tured GP-sup port, tele phone coun sel ing, nic o tine re place ment ther a py with min i mal and in ten sive coun sel ing, and bu pro pi on with in ten sive coun sel ing. To es ti mate costs per (qual-i ty ad just ed) life year gained, a dy nam ic pop u la tion mod el, the RIVM chron ic dis ease mod el, was used to pro ject health gains and ef fects on health care costs. Sen si tiv i ty anal y ses were per formed for vari a tions in costs, ef fects, time ho ri zon, pro gram size and dis count rates.Tax in creas es re sult ed in costs per QALY around €5000. The costs per QALY for a mass me dia cam paigns was be low €10,000 for a broad range of ef fects. Costs per QALY for in di vid u al ces sa tion sup port var-ied from about €7000 for GP sup port to €21,000 for tele phone coun-sel ing. In con clu sion, most in ter ven tions were cost-ef fec tive com pared to cur rent prac tice. Eval u at ing all in ter ven tions with the same mod el im proved com pa ra bil i ty. How ev er, com par i son of in ter ven tions is dif-fi cult, be cause tax es and cam paigns are com bined with in di vid u al sup-port. Tak ing that into ac count, tax es seem to pro vide most val ue for mon ey, with tax rev enues prob a bly more than mak ing up for pos si ble costs of reg u la tion.

0255

The Eff ects of Op tion al De ductibles in Ger man So cial Health In sur anceFelder S. (In sti tute of So cial Med i cine and Health Eco nomics, Uni ver si ty of Magde burg, Ger many)Werblow A.

A Ger man sick ness fund of fers 240 € per year to the clients if they pay the first 300 € of their health care bills, ex cept for doc tor vis its where a flat rate of 20 € ap plies. The pa per stud ies the ef fects of this de ductible on health care de mand by com par ing the 12,000 par tic i pants with a con-trol sam ple. We use in sur er’s claims data cov er ing in pa tient care, pre-scrip tion drugs and am bu la to ry care. The data ex tends to three years in clud ing two years be fore and the year when the pro gram start ed. We ap ply two meth ods, a match ing and a para met ric ap proach which mod-el the choice of the de ductible, the prob a bil i ty of pos i tive ex pens es, as well as the de mand for health care ser vices con di tion al on hav ing pos i-tive de mand. study shows that in di vid u als ra tio nal ly opt for or against the de ductible. Con trol ling for the fac tors that ex plain the choice of the pro gram, the num ber of gen er al prac ti tio ner con sul ta tions de creas es by 24 per cent and that of spe cial ists by 42 per cent. More over, the out lays for pre scrip tion drugs and in pa tient care also sig nif i cant ly de crease. Pre ven-tion ac tiv i ties, not sub ject to the de ductible, how ev er, re main con stant. The qual i ta tive re sults do not de pend on whether we use a non-para met-ric or a para met ric ap proach.

0479

High Costs for Chil dren with Ju ve nile Id io path ic Ar thri tis (JIA)Feld man D. (Uni ver sité de Mon tre al, Ecole de réadap ta tion (School of re ha bil i ta tion), Mon tre al, Can a da)Bernatsky S., Duff y C., St. Pierre Y., Malle son P., Feld man D., Gib bon M., Oritz-Avarez O., Clarke A.

Ju ve nile Id io path ic Ar thri tis (JIA) is a po ten tial ly dev as tat ing chron-ic pe di at ric dis ease. OB JEC TIVE: To de scribe di rect health care costs in JIA, com pared to pe di at ric con trols. METH ODS: Con sec u tive clin-ic at ten dees (N=155) with JIA were en rolled from two pe di at ric cen-tres along with out pa tient clin ic and com mu ni ty con trols with out JIA (N=181). Data on di rect health care costs were ob tained at 3-month in ter vals, us ing The Cost As sess ment Ques tion naire. Unit costs for health ser vices were ob tained from fed er al, provin cial, hos pi tal, lab, and pro fes sion al as so ci a tion sources. Av er age an nu al ized di rect health care costs were cal cu lat ed in 2002 Cana di an dol lars and com pared for JIA sub jects vs. con trols. Re sults: The av er age age at en roll ment was sim i-lar in the JIA sam ple (10 years, SD 4.3) vs. con trols (10.5 years, SD 4.0). The to tal dif fer ence in an nu al ized av er age di rect health care costs for JIA vs. con trols was $ 1,261 (95% con fi dence in ter val: $606, $1,916). Re gard-ing cost com po nents, JIA sub jects had sub stan tial ly high er costs re lat ed to med i ca tion use: dif fer ence of $682 (95% con fi dence in ter val: $460, $904). JIA sub jects also had high er costs re lat ed to vis its to health care pro fes sion als and di ag nos tic tests (im ag ing/lab). Con clu sions: The eco-nom ic im pact of JIA is sub stan tial. Work is in progress to de scribe the to tal eco nom ic im pact of JIA, in clud ing in di rect costs, and es tab lish clin-i cal/so cial de ter mi nants of cost in JIA.

0048

Cost-eff ec tive ness anal y ses of a ro ta vi rus vac ci na tion pro gram in BrazilFer raz M. (Sao Paulo Cen ter for Health Eco nomics, Sao Paulo, Brazil)Soarez P.C., Ci conel li R. M., Fer raz M.B.

Back ground: Ro ta vi rus is the lead ing cause of se vere acute gas tro en-te ri tis in chil dren < 5 years of age world wide. It is es ti mat ed that, each year, 350,000–600,000 chil dren die of ro ta vi rus in fec tion, 2 mil lion are hos pi tal ized and 25 mil lion re quire an out pa tient vis it. A new ro ta vi rus vac cine was re cent ly li censed, and Brazil was the first coun try to im ple-ment a uni ver sal vac ci na tion pro gram.Ob jec tives: The aim of this study was to es ti mate the cost-ef fec tive ness of a uni ver sal ro ta vi rus im mu ni za tion pro gram in an in fant pop u la tion in Brazil.Meth o dol o gy: A de ci sion tree used sources of lo cal ro ta vi rus dis ease in ci dence, health care ex pen di ture, vac cine cov er age, ef fi ca cy, and price. A sen si tiv i ty anal y sis us ing case sce nar ios to ward and against vac ci na-tion was per formed in some vari ables. Fu ture costs were dis count ed to pres ent val ue. Es ti mates were made from the so ci etal per spec tive.Re sults: A uni ver sal ro ta vi rus vac ci na tion pro gram could pre vent 14,362 do mi cil i ary cas es, 11,127 out pa tient cas es and 1,258 hos pi tal iza-tion cas es. It also could avert ap prox i mate ly, 26,746 di ar rhea episodes, and 78 deaths among these chil dren. The cost per case and death avert-ed would be $1,487 and $512,635, re spec tive ly. And a QALY gained would cost $10,614.Con clu sions: A ro ta vi rus vac ci na tion pro gram is cost-ef fec tive de pend-ing on the vac cine price, mor tal i ty and mor bid i ty in ci dences.Dis clo sure in for ma tion: This re search was car ried out on be half of CPES. CPES is a not for prof it or ga ni za tion as so ci at ed to the Fed er al Uni ver si ty of Sao Paulo. The au thors are re searchers of CPES and have no con flict of in ter est with re gard to this pro ject.

Eur J Health Econom Suppl 1 · 2006 | S35

0293

How con sis tent are health util i ty val ues?Fer reira P. (Fac ul ty of Eco nomics, Uni ver si ty of Coim bra, Por tu gal)Fer reira L.N.

The use of pref er ence-based ge ner ic in stru ments to mea sure Health Re lat ed Qual i ty of Life of a gen er al pop u la tion or of in di vid u als suf fer-ing from a spe cif ic dis ease has been in creas ing. How ev er, there are sev-er al dis crep an cies in terms of util i ty re sults be tween in stru ments.study seeks to com pare SF-6D and EQ-5D across sub jects with cataracts and to in ves ti gate the dif fer ences in agree ment be tween them. The main ob jec tive is to ex plore the even tu al rea sons for di ver gences found and to ex plore their im pli ca tions.be tween EQ-5D and SF-6D health state clas si fi ca tions is as sessed by cor re la tion co ef fi cients. The dis tri bu tion of in di vid u als re port ing the low est or high est health state in each in stru-ment is anal y sed in terms of their re port in the al ter na tive in stru ment. Econo met ric mod els were es ti mat ed to ex am ine the na ture of the re la-tion ship be tween both in dices. is ev i dence for floor ef fects in SF-6D and ceil ing ef fects in EQ-5D. Com par isons of mean in dices found that SF-6D val ues ex ceed EQ-5D val ues. Dif fer ences in val u a tion meth ods and in scor ing al go rithms con tribute to the main dif fer ences. The in ter pre-ta tion of the con stant term and the in ter ac tion terms gen er ate im por-tant ef fects on the in dices.over come their weak ness es, re vi sions of one or both in stru ments in their de scrip tive sys tems or on their scor ing al go-rithm are nec es sary.

0310

An at tempt to re duce the fl oor eff ect in the health util i ty mea sure mentFer reira L. (Uni ver si ty of Al garve, Faro, Por tu gal)Fer reira P.L.

The SF-6D is a new pref er ence-based mea sure of health de rived from the SF-36. It has be come wide ly used in eco nom ic eval u a tion, but it still has sev er al lim i ta tions.study aims to in ves ti gate the prob lems found in this mea sure and to sug gest some chang es to it. This work also seeks to study the mod els un der ly ing the SF-6D and to es ti mate new mod els for pre dict ing health state util i ties.sam ple of 249 health states de fined by the SF-6D have been val ued by a rep re sen ta tive ran dom sam ple of the gen er al pop u la tion, strat i fied by gen der and age, us ing the Stan dard Gam ble (SG). Ad di tion al 50 health states in clud ing ex tra lev els on two di men sions of the SF-6D were val ued, aim ing to solve the floor ef fect as signed to SF-6D mod els were es ti mat ed on the re la tion ship be tween the SF-6D and the SG val ues and anal y sed in terms of their co ef fi cients, over all fit and the abil i ty for pre dict ing the SG val ues for all health states. The co ef fi cients were found to be ro bust across mod el spec i fi ca tion, both in the case of the SF-6D pre vi ous ly de fined by Bra zier and in the case of the SF-6D added with ex tra lev els in two di men sions.pref er ence-based util i ty mea sure used seems to ad e quate ly pre dict the health states val ues of the gen er al pop u la tion. The re sults con firm the use ful ness of ad di tion al lev els on the SF-6D, im prov ing its ef fi cien cy in mea sur ing the health states util i ties and in di min ish ing the floor ef fect.

0133

Es ti mat ing het ero ge ne ity in pa tient pref er ences for a der ma tol o gy con sul ta tionFly nn T. (MRC HSRC, Uni ver si ty of Bris tol, UK)Lou viere JJ., Pe ters TJ., Coast J.

Greater pa tient choice is re gard ed as in creas ing ly im por tant in the de liv-ery of health care. How ev er, whilst an an a lyt i cal frame work ex ists to help in form pop u la tion-lev el pri or i ty-set ting in health care, there are lit-tle quan ti ta tive data about in di vid u al pa tient pref er ences for at tributes

of ser vice pro vi sion and treat ment. Best-worst scal ing (BWS) stud ies not only pro vide quan ti ta tive es ti mates of pa tient pref er ences but they are par tic u lar ly well-suit ed to es ti mat ing dif fer ences in pref er ences be tween pa tient sub groups de fined by clin i cal or so ciode mo graph ic fac tors. BWS study was ad min is tered in a tri al to val ue pa tients pref-er ences for four as pects of a der ma tol o gy con sul ta tion wait ing time, con ve nience of at tend ing, ex per tise of doc tor and de gree of in di vid u-alised care. Whilst wait ing time was found to be the least im por tant at tribute, multi no mi al log it mod els in di cat ed that it be came more im por tant when pa tients felt that as pects of their dai ly lives were af fect-ed by their skin con di tion. Fur ther more, ‘widen ing’ of lev el scale val ues around the at tribute im por tance es ti mates was found in more ed u cat ed pa tients. The pol i cy im pli ca tions of these find ings will be sum marised and is sues sur round ing the com pat i bil i ty of pa tient-cen tred care with na tion al cost-ef fec tive ness guide lines will be raised.

0509

The role of health eco nomics anal y sis in de ci sion mak ing – an il lus tra tion from Swe denFors berg B. (Dept of Pub lic Health Sci ences Karolin s ka In sti tutet, Med i cal Man age ment Cen tre Karolin s ka In sti tutet, Dept. of Pub lic Health Sci ences Karolin s ka In sti tutet, Stock holm, Swe den)Me din E., Rehn berg C.

This is a study of the de ci sion mak ing pro cess around the pur chase of high-cost tech ni cal equip ment at a ma jor uni ver si ty hos pi tal in Swe den. The Coun ty Coun cil and the hos pi tal man age ment were faced with dif fer ent al ter na tives for pro vid ing the ser vices of a “Gam-ma Knife”: pur chase the ser vice from a pri vate provider on an item ba sis, pur chase the equip ment in the in ter na tion al mar ket and op er-ate it di rect ly with in the pub licly owned hos pi tal or pur chase it lo cal-ly for the same pur pose. The cost-ef fec tive ness of each of the op tions is pre sent ed. The ev i dence base in the de ci sion mak ing pro cess was re viewed and key ac tors were in ter viewed on the role of var i ous pieces of in for ma tion, in par tic u lar cost-ef fec tive ness and fi nan cial anal y sis, in tak ing the de ci sion on pur chase and ser vice pro vi sion. The study shows that de ci sions on such huge in vest ments are pre ced ed by a com-plex pro cess in which health eco nomics makes an im por tant con tri bu-tion. Still, de ci sions are in the end in flu enced by many fac tors, health eco nomics anal y sis be ing only one of them. The study sug gests how the role of cost-ef fec tive ness and fi nan cial anal y sis can be strength-ened in health care de ci sion mak ing.

0035

Fa tal and Non fa tal Mo tor cy cle In juries: Can Al co hol Poli cies In fl u ence Rid er Safe ty and Re duce Ac ci dents?French M. (Uni ver si ty of Mi a mi, Coral Gables, Flori da, USA)

Nu mer ous stud ies have es tab lished the ef fec tive ness of al co hol poli cies (e.g., blood al co hol con tent for driv ing un der the in flu ence, DUI penal-ties and fines, min i mum le gal drink ing age, bev er age tax es) in re duc-ing rates for au to mo bile ac ci dents, in juries, and fa tal i ties. Only a few stud ies have an a lyzed the im pact of al co hol poli cies on mo tor cy cle ac ci-dents and none with in the past 5 years. Giv en the grow ing pop u lar i-ty of mo tor cy cle rid ing among all age groups and the in her ent safe ty risks, a new and com pre hen sive in ves ti ga tion is war rant ed. The pres-ent study uses state-lev el lon gi tu di nal data from 1994 to 2003 to de ter-mine whether a va ri ety of dif fer ent al co hol and mo tor cy cle safe ty poli-cies have a sig nif i cant im pact on both fa tal and non fa tal mo tor cy cle in juries. Be sides state-lev el poli cies, the anal y sis con trols for nu mer ous de mo graph ic and en vi ron men tal fac tors in each state through the es ti-ma tion of state fixed-ef fects mod els. The re sults lead to di rect pol i cy rec om men da tions for how states can re duce mo tor cy cle in juries and en hance over all mo tor cy cle safe ty.

S36 | Eur J Health Econom Suppl 1 · 2006

0542

Im ag es of In for mal Pay ments for Health Care: Defi ni tions, The o ries and Prac ticeGaal P. (Health Ser vices Man ag ment Train ing Cen tre, Sem mel weis Uni ver si ty, Bu dapest, Hun gary)

Ob jec tives: In for mal pay ments are known to be widespread in the post-com mu nist health care sys tems of Cen tral and East ern Eu rope and the coun tries of the for mer So vi et Union. How ev er their role and na ture re mains con tentious, with the de bate char ac ter ised by much polemic. There is not even con sen sus on the def i ni tion of the phe nom e non, al though there is a gen er al un der stand ing of what is con sid ered in for-mal pay ments and what is not. This study steps back from the de bate to ex am ine the the o ret i cal ba sis for un der stand ing the per sis tence of in for mal pay ments, and con front this con cep tu al anal y sis with em pir-i cal ev i dence.Meth o dol o gy: The study com bines the o ret i cal and em pir i cal meth ods, in clud ing the re view of the the o ret i cal and em pir i cal lit er a ture, con cep-tu al anal y sis and case stud ies. In par tic u lar the study:– ex am ines the vari ants of in for mal pay ments that have been re port-

ed in the lit er a ture,– anal y ses the pro posed def i ni tions of the phe nom e non, points out

their short com ings and sug gests a new def i ni tion based on the con-cept of en ti tle ments and the ad di tion al na ture of pay ments as the dis tinc tive fea ture com mon to all types of in for mal pay ments,

– con sid ers the im pli ca tions of this new def i ni tion for re search and pol i cy mak ing,

– iden ti fies the mo ti va tion for in for mal pay ments as the key is sue for health pol i cy, and de vel ops of new the o ret i cal frame work on the ba sis of the the o ry of gov ern ment fail ure and Hirschman’s the o ry of “exit, voice, loy al ty”,

– uses a case study of pri vate sec tor in for mal pay ments to un der stand the mo ti va tion for in for mal pay ments and to test the va lid i ty of the “in x it” the o ry of in for mal pay ments.

Re sults: The wide va ri ety of the dif fer ent forms (or im ag es) of in for mal pay ments in clud ing mon e tary trans ac tions, in kind gifts (such as choco-lates, spir its or flow ers) and in kind con tri bu tions (such as drugs, clean linen, meals or nurs ing ser vices) are not ex clu sive ly il le gal, cor rupt or in for mal and are not con fined to the pub lic sec tor ei ther. The com mon to all types of in for mal pay ments is that they are giv en to health care providers in ad di tion to any con tri bu tion that has been stip u lat ed in the terms of en ti tle ment. This rais es the ques tion: ‘Why do peo ple pay more than what is re quired?’ Is it be cause they are gen uine ly grate ful for be ing cured (do na tion hy poth e sis)? Is it be cause they are not aware of what they are en ti tled to? Or is it be cause they want to se cure that they get the care they need (fee-for-ser vice hy poth e sis)? To an swer these ques tions we have ex plored the case of pri vate sec tor in for mal pay ments in a small pri vate for-prof it hos pi tal in Hun gary, and it turned out that at tempts by pa tients to pay physi cians in for mal ly do ex ist in the pri vate sec tor. Nev-er the less, the deep er anal y sis of mo ti va tion for such pay ments re vealed that they are rather at tributable to the blurred bound aries be tween the pub lic and the pri vate sec tor than gen uine grat i tude.Con clu sions: The key health pol i cy ques tion is the mo ti va tion for in for-mal pay ments: whether it is grat i tude or there is a per va sive fail ure of the health care sys tem be hind them. The the o ry of “in x it” con sid ers in for mal pay ments as a po ten tial re ac tion of pa tients and doc tors to de clin ing or ga ni za tion al and sys tem per for mance, in ad di tion to exit and voice de scribed ear li er by Hirschman. Al though the ex is tence of phe nom e non in the pri vate sec tor seems to in val i date this ex pla na tion, em pir i cal ev i dence shows that even in these ‘ex treme’ cas es, gen uine grat i tude is prob a bly rarely mo ti vates in for mal pay ments. On the oth-er hand the ex am ple of pri vate sec tor in for mal pay ments high lights the com plex i ty of the prob lem, pol i cy mak ers face if they are to erad i cate the phe nom e non. Poli cies to tack le in for mal pay ments should find the del i cate bal ance be tween exit and voice to op ti mise the chances of main-tain ing a good stan dard of pub lic ser vices.

0047

Sources of in effi cien cy among hos pi tals in Ire landGan non B. (Eco nom ic and So cial Re search In sti tute, Dub lin, Ire land)

The anal y sis of ef fi cien cy in hos pi tals can make a ma jor con tri bu tion to im prov ing health ser vices. The ul ti mate aim is to (1) iden ti fy poor-ly per form ing hos pi tals, (2) to un der stand why and (3) to ad dress the un der ly ing caus es. Pre vi ous re search sug gests that there is sub stan tial vari a tion in ef fi cien cy among hos pi tals in Ire land, (Gan non, 2005). The aim of this pa per is to ex plore the un der ly ing caus es. A two-stage mod-el is ap plied to hos pi tal lev el data be tween 1995 and 2004. Po ten tial con-trib u tors to ef fi cien cy vari a tion in clude hos pi tal size, age dis tri bu tion of pa tients and lo cal en vi ron men tal fac tors. Fur ther more the is sue of qual i-ty is ad dressed, and po ten tial qual i ty in di ca tors in clude hos pi tal spe cif ic mor tal i ty rates. In ad di tion, the mod el in cludes re sults from a re cent in-depth hy giene au dit on all hos pi tals. By iden ti fy ing the un der ly ing links be tween in ef fi cien cy and re lat ed fac tors, the re sults are use ful in the con-text of on go ing change in the na tion al health pol i cy, B. (2005). “Test ing for vari a tion in tech ni cal ef fi cien cy among hos pi tals in Ire land”, The Eco-nom ic and So cial Re view, Forth com ing De cem ber 2005.

0051

The In fl u ence of Eco nom ic In cen tives on Re port ed Dis abil i ty Sta tusGan non B. (Eco nom ic and So cial Re search In sti tute, Dub lin, Ire land)

Self-re port ed dis abil i ty sta tus is of ten re lied upon in labour force par-tic i pa tion mod els, but this may be re port ed with er ror for eco nom ic or psy cho log i cal rea sons and can lead to a bias in the ef fect of dis abil i ty on par tic i pa tion. In this pa per, we ex plore the pos si bil i ty that re port ed lim-i ta tions in dai ly ac tiv i ties are mis re port ed, in par tic u lar for those who de fine their labour force sta tus as dis abled, and as sess if fi nan cial in cen-tives in flu ence this group to mis-re port. The main ques tions we wish to ad dress are (1) was there state de pen dent re port ing er ror and did fi nan-cial in cen tives play a role, and (2) did this change over the years 1995 to 2001? Us ing a gen er alised or dered log it mod el, we com pute cleansed mea sures of dis abil i ty that cor re spond to pre dict ed re spons es in di vid u-als would have made if em ployed. The pre lim i nary re sults in di cate that the dis abled group did over-re port and the dif fer ence be tween ac tu al and pre dict ed prob a bil i ties fluc tu at ed be tween 1995 and 2001. We dis-cuss two par tic u lar in sti tu tion al chang es in Ire land that help to ex plain how eco nom ic in cen tives in flu enced re port ing be hav iour.

0448

A re view of the phar ma coeco nom ic stud ies con duct ed in Italy.Garat ti ni L. (Mario Ne gri In sti tute, Mi lan, Italy)Bassi L., Cor na go D.

To as sess the state of phar ma coeco nomics in Italy we re viewed the full phar ma coeco nom ic EEs done there and adopt ed com mon cri te ria of anal y sis to al low method olog i cal com par i son of the stud ies. The vari-ables in ves ti gat ed can be grouped in three cat e gories: gen er al meth ods, costs, and con se quences. We se lect ed all the orig i nal stud ies pub lished by Ital ian au thors in na tion al and in ter na tion al jour nals from Jan uary 1994 to De cem ber 2003. We re viewed 70 ar ti cles and broad ly as sessed 92 EEs since some ar ti cles con tained mul ti ple anal y ses.Only 20 EEs were clas si fied as “ide al” ac cord ing to the qual i ty of the sources of clin i cal ev i dence and 21 EEs were clas si fied as “use ful to the NHS” ac cord ing to the cred i bil i ty of eco nom ic ev i dence: by com bin ing the re sults of these two sep a rat ed anal y ses, we found that only sev en out of the 92 EEs ap peared to be cred i ble. To com plete our crit i cal eval u a-tion, we anal y sed whether spon sor ship might have some how af fect ed

Eur J Health Econom Suppl 1 · 2006 | S37

the re sults and found that the vast ma jor i ty of spon sored EEs showed pos i tive re sults for the spon sored drugs.Our re view on the EEs by Ital ian au thors con firms the le git i ma cy of the pub lic au thor i ties’ scep ti cism to wards phar ma coeco nom ic stud ies, whose re sults seem to be bi ased by flawed meth ods and spon sors’ in ter-fer ence on re sults.

0475

Child Obe si ty and Ma ter nal Em ploy mentGar cía E. (Foun da tion for Ap plied Eco nom ic Stud ies (FEDEA), Madrid, Spain)

In crease of over weight ed and obese chil dren has been dra mat ic for the last decades of the XX cen tu ry in de vel oped coun tries. More than so cial ac cep tance or aes thet ic con sid er a tions, obe si ty con se quences on health and well be ing are dan ger ous. Con se quences of obe si ty have been large-ly dealt with in the lit er a ture. How ev er, its caus es still need to be cleared out. We cen ter our work in some of the caus es of obe si ty. Specif i cal-ly, this pa per in ves ti gates whether chil dren are more or less like ly to be over weight if their moth ers works. Dur ing the last decades the evo-lu tion of wom en em ploy ment and over weight chil dren in Spain has shown sim i lar trends. In this sense, it is pos si ble that fe male la bor force par tic i pa tion has lead to a change in the tra di tion al con cept of child-hood care and in fam i ly habits that may have af fect ed chil dren phys i-cal ap pear ance and health. The main aim of this pa per is to help de ter-mine if these par al lel trends are just drawn by spu ri ous cor re la tion or by a caus al re la tion ship be tween the two vari ables. Whether or not we find caus al ef fects has im por tant im pli ca tions for pol i cy mea sures ei ther in the labour mar ket or fis cal ones. Us ing data from the Na tion al Health Sur vey for 2003, we re late moth ers’ per son al and pro fes sion al sit u a tion with the de gree of over weight and obe si ty of their chil dren. Our re sults in di cate that obe si ty ranges with the age and sex of chil dren. Chil dren of low-ed u cat ed moth ers and of over weight and obese moth ers are also more like ly to suf fer from over weight or obe si ty. Fi nal ly, a child is more like ly to be over weight or obese if his moth er works, even if we con trol for ge net ic, en vi ron men tal and so cio-eco nom ic fac tors.

0268

Health Shocks, Em ploy ment and In come in the Span ish Labour Mar ketGar cía Gómez P. (Cen tre de Re cer ca en Econo mia i Salut (CRES)Pom peu Fab ra, Barcelona, Spain)Nicolás A.L.

This pa per in ves ti gates the re la tion ship be tween health shocks and labour out comes in the Span ish pop u la tion us ing the Eu ro pean Com-mu ni ty House hold Pan el. In or der to con trol for the non-ex per i men-tal na ture of the data we use match ing tech niques. Our re sults sug gest that there is a sig nif i cant ef fect run ning from health to the prob a bil i ty of em ploy ment and to labour in come. More over, while we can not in ves-ti gate the in flu ence of child hood events and oth er phe nom e na that trig-ger long run caus al path ways from so cio-eco nom ic sta tus to health, we are able to find a sig nif i cant re duc tion in the prob a bil i ty of re port ing good health in in di vid u als who tran sit out of em ploy ment in com par i-son with in di vid u als who are oth er wise iden ti cal in terms of re port ed health sta tus at the time of the tran si tion.

0062

Hy brid Risk Ad just ment for phar ma ceu ti cal ben e fi tsGar cia-Goni M. (Uni ver si dad Com plutense de Madrid, Pozue lo de Alar cón, Spain)Ibern P.

Phar ma ceu ti cal ben e fits are in creas ing ly un der close mon i tor ing since costs, qual i ty, and ap pro pri ate ness are cru cial for health out comes. While prospec tive risk ad just ment has been shown to pro mote in cen-tives for ef fi cien cy through con trol ling the costs, ret ro spec tive or con-cur rent for mu lae may ob tain a high er pre dic tive pow er and avoid in cen-tives for se lec tion. This pa per fol lows a rel a tive ly new lit er a ture on risk ad just ment in which a mixed for mu la – with both prospec tive and con-cur rent pay ments – seeks to max i mize the ef fi cien cy in cen tives in volved in the prospec tive risk ad just ment and min i mize the se lec tion in cen-tives through a con cur rent risk ad just ment for high risk in di vid u als. We uti lize in di vid u al data on phar ma ceu ti cal ex pen di tures and health con di-tions -us ing Clin i cal Risk Groups (CRGs) and Di ag nos tic Cost Groups (DCGs) for mor bid i ty ad just ment- for the pop u la tion be long ing to an in te grat ed health care de liv ery or ga ni za tion in Cat alo nia in years 2002 and 2003. For mer re sults with the same database showed that pre dic-tive ra tios pre dic tive ra tios and vari ance ex plained were in line with pub-lished re search. The goal of this pa per is to show the gain of a hy brid risk ad just ment that can be used for re source al lo ca tion and man age ment, fo cus ing on a def i ni tion of reg u la to ry mech a nisms that can be ap plied in a set ting with uni ver sal cov er age and pub lic fi nanc ing.

0141

The im pact of Aus tralian gov ern ment pol i cy change on the pri vate price of nurs ing home careGar gett S. (The Uni ver si ty of Queens land, Wa col, Bris bane, Aus tralia)

This pa per will an a lyse the im pact that chang es in Aus tralian Gov ern-ment pol i cy may have had, on the pri vate price of nurs ing home care. The Aus tralian Gov ern ment has sub sidised nurs ing home care since 1963, with res i dents also con tribut ing to the cost of care. The Gov ern-ment’s pol i cy as to amounts res i dents have had to con tribute has var-ied, with new poli cies in tro duced in 1973, 1991, and 1997-98. Of spe-cif ic in ter est is whether the most re cent re forms, which re quired that res i dents con tribute based on their as sessed abil i ty to pay, sig nif i cant ly al tered the price res i dents paid. ‘in ter ven tion anal y sis ap proach’ will be used to an a lyse data on the price paid by res i dents. Es ti mates of the av er-age an nu al net price paid per res i dent per oc cu pied-care day, have been de ter mined for 1960-61 on wards. Af ter as sess ing the sta tion ar i ty of the data, an au tore gres sive in te grat ed mov ing av er age mod el (ARI MA) will be spec i fied and es ti mat ed. Dum my vari ables are in clud ed to re pres ent the pol i cy in ter ven tions. The im pact of the poli cies will be in ter pret ed in the light of the co ef fi cient val ues and the ad e qua cy of the mod el. Giv-en the pre dict ed in crease in ex pen di ture on aged care ser vices over com-ing decades, it is use ful to eval u ate the ef fects that poli cies, which may in flu ence the de mand for such ser vices, may have had.

0059

The over all eff ect and sig nifi cance of drug price elas tic i ty among US se niorsGem mill M. (Lon don School of Eco nomics, Lon don, UK)McGuire A.

De spite the im por tance of pre scrip tion drugs for the el der ly and in creas-ing pri vate and pub lic ex pen di tures on pre scrip tion medicines, few stud ies have es ti mat ed the elas tic i ty of de mand for pre scrip tion drugs among the el der ly, and none have de rived an es ti mate for the el der ly as a whole in the Unit ed States. This pa per draws upon the 1996-2002 Med-

S38 | Eur J Health Econom Suppl 1 · 2006

i cal Ex pen di ture Pan el Sur vey and uses pan el data tech niques to pro-vide ad di tion al em pir i cal ev i dence that fills the ex ist ing gap in the lit er-a ture. The econo met ric tech niques re fer to mod els that treat data counts in the pres ence of mis sing ob ser va tions in two dis tinct ways one mod-el uses tra di tion al meth ods of ac count ing for at tri tion and one fixed ef fects mod el si mul ta neous ly con trols for ro tat ing pan els and un ob-served het ero ge ne ity. The re sults in di cate that in creased lev els of cost shar ing lead to a de crease in the de mand for pre scrip tion drugs with pro nounced elas tic i ty es ti mates that dif fer from ear li er stud ies. The es ti-mates de pend on the spec i fi ca tion con trol em ployed but are gen er al ly cal cu lat ed to be with in a nar row range. In com par i son to oth er stud ies that have cal cu lat ed elas tic i ties for the gen er al pop u la tion, our es ti mates are low er, pos si bly in di cat ing that the el der ly per ceive few er sub sti tutes for pre scrip tion medicines than the gen er al pop u la tion.

0472

Ref er ence Price on off -patent drugs: an anal y sis of the Ital ian and the Span ish ex pe ri enceGhis lan di S. (CE SAV, Mario Ne gri In sti tute, Ran i ca BG, Italy)Junoy J.P., Garat ti ni L.

A com par a tive anal y sis of the Ital ian and the Span ish ex pe ri ence with Ref er ence Price (RP) is per formed. In Italy, the RP for off-patent prod-ucts was first in tro duced in De cem ber 2001. In Spain, the RP was in tro-duced in De cem ber 2000 and re formed in Jan uary 2004. As Italy and Spain pres ent very sim i lar sit u a tions in terms of phar ma ceu ti cal mar-ket struc ture (late in tro duc tion of the patent sys tem, over crowd ed mar-ket for copies, mar gin al role of gener ics, heavy price reg u la tion), it is in ter est ing to com pare the out comes of the two coun tries. Prices and RP trends are anal y sed for both coun tries us ing a sam ple of month ly ob ser va tions. In Italy, the com pet i tive pres sure of gener ics is shown to play a pri ma ry role in the down ward trend of both the RP and brand-ed prices. In Spain, price re duc tions are also sig nif i cant, but some how de layed. The re sults con firm find ings from the pre vi ous eco nom ic lit-er a ture on RP.

0473

Op ti mal Pric ing with En dog e nous Ref er ence PriceGhis lan di S. (Uni ver si ty of Ox ford and CE SAV, Italy)

Here it is pre sent ed a mod el which tries to ad dress some of the main prob lems re lat ed to the Ref er ence Price (RP) lit er a ture. First, the RP is en dog e nous. Sec ond, we im prove the pre vi ous lit er a ture by in tro duc-ing one brand ed prod uct and n ge ner ic firms that are al lowed ei ther to com pete or to col lude among them selves. Third, the pric ing game is mod elled first as a one shot game, then as a two-stag es game where in the first pe ri od firms set the RP, while in the sec ond they com pete tak-ing the RP as ex og e nous. Fi nal ly, we will keep the anal y sis as gen er al as pos si ble, ob tain ing the re sults from a very broad set of re al is tic as sump-tions. Re sults are clear. RP mech a nisms where the re im burse ment lev el de pends on the brand ed price are shown to be al ways less ef fec tive in keep ing price down, in de pen dent ly from both the lev el of com pet i tive-ness among gener ics and the type of the game played. In case of a one shot game, no Pure Strat e gy Nash Equi lib ria ex ist when the RP is a func-tion of the brand ed prod uct. In the two stage game, col lu sive out come are shown to be al ways worse than the com pet i tive one. How ev er, in ter-est ing ly, first stage gener ics prices can be strate gi cal ly low er un der col-lu sion than un der per fect com pe ti tion.

0291

Tech no log i cal Char ac ter is tics and Cost Effi cien cy of Pub lic Hos pi tals in Pied montPi a cen za M. (Na tion al Re search Coun cil (Ceris-CNR), Mon calieri, Italy) Al ber to C., Tu rati G., Van noni D.

In this pa per we eval u ate cost ef fi cien cy and tech no log i cal char ac ter is-tics of pub lic hos pi tals in Pied mont – a Re gion of the North ern Italy – over the pe ri od from 2000 to 2004. Dur ing the Nineties, dif fer ent reg-u la to ry re forms aim ing at con trol ling health ex pen di ture af fect ed the Ital ian Na tion al Health Ser vice, rang ing from the in tro duc tion of a new re im burse ment scheme for hos pi tals (DRG-based) at the mi cro lev el, to the im ple men ta tion of fis cal fed er al ism at the mac ro lev el. We ar gue that all these leg isla tive in ter ven tions ren dered pro duc ers more prone to con-trol costs, in or der to be able to meet fi nan cial con straints. Our em pir i-cal find ings sup port this hy poth e sis: av er age cost in ef fi cien cy, com put-ed af ter es ti mat ing a Translog sto chas tic cost fron tier by the Bat tese and Coel li (1992) ap proach, re duced re mark ably dur ing the ob served years, while the adop tion of more ef fec tive tech nolo gies shift ed up ward the min i mum-cost fron tier. We also find ev i dence of rel e vant scale economies not ex ploit ed by pro duc ers, which de crease with hos pi tal size (num ber of beds) and out put com plex i ty (av er age DRG weight).

0357

Mod el ing the choice of med i cal spe cial tyGon za lez Lopez-Val car cel B. (Uni ver si ty of Las Pal mas de GC, Spain)Vazquez-Polo FJ., Bar ber P.

Mech a nisms for match ing sup ply and de mand of med i cal res i dence po si tions vary among coun tries. From the mi cro per spec tive of young physi cians who are de cid ing their fu ture, med i cal spe cial iza tion is de ter-mined by sev er al at tributes of the avail able po si tions. These at tributes in flu ence the in di vid u al util i ty func tion. They in clude char ac ter is tics of the hos pi tal: “pres tige”, tech no log i cal lev el, case-mix com plex i ty- as well as char ac ter is tics of the med i cal spe cial ties – in come and pro fes sion-al per spec tives-. We es ti mate a choice mod el for the med i cal res i dence po si tions: what spe cif ic hos pi tal and med i cal spe cial ty has each can di-date cho sen- with mi cro data of about 15000 physi cians from Spain in three con sec u tive years (2003–2005). The mod el shows that the ge o-graph i cal lo ca tion of the hos pi tal and its dis tance from the can di date’s res i dence is a ma jor de ter mi nant of the phy si cian choic es. In come ex pec-ta tions in pri vate med i cal prac tice have a sig nif i cant in flu ence in the choice of med i cal spe cial ty, as well as the “tech no log i cal lev el” of the spe cial ties. De spite in the o ry there is a na tion al mar ket of physi cians cov er ing the whole coun try, our mod el sug gest that this mar ket is seg-ment ed re gion al ly.

0162

Cost-eff ec tive ness thresh olds and phar ma coeco nom ic eval u a tion – lim i ta tions in clar i ty and guid anceGothe H. (IGES In sti tute for Health care and So cial Re search, Ber lin, Ger many)Seid litz C., Mank J., Caeser M., Häus sler B.

Ob jec tives: To re view the lit er a ture for in for ma tion about the im pact of phar ma coeco nom ic data and cost-ef fec tive ness thresh olds on de ci sion mak ing pro cess es in Aus tralia, Can a da, Eng land, and Swe den.Meth ods: The web sites of the in sti tu tions, re spon si ble for the eco nom-ic eval u a tion and rec om men da tion of medicines, were searched for top i-cal ly rel e vant terms such as re im burse ment, pric ing, thresh old, phar ma-coeco nomics, for mu lary list ing.Re sults: From the doc u ment search we ob tained a to tal of n=7,717 hits for the se lect ed search terms. In n=599 doc u ments terms were com-

Eur J Health Econom Suppl 1 · 2006 | S39

bined with oth er key words (i.e. “phar ma ceu ti cal”, “thresh old”), con tent anal y sis showed that only n=38 doc u ments were rel e vant for the study aims. None of the coun tries has pub lished an of fi cial cost-ef fec tive ness thresh old, but it ap pears that an im plic it thresh old ex ists (e.g. 30,000 £ in UK). Con cern ing the rec om men da tions of sev er al medicines, pub-licly avail able in for ma tion is het ero ge ne ous be tween the four coun tries ei ther with re gard to the de tailed ness or avail abil i ty.Con clu sion: Ex ten sive ma te ri al and data can be iden ti fied but it does not nec es sar i ly pro vide re li able guid ance. The in ter pre ta tion of the find-ings may be dif fi cult be cause of the het ero ge ne ity of the avail able ma te ri-al. In or der to guide sub mis sions and to en hance as sess ment pro ce dures au thor i ties need to be more ex plic it about cri te ria for de ci sion mak ing, in clud ing cost-ef fec tive ness thresh olds.

0159

Cost-Eff ec tive ness of Ro su vas tatin in the Pre ven tion of Isch emic Heart Dis ease in Por tu galGou veia Pin to C. (Tech ni cal Uni ver si ty of Lis bon, Por tu gal)Car rage ta M., Miguel L.S.

Ob jec tive: To as sess the cost-ef fec tive ness of ro su vas tatin com pared to ator vas tatin in the treat ment of hy per cho les ter ol e mia and pre ven tion of isch emic heart dis ease (IHD) in Por tu gal.Meth ods: A prob a bilis tic Markov mod el was de vel oped to an a lyse the costs and con se quences of life time treat ment with each statin. Re sults from head-to-head, ran dom is ed, dou ble-blind tri als eval u at ing low-den-si ty li po pro tein (LDL) chang es and from a meta-anal y sis defin ing the re la tion ship be tween LDL lev els and fa tal and non-fa tal IHD events were com bined. In ci dence of myo car dial in farc tion (MI) was de rived from a 9-year Por tuguese ob ser va tion al study. Re source use in the treat-ment of MI was es ti mat ed by a Del phi pan el of 8 Por tuguese car di ol o-gists with at least 15 years of clin i cal prac tice. Costs were cal cu lat ed in both the so ci etal and the pa tients’ per spec tives.Re sults: Ro su vas tatin in creas es life ex pect an cy in 5.63 days per pa tient. More over, it saves 1,051 € (622 €) per pa tient in the so ci ety’s (pa tients’) per spec tive. The in cre men tal cost-ef fec tive ness ra tio is –68,107 € (–40,296 €) per life year saved ac cord ing to the so ci ety’s (pa tients’) per-spec tive. In the 10,000 sim u la tions car ried out ro su vas tatin was al ways more ef fi ca cious, be ing cost sav ing in more than 9,800 cas es for both per spec tives.Con clu sion: Ro su vas tatin is a dom i nant al ter na tive in the pre ven tion of IHD in Por tu gal.

0415

So cio-eco nom ic de ter mi nants of na tion al sui cide ratesGar vey E. (NUI Gal way, Ire land)Ken nel ly B., Oea E.

This pa per anal y ses the so cio-eco nom ic de ter mi nants of na tion al sui-cide rates. Pan el es ti ma tion tech niques have been used with in ter na tion-al data and na tion al re gion al data to test the ef fects of a va ri ety of so cial and eco nom ic vari ables on sui cide rates. This pa per tries to im prove on the spec i fi ca tions used in pre vi ous mod els. We take ac count of the time se ries prop er ties of the data in our em pir i cal work and es ti mate both a long- and short-run mod el based on the re sults of these prop er-ties.a time se ries frame work for pan el data, we test ed the main vari ables for (non-) sta tion ar i ty and cat e gorised the vari ables as be ing ei ther I(1) or I(2). We es ti mat ed both a short term mod el with pure ly sta tion ary vari ables as well as a long term coin te gra tion re la tion ship. In the short term mod el we found a pos i tive re la tion ship be tween the change in al co hol con sump tion and chang es in male sui cide rates and a neg a tive re la tion ship be tween ac cel er a tion of fe male labour force par tic i pa tion and change in male sui cide rates.the long term mod el, we found that it was plau si ble that the four des ig nat ed I(1) in de pen dent vari ables (Gini,

un em ploy ment, GDP per/cap i ta and al co hol con sump tion) were coin-te grat ed with sui cide rates. The re sults of the coin te grat ing mod el sug-gest that in come in equal i ty is an im por tant de ter mi nant of sui cide for men in OECD coun tries, as is al co hol con sump tion. Un em ploy ment is an im por tant de ter mi nant for fe male sui cide rates and GDP per cap i ta is im por tant for both sex es.

0063

Re gion, health in sur ance pre mi ums and risk ad just ment: a fi ve coun try com par i sonGress S. (De part ment of Eco nomics, In sti tute for Health Care Man age ment, Uni ver si ty of Duis burg-Es sen, Ger many)Beck K., Behrend C., Schokkaert E., Shmueli A., Vli et R., Vo orde C., Wasem J.

Re search ques tions: This pa per aims to an swer the fol low ing ques-tions: What are the con se quences of for bid ding or al low ing re gion al pre mi um dif fer en ti a tion by sick ness funds? What are the ef fects of dis-re gard ing or cap tur ing dif fer ences in re gion al health care ex pens es in a risk ad just ment for mu la? In how far are re gion al pre mi um dif fer en ti a-tion by sick ness funds and re gion al dif fer en ti a tion in a risk ad just ment for mu la in ter de pen dent? What are the ad van tages and dis ad van tages of di ver gent reg u la to ry regimes with re gard to the ques tions above? Meth ods: The pa per is based on the con cep tu al frame work of so cial ly “ac cept able costs”, which is ap plied to the in sti tu tion al set tings and reg u-la to ry regimes of five coun tries (Bel gium, Ger many, Is rael, the Nether-lands and Switzer land). Re sults: The so ci etal choice on what vari ables to in clude in a risk ad just ment for mu la pos es a fun da men tal trade-off be tween ef fi cien cy and eq ui ty. We found that this is es pe cial ly true for the risk ad just ment vari able “re gion”. Our five-coun try com par i son shows that the ex plic it or im plic it choic es on ac count ing for dif fer ences in re gion al health care ex pens es vary. The im pli ca tions of these choic es de pend on in sti tu tion al fea tures of the reg u la to ry regime, in clud ing the in stru ments avail able to sick ness funds to man age care and the im ple-men ta tion or not of a health-based risk ad just ment for mu la.

0592

In vest ing in Mi gra tion Health in Eu rope: For the Ben e fi t of AllGrondin D. (In ter na tion al Or ga ni za tion for Mi gra tion, Mi gra tion Health Ser vices, Gen e va, Switzer land)

In vest ing in and man ag ing mi gra tion health en ables eco nom ic progress. Mi grants in good health tend to en joy an im proved qual i ty of life and raised life ex pect an cy. Gen er al ly, they are more re cep tive to ed u ca tion and more pro duc tive, thus in creas ing na tion al in come and en cour ag-ing for eign in vest ment. En joy ing phys i cal, men tal and so cial well be ing means mi grants can more eas i ly seize the op por tu ni ties to par tic i pate pos i tive ly in their com mu ni ties. In te gra tion poli cies that en cour age mi grants to strive for ed u ca tion al at tain ment, em ploy ment, and com mu-ni ty in volve ment can fur ther am pli fy these gains. A fail ure to rec og nize these ben e fits could lead to a high er lev el of dis ease among mi grants, in clud ing men tal and so cial ill be ing, re duced in di vid u al in comes, and slowed na tion al out put. De spite these facts, the man age ment of mi gra-tion health is still seen as ex pen di ture rather than an in vest ment. By in vest ing in mi gra tion health na tions and pol i cy-mak ers world wide can cre ate a pos i tive syn er gy that will mag ni fy so cial and eco nom ic gains for all.

S40 | Eur J Health Econom Suppl 1 · 2006

0240

Effi cien cy of pro cure ment pro ce dures for med i cal equip mentGuc cio C. (Uni ver si ty of Reg gio Cal abria, Reg gio Cal abria, Italy)Pig nataro G., Riz zo I.

The pa per in ves ti gates the ef fi cien cy of pro cure ment for med i cal equip-ment. Dif fer en ti a tion of prod ucts in this mar ket, due to doc tors’ pref er-ences for spe cif ic tech nolo gies, might re duce the num ber of sup pli ers and the po ten tial pos i tive im pact of auc tion rel a tive to ne go ti a tion. a large of fi cial dataset on tech no log i cal equip ment pur chased by Ital ian hos pi tals in the pe ri od 1996-2003, we run an em pir i cal anal y sis of the dif fer en tial im pact of pro cure ment pro ce dures on the pur chas ing price con trol ling for sev er al fac tors like prod uct dif fer en ti a tion, char ac ter is-tics of pur chasers, con cen tra tion of sup pli ers. The pol i cy im pli ca tions stem ming from the pa per point to stress whether in cen tives are need ed for man agers and doc tors when auc tions are not sat is fac to ry means to en sure ef fi cien cy in pro cure ment.

0299

Defi cits, soft bud get con straints and bailoutsHa gen T.P. (In sti tute of Health Man age ment and Health Eco nomics of Oslo, Nor way)Tjer bo T.

Back ground: The Nor we gian hos pi tal re form of 2002 trans ferred the own er ship of the hos pi tals from the coun ties to the cen tral state, and cre-at ed five re gion al semi-au ton o mous health en ter pris es with the re spon-si bil i ty of gov ern ing the hos pi tals in their re gion. The hos pi tal re form had el e ments of po lit i cal cen tral iza tion since the Par lia ment be came the po lit i cal body ul ti mate ly re spon si ble for the de ci sion mak ing, but also of ad min is tra tive de cen tral iza tion as more de ci sions were ex pect ed to be made by non-po lit i cal boards and di rec tors at the re gion al and lo cal lev-els. There were sev er al ar gu ments for re form. How ev er, what trig gered the re form were in creased deficits at the coun ty lev el in the last part of the 90s and de mand for sup ple men tary funds from the par lia ment to the hos pi tal sec tor dur ing the fis cal years. Ques tion: Has cost con trol im proved af ter the re form? Are there dif fer-ences be tween the five re gion al health en ter pris es in bud get ing pro ce-dures and deficits af ter the re form? How has the Par lia ment even tu al ly re spond ed to de mand for sup ple men tary funds af ter the re form? The o ry: Clas sic con tri bu tions in the lit er a ture of fis cal fed er al ism point to wards de cen tral iza tion as a mean for achiev ing al lo ca tion ef fi cien cy and cost con trol. Re cent con tri bu tions do how ev er in di cate that the state-lo cal in sti tu tion al ar range ments such as tax dis cre tion and bud get-ing pro ce dures af fect both ef fi cien cy and cost con trol. Meth ods: Bud get and ac count ing data, qual i ta tive in ter views. Re sults (pre lim i nary): Re gion al health en ter pris es have strong in cen tives to in crease pro duc tion with out car ing for the mon e tary costs of the pro-duc tion in creas es. The re gion al health en ter pris es ex pect that a def i cit will be bal anced by in ter ven tion from the cen tral state, sim ply be cause the po lit i cal costs of not bail ing out out weigh the costs of stand ing firm, at least in the short run.

0013

Who’s Go ing Broke? – Com par ing Health care Costs in Ten OECD Coun triesHag ist C. (Freiburg Uni ver si ty, Freiburg, Ger many)Kot likoff L.J.

In the frame work of this study, a de mo graph ic mod el is used to es ti mate the ben e fit lev el growth of pub lic health care ex pen di ture in ten OECD coun tries (Aus tralia, Aus tria, Can a da, Ger many, Japan, Nor way, Spain,

Swe den, the UK and the U.S.). We show that ex cept for Japan, de mog-ra phy was not a ma jor driv er of pub lic health care ex pen di ture from 1970 to 2002. Fur ther more, our es ti ma tion shows that the ben e fit lev el growth rates dif fer sig nif i cant ly be tween the ten ob served coun tries. By ap ply ing dif fer ent pop u la tion pro jec tions for each coun try to our mod-el we es ti mate the fu ture fis cal bur den of pub lic health care sys tems. We con clude that un sus tain able lev els of pub lic health care ex pen di ture will oc cur in case of slow pol i cy re spons es and in case that pub lic health care ex pen di ture grows as it did in the past three decades.

0242

Down (Un der) in the Dumps: In ci dence of Clin i cal De pres sion in Aus traliaHaisken-De New J. (RWI Es sen, Ger many)

In most west ern cul tures, the in ci dence of clin i cal de pres sion is a dif fi-cult so cial is sue to deal with. As the caus es for de pres sion are of ten dif fi-cult to iden ti fy, an em pir i cal anal y sis with rich fam i ly and job in for ma-tion will al low more in sight into this com plex is sue. Us ing three waves of the Aus tralian house hold pan el sur vey HIL DA, de tailed in for ma-tion con cern ing not only over all life sat is fac tion but also de pres sion is em ployed to iden ti fy the in ci dence and de ter mi nants of de pres sion in Aus tralia. The HIL DA iden ti fies symp toms of clin i cal de pres sion sep-a rate from life sat is fac tion, al low ing one to quan ti fy the as so ci a tion be tween the two mea sures of well-be ing. In ad di tion to stan dard con-trols, this pa per ex am ines trig gers of de pres sion, such as shocks to one-self or fam i ly mem bers with re spect to in come, labour mar ket sta tus (fir ing, pro mo tion), health (in ju ry, death), and fam i ly sta tus (i.e. sep a ra-tion, di vorce, birth). Due to the pan el na ture of the mi cro data, a clear sep a ra tion of in di vid u al un ob served het ero ge ne ity and ex og e nous vari-ables in the mod el can be made. This anal y sis iden ti fies fi nan cial wors-en ing, mar i tal sep a ra tion, death of spouse or child, be ing a vic tim of crime or vi o lence as be ing the sig nif i cant trig gers for de pres sion. De pres-sion it self, as de fined by be ing in the low est 5% of the men tal health dis-tri bu tion great ly re duces life sat is fac tion by as much as 0.5%-points on 0 to 10 scale. This is equiv a lent to negat ing any pos i tive ben e fit of mar-riage on life sat is fac tion.

0447

Com par i son of EQ-5D and SF-6D util i ties in men tal health pa tientsHakkaart L. (In sti tute for Med i cal Tech nol o gy As sess ment (iMTA), Rot ter dam, the Nether lands)Lamers L.M., Bouw mans C.A.M., Strat en A., Donker M.C.H.

Ab stract pref er ence-based mea sures of health are avail able for use as an out come mea sure in cost util i ty anal y sis. The aim of this study is to com-pare two such mea sures EQ-5D and SF-6D in men tal health pa tients. data from a Dutch multi-cen tre ran dom is ed tri al of 616 pa tients with mood and/or anx i ety dis or ders were used. Mean and me di an EQ-5D and SF-6D util i ties were com pared, both in the to tal sam ple and be tween sever i ty sub groups based on quar tiles of SCL-90 scores. Util-i ties were ex pect ed to de cline with in creased sever i ty. EQ-5D and SF-6D util i ties dif fered sig nif i cant ly be tween pa tients of ad ja cent sever i ty groups. Mean util i ties in creased from 0.51 at base line to 0.68 at 1,5 years fol low-up for EQ-5D and from 0.58 to 0.70 for SF-6D. For all sever i ty sub groups the mean change in EQ-5D util i ties as well as in SF-6D util i-ties was sta tis ti cal ly sig nif i cant. Stan dard ised re sponse means were high-er for SF-6D util i ties.con clud ed that both EQ-5D and SF-6D dis crim i-nat ed be tween sever i ty sub groups and cap tured im prove ments in health over time. How ev er, the use of EQ-5D re sult ed in larg er health gains, which will be trans lat ed into low er cost-util i ty ra tios, es pe cial ly for the sub group with the high est sever i ty of men tal health prob lems.

Eur J Health Econom Suppl 1 · 2006 | S41

0180

Ag ing, health ex pen di ture, prox im i ty of death and in come in Fin landHäkki nen U. (Stakes, CHESS, Helsin ki, Fin land)Mar tikainen P., Noro A., Ni htilä E., Pel to la M.

The aim of the pa per is to eval u ate how to tal health ex pen di ture and its main com po nents (so mat ic care, non acute in pa tient care, long term care and pre scribed medicines) are re lat ed to age, gen der, house-hold in come and prox im i ty of death. In ad di tion, we will ex plore how ac count ing for age as well as prox im i ty of death af fects pro jec tions of health ex pen di ture. a data source, we used a 40 % sam ple of the Finnish pop u la tion aged 65 and over at the end of 1997 (N = 285 317). Fol low-up for death, hos pi tal and med i ca tion use was un til the end of year 2002. With an in di vid u al lev el unique iden ti fi ca tion code we linked data from Sta tis tics Fin land Pop u la tion Reg is tra tion, Finnish Hos pi tal Dis charge Reg is ter, Finnish Death Reg is ter, reg is ters of the So cial In sur ance In sti-tu tion and data from the Finnish Hos pi tal Bench mark ing Pro ject.each per son in our sam ple we cal cu lat ed health ex pen di ture in 1998, which is used as the de pen dent vari able. As in de pen dent vari ables we used age, gen der, time to death, death (1, if an in di vid u al died pri or to the end of the year 2002), and fam i ly in come (di vid ed by OECD con sump-tion unit scale) and sig nif i cant in ter ac tions of the vari ables. We es ti mat-ed a two part mod el (log it + OLS) for health ex pen di ture. A SUR (seem-ing ly un re lat ed) es ti ma tion meth od was used in the sec ond part for the main com po nents of health care ex pen di ture we an a lyzed. In ad di-tion, we es ti mat ed sep a rate mod els for in di vid u al re ceiv ing long term care (LTC) ser vices and non-LTC ser vices. These re sults were com pared with a naive es ti ma tion, which does not take into ac count the prox im i ty of death.to death was an im por tant de ter mi nant of health ex pen di ture. LTC ex pen di ture in creas es clear ly with age among both the sur vivors and the de ceased. How ev er, its ef fect is much low er than that es ti mat-ed us ing a naive mod el. On the oth er hand, the op po site is true for oth-er com po nents of health care. Es pe cial ly in so mat ic health care and pre-scribed medicines health ex pen di ture seems to de crease with re spect to age. in come is neg a tive ly re lat ed to LTC ex pen di ture, but the as so ci a tion with non-LTC ex pen di ture is neg li gi ble. Only in use of pre scribed med-i cine we find a clear pos i tive re la tion ship be tween in come and ex pen-di ture.also pro ject ed health ex pen di ture for in di vid u als aged over 65 to the year 2036. Ac cord ing to our re sults a mod el which ac counts for prox im i ty of death gives about 25 % low er ex pen di ture es ti mates than a naive mod el.

0597

Hos pi tal fi nanc ing and effi cien cy in the Nordic coun triesHäkki nen U. (Stakes, CHESS, Helsin ki, Fin land)Kit telsen S., Lin na M., Mag nussen J., Me din E., Niko la jsen J., Rehn berg C., Søberg Roed A.

Any em pir i cal anal y sis of the ef fect of a fi nanc ing regime for hos pi tals must have ob ser va tions with and with out such a regime in place, while at the same time ac count ing for oth er dif fer ences fac ing the hos pi tals. Even with ob ser va tions be fore and af ter a re form in the fi nanc ing sys-tem in a sin gle coun try, oth er con cur rent chang es e.g. in tech nol o gy, in sti tu tions or de mand may also af fect hos pi tal be hav iour. Our anal y-sis uses the fact that the Nordic coun tries in may ways are broad ly sim i-lar in its cul ture, liv ing stan dards and in sti tu tions of the health care sec-tor, but have had dif fer ent fi nanc ing regimes for hos pi tals and chang-es of the regimes at dif fer ent points of time. In par tic u lar, DRG based fi nanc ing ar range ments are pres ent in some but not all Nordic coun tries and with dif fer ent in ten si ties. Data are col lect ed for har monised def i ni-tions of in puts and out puts for a pan el of about 200 hos pi tals in each year and Data en vel op ment anal y sis is used to cal cu late Far rell ef fi cien-cy es ti mates and Malmquist pro duc tiv i ty change in dex es. We pres ent

the struc tur al sim i lar i ties and dif fer ences of the Nordic sys tems over the time pe ri od 1999-2005, and use these as con trols in the anal y sis of the ef fect of fi nanc ing regimes on hos pi tal per for mance.

0319

Mor tal i ty and in come in Den markHan sen K.S. (Uni ver si ty of Aarhus, In sti tute of Pub lic Health, De part ment of Health Ser vices Re search, Aarhus, Den mark)En e mark U., Foldspang A.

A 10 per cent sam ple has been drawn among the in hab i tants of 4 coun-ties of Den mark cor re spond ing to 160,000 in di vid u als. Us ing ad min is-tra tive reg istries, in for ma tion for each in di vid u al with re spect to dif fer-ent in come mea sures and a wide range of per son al char ac ter is tics in clud-ing ed u ca tion, fam i ly sta tus, type of job, em ploy ment sta tus, con sump-tion of var i ous health ser vices and im mi gra tion sta tus for the pe ri od 1990-2003 has been ex tract ed. This data base will be utilised to ex plore the as so ci a tion be tween in come and mor tal i ty us ing dif fer ent re gres-sion anal y ses and con trol ling for rel e vant char ac ter is tics. In par tic u-lar, a num ber of com pet ing hy pothe ses con cern ing what is the most im por tant in come mea sure will be test ed such as ab so lute in come, rel a-tive in come, in come in equal i ty or dep ri va tion. Fi nal ly, the as so ci a tion be tween fam i ly in come and child mor tal i ty con trolled for var i ous fam i-ly char ac ter is tics will also be in ves ti gat ed.

0589

Pri va ti za tion of Hos pi tals in ECA Coun triesHard ing A. (World Bank)

Much has been writ ten about the role of the pri vate sec tor dur ing the tran si tion to a mar ket econ o my in ECA coun tries. In re al i ty, al though there has been some out sourc ing of some ser vices and oth er forms of pri vate sec tor par tic i pa tion, most hos pi tals re main pub lic or cor po ra-tized pub lic en ter pris es. This pa per will look at ear ly ex pe ri ence in pri-va tiz ing hos pi tals in the ECA re gion.

0522

Pa tient ac cess to pri ma ry care dur ing out of prac tice hours- Or ga ni sa tion and in cen tives in Eu ropeHart mann L. (Uni ver si ty of Lille, France)Ul mann P., Rochaix L.

This pa per fo cus es on pa tient ac cess to pri ma ry care dur ing out of prac-tice hours and for pa tients liv ing in un der-served ge o graph i cal ar eas, on the ba sis of a Eu ro pean health care sys tems’ ap praisal. We try to iden-ti fy the con di tions of al loca tive and pro duc tive ef fi cien cy, and hor i zon-tal eq ui ty of OOH ser vices’ de liv ery, in a frame work where de mand for these ser vices tends to in crease (age ing, chron ic dis eases…) and sup ply to de crease (work ing time …). Re ly ing on the ex pe ri ence of six Eu ro pean coun tries (France, Ger many, Italy, Unit ed-King dom, Spain, Swe den), we study how ac cess rules to health care and work ing con-di tions of the GPs’mar ket have an im pact on ef fi cien cy and eq ui ty of out-of-hours (OOH) ser vices’ de liv ery. More over, we study the de sign-ing of OOH ser vices (re quired or op tion al du ties, sub con tract ing, del e-gat ing…), their rel e vance and their lim its. In each coun try, the re cent re forms of pri ma ry care seem to set up a com mon mod el of OOH ser-vices’ de liv ery – but with dif fer ent de grees of de vel op ment: the main fea-tures are the cen tral i sa tion of calls to wards a nurse’s tri age (ver ti cal or ga-ni sa tion of care), the in tro duc tion of emer gen cy pri ma ry health care cen-tres and the de vel op ment of tools for im prov ing care con ti nu ity.

S42 | Eur J Health Econom Suppl 1 · 2006

0235

Eco nom ic eval u a tion of in grown toe nail sur gery in Scot landGra ham B. (NHS Na tion al Ser vices Scot land, Ed in burgh, Scot land)Dench H.C., Rus sell I.T., Thom son C.E.

Aims cal cu late the cost ef fec tive ness of sur gery for in grown toe nails per-formed by po di a trists in the com mu ni ty set ting com pared to sur geons in the hos pi tal set ting, and the eco nom ic im pact of mov ing all cas es from their cur rent set ting to the more cost ef fec tive set ting.full eco nom-ic eval u a tion was car ried out along side a ran dom is ed con trolled tri al. Out comes were mea sured be tween the two groups by means of a change in the Eu ro qol EQ-5D val ue be tween base line and at a two month fol-low-up pe ri od. Costs were anal y sed from the view point of the NHS in Scot land and the pa tient us ing 2001/02 val ues. for in grown toe nails was con sis tent ly more cost ef fec tive when car ried out by po di a trists in the com mu ni ty set ting than by sur geons in the hos pi tal set ting. If the 787 pa tients op er at ed on as hos pi tal pa tients in 2004/05 had been treat ed by po di a trists in the com mu ni ty set ting, the anal y sis pre sent ed sug gests that there were over €;854,000 worth of sav ings to NHS Scot land alone that could have been re alised, whilst still de liv er ing the ser vice to the pa tients. anal y sis pro vides com pelling ev i dence that the po ten tial sav-ings are so great that these pro ce dures should be trans ferred with out de lay to po di a trists to car ry out in the com mu ni ty set ting.

0460

Com par ing phar ma ceu ti cals’ costs among coun tries: A Pro pos al of a Rel a tive Price In dex for Cen tral Amer i caHer nan dez-V J.A. (Uni verisi ty of Cos ta Rica, San Pe dro de Mon tes de Oca, San José)Xiri nachs Y., Jara M.

Com par ing prices among dif fer ent coun tries has al ways been source of many con tro ver sies as it is dif fi cult to mix ho mo ge ne ity with rep re sen ta-tiv i ty when con struct ing the in dex and se lect ing the goods’ bas ket, es pe-cial ly when it comes to be phar ma ceu ti cals. It is dif fi cult to find out the best in for ma tion to do both: use sim ple and con ven tion al meth ods and re duce the sources of price in dex bias. The ob jec tive of this pa per is to pro pose a method olog i cal vari ant of a rel a tive price in dex meth od that al lows the use of a wide and rep re sen ta tive sam ple of phar ma ceu ti cals for dif fer ent coun tries of the same re gion, in this case Cen tral Amer i-can coun tries. The pro posed price in dex uses a sam ple of phar ma ceu-ti cals from a quar ter ly IMS sur vey dur ing the pe ri od 1999–2002. The sur vey pro vides in for ma tion on prod ucts sold in pri vate drug stores in Guatemala, El Sal vador, Hon duras, Nicaragua, Cos ta Rica and Pana ma. 2089 dif fer ent pre sen ta tions of phar ma ceu ti cals are picked from the 10510 pool to be phar ma ceu ti cals of gen er al use, sold at ev ery time at any of the coun tries, and were weighed by their de fined dai ly dosages (DDD). The pro posed meth od al lows the use of a wider phar ma ceu ti-cals’ sam ple from the pool and shows less dis per sion of prices among the dif fer ent coun tries than us ing a ho mo ge ne ous sam ple. The sur vey shows Nicaragua and Hon duras to be the cheap er coun tries, Guatemala the most ex pen sive coun try and Cos ta Rica to fol low an av er age ten den-cy. It also shows how Pana ma holds and even re duces the phar ma ceu ti-cals prices, pass ing from be ing the most ex pen sive coun try at the pe ri-od’s be gin ning and al most at the av er age at the end while El Sal vador pass es from be ing around the me di an to be the sec ond most ex pen sive coun try of the re gion.

0163

The caus al eff ect of so cioe co nom ic char ac ter is tics in health prob lems across Eu rope: a lon gi tu di nal anal y sis us ing the Eu ro pean Com mu ni ty House hold Pan el sur veyQueve do C.H. (DERS, Uni ver si ty of York, UK)Jones A.M., Rice N.

The main aim of this pa per fo cus on an a lys ing the dy nam ics of the so cioe co nom ic gra di ent in two bi na ry in di ca tors of health lim i ta tions across the Eu ro pean Union. For that pur pose, we ex ploit the lon gi tu-di nal na ture of the Eu ro pean Com mu ni ty House hold Pan el (ECHP) dataset. We are in ter est ed in whether, and to what ex tent, so cioe co-nom ic char ac ter is tics as house hold in come and ed u ca tion at tain ment af fect health prob lems and how this varies across time and coun tries in clud ed in the ECHP, con sid er ing the dif fer ences be tween age and sex groups. This pa per uses the Eu ro pean Com mu ni ty House hold Pan el Users’ Database (ECHP-UDB). The ECHP-UDB is a stan dard ised an nu-al lon gi tu di nal sur vey, which pro vides 8 waves (1994–2001) of com pa-ra ble mi cro-data about liv ing con di tions in the Eu ro pean Union Mem-ber States (EU-15). Our anal y sis fo cus on two bi na ry mea sures of health lim i ta tions, con struct ed from the an swers to the ques tion: “Are you ham-pered in your dai ly ac tiv i ties by any phys i cal or men tal health prob lem, ill ness or dis abil i ty?”, in clud ed in the ECHP-UDB. The es ti ma tion of dy nam ic pan el data mod els rais es some em pir i cal chal lenges that are ad dressed in our anal y sis: the ex is tence of cor re lat ed in di vid u al ef fects, the ini tial con di tion prob lems and the ex is tence and con se quences of health-re lat ed at tri tion in the sam ple.

0263

Di rect and in di rect costs of smok ing in Ger manyHes sel F. (In sti tute for Health Care Man age ment of Duis burg-Es sen, Ger many)Weg ner C., Anker G., Wasem J.

Ob jec tive and Meth ods: The health care costs and the costs of pro duc-tiv i ty loss due to smok ing in Ger many were es ti mat ed. Data on smok ing be hav iour were tak en from Ger man mi cro cen sus and com bined with at tributable risk frac tions of the US can cer pre ven tion tri al and stan dard unit costs for Ger many. Re sults: The an nu al di rect med i cal costs were as 7.7 bil lion EUR main ly due to cor o nary heart dis ease (57%), res pi ra to ry dis eases (27%) and can-cer (16%). The an nu al in di rect costs of smok ing were es ti mat ed to be 4.3 bil lion EUR ac cord ing to the fric tion cost meth od re spec tive ly 14.5 bil-lion EUR us ing the hu man cap i tal ap proach. Large dif fer ences be tween the two ap proach es are seen con cern ing mor tal i ty and long time in abil-i ty to work. The by far high est costs ac cord ing to the fric tion cost meth-od in curred for work off days (4.2 bil lion EUR) as the costs for mor tal i-ty, long-time in abil i ty to work and work off days were in a com pa ra ble range ac cord ing to the hu man cap i tal ap proach.Con clu sions: Al though there is no doubt about the rel e vance of the health dam age and the pro duc tiv i ty loss as so ci at ed with smok ing the es ti mat ed di rect and even more the in di rect costs of smok ing dif fer due to the cho sen method olog i cal ap proach.

0265

Is there a chance for the QALY? Eth i cal as pects con cern ing the QALY con ceptHes sel F. (In sti tute for Health Care Man age mentof Duis burg-Es sen, Ger many)

The ques tion of a per fect al lo ca tion of health care is a cru cial task for eth ics as well as health eco nomics. The most well-known con cept to com pare med i cal tech nolo gies for dif fer ent in di ca tions and from dif fer-

Eur J Health Econom Suppl 1 · 2006 | S43

ent sec tors of the health care sys tem is the con cept of qual i ty-ad just ed life years (QALYs). Based main ly on util i taris tic as sump tions it is not only crit i cized for its method olog i cal lim its but also from an eth i cal and philo soph i cal point of view. In this pa per the fol low ing three ba sic eth i-cal ques tions are iden ti fied and the pos si bil i ties of adapt ing these eth i cal as pects in the method olog i cal frame work are dis cussed (1) Do the num-bers count? Is a max i miza tion of the ag gre gat ed util i ty more im por tant than the in di vid u al ly equal right for health care? (2) Fair ness and good-ness? Is it pos si ble to com bine the max i miza tion of the ag gre gat ed util-i ty with an equal dis tri bu tion of health care? (3) Pri or i ty to the worse off? How to in clude the rule of res cue in a con cept for max i miza tion of the ag gre gat ed util i ty?might be one of the fu ture chal lenges in health eco nomics to in crease the di a logue be tween eth ics and eco nomics and to con sid er these eth i cal as pects in rec om men da tions for re source al lo-ca tion in health care.

0563

Uni ver sal Cov er age in a Most ly Pri vate Sys tem: The Case of the USARichard H. (Uni ver si ty of Michi gan, USA)

Unique ly for the U.S., in sur ance for pa tients with kid ney fail ure is pro-vid ed un der a uni ver sal, pub licly fund ed pro gram, in an en vi ron ment of pri vate ly dom i nat ed, fee-for-ser vice med i cine. Sur pris ing ly, the U.S, is ranked rough ly in the me di an lev el of per-cap i ta ESRD ex pen di tures for ISH COF coun tries, but achieves rel a tive ly good out comes. ESRD pa tients, re gard less of age, are en ti tled to cov er age un der Medi care, the fed er al health in sur ance pro gram that serves pri mar i ly the el der ly. Be cause the Medi care pro gram is rel a tive ly more in flu en tial (a near sin-gle buy er) in the mar ket for ESRD-re lat ed ser vices than it is for most oth er med i cal ser vices, price con trols have been more strin gent than else where in the US health care sys tem. Nonethe less, costs have grown sub stan tial ly due to in creas es in both the prev a lence of ESRD and in the vol ume of an cil lary ser vices pro vid ed (e.g., in ject able med i ca tions) and the num ber of pri vate ly owned di al y sis fa cil i ties has con tin ued to grow along with the pa tient base. Over all treat ment costs are also con-trolled to some ex tent by the rel a tive ly high rate of trans plan ta tion com-pared to oth er ISH COF coun tries as ESRD pa tients with trans plants have sub stan tial ly low er costs than di al y sis pa tients af ter the year in which the trans plant pro ce dure oc curs. Pro posed pay ment re forms in the US in clude bundling a broad er range of di al y sis-re lat ed ser vices into a prospec tive pay ment sys tem, de vel op ing mod els to case-mix ad just pay ment rates, and fi nan cial ly re ward ing providers whose pa tients have bet ter than ex pect ed out comes (“pay for per for mance”).

0226

Which fac tors do in di vid u als fi nd im por tant when choos ing be tween pri ma ry care mod els? A dis crete choice ex per i mentHjelm gren J. (The Swedish In sti tute for Health Eco nomics, Lund, Swe den)Anell A., Nordling S.

Ob jec tive: To ex am ine which fac tors in di vid u als find im por tant when choos ing be tween pri ma ry care mod els.Meth od: A ques tion naire sur vey was sent to 1 600 in di vid u als in Swe-den. In the ques tion naire, dif fer ent pri ma ry care mod els were con struct-ed on the ba sis of five at tributes: choice of gen er al prac ti tio ner (GP) or pri ma ry care team (PCT), wait ing time and pa tient fee per vis it, free-dom to chose a provider, and de gree of in flu ence over the care re ceived. In di vid u al choic es were cor re lat ed with age, gen der, ed u ca tion, and health sta tus (EQ-5D). Re sults: The re sponse rate was 58 %. Im por tant fac tors in the choice be tween mod els was: wait ing time, pa tient fee, free dom to chose a provider, and the de gree of in flu ence over the care re ceived (p<0,001).

Sub group anal y sis also showed that old er in di vid u als and in di vid u als with poor psy chi cal health pre fer an “own” GP where as in di vid u als who lived far from a hos pi tal pre ferred a PCT. The most im por tant at tribute was “the de gree of in flu ence over the care they re ceive” (WTP SEK 229) fol lowed by free dom to choose a provider (WTP SEK 161 per vis it) and short er wait ing time (WTP SEK 112 per day).

0042

A health warn ing about mod elling health pro duc tion across coun tries.Hollingsworth B. (Cen tre for Health Eco nomics, Monash Uni ver si ty, Mel bourne, Vic to ria, Aus tralia)Spinks J.

The pro duc tion of health in a pop u la tion is a mul ti fac to ri al and com plex is sue. Con sid er a tion of the so cioe co nom ic de ter mi nants of health in cross-coun try eco nom ic anal y ses has pre vi ous ly been some what lim it ed by the lack of avail able data and suit able an a lyt i cal tech niques. The col-la tion of more com pre hen sive cross-coun try data bases in re cent years pro vides an op por tu ni ty to ap ply ‘cut ting-edge’ tech niques to an a lyse the tech ni cal ef fi cien cy of health pro duc tion at a coun try lev el. It has been pro posed that cross-coun try com par isons of the tech ni cal ef fi cien-cy of health pro duc tion, es ti mat ed us ing such a tech nique, data en vel-op ment anal y sis (DEA), have use ful ap pli ca tions for pol i cy mak ers. In the o ry such an anal y sis ut ilises mea sures of the so cioe co nom ic de ter mi-nants of health rel e vant to all so cial pol i cy, not just health pol i cy. Us ing OECD and WHO data, this pa per pro pos es a con cep tu al frame work, and crit i cal ly anal y ses a num ber of out stand ing the o ret i cal ques tions re gard ing the use of DEA in this set ting. It con cludes that un til such ques tions are ad dressed, the re sul tant im pli ca tions for pol i cy will be based on mis lead ing in for ma tion.

0461

Tech ni cal effi cien cy of health pro duc tion and the so cioe co nom ic de ter mi nants of health in OECD coun triesHollingsworth B. (Cen tre for Health Eco nomics, Monash Uni ver si ty, Mel bourne,Vic to ria, Aus tralia)

The pro duc tion of health in a pop u la tion is a mul ti fac to ri al and com plex is sue. Con sid er a tion of the so cioe co nom ic de ter mi nants of health in cross-coun try eco nom ic anal y ses has pre vi ous ly been some what lim it ed by the lack of avail able data and suit able an a lyt i cal tech niques. The col-la tion of more com pre hen sive cross-coun try data bases in re cent years pro vides an op por tu ni ty to ap ply ‘cut ting-edge’ tech niques to an a lyse the tech ni cal ef fi cien cy of health pro duc tion at a coun try lev el. It has been pro posed that cross-coun try com par isons of the tech ni cal ef fi cien-cy of health pro duc tion, es ti mat ed us ing such a tech nique, data en vel-op ment anal y sis (DEA), have use ful ap pli ca tions for pol i cy mak ers. In the o ry such an anal y sis ut ilises mea sures of the so cioe co nom ic de ter mi-nants of health rel e vant to all so cial pol i cy, not just health pol i cy. Us ing OECD and WHO data, this pa per pro pos es a con cep tu al frame work, and crit i cal ly anal y ses a num ber of out stand ing the o ret i cal ques tions re gard ing the use of DEA in this set ting. It con cludes that un til such ques tions are ad dressed, the re sul tant im pli ca tions for pol i cy will be based on mis lead ing in for ma tion.

S44 | Eur J Health Econom Suppl 1 · 2006

0215

Ne go ti a tions with the Phar ma ceu ti cal In dus try – Les-sons LearnedHol lo I. (Eu ro pean In vest ment Bank, Lux em bourg)

In 2001, 2002, 2004 and 2005 the sub se quent Hun gar i an ad min is tra-tions con clud ed agree ments with the rep re sen ta tives of the phar ma ceu-ti cal in dus try. The aim of the deals was to lim it the out lays of the Health In sur ance Fund (HIF) and to re duce the bur den of pa tients (co-pay-ments) by in flu enc ing the ex-man u fac tur er prices of phar ma ceu ti cals. The out come of these ef forts is known: con tin ued in crease of phar ma-ceu ti cal spend ing of the HIF and fur ther in crease of co-pay ments.The pre sen ta tion will an a lyze the agree ments and con clude lessons learned from this ex pe ri ence.

0185

In cen tives for Ex ert ing Eff ort and Pa tients Sat is fac tionHol mas T.H. (Uni ver si ty of Bergen, Dep of eco nomics, Bergen, Nor way)Kaar boe O.

We test if a de mand re sponse ex ists in the Nor we gian pri ma ry care sec-tor. The Nor we gian physi cians are re mu ner at ed ei ther by salary or by in cen tive con tracts, and we have ac cess to a large data sur vey that al low us to study the re la tion ship be tween con sumer sat is fac tion with pri ma-ry phy si cian ser vices and the way physi cians are paid. When a de mand re sponse ex ists we ex pect that pa tients are more sat is fied when vis it ing a con tract phy si cian. As ex pect ed we find very small ef fects of the salary phy si cian den si ty on re port ed pa tient sat is fac tion in mu nic i pal i ties with ex cess de mand. In mu nic i pal i ties with out ex cess de mand we find a neg-a tive as so ci a tion be tween salary phy si cian den si ty and pa tients sat is fac-tion with their phy si cian.

0019

In vest ing in den tal health in Aus traliaHop kins S. (Dept of Eco nomics Curtin Uni ver si ty, Perth, Aus tralia)Kidd M.

Den tal ser vices in Aus tralia are avail able both pri vate ly and pub licly. Ac cess to pub lic den tal ser vices is free, sub ject to a con sid er able wait-ing pe ri od and is re strict ed to so cial wel fare ben e fi cia ries. Ac cess to pri-vate ser vices for pri vate health in sur ance pol i cy hold ers is sub ject to a co-pay ment. Those with nei ther pri vate health in sur ance nor ac cess to free pub lic ser vices pay the full cost for pri vate ly pro vid ed den tal care. We con sid er the re la tion ship be tween den tal util i sa tion and health in sur ance us ing an or dered pro bit mod el and an en dog e nous in sur ance vari able. We find that Aus tralians with pri vate in sur ance and/or high in comes have more fre quent den tal vis its. There have been some chang-es in ac cess of the so cial wel fare ben e fi cia ries since 2000 when a high-er pro por tion of Aus tralians pur chased pri vate health in sur ance. The re strict ed ac cess cre ates a prob lem of den tal health for those on low in comes and as a re sult there are dif fer ences in the den tal health of high and low in come groups in Aus tralia.

0101

Health Care Pro duc tiv i ty with Un cer tain DataHougaard J.L. (Uni ver si ty of Copen hagen, Den mark)Over gaard C.

Data un cer tain ty is a huge prob lem com par ing the per for mance of health care sys tems and/or var i ous health care pro duc ers. We sug-gest to ex tend the FDH-meth od, known from the ef fi cien cy mea sure-

ment lit er a ture, which mea sures the pro duc tiv i ty of sim i lar pro duc tion units to cov er in ter val pro duc tion data. In ter val data re pres ent a di rect way to han dle data un cer tain ty and prob lems with data com pa ra bil i ty which seem par tic u lar ly preva lent con cern ing health care ap pli ca tions. We il lus trate the “me chan ics” of the sug gest ed meth od us ing a sim ple 1-in put-2-out put mod el on health care data from the OECD health sta-tis tics com par ing the per for mance of the OECD health care sys tems.

0578

A frame work for de scrib ing and clas si fy ing fourth hur dle de ci sion-mak ing sys temsHut ton J. (De part ment of Eco nomics, Curtin Uni ver si ty, Lon don, UK)

Ob jec tives: to achieve bet ter un der stand ing of the po ten tial for use of HTA in de ci sion-mak ing on the re im burse ment of drugs and oth er tech-nolo gies, by de vel op ing an an a lyt i cal frame work for sys tem de scrip tion and clas si fi ca tion.Meth ods: key as pects of 4th hur dle sys tems were iden ti fied at 2 lev els – pol i cy im ple men ta tion and in di vid u al tech nol o gy de ci sion.Char ac ter is tics of sys tems were grouped un der 4 main head ings – ob jec-tives, use of ev i dence, de ci sion pro cess es and ac count abil i ty. A pi lot ap pli ca tion was car ried out for 8 coun tries us ing pu bli ca tions, web sites and ex pert opin ion as data sources.Re sults: the frame work was broad enough to en com pass the main is sues, but the pro por tion of in for ma tion avail able to com plete the frame work from pub lished sources was less than 50%.Con clu sions: the frame work will be help ful to re searchers and pol i cy-mak ers in un der stand ing the na ture and pur pose of dif fer ent 4th hur dle sys tems. Giv en the need for sub jec tive in put for its com ple tion, more ex pe ri ence will be need ed to judge whether the frame work will pro vide the ba sis for more for mal com par i son of sys tems.

0388

An tic i pa to ry be hav iour pri or to the in tro duc tion of a prospec tive pay ment sys tem for hos pi tals in Eng landIken wi lo D. (Health Eco nomics Re search Unit, Uni ver si ty of Ab erdeen, UK)Far rar S., Amaya-Amaya M., Sut ton M., Chalk ley M. Yuen P.

In April 2004 a new prospec tive pay ment sys tem for hos pi tals – Pay-ment by Re sults (PbR): was in tro duced in Eng land. This na tion al tar-iff, based on av er age costs, is in tend ed to in crease ac tiv i ty, ef fi cien cy and qual i ty and re duce wait ing times. In 2003/04, tar iffs were used for all hos pi tals for chang es in ac tiv i ty in 15 Health care Re source Groups (HRGs) from a pos si ble 550. In 2004/05, for most hos pi tals (non-Foun-da tion Hos pi tal Trusts – NFTs) the sys tem was ex tend ed to 48 HRGS, whilst a self-se lect ed group of Foun da tion Hos pi tal Trusts (FTs) moved to pre dom i nant ly tar iff-based fund ing. hy poth e sise that the re sponse to the in cen tives will have been dif fer ent for the soon-to-be FTs and NFTs and be tween tar iffed and non-tar iffed ac tiv i ty. For in stance, soon-to-be FTs may con tain their ac tiv i ty pri or to the in tro duc tion of PbR al low ing more scope for fu ture in creas es in ac tiv i ty fund ed by tar iff. We iden ti-fy a matched con trol group us ing propen si ty score match ing of FT sta-tus on a range of pub lished per for mance in di ca tors in 2002/3. We com-pare trends be tween FTs and NFTs us ing a matched dif fer ences-in-dif-fer ences de sign and trends in tar iffed and non-tar iffed HRGs. We con-sid er chang es in means and mea sures of dis per sion of ac tiv i ty and costs and the in flu ence of mar ket con cen tra tion.

Eur J Health Econom Suppl 1 · 2006 | S45

0267

Pric ing poli cies for the phar ma ceu ti cal mar ket – an in ter na tion al per spec tiveIl gin Y. (Jo hann Wolf gang Goethe Uni ver si ty, Frank furt am Main, Ger many)Eisen R.

Gov ern men tal price reg u la tion of drugs has be come a pop u lar mea sure to con tain health care spend ing. The aim of our re search is to eval u ate the ef fec tive ness of se lect ed de mand and sup ply side mea sures, keep ing in mind cru cial fac tors in this mar ket, for in stance the free rid er prob lem and moral haz ard. To an a lyze ref er ence price lim its on re im burse ment, a stat ic two class prod uct mod el is in tro duced. Be side this mea sure ad di tion-al ly patents, par al lel im ports as sup ply side price reg u la tion and drug bud-get for physi cians and ge ner ic drugs as de mand side price reg u la tion will be re viewed. By us ing a se quen tial price-set ting pro cess with in the mod-el it can be shown that ap ply ing mar gin al cost pric ing for drugs clus tered with in Phase 1, wel fare can be in creased. If gov ern ment sets the ref er ence price equal to the mar gin al costs wel fare can be in creased with out free rid-ing on the sunk R&D costs of re search ing phar ma ceu ti cal firms be cause the patent pro tec tion has ex pired. To give a com pre hen sive eval u a tion of the oth er pric ing poli cies the in ter ac tions be tween reg u la tive mea sures are tak en into ac count. In the past too many reg u la tive mea sures to con-tain health care ex pen di tures have been tar get ed pri mar i ly to sup ply side mea sures or to de mand side mea sures. But, reg u la tion that only ap plies on one side does lit tle to con trol the ris ing ex pen di tures. With out si mul-ta ne ous use of de mand side in cen tives and vol ume con trols, phar ma ceu-ti cal ex pen di tures prob a bly can not be re duced ef fec tive ly.

0523

In vest ment in healthIvády V. (Sem mel weis Uni ver si ty, Bu dapest, Hun gary)Sinkó E.

Aims: How can we ex press the im pact of health care on the econ o my, and how is it re flect ed in the in volve ment of re sources (the eco nom-ic ba sis of the eco nom ic stim u lat ing role of health care)? Spend ing on health: bur den or in vest ment: chal lenges for mid dle-in come coun tries to con sid er health sec tor as a ma jor de ter mi nant of their de vel op ment? What im pacts do the eco nom ic ef fects of the op er a tion of the health care sec tor have on the for mu la tion and im ple men ta tion of the aims of health care pol i cy?Meth ods: Re view of Lit er a ture; Anal y sis of of fi cial data; Anal y sis of doc-u men tary pa persRe sults: In the health sec tor the out come of the al lo ca tion of the re sources is split be tween health gains and oth er gains. The cat e go ry of “oth er gains” should in clude such im por tant fac tors as the im prove-ment of the feel ing of se cu ri ty of the peo ple, im proved eq ui ty in ac cess to care, im ple men ta tion of pa tients’ rights, the em ploy ment and sat is-fac tion of work ers in the health care sec tor. Ac cord ing to our as sump-tions at the low er lev el of eco nom ic de vel op ment a high er ra tio of the health ex pen di tures goes to in crease the health gains of the ac tive age groups (ex pen di tures with di rect eco nom ic re turn) than at a high er lev-el of eco nom ic de vel op ment, where an in creas ing ra tio of the ris ing health ex pen di tures goes to in crease the health gains of the in ac tive agree groups and to oth er gains (so-called eq ui ty or bur den ex pen di-tures). From among the typ i cal aims of health pol i cy would like to high-light two ob jec tives that all coun tries should adopt: ad vance in the field of “eq ui ty” and “ef fi cien cy.” If, in the field of the im prove ment of eq ui-ty, Hun gary in tends to pro mote in vest ments, i.e. if the coun try would pri mar i ly like to ex pand the qual i fi ca tion of the pop u la tion for treat-ment, fur ther more, if it in tends to en sure the widest pos si ble ac cess to ser vices, then we must ex pect an in crease in bur den ex pens es. Putting those mea sures in fo cus that are aimed to im prove ef fi cien cy will jus ti-fy in vest ments re sult ing in the in crease of health gains.

Con clu sion: New the o ret i cal frame work for gov ern ment in volve ment in in vest ing health.

0219

Prospec tive pay ment sys tem for Trau ma in pa tients, in Is raeli hos pi talsIvan coc sky M. (The Gert ner In sti tute for epi de mi ol o gy and health pol i cy re search, Ra mat-Gan, Is rael)Shmueli A., Ober man B., Freed man L.S., Pe leg K.

Ab stract in Is rael are cur rent ly com pen sat ed for all pa tients by some func tion of length of in-pa tient stay (LOS) us ing a per-diem rate, but this may be in cor rect for trau ma pa tients. The aim of this work is to sug gest a fair er and more eq ui table prospec tive pay ment sys tem. 409 pa tients hos pi tal ized be tween 998-2000 in eight trau ma cen ters in clud-ed in the Is rael Na tion al Trau ma Reg is try, formed the train ing set and pa tients hos pi tal ized be tween 2001-2003 formed the learn ing set. In ad di tion, ac tu al pa tient costs were ob tained for two of these hos pi tals, a non-para met ric tree build ing tech nique, was em ployed to cre ate a mod el with “equal re source uti li za tion” groups (“ERUG”s). Cost days, a vari able based on LOS, was used as the de pen dent vari able and pa tient ad mis sion data com prised the in de pen dent vari ables. Learn ing mod els were used to val i date the pre dic tive abil i ty. or der to eval u ate whether “cost days” is an ap pro pri ate sur ro gate for ac tu al costs, two train ing mod-els, one based on “cost days” and the oth er on ac tu al costs, were com-pared. These mod els were also com pared with the eight hos pi tal mod-el. “Cost days” was found to be a good sur ro gate vari able for ac tu al costs, this was shown con sis tent ly by per form ing a large num ber of sim u la-tions. ERUGs were cre at ed, each defin ing a unique pro file of pa tients.

0175

A study of in come-mo ti vat ed be hav ior among gen er al prac ti tion ers Iversen T. (Uni ver si ty of Oslo, Nor way)

Back ground: We study the ef fect of a mixed cap i ta tion and fee-for-ser-vice sys tem on the amount of ser vices pro vid ed by physi cians. In par tic u-lar, we study to what ex tent the vari a tion in ser vice in ten si ty among gen-er al prac ti tion ers (GPs) may be ex plained by an ob ser va tion that some physi cians have few er reg u lar pa tients than they would like to have.The o ry: By means of non-lin ear pro gram ming a GP’s op ti mal prac tice style is de rived. The the o ry pre dicts that a GP, who ex pe ri ences a short-age of pa tients, is like ly to in crease the num ber of ser vices he pro vides to his pa tients if the mar gin al util i ty of leisure is less than the mar gin al util i ty of in come from the ex tra ser vices.Em pir i cal strat e gy: The sam ple con sists of all GPs (3650) dur ing the pe ri od 2000-2004 in the na tion wide list pa tient sys tem in Nor way. Mod-els are es ti mat ed by gen er al ized least squares re gres sion that takes un ob-served het ero ge ne ity and het eroskedas tic i ty into ac count. Self se lec tion is ad just ed for by means of a Dif fer ence-in-dif fer ences es ti ma tor. Re sults: We find that pa tient short age in creas es a GP’s in ten si ty of ser-vice pro vi sion (in par tic u lar the length of each vis it) with 10 – 15 per cent. Re sults are also valid when pos si ble se lec tion bias is ac count ed for.

0065

Com pos ite per for mance mea sures for hos pi talsJa cobs R. (Uni ver si ty of York, UK)God dard M., Smith P.C.

Com pos ite in dices of health care per for mance are an ag gre ga tion of un der ly ing in di vid u al per for mance mea sures. They are in creas ing ly be ing used world wide to rank health care or gan i sa tions. While they pres-

S46 | Eur J Health Econom Suppl 1 · 2006

ent the ‘big pic ture’ in a way that is easy to in ter pret, mis lead ing con-clu sions may be drawn if at ten tion is not paid to key method olog i cal is sues in their con struc tion. We il lus trate how vari abil i ty in the un der-ly ing data and the re sult ing com pos ite may un der mine the ro bust ness of per for mance mea sures in health care. We use pan el data for En glish acute hos pi tals from 2000/01 to 2004/05 based on the “star rat ing” data – a com pos ite per for mance in di ca tor used in the En glish NHS. We il lus-trate ge ner ic method olog i cal is sues that will arise in any con text by cre at-ing a com pos ite in dex from the un der ly ing per for mance in di ca tor data, and us ing Monte Car lo sim u la tions to ex am ine the ro bust ness of the com pos ite. The vari ance in per for mance mea sures is par ti tioned into ‘con trol lable’ and ‘un con trol lable’ el e ments. Ran dom vari a tion gives rise to con sid er able un cer tain ty in per for mance scores. Our re sults sug gest some hos pi tals can jump enor mous ly in the league ta ble of per for mance as a re sult of sub tle chang es in the meth ods of cre at ing the com pos ite. Great care is war rant ed in in ter pret ing the re sults of com pos ite per for-mance mea sures.

0305

Is in for mal pay ment as eq ui table as physi cians claim? Ev i dence from the Kyr gyz Re pub licJakab M. (World Health Or ga ni za tion, Bishkek, Kyr gyz Re pub lic)Kutzin J.

There is in creas ing ev i dence about var i ous as pects of in for mal pay ment in tran si tion economies. How ev er, the dis tri bu tion al im pact of in for mal pay ment has not yet been stud ied. Physi cians of ten make the case that in for mal pay ment is eq ui table as pa tients pay based on their abil i ty to pay. How ev er, qual i ta tive re search speaks to the con trary. In this pa per, we for mal ly test whether physi cians are ef fec tive agents of re dis tri bu tion. We use a unique sur vey of pa tients dis charged from hos pi tal con duct ed in the Kyr gyz Re pub lic in 2004 (n=4,533). The sur vey asks de tailed ques-tions about pay ment for ad mis sion, per son nel, drugs dur ing hos pi tal iza-tion as well as so cio-eco nom ic sta tus. The sur vey data was merged with the database of the Manda to ry Health In sur ance Fund to ob tain fur ther in for ma tion about the hos pi tal iza tion ep i sode (e.g. DRG weight to con-trol for sev ere ity, type of acil i ty, etc). We use a two-part mod el to an a-lyze the de ter mi nants of in for mal pay ments. We find that con trol ling for a va ri ety of fac tors, so cio-eco nom ic sta tus does not ex plain whether pa tients give in for mal pay ment and the lev el of pay ment. We hy poth e-size sev er al rea sons for this find ing.

0201

In for ma tion Tech nol o gy and its Im pact on the In te gra tion of Health Care De liv ery: Ex pe ri ences from Cal i for niaJa nus K. (Han no ver Med i cal School for Epi de mi ol o gy, So cial Med i cine and Health Sys tem Re search, Han no ver, Ger many)Amelung V.E.

In for ma tion tech nol o gy (IT) sup ports dif fer ent modes of gov er nance for the or ga ni za tion of health care trans ac tions. Based on Wil liam son’s rea-son ing (1996) that IT fa cil i tates the ex change of in for ma tion in net work-like or ga ni za tions care de liv ery in hi er ar chies, such as com plete ly in te-grat ed de liv ery sys tems, be comes less worth while. This rais es the ques-tion whether the em pha sis on health care pro vi sion in in te grat ed de liv-ery sys tems is based on a dif fer ent rea son ing or does not take the emer-gence of tech nolo gies into con sid er a tion.pa per deals with the im pact of IT on the or ga ni za tion of health care ser vices. Based on a long-term case study the in ter ac tion be tween IT and the in te gra tion of play ers in the Cal i for ni an health care mar ket have been eval u at ed. An em pha sis is put on the un der stand ing of in te gra tion which im plied mere ag gre ga-tion in the past in stead of ac tu al in te gra tion sup port ed by vir tu al in te gra-tion.with se nior man age ment ex ec u tives in the San Fran cis co Bay Area

re vealed that this is not an “ei ther-or” de ci sion, but rather a stage-like pro cess in which IT first acts as a tech no log i cal fa cil i ta tor and change agent and lat er has a psy cho log i cal im pact on in te gra tion. To geth er with the man age ment of hu man re sources IT rep re sents a con stant chal lenge to health care or ga ni za tions in in dus tri al ized coun tries.

0118

Are safe ty pro mo tion in ter ven tions for el der ly also cost-eff ec tive?Jo hans son P. (Stock holm Cen tre for Pub lic Health, Stock holm, Swe den)Per T., Siv S., An to nio P.L.

Aims. Sev er al phar ma ceu ti cal in ter ven tions against in juries among the el der ly are con sid ered cost-ef fec tive. As al ter na tives to phar ma ceu ti-cal in ter ven tions sel dom have been sub ject ed to eco nom ic eval u a tions, we re port a cost-ef fec tive ness anal y sis of an el der ly safe ty pro mo tion in ter ven tion. A cost-ef fec tive ness anal y sis is per formed on Safe Se niors in Sund by berg, a 5-year safe ty pro mo tion pro gramme against el der ly in juries in the metropoli tan area of Stock holm, Swe den. The ef fects are avoid ed hip frac tures. The so ci etal per spec tive is adopt ed, with hip frac ture costs and qual i ty-of-life con se quences based on Swedish data.To tal so ci etal in ter ven tion costs amount ed to 7.3 mil lion SEK. The ef fect eval u a tion shows dif fer ing ef fects among pop u la tion groups, with a net num ber of avoid ed hip frac tures of 14 (0,44 per 1000). Con se quences dur ing the first year af ter a hip frac ture are so ci etal costs of 130.000 SEK and a loss of 0.17 QALYs. A first es ti mate, only in clud ing first year con se quences, gives a cost-ef fec tive ness ra tio of 2.3 mil lion per QALY. The full eco nom ic eval u a tion will also con sid er con se quences dur ing sub se quent years, in clud ing long-term hip frac ture con se quences on costs, mor tal i ty and qual i ty-of-life. The first crude cost-ef fec tive ness es ti mates of the safe ty pro mo tion in ter ven tion shows that it can not be con sid ered cost-ef fec tive, but fur ther work will also in clude long-term con se quences.

0274

Pa tient self-man age ment of an ti co ag u la tionJowett S. (Health Eco nomics Fa cil i ty, Ser vice Man age ment Cen tre, Uni ver si ty of Birm ing ham, Edg bas ton, Birm ing ham, UK)Bryan S., Mc C a hon D., Mur ray E., Fitz mau rice D.

Pa tient self-man age ment (PSM) is a means of en hanc ing pa tient choice and au ton o my. In the man age ment of pa tients re ceiv ing war farin for atri al fi bril la tion, reg u lar pa tient mon i tor ing is un der tak en in a pri-ma ry or sec ond ary care clin ic. The de vel op ment of near pa tient test-ing means PSM is now fea si ble. A ran dom is ed con trolled tri al in volv-ing 617 pa tients (the SMART tri al) com pared PSM with rou tine care. The eco nom ic eval u a tion along side the tri al re vealed PSM had a high-er mean health care cost per pa tient (£417 vs £ 122), with lit tle dif fer-ence in clin i cal out comes or qual i ty of life fol lowed over 12 months. How ev er, re source use un der tri al con di tions may not re flect ac tu al use by pa tients car ry ing out PSM rou tine ly. A fur ther study was there fore un der tak en in volv ing 78 pa tients fol lowed over 12 months. Whilst PSM again had a high er mean cost per pa tient (£299 vs £118), the dif fer ence was much small er. The re duc tion might not change the de ci sion in this case, but such a sig nif i cant re duc tion in costs un der non-tri al con di-tions should alert both re searchers and de ci sion mak ers to the im por-tance of as sess ing the im pact of tri al con di tions on the re sults of eval u-a tions. This study ex plores the ex tent to which this prob lem is like ly to arise in oth er con texts.

Eur J Health Econom Suppl 1 · 2006 | S47

0120

The costs of in for mal care in neu ro log i cal dis or ders in SpainOli va J. (Univ Car los III. SESAM/De part ment of Eco nomics, Getafe (Madrid), Spain)Os una R., Lobo F., Ca banas M., Jor gensen N.

In for mal care is fre quent ly an in vis i ble part of to tal care in terms of costs and ef fects over pa tients and care givers. How ev er, if the so ci etal per spec-tive is adopt ed, in for mal care needs to be iden ti fied, mea sured and val-u at ed. The pur pose of the pres ent work is to iden ti fy, mea sure and eval-u ate the costs of in for mal care for neu ro log i cal dis eases in Spain. Data col lect ed in the Sur vey on Dis abil i ties, Im pair ments, and State of Health (ED DES, for its ini tials in Span ish) of the Na tion al In sti tute of Sta tis tics (INE) was used to es ti mate the hours of in for mal care. We used sev er-al ap proach (op por tu ni ty costs and proxy good meth ods) for the mon-e tary es ti ma tion of the hours of in for mal care. We dis tin guish be tween hours of care givers em ployed and not em ployed. In for mal costs es ti mat-ed range be tween 2,402 and 2,926 mil lions of eu ros (at year 2002 prices), de pend ing on the meth od used. The es ti mat ed costs of in for mal care of each neu ro log i cal dis ease were stroke (823 to 1,007); de men tia (1,021 to 1,246); Par kin son dis ease (329 to 401); and mul ti ple scle ro sis (229 to 272). The es ti mat ed in for mal costs re pres ent a 6.3 to 7.7 per cent of the to tal health care costs of the Span ish Na tion al Health Sys tem.

0272

De ter mi nants of Health Care and In for mal Care Costs of Alz hei mer dis ease in SpainJuan O. (Uni ver si dad Car los III. SESAM. De part ment of Eco nomics, Getafe Madrid, Spain)Os una R., Basti da J.L., Ser ra no P.

Ob jec tive saim of the study is to ex plain the to tal cost of the ill ness, by dis tin guish ing pub lic and pri vate health care costs and for mal and in for-mal care. We also anal y sed the de ci sion mak ing pro cess in side the house-hold re lat ed to the time ded i cat ed to for mal and in for mal care.In this study we anal y sed the de ter mi nants of the costs of Alz hei mer dis ease from a sur vey to 237 af fect ed peo ple liv ing in Spain. The sur vey in clud-ed an ex ten sive set of ques tions about the use of health care ser vices, time of care giv ing (for mal and in for mal), so cioe co nom ic char ac ter is tics of the pa tients and care givers, health-re lat ed qual i ty of life (HRQOL), dis ease sever i ty (Clin i cal De men tia Rat ing scale) and Barthel ques tion-naire. stage of the dis ease and the HRQOL are the most sig nif i cant vari-ables in ex plain ing the pub lic health care cost. On the con trary, in come house hold lev el is the main de ter mi nant of the pri vate health care cost. The to tal amount of time ded i cat ed to the as sis tance of the per son af fect-ed by Alz hei mer does not seem to de pend on in come, and this vari able only de ter mines the amount of for mal but pri vate care.

0328

The cost eff ec tive ness of al ter na tive re fer ral stra te gies for sus pect ed bow el can cerJuarez-Gar cia A. (Health Ser vices Mange ment Cen tre, Uni ver si ty of Birm ing ham, Unit ed King dom)Bak er R., Stokes T., Thomp son M., Shaw E., Camosso-Stefi novic J.

In tro duc tionguide lines on the symp toms and signs in di cat ing the need for re fer ral have been pub lished in the UK, but lit tle is known about the cost im pli ca tions of the re fer ral rec om men da tions.cost ef fec tive ness study an a lyz ing three re fer ral stra te gies were ex am ined)age plus bleed-ing and change in bow el hab it;)all pa tients in (a) plus oth er pa tients with an ab dom i nal and/or rec tal mass and iron de fi cien cy anae mia;)this strat e gy was based on the as sump tion that all pa tients pre sent ing any

symp tom or sign of bow el can cer are ur gent ly re ferred.epi demi o log i cal pa ram e ters were based on a UK study of 8000 pa tients re ferred to a sur-gi cal out pa tient clin ic in which there were 601 can cers. The cost-ef fec-tive ness mea sure was cost per ear ly de tect ed can cer case.(b) showed an in cre men tal cost-ef fec tive ra tio of £2446 per ear ly de tect ed can cer case com pared with strat e gy (a). The in cre men tal cost-ef fec tive ness ra tio for each ex tra ear ly di ag nosed can cer in creased to £20,927 in strat e gy (c) com pared with strat e gy (b). of pa tients for re fer ral should be based on com bi na tions of symp toms, the two phys i cal signs and the pres ence or ab sence of iron de fi cien cy anae mia.

0468

Phar ma ceu ti cal in no va tion, ref er ence pric ing and ther a peu tic class esJul lien B. (Idei and Uni ver si ty of Rosario Bo go ta, Toulouse, France)Bom mi er A., Bardey D.

This pa per is a first at tempt to mod el the ef fects of ref er ence pric ing on the in no va tion ef fort of phar ma ceu ti cal firms. The mod el is based on a dy nam ic game in volv ing three types of agents: phar ma ceu ti cal firms, con sumers and a reg u la to ry en ti ty. The game in cludes re search stag es where the in no va tion ef forts by the firms are de ter mined and in tro duc-to ry stag es where a price for a new me di ca ment is fixed. We mod el the ne go ti a tion be tween the drug own er and the reg u la tor to fix the price, first with out le gal con straint, sec ond un der the regime of ref er ence pric-ing in ther a peu tic class es. We then solve the in no va tion game where the firms an tic i pate the re sults of the ne go ti a tion round on prices. We thus con sid er the ef fect of the ther a peu tic class reg u la tion on both prices and the in no va tion pace. The fi nal stage con sists in cal i brat ing the mod-el with a small data on statin in France and sim u lates the ef fect of the change in reg u la to ry regime.

0537

Ca pac i ty build ing for men tal health eco nomics in Ro ma nia: A case study es ti mat ing the cost of re lapse in peo ple with schizo phre nia – a one year au ditMi cluţia I. (Fac ul ty of Po lit i cal and Ad min is tra tive Sci ence, Babes-Bolyai Uni ver si ty, Ro ma nia)Jun jan V., Popes cu C.A.

Eco nom ic eval u a tions re main scarce in Ro ma nia and among these stud-ies look ing at men tal health are even rar er. There are few at tempts to use eco nom ic eval u a tion meth ods in aca dem ic cir cles, but there are in creas-ing sig nals from health pol i cy mak ers for more such stud ies. Re lapse in peo ple with schizo phre nia it is hy poth e sised strong ly in creas es hos-pi tal costs, thus de mand ing a greater share of scarce hos pi tal bud gets. This study ex am ines the re source uti li za tion and costs for pa tients with schizo phre nia who ex pe ri ence of re lapse and at tend a psy chi at ric clin ic in Cluj-Napoca in 2005. The evo lu tion of in sur ance cov er age for spe cif-ic med i ca tions for schizo phre nia is also ex am ined. This is the first study of its kind in the coun try and some of the prac ti cal chal lenges in con-duct ing such stud ies in a sys tem where ca pac i ty for health eco nomics re mains lim it ed are dis cussed as well as the way in which such stud ies can in form the de ci sion mak ing pro cess. As such stud ies re main rare, es pe cial ly in the field of men tal health in Ro ma nia, they can play an im por tant part in the de vel op ment of meth ods and study pro to cols that might in fu ture be con duct ed at the na tion al lev el. They can be of use to lo cal lev el health de ci sion-mak ers in de vel op ing me di um-and-long term stra te gies and in form ing bud getary ne go ti a tions.

S48 | Eur J Health Econom Suppl 1 · 2006

0368

The im pact of so cial de ter mi nants of health on health in equal i ties in FranceJu sot F. (IRD ES Re search and in for ma tion in sti tute for health eco nomics, Par is, France)Dourgnon P., Grignon M.

This pa per looks at the role of so cial de ter mi nants of health in the ex pla-na tion of so cial health in equal i ties in France in ad di tion to well es tab-lished so cioe co nom ic di men sions, such as in come, ed u ca tion and oc cu-pa tion.lit er a ture sug gests that so cial fac tors, par tic u lar ly so cial cap i tal, so cial sup port and rel a tive so cial po si tion with in a ref er ence group, are im por tant in the con struc tion pro cess of health in equal i ties. Nev er the-less, the im pacts of these fac tors on health in equal i ties are only stud ied in iso la tion so far, the re spec tive im pact of each de ter mi nant on health is not es tab lished.the 2004 Sur vey on Health and Health In sur ance – which is the unique French dataset pro vid ing mi cro-data on health sta-tus of the gen er al pop u la tion, as well as a large num ber of so cial and eco nom ic de ter mi nants of health – we pro pose to as sess the di rect and in ter ac tion ef fects of so cial cap i tal, so cial sup port and rel a tive so cial po si tion on health sta tus, mea sured as self-as sessed health. First, we an a-lyse the cor re la tion be tween each so cial de ter mi nant with the so cioe co-nom ic sta tus as well as the cor re la tion be tween the var i ous so cial de ter-mi nants of health. Sec ond, we con duct a mul ti var i ate anal y sis of the link be tween each of these vari ables with self-as sessed health, con trol ling for so cioe co nom ic sta tus.

0262

Re la tion ship be tween the Eu ro QoL-5D and Barthel In dex – Ex am in ing the use of proxy out come mea sures for old er peo pleKaamb wa B. (Health Eco nomics Fa cil i ty, Ser vices Man age ment Cen tre, Uni ver si ty of Birm ing ham, UK)Bryan S., Bar ton PM.

In ter me di ate care (IC) of old er peo ple is a key com po nent of UK gov ern-ment health pol i cy. Ev i dence on out comes as so ci at ed with IC is scarce. In many in stances, health re lat ed qual i ty of life (HRQoL) out come mea-sures are not avail able main ly be cause old er peo ple are phys i cal ly or men tal ly not able to (self-) re port their HRQoL. The re sult ing mis sing out come val ues may lead to bi ased sta tis ti cal re sults. Proxy out come mea sures may help but their suit abil i ty as prox ies needs to be test ed and ver i fied. We con sid ered out come mea sures from a to tal of 1589 IC pa tients par tic i pat ing in the na tion al eval u a tion of IC for old er peo ple in the UK. We ex am ined the di rect re la tion ship be tween a con ven tion-al clin i cal scale of func tion al sta tus that is suit ed for proxy-as sess ment (Barthel In dex (BI)) and a mea sure of HRQoL (Eu ro QoL-5D). Us ing jack knife re gres sion, mul ti ple com par i son tests and mul ti ple im pu ta-tion meth ods, we es tab lished a plau si ble and sig nif i cant re la tion ship be tween the mea sures. This re la tion ship was valid across all di ag nos tic groups in the sam ple. There is con sid er able doc u men ta tion sup port ing the con struct va lid i ty of us ing the Eu ro QoL-5D in ge ri at ric care and these re sults add to the ev i dence that BI scores may be used as proxy for HRQoL in case of mis sing val ues on Eu ro QoL-5D.

0100

The in fl u ence of hos pi tals eim burse ment schemes on in ter nal wage con tractsKaar boe O. (Health Eco nomics Bergen, Uni ver si ty of Bergen, Nor way)Hehenkamp B.

The start ing point of the pa per is the em pir i cal ob ser va tion that more and more pay ers in clude re wards for qual i ty deals. These deals re ward

hos pi tals fi nan cial ly if a cer tain qual i ty stan dard is met. Of ten these fi nan cial bonus es take the form of in creas ing the re im burse ment of all ser vices by a cer tain per cent of the price the hos pi tal gets if the stan-dard is not met. ques tion we ask in this pa per is how such a re im burse-ment scheme af fects the op ti mal con tracts with in the hos pi tal de part-ment? Fur ther more, giv en that the pay er wants to im ple ment the qual-i ty stan dard, what is the min i mal trans fer she has to pro vide to en sure that the hos pi tal man age ment pro vides wage con tracts for the em ploy-ees that in clude in cen tives for ex ert ing ef fort on qual i ty?an swer these ques tion is a two-pe ri od game with three play ers, the pay er, the hos pi-tal and the phy si cian. We char ac ter ize how the re im burse ment sys tem that the spon sor of fers the hos pi tal af fects the wage con tracts with in the hos pi tal. Fur ther more we an a lyze how the min i mal price that the pay-er pro vides to the hos pi tal to en sure that the hos pi tal choose to im ple-ment the qual i ty stan dard vary over time.

0524

Eco nom ic in fl u ences on end of life de ci sion mak ingKa hana B. (Cleve land State Uni ver si ty and Case West ern Re serve Uni ver si ty, Ohio, USA)Ka hana E.

Ad vanced di rec tives and oth er as pects of end of life de ci sion mak ing are gen er al ly ar rived at by mem bers of a health care part ner ship. These part-ner ships in clude pa tients, physi cians and fam i ly care givers who share in the pro cess of de ci sion mak ing. This poster will fo cus on the in flu ence of eco nom ic sta tus of el der ly pa tients on end of life de ci sion mak ing.Data were ob tained from 284 com mu ni ty dwelling old er adults paric-i pat ing in a pan el study of ad ap ta tion to frailty. (Ka hana et al., 2003) In ter views were also con duct ed with pri ma ry care physi cians and fam-i ly care givers of el der ly re spon dents. Find ings in di cate that fam i ly care-givers were sig nif i cant ly more in volved than were physi cians in end of life plan ning. Eco nom ic sta tus of re spon dents served as a ma jor pre dic-tor of mak ing plans for end of life care. Eco nom ic fac tors may dif fer en-tial ly im pact each mem ber of the health care part ner ship tri ad in re gard to end of life de ci sion mak ing. Un der stand ing of di ver gent and con ver-gent in ter ests of con stituent par ties al lows for bet ter un der standig of bar-ri ers to suc cess ful plan ning for end of life care.

0483

Does ther a peu tic ref er ence pric ing al ways re sult in cost-con tain ment? The Hun gar i an ev i denceKalo Z. (No var tis Hun gary Ltd., Bu dapest, Hun gary)Muszbek N., Bo dro gi J.

Ther a peu tic ref er ence pric ing (RP) is one of the po ten tial cost con tain-ment meth ods for phar ma ceu ti cals. The most crit i cal ques tion of RP is how to se lect ref er ence prod uct(s) if their ef fi ca cy is dif fer ent, es pe cial-ly if dif fer ent strengths of the same sub stance are avail able. Au thors de scribe the Hun gar i an ex pe ri ence re lat ed to the in tro duc tion of ther a-peu tic RP for statin ther a pies as of 1 Septem ber 2003. Ther a peu tic RP was ex pect ed to re duce the ex pen di ture on statins by switch ing ther a py to cheap er al ter na tives and there fore de creas ing the av er age price per pre scribed unit. The Na tion al Health In sur ance Fund ex pect ed price ero sion not only for brand ed prod ucts di rect ly af fect ed by gener ics but even for patent ed ones. De spite switch ing many pa tients from the orig i-nal sim vas tatin to gener ics, the av er age unit price of statins was re duced by only 3% at 6 month af ter the in tro duc tion of the RP sys tem. Dur ing the same pe ri od the av er age DDD per pre scrip tion was in creased from 1.14 to 1.65. The price of patent ed statins was not changed over this pe ri od. In tro duc tion of ther a peu tic RP in Hun gary for statin ther a pies ne glect ed ev i dence-based med i cine re sults and ul ti mate ly in creased drug ex pen di ture. Se lec tion of the cheap est DDD per unit as the ref-er ence prod uct re sult ed in growth of DDD per pre scrip tion, and con-

Eur J Health Econom Suppl 1 · 2006 | S49

se quent ly in creased price per pre scribed unit of statins. The fail ure of the sys tem could have been even more dra mat ic if in creased util i sa tion of ge ner ic statins had not re duced the neg a tive ef fect of ther a peu tic RP. Ex ten sion of RP to ther a peu tic cat e gories from gener ics is not jus ti fi able based upon the first ex pe ri ences of the Hun gar i an im ple men ta tion.

0405

Drug prices and prod uct diff er en ti a tionKanavos P. (Lon don School of Eco nomics, Lon don, UK)Cos ta-Font J., Ea gan L.

Lit tle ev i dence is avail able on the de ter mi nants of ge ner ic pen e tra tion in coun tries sub ject to sig nif i cant mar ket reg u la tion. This pa per em pir-i cal ly anal y ses the de ter mi nants of ge ner ic mar ket en try in Eu ro pean coun tries, the USA and Can a da, by us ing IMS data over the 2000–2005 pe ri od on a quar ter ly ba sis. The pa per also anal y ses the ex tent to which ge ner ic pen e tra tion ex plains cross-coun try price dif fer ences for ge ner ic prod ucts in dif fer ent coun tries. We find that coun try size and coun try spe cif ic fixed ef fects are the most sig nif i cant fac tors in ex plain ing mar-ket pen e tra tion rather than cross-coun try price dif fer ences.

0577

Cost-eff ec tive ness as sess ment in the Hun gar i an drug re im burse ment, 2004-2005Kár páti K. (Corv i nus Uni ver si ty of Bu dapest, Hun gary)Brandt müller Á., Gulác si L., Dávid T., Lengyel G.

Ac cord ing to the Hun gar i an laws health tech nolo gies sub sidised by the Hun gar i an Na tion al Health In sur ance Fund Ad min is tra tion (NHI FA)are re quired to be ef fi cient and cost-ef fec tive. How ev er, Hun gar i an health eco nomics stud ies or ad ap ta tion of in ter na tion al re sults are rarely avail able. In many cas es, the size of the tar get pop u la tion isn’t known. In the ab sence of suf fi cient in for ma tion and of a guide line as sist ing adap ta-tions, HTAs car ry con sid er able un cer tain ty. The ef fec tive ness of the cov ered tech nolo gies should be ver i fied on a reg u-lar ba sis, since the ef fec tive ness of re source al lo ca tion should be im proved con tin u ous ly and trans paren cy of pub lic fi nanc ing is a re quire ment. To achieve this, sig nif i cant as sess ment ca pac i ty and re li able data bases are need ed. A more sys tem at ic ap proach and set ting ex plic it cri te ria (e.g. sig-nif i cant bud get im pact, high prev a lence) for pri or i ti za tion of HTAs would help to use scarce re search ca pac i ties. De vel op ment of pa tient reg is ters and avail abil i ty of pa tient lev el data from clin i cal tri als are high ly need ed, too.In Hun gary, the sub si diza tion of phar ma ceu ti cals amount ed to 289 bil-lion HUF in year 2004. Af ter ex pert con sul ta tions, ac cord ing to our study the NHI FA spent more than 536 mil lion HUF on clin i cal ly ob so-lete medicines for di a be tes. An oth er 1.720 mil lion HUF were spent on non-ef fec tive lo co mo tor dis or der and var i cose vein ther a pies and 2.228 mil lion HUF on nootrop ics with lim it ed ev i dence. The 6 agents and for-mu la tions we ex am ined are sub si dized on a small er scale (0-40%) or they are con sid ered to be nu tri cial sup ple ments in 8 EU mem ber states. How ev er, they to tal up to 2% of the Hun gar i an Phar ma ceu ti cal Bud get (with 50-70% re im burse ment), which is more than the whole sub sidi s a-tion of H2-re cep tor in hibitors.

0613

Mea sur ing health care qual i ty at the in ter na tion al lev el: Chal lenges and fi nd ings from the OECD Health Care Qual i ty In di ca tors Pro jectKel ley E. (OECD, Par is, France)

Mea sur ing health care qual i ty at the in ter na tion al lev el: Chal lenges and find ings from the OECD Health Care Qual i ty In di ca tors Pro ject

Ob jec tive/Aims: The ob jec tive of this pre sen ta tion is to pres ent the back ground and find ings from the first phase of the Health Care Qual i-ty In di ca tors Pro ject. The long-term ob jec tive of the HCQI Pro ject is to de vel op a set of in di ca tors that can be used to raise ques tions for fur ther in ves ti ga tion con cern ing qual i ty of health care across coun tries. It was en vi sioned that the in di ca tors that were fi nal ly rec om mend ed for in clu-sion in the HCQI mea sure set would be sci en tif i cal ly sound, im por tant at a clin i cal and pol i cy lev el and fea si ble to col lect in that data would be avail able and could be made com pa ra ble across coun tries. This pre sen-ta tion will sum ma rize the find ings of the HCQI Ini tial In di ca tor Re port, re leased in March 2006 as OECD Health Work ing Pa per 22.Meth od: The HCQI Pro ject in cludes 23 coun tries in its ini tial re port. The pro ject has been di vid ed into two phas es. The ini tial phase, for which this re port serves as the sum ma ry re port, con cen trat ed on 17 im por tant and read i ly avail able in di ca tors of ef fec tive ness of care. All of the par tic-i pat ing coun tries with one ex cep tion sub mit ted data on at least five of these in di ca tors and twelve of the sev en teen in di ca tors have data from 15 coun tries or more. The OECD car ried out ex ten sive data val i da tion on each in di ca tor and un der took de tailed anal y sis on a set of five ques tions posed by HCQI coun try ex perts. These data-based ques tions fo cus on data com pa ra bil i ty is sues across coun tries on par tic u lar in di ca tors: – What is the ap pro pri ate ref er ence pop u la tion for age ad just ment?– What is the im pact of dif fer ent poli cies for han dling mis sing data?– What is the im pact of no ti fi ca tion poli cies on cas es of vac cine-pre-

ventable dis ease?– What is the im pact of vari a tion in cod ing prac tices (for asth ma)? – What is the ef fect of unique iden ti fiers when deal ing with mor tal i ty

rates?Re sult: The HCQI Ini tial In di ca tor Re port pre sents de tailed data on 13 in di ca tors re tained as in ter na tion al ly use able for rais ing ques tions on qual i ty of care and on 4 in di ca tors that are not cur rent ly use able in an in ter na tion al qual i ty in di ca tor set. Across the in di ca tors, no one coun try does best or worst on any of the in di ca tors and most coun tries ex hib it ar eas of pos si ble best prac tice. All of the in di ca tors raise ques tions about caus es of dif fer ences in qual i ty of care across coun tries. Two ex am ples of this will be high light ed for ex plo ra tion, AMI 30-day mor tal i ty and breast can cer 5-year sur vival rates.Con clu sion/dis cus sion: It is clear that the as sess ment of health care qual i ty is top ic of con cern across the OECD. De riv ing a set of in di ca-tors that can be used re li ably to as sess dif fer ences across coun tries is a ma jor step for ward. This pre sen ta tion, and the pa per on which it is based, of fer data on coun try-based qual i ty dif fer ences and sug gest how such data should be used to un der stand in ter na tion al dif fer ences, iden-ti fy best prac tices and im prove qual i ty of care.

0387

Eff ects of To bac co Con trol Poli cies on Smok ing Be hav iorKenkel D. (Cor nell Uni ver si ty of Pol i cy Anal y sis & Man age ment, Itha ca, NY USA)Lil lard D.

We use data from the Eu ro pean Com mu ni ty House hold Pan el to es ti-mate whether and how to bac co con trol poli cies af fect in di vid u al de ci-sions about smok ing ini ti a tion and ces sa tion over the life course. We use vari a tion in coun try spe cif ic poli cies such as tax es, mar ket ing re stric-tions, ad ver tis ing re stric tions, and pub lic health in for ma tion cam paigns to in ves ti gate how those poli cies af fect the prob a bil i ty that a per son starts or stops smok ing cigarettes. These poli cies vary across coun tries and over time with in a coun try. We match poli cies to in di vid u als in each coun try in each year un der the as sump tion that the de ci sion to start smok ing oc curred be tween the years a per son was 14 to 18 years old. The anal y sis will in form pol i cy mak ers of the sen si tiv i ty of smok ers to to bac co con trol poli cies and will make it pos si ble to es ti mate caus al ef fects of those poli cies be cause we will be able to con trol for coun try fixed ef fects us ing tem po ral vari a tion in poli cies.

S50 | Eur J Health Econom Suppl 1 · 2006

0536

Will ing ness-to pay for men tal health: a con tin gent val u a tion studyKen nel ly B. (De part ment of Eco nomics, Na tion al Uni ver si ty of Ire land, Gal way)O’Shea A.

This pa per uses a con tin gent val u a tion cost-ben e fit ap proach to ex am-ine pub lic pref er ences for the al lo ca tion of re sources to men tal health care in Ire land. The study uses a will ing ness to pay meth o dol o gy to elic-it cit i zens’ pref er ences for the al lo ca tion of ad di tion al re sources to men-tal health care rel a tive to oth er health care pro grammes. Con tin gent val u a tion of fers an op por tu ni ty to ob tain di rect val u a tions of men tal health out comes by the gen er al pub lic through a sur vey-based meth o-dol o gy which asks peo ple di rect ques tions on their will ing ness to pay to ex pand ser vices to achieve a giv en health state or health gain in men-tal health. Peo ple are first of all asked to rank spe cif ic health care pro-grammes to im prove health out comes in three fields: men tal health, can-cer and hearts. The sur vey asks re spon dents about their will ing ness to pay ad di tion al tax a tion and/or vol un tary con tri bu tions to fund health care in ter ven tions in the three ar eas. Peo ple’s will ing ness to pay for an ex pand ed pro vi sion in men tal health care is then com pared to the oth-er two pro grammes

0534

The eco nom ic eval u a tion of pri ma ry and sec ond ary men tal dis or der pre ven tion: A sys tem at ic re viewKil ian R. (Uni ver si ty of Ulm, De part ment of Psy chi a try II, BKH Guenz burg, Ger many)

There is an in creas ing eco nom ic bur den linked to men tal dis or ders in most Eu ro pean coun tries. There fore the pre ven tion of men tal ill ness should be con sid ered as a key task of Eu ro pean health pol i cy. A sys tem-at ic lit er a ture search has been con duct ed to iden ti fy rel e vant stud ies on the health eco nom ic eval u a tion of pri ma ry and sec ond ary men tal dis or-der pre ven tion pro grammes. Only a few stud ies were found in sci en tif-ic jour nals but a great body of re search was pub lished in the grey lit er a-ture. The ma jor i ty of pro grammes iden ti fied were tar get ed at par tic u lar groups with an in creased risk of de vel op ing men tal dis or ders such as eco nom i cal ly de prived fam i lies, young sin gle moth ers, or fam i lies with a par ent with a men tal ill ness. The most rig or ous em pir i cal ev i dence was found for the cost-ef fec tive ness of ear ly child hood de vel op ment pro grammes im ple ment ed since the 1960s in the USA. Sev er al of these pro grammes have been eval u at ed by ran dom is ed con trolled tri als over more than 25 years and large ly were found to pro duce eco nom ic ben e-fits, par tic u lar ly in the long run. Re sults of the re view sug gest that cost-ef fec tive pro grammes for the se lec tive pre ven tion of risk fac tors of men-tal ill ness ex ist but that fur ther re search is nec es sary on the cost-ef fec-tive ness of pro grammes for the di rect pre ven tion of men tal dis or ders.

0001

The Role of Firms’ Strate gic In no va tion De ci sion in Shap ing Pa tient Wel fare in Phar ma ceu ti cal In dus tryKim W. (Yale School of Man age ment, New Haven, USA)Clean t hous P., Kim W., Wit think D.R.

This pa per mea sures the firms’ strate gic in no va tion de ci sion ef fects on stat ic and dy nam ic wel fare change. The con sid er able dif fer ence be tween stat ic and dy nam ic wel fare change proves that pub lic pol i cy which ac tive ly shap ing firms’ strate gic in no va tion de ci sion has more ex ten sive im pact on dy nam ic wel fare change than that is not. Such rec-og ni tion pro vides new per spec tive on op ti mal pub lic pol i cy and broad-ens its scope of im ple men ta tion. So cial wel fare and firms’ strate gic in no-

va tion de ci sions are close ly re lat ed through firms’ in no va tion ac tiv i ties, their re la tion ship is still left un ex plored sur pris ing ly. In this pa per, by mea sur ing their re la tion ship, we un veil how firms’ strate gic de ci sion shapes the over all de mand struc ture and the con sumer wel fare. Con-se quent ly, we em pir i cal ly em pha size the ac tive role of pub lic pol i cy in in duc ing and di rect ing in no va tion and shap ing so cial wel fare, we fo cus on the phar ma ceu ti cal mar ket where tech no log i cal in no va tion, such as new drugs, has huge im pact on con sumer wel fare. In this mar ket, as a con se quence, ear li er suc cess ful in no va tion stra te gies have al tered not only con sumer wel fare, but also mar ket struc ture and even sci ence base to a large ex tent. Ac cord ing ly, in no va tion stra te gies have been sub-stan tial ly changed over the decades in re sponse. How ev er, we re mark-ably know lit tle about how im por tant firms’ strate gic in no va tion be hav-ior is in shap ing so cial wel fare and how it is de ter mined. In ad di tion, firms’ strate gic be hav ior and its ef fect on so cial wel fare have been out of radar in pub lic pol i cy re search. With so cial wel fare im prove ment in mind, pub lic pol i cy can be cat e go rized into ac tive and pas sive ap proach de pend ing on the tar get ing pro cess es in in no va tion. The bulk of ex ist-ing pub lic pol i cy has been fol low ing most ly the pas sive ap proach. Pas-sive ap proach in pub lic pol i cy in the form of de mand-side reg u la tions and sub si dies is ex e cut ed to di rect ly im prove con sumer wel fare, es pe-cial ly in phar ma ceu ti cal mar ket, by chang ing con sumer char ac ter is-tics. For in stance, in clud ing a new drug in Med i caid cov er age can be ac cept ed as a pas sive one. There fore, re searchers eval u ate pa tient wel-fare ben e fits aris ing from phar ma ceu ti cal in no va tion and, sub se quent-ly, sug gest de mand-side mod i fi ca tions to im prove con sumer wel fare, ac tive ap proach in pub lic pol i cy, which cov ers firms’ strate gic be hav ior and its ef fect, has not been ful ly ex plored. Ac tive pol i cy, in the form of in cen tives and reg u la tions for sup ply-side, is im ple ment ed to guide the be hav ior of de ci sion mak ers and/or the over all di rec tion of in no va tion and, ul ti mate ly, wel fare. For in stance, fund ing firm re search for cures of ne glect ed dis eases can be viewed as an ac tive pol i cy. How ev er, we have ne glect ed long enough the fact that the strate gic in no va tion be hav ior of firms is one of the ma jor de ter mi nants of in no va tion di rec tions and the out comes of it. For ex am ple, we know lit tle about what the de ter mi-nants are for phar ma ceu ti cal firms’ strate gic de ci sion whether to in vest enor mous amount of re sources into a new drug in no va tion pro ject for long term prof it or into the de vel op ment of sev er al gener ics for short term prof it and, con se quent ly, its ef fect on con sumer wel fare. im por-tant ly, ac tive pol i cy for firms’ strate gic in no va tion de ci sion is es pe cial-ly im por tant in the ar eas of ne glect ed dis eases. Be cause the in no va tion for ne glect ed dis eases is left be hind in firms’ strate gic in no va tion pri or i-ties and, in the per spec tive of pub lic goods, it is ur gent ly re quired to be ac tive ly pur sued to meet the so cial need. For in stance, Less than 10 per-cent of the glob al spend ing on health care R&D is ded i cat ed to the ma jor health prob lems of 90 per cent of the world pop u la tion (Pull Mech a nism work ing Group 2004) The one of the main rea sons why large num bers of ne glect ed dis eases have been out side of firms’ in no va tion scope is that the de mand for each is rel a tive ly small.

0170

Dis tin guish ing the wood from the trees Kind P. (De part ment of Phar ma cy, Up p sala, Swe den)

The mea sure ment of health out comes for eco nom ic eval u a tion places spe cif ic re quire ments on the re searcher. For ex am ple, an in dex mea-sure cal i brat ed on a 0-1 scale is wide ly re gard ed as an es sen tial prop er-ty for CUA. Ge ner ic mea sures of health-re lat ed qual i ty of life (HrQoL) have been wide ly re port ed in the health eco nomics lit er a ture and these in clude AQLQ, EQ-5D, HUI and 15-D, to geth er with an SF-36 de riv a-tive (SF-6D). These mea sures are de signed to re pres ent the (dis)util i ty of (ill)health states as de scrip tive ly re port ed by pa tients. The meth ods by which these mea sures have been con struct ed and the ex tent to which de vel op ers have been suc cess ful in cal i brat ing in stru ments in terms of so cial pref er ences are rarely scru ti nized. Such a crit i cal re view is an es sen tial pri or in the se lec tion of any HrQoL mea sure for use in tech-

Eur J Health Econom Suppl 1 · 2006 | S51

nol o gy as sess ment. This pa per re views the prin ci pal in stru ments re port-ed in the eco nomics lit er a ture in terms of the source of its de scrip tive sys tem and the meth ods used to es tab lish health state val ues, the rep-re sen ta tive ness of ref er ence pop u la tions, the to dis crim i nate be tween in di vid u als and over time, and the va lid i ty / re li abil i ty in (a) de scrip-tive sys tem and (b) val ue sys tem. This re view ut ilises sec ond ary data to demon strate the com par a tive per for mance of these in di rect as sess-ment meth ods.

0423

The im pact of an ti so cial be hav iour in child hood and ad o les cence on health, so cial care and oth er ser vice use and costs in adult hoodKing D. (Lon don School of Eco nomics Health and So cial Care, Lon don, UK)Knapp M.

The aim of this study is to de ter mine the ef fect of an ti so cial be hav iour and con duct dis or der in child hood and ad o les cence on ser vice use and costs in adult hood. While pri mar i ly look ing at health and so cial care, oth er so ci etal ser vices and costs, such as crim i nal jus tice costs and the cost of lost em ploy ment, are con sid ered. Ad di tion al ly, we aim to es ti-mate the re duc tion in ser vice use and costs which would re sult from im prove ments in the av er age scores on mea sures of an ti so cial be hav-iour across the co hort.anal y sis uses re cent ly col lect ed data from the Cam bridge Study of De lin quent De vel op ment – a prospec tive lon gi tu-di nal study which ini tial ly stud ied a group of boys in 1961/2 when they were 8 years of age, and sub se quent ly in ter viewed them at ages 18, 32 and most re cent ly at age 48. The data are linked us ing stan dard meth-ods for anal y sis of lon gi tu di nal data. An ti so cial be hav iour, as sessed in child hood by peers and teach ers and in ad o les cence us ing a mea sure based on crim i nal con vic tions, along with co vari ates, are linked to data on use of health, so cial care and oth er ser vices in adult hood. Ad di tion-al ly, as sess ments of psy chi at ric health are in clud ed to de ter mine if the path way from an ti so cial be hav iour to ser vice use is in flu enced by men-tal ill ness.

0471

Qual i ty, effi cien cy and scope in Nor we gian hos pi tal pro duc tionKit telsen S.A.C. (Frisch Cen tre, Oslo, Nor way)Her naelig;s K., Mag nussen J.

If there are economies or dis ec onomies of scope, the pro duc tion of hos-pi tal ser vices in a re gion could be come more ef fi cient by ex ploit ing any cost sav ings that may stem from an op ti mal di vi sion of ser vice pro duc-tion be tween units. Pre vi ous stud ies us ing hos pi tal lev el cost func tion es ti mates have found no ev i dence of dis ec onomies of scope. Stud ies of in di vid u al pa tient groups or treat ments have, how ev er, found im prove-ments in health out comes with the size of ser vice pro duc tion. Thus, med i cal economies of scale may well im ply im proved health out comes or bet ter ser vice qual i ty, with out cost sav ings, if hos pi tals were more spe cialised. Test ing for economies of scope must then con trol for the qual i ty lev el. This pa per uses qual i ty in di ca tors at the in di vid u al pa tient lev el to es ti mate the over all qual i ty lev el of hos pi tals. These in di ca tors are then used with con ven tion al in put-out put vari ables to es ti mate a mul ti ple out put cost func tion from a five year pan el of data on Nor we-gian hos pi tals us ing the non-para met ric Data En vel op ment Anal y sis (DEA) meth od. To over come the method olog i cal as sump tion of con vex-i ty in her ent in DEA, the sam ple is split into rel a tive spe cialised and dif-fer en ti at ed hos pi tals, be fore com par ing costs. Boot strap ping meth ods are used to test the sig nif i cance of re sults.

0505

Sup port ing heal thy age ing in the Eu ro pean UnionKjae serud G. (Eu ro pean Com mis sion Health Strat e gy Unit, Pub lic Health and Risk As sess ment Di rec torate Gen er al for Health and Con sumer Pro tec tion, Brus sels, Bel gium)Sid dall C.

Part of the or gan ised ses sion by the Eu ro pean Com mis sion: Pol i cy choic-es for Eu rope- age ing and sus tain abil i ty. “Heal thy and ac tive age ing plays an im por tant role in stim u lat ing eco nom ic growth and in mak ing pub lic fi nances sus tain able. The Com mu ni ty Lis bon pro gramme adopt-ed in July 2005, fore sees EU mea sures to help Mem ber States de vel op ac tive age ing stra te gies and en cour ages gov ern ments to in crease heal thy life years as a means to boost em ploy ment. In March 2005 the Eu ro pean Coun cil asked the Com mis sion to re flect on “how to en sure the sus tain-able fund ing of our so cial mod el.” As a re sult the Com mu ni ca tion “Eu ro-pean val ues in the glob alised world” was dis cussed by the Heads of State or Gov ern ment at Hamp ton Court in Oc to ber 2005. It pro pos es ways to bal ance re quired re forms with Eu ro pean val ues through in creased em ploy ment, pro duc tiv i ty, fa cil i tat ing in di vid u al chang es and mo bil i-ty. Poli cies to en sure health age ing must be in te grat ed into this work. The Com mis sion pro pos al for a Health and Con sumer Pro tec tion Pro-gramme (2007 – 2013) fore sees age ing as a cross cut ting theme and will en able dis sem i na tion of good prac tice, and sup port of pro jects that add to our knowl edge ef fec tive poli cies to en sure heal thy age ing. How-ev er, in line with the Treaty ar ti cle 152 the Com mis sion is work ing to im prove the un der stand ing of the im pact of dif fer ent poli cies and ac tions on health and health sys tems, and to how those im pacts can be de ter mined and tak en into ac count in the pol i cy cy cle.”

0594

In tro duc tion on the the o ry and pol i cy prac tice of pub lic health eco nomicsKlazin ga N. (De part ment of So cial Med i cine, Aca dem ic Med i cal Cen ter/Uni ver si ty of Ams ter dam, The Nether lands)

The role of economists in health care is in creas ing. Both the need for cost-ef fec tive ness in for ma tion to un der pin de ce sion-mak ing and a grow ing in ter est in the func tion ing of health care mar kets have give voice to eco nom ic rea son ing and eco nom ic stud ies in healh care. The whole field of health eco nomics ias such is a tes ti mo ny of this grow ing in ter est. How ev er, health economists are not nec es sare ly tak ing a pop-u la tion health per spec tive as the start of their ar gu men ta tion. As such, stud ies of health economists may re pres ent the per spec tive of var i ous stake-hold ers in the health care sys tem and as in the broad er eco nom-ic de bate may re pres ent var i ous in es sence po lit i cal vi sions on so ci ety and its de vel op ment goals. This ses sion will ex plore to what ex tent health economists are good for your health by look ing at the health economists ap proach es in var i ous coun tries from a pub lic health per spec tive. The pub lic health per spec-tive takes the health of the pop u la tion as the ul ti mate goals of health care ef forts and rea sons that health care costs are at the same time an in vest ment in a pro duc tion pro cess that tries to max i mize the health po ten tial of a pop u la tion.

0566

Glob al bud get and In te grat ing Tech nol o gy-In ten sive Modal i ties: Ger manyKleophas W. (Di al y sis Cen ter, Düs sel dorf, Ger many)Reich el H.

Ger many rep re sents the case of a glob al bud get with ne go ti at ed fees and com pet ing med i cal in sur ances. Di al y sis ther a py is pro vid ed most-

S52 | Eur J Health Econom Suppl 1 · 2006

ly by physi cians in pri vate prac tice and by non-prof it di al y sis provider as so ci a tions. ESRD modal i ties are well in te grat ed into the over all health care sys tem. Di al y sis ther a py, in de pen dent from the mode of treat ment, is re im bursed with a week ly flat rate. Health ex pens es in clud ing those re lat ed to ESRD are cov ered for more than 90% of the pop u la tion by a manda to ry health in sur ance (pay ments are di vid ed equal ly be tween em ploy ees and em ploy ers). The re main der of the pop u la tion is cov ered by pri vate med i cal in sur ance. Ac cess to treat ment, in clud ing di al y sis ther a py, is uni form ly avail able.

0392

So ci etal costs of al lo ge ne ic blood trans fu sion in the Nether landsKlok R. (Gronin gen Uni ver si ty In sti tute for Drug Ex plo ra tion (GUIDE), De parte ment of So cial phar ma cy, Phar ma coepi demi ol o gy and Phar ma co ther a py, Gronin gen, Nether lands)Hulst M., Es chbach MA., Slap pen del R., Post ma MJ.

In tro duc tion es ti mat ing the cost-ef fec tive ness of in ter ven tions to avert blood-trans fu sions it is im por tant to es ti mate the costs of one unit of al lo ge ne ic blood. An ex am ple of such an in ter ven tion is ad min is tra tion of eryth ro poi e tin.of this study was es ti mat ing the costs per unit of eryth-ro cytes in the Nether lands from a so ci etal per spec tive.the es ti ma tion of the costs we fol lowed the path from do nor to pa tient. In this path 6 steps were elab o rat ed do na tion, pro duc tion, trans port, stor age and prep a ra tion, ad min is tra tion and the con se quences of ad min is tra tion. In these dif fer ent steps the cost-con se quences were es ti mat ed.not all cost-fac tors could yet be iden ti fied, the cost-es ti mate is €240,– for a unit of eryth ro cytes. The in di rect costs are re spon si ble for ap prox i mate ly 3% of the unit costs. The pro duc tion and trans port part by the Dutch blood banks is re spon si ble for the ma jor i ty of the costs. & Con clu sion cost-es ti-mates vary wide ly. Cost-es ti mates for the Unit ed States, Unit ed King-dom, Swe den and Can a da vary from ap prox i mate ly €130,– to €930. For the Nether lands we es ti mat ed the unit costs for a unit of eryth ro cytes at €240,– from a so ci etal per spec tive.

0139

A diff er ence in cost es ti mates us ing diff er ent cost sur vey meth od in asth ma bur den anal y sisKo S. (Health In sur ance Re view Agen cy, Seoul, South Ko rea)Kim C., Chae S.

Ob jec tives: The pur pose of this study was to com pare cost es ti mates as dif fer ent cost sur vey meth od was ap plied to get es ti mates in cost anal y sis.Meth ods: Two types of sur vey were im ple ment ed to sam pled asth ma pa tients. First ly, main sur vey was con duct ed us ing face-to-face ques tion-naire and in clud ed 660 pa tients from 31 in sti tu tions. The sur vey par tic i-pants were re quired to re mem ber ex pen di tures as so ci at ed with asth ma dur ing the last 3 months (ret ro spec tive sur vey meth od). Sec ond ly, these pa tients were asked to record their dai ly ex pen di tures as so ci at ed with asth ma on cost di aries de signed for this pur pose for 3 months (prospec-tive sur vey meth od).Re sults: Out pa tient and phar ma cy cost was US$411 and $370 in the ret ro spec tive meth od and in the prospec tive meth od, re spec tive ly. In pa-tient cost was $162 in the ret ro spec tive meth od while $35 in the prospec-tive meth od. Costs re lat ed to emer gen cy vis it were $19 and $5, re spec-tive ly. In case of the al ter na tive med i cine cost, the fig ures were $104 and $90. The num ber of ab sence due to asth ma was also low er in the prospec tive meth od.Con clu sions: The ac cu rate as sess ment of the bur den of asth ma is dif-fi cult and ob tained val ues may dif fer ac cord ing to cost sur vey meth-od. Costs in the prospec tive meth od were no tably re duced; record ing di aries could af fect dis ease con trol.

0122

Eco nom ic eval u a tion of can cer screen ing pro mo tionKoinu ma N. (De part ment of Health Ad min is tra tion and Pol i cy, To hoku Uni ver si ty Grad u ate School of Med i cine, Sendai, Japan)Ito M., Takeyoshi H.

Ob jec tive: New anti-can cer strat e gy aim ing at a sharp de crease of both mor bid i ty and mor tal i ty has been raised as the top-pri or i ty health pol-i cy in Japan. As long as the press ing goal to im prove a five-year sur-vival rate for 20% is put up, can cer pre ven tion be comes the im por tant pil lar to be con crete and the ef fec tive screen ing pro grams are strong ly de mand ed. The ob jec tive of our study is to find out the bal ance sheet of the can cer screen ing pro mo tion.Meth ods: We per formed sim u la tion to as sess the change of med i cal ex pen di ture when the rate of can cer screen ing im proved to 1.5-3 times in the pro ject ed pop u la tion from the ex ist ing rate in five main can cers. We de vel oped sys tem mod el of can cer treat ment along with Markov mod el, and per formed a cost-ben e fit anal y sis to find out the in cre men-tal ben e fit for can cer pa tients de tect ed in screen ing. Three el e ments; re duc tion of screen ing cost, im prove ment of de tec tion rate, and de tec-tion in ear li er stage are an tic i pat ed in the im prove ment of screen ing rate. We de fined 8 ways of com bi na tions of these el e ments and es ti mat-ed them ac cord ing to can cer, sex and age.Re sults: A re duc tion ef fect of med i cal ex pen di ture of 396 mil lion EUR is ex pect ed in to tal when the screen ing rate im proves 1.5 times from the cur rent rate ac com pa ny ing 3 el e ments. The im prove ment of screen-ing rate for 3 times saves 2.6 bil lion EUR. On the oth er hand, med i cal ex pen di tures in crease 185 mil lion EUR and 742 mil lion EUR re spec-tive ly, when there is no im prove ment in 3 el e ments. For the pro mo tion of can cer screen ing, re duc tion of screen ing cost is es sen tial in fe male stom ach, co lon and lung can cers. The im prove ment of de tec tion rate con tributes large ly to re duc tion of med i cal ex pen di tures in male stom-ach, co lon and lung can cers.Con clu sions: From the view point of can cer eco nomics, tech ni cal progress, i.e., re duc tion of screen ing cost, im prove ment of de tec tion rate and the ear li er de tec tion are in dis pens able for the im prove ment of the rate of can cer screen ing.

0195

Eff ects of a hos pi tal merg erKok L. (SEO Eco nom ic Re search of Ams ter dam, Nether lands)Hop J.P.

The pa per de scribes the re sults of an ex-ante in ves ti ga tion in the ef fects of a merg er case of two hos pi tals in the Nether lands. As pa tients do not pay a price for treat ment in a hos pi tal a straight for ward SS NIP-test based on price-elas tic i ties is not pos si ble. The idea be hind the SS NIP-test is that the merged firms might de te ri o rate their of fer and still make more prof its than be fore the merg er. We ap plied three al ter-na tive ap proach es which are in line with the idea be hind the SS NIP-test.first is the time elas tic i ty ap proach which is de vel oped by Capps et al (2001). This ap proach looks at the con se quences of a hy po thet i cal in crease of trav el time of the two hos pi tals. The idea is that pa tients do not pay a mon ey price for their treat ment but they pay in terms of trav-el time. Their util i ty of a hos pi tal de pends on qual i ty and trav el time. sec ond ap proach looks at the con se quences of a de cline in qual i ty of treat ment in the merged hos pi tals. We used con joint anal y ses to mea-sure pa tients will ing ness to trav el for qual i ty. third ap proach mea sures the will ing ness to pay for an in sur ance in clud ing treat ment in the two merg ing hos pi tals.

Eur J Health Econom Suppl 1 · 2006 | S53

0110

Va lid i ty of QALY weights de rived from the SF-36. Em pir i cal ev i dence from pa tients on re nal re place ment ther a pyKon todi mopou los N. (Hel lenic Open Uni ver si ty, Fac ul ty of So cial Sci ences, Pa tras, Greece)Ni akas D.

This study aimed to pro vide em pir i cal ev i dence on the va lid i ty of QALY weights (util i ties) de rived from the SF-36 Health Sur vey. The Bra zier al go rithm was used to re struc ture the SF-36 into a sin gle health-state mea sure known as the SF-6D. Data was ob tained from Greek end stage re nal dis ease pa tients with the KDQOL-SFTM psy cho me t ric in stru-ment, in cor po rat ing the SF-36 and a kid ney dis ease ques tion naire. The sam ple com prised 642 hos pi tal di al y sis (HD) pa tients, 65 peri to ne al di al y sis (PD) pa tients and 167 trans plant ed (Tx) pa tients, rep re sent ing ap prox i mate ly 9% of the na tion al pop u la tion for each mo dal i ty. Re sult-ing util i ty scores were 63.85 (HD), 59.87 (PD) and 71.73 (Tx), with the lat ter sta tis ti cal ly sig nif i cant ly dif fer ent (P<0.001). Va lid i ty was sup port-ed by ex pect ed cor re la tions (P<0.001) be tween util i ties and an over all health-rat ing scale in clud ed in the in stru ment. Lin ear step wise re gres-sion re vealed that kid ney dis ease scales ex plained large por tions of the vari ance of SF-6D util i ties, specif i cal ly R2=63.5% (HD), R2=59.2% (PD) and R2=43.8% (Tx). Con trol ling for sex, age and ed u ca tion re vealed that men scored high er, where as age was neg a tive ly and ed u ca tion pos i-tive ly cor re lat ed with util i ties re spec tive ly. Fur ther more, co mor bidi ties and hos pi tal iza tions were both neg a tive ly cor re lat ed with util i ties. Dif-fer ences were sta tis ti cal ly sig nif i cant (P<0.001) for HD pa tients and in the ex pect ed di rec tions, but not al ways sta tis ti cal ly sig nif i cant for PD and Tx pa tients. Re sults pro vid ed ini tial ev i dence of valid pa tient pref-er ence mea sures from the SF-36 in this par tic u lar clin i cal set ting. Fur-ther re search is re quired to com pare these util i ty scores with those from di rect pref er ence meth ods.

0466

How to val ue in for mal care in eco nom ic eval u a tions? Koop man schap M. (Eras mus Med i cal Cen ter, Rot ter dam, Nether lands)

In this pre sen ta tion sev er al ways to val ue in for mal care in eco nom ic eval u a tions of health care are to be dis cussed: the proxy good meth od, the op por tu ni ty cost meth od, con tin gent val u a tion and con joint anal y-sis. All val u a tion meth ods will be dis cussed from a the o ret i cal point of view, but in ad di tion em pir i cal re sults of ap ply ing these meth ods will be shown. The proxy good and op por tu ni ty cost meth od are rel a tive ly sim ple to ap ply, but are prob lem at ic with re spect to mea sur ing the rel e vant amount of time in vest ed in pro vid ing in for mal care. Con tin gent val u a-tion and con joint anal y sis are promis ing al ter na tives, as these meth ods should be ca pa ble of in cor po rat ing op por tu ni ty costs of time and the bur den of pro vid ing care in one out come. How ev er, these meth ods need fur ther val i da tion in the field of in for mal care.

0572

Cost-eff ec tive ness of fl u vas tatin ther a py fol low ing suc cess ful per cu ta ne ous cor o nary in ter ven tion in the Hun gar i an health care set tingsKósa J. (No var tis Hun gary Ltd., Bu dapest, Hun gary)Scuff ham P.A.

Aims: To es ti mate the costs, ben e fits, and cost-ef fec tive ness of flu vas-tatin used fol low ing first per cu ta ne ous cor o nary in ter ven tion (PCI). Meth ods: A cost-ef fec tive ness anal y sis was un der tak en us ing ef fi ca cy data from the Le scol In ter ven tion Pre ven tion Study (LIPS). That study

was a ran dom ized dou ble-blind pla ce bo-con trolled tri al un der tak en in 77 cen tres, pre dom i nant ly in Eu rope, of pa tients with mod er ate hy per-cho les ter ol e mia who had un der gone their first PCI. Flu vas tatin (Le scol) 40mg twice-dai ly plus di e tary coun selling was giv en to the in ter ven tion group; the con trol group re ceived di e tary coun selling only. A de ter min-is tic Markov mod el was used to es ti mate the in cre men tal costs per qual-i ty-ad just ed life year gained, with cost data drawn from the Hun gar i-an Na tion al Health In sur ance Found. Ef fec tive ness data on flu vas tatin was de rived di rect ly from LIPS and util i ty weights from pre vi ous stud-ies on heart dis ease. One-way sen si tiv i ty anal y sis was con duct ed around key pa ram e ters and anal y ses were con duct ed for sub groups iden ti fied in LIPS.Re sults: Treat ment with flu vas tatin cost an ad di tion al HUF 417,179 and re sult ed in an ad di tion al 0.107 QALYs per pa tient dis count ed over 10-years com pared with con trols. The in cre men tal cost per qual i ty-ad just-ed life year gained with flu vas tatin ver sus con trol was HUF 3,895,745. The key de ter mi nants of cost-ef fec tive ness were the ef fec tive ness of flu-vas tatin in re duc ing Ma jor Ad verse Car di ac Events (es pe cial ly car di ac deaths), the util i ty weights used, the cost of flu vas tatin, and the time ho ri zon eval u at ed. Flu vas tatin was sub stan tial ly more cost-ef fec tive in pa tients with di a be tes, re nal dis ease, multi-ves sel dis ease or LDL-cho-les ter ol >3.4 mmol/L.Con clu sions: Flu vas tatin is a vi a ble and eco nom i cal ly ef fi cient phar ma-ceu ti cal to re duce heart dis ease in Hun gary when giv en rou tine ly to all pa tients fol low ing PCI.

0327

An tipsy chotics and an tide pres santsKosk i nen H. (The So cial In sur ance In sti tu tion, Re search De part ment, Helsin ki, Fin land)Mal ja nen T., Jaana M.

Back ground: Pre scrip tion drug ex pen di tures in Fin land (pop u la tion 5.2 mil lion) have been snow balling since the 1980’s, cre at ing con sid er able eco nom ic pres sure to the so ci ety. Par tic u lar ly the growth can be seen with an ti psy chot ic and an ti de pres sant drug spend ing, which has more than dou bled since 1998 amount ing to 150 mil lion eu ros in 2004.Ob jec tive: To de scribe and an a lyze an ti psy chot ic and an ti de pres sant drug ex pen di ture and uti li za tion trends in Fin land from 1998 to 2005.Meth ods: The data was col lect ed from the So cial In sur ance In sti tu tion’s reg is ters and it com pris es of near ly all the pre scribed out pa tient an ti psy-chot ic and an ti de pres sant pur chas es. The out come mea sures in clud ed uti li za tion of the drug groups mea sured as num ber of pa tients per pop u-la tion, num ber of pre scrip tions filled and vol ume of De fined Dai ly Dos-es as well as the costs per pa tient, cost per pre scrip tion and the cost per one De fined Dai ly Dose.Re sults: The rise in an ti de pres sant spend ing can be most ly ex plained by the growth in num ber of pre scrip tions filled, where as with an ti psy chot-ic drugs the cost in crease re sult ed most ly from the in creased pre scrib-ing of new er and more ex pen sive drug al ter na tives.Con clu sions: Fac tors un der ly ing ris ing pre scrip tion drug costs vary con sid er ably ac cord ing to ther a peu tic class es. There fore, in plan ning cost con tain ment mea sures there should be sol id un der stand ing of the rea sons caus ing drug ex pen di tures to rise in each spe cif ic drug group.

0426

Which ge ner ic HRQoL in stru ment re fl ects best the di rect TTO val u a tions of own health by gen er al pop u la tion?Ko tomä ki T. (Uni ver si ty of Helsin ki, Dept. of Pub lic Health, Fin land)Honkalampi T., Sin to nen H.

To be valid for QALY cal cu la tions, the HRQoL scores pro duced by ge ner-ic in stru ments for health states should re flect a true trade-off be tween qual i ty and length of life. At least the o ret i cal ly, TTO val u a tions of own

S54 | Eur J Health Econom Suppl 1 · 2006

health should do that. To find out how the av er age scores pro duced by 15D, HUI3, EQ-5D (with UK TTO val u a tions), AQoL and SF-6D in dif-fer ent age/gen der groups of gen er al pop u la tion re flect the di rect TTO val u a tions of own health in these groups.. Pop u la tion sur vey with a rep-re sen ta tive sam ple from 16 age/gen der groups (n=250 per group, 17+ years). The trade-offs be tween length and qual i ty of life im plic it in the av er age scores pro duced by the in stru ments in these groups were made ex plic it. The re spon dents in each group chose be tween the num ber of years im plied by dif fer ent in stru ments that the re spon dents on av er age should be will ing to give up for full health or in di cat ed their own pre-ferred num ber or un will ing ness to trade-off. The av er age 15D scores were al most iden ti cal with the av er age TTO val u a tions up to the age of 75, but there af ter low er. The HUI scores were sec ond clos est, where-as the scores of oth er in stru ments were much low er, es pe cial ly in old-er age groups.

0424

Ear ly re tired pen sion ers and Lon gev i ty:Fac tors aff ect ing Pen sion Schemes in Hun garyKo vacs E. (Corv i nus Uni ver si ty of Bu dapest, Hun gary)Szule B.

Hun gar i an pay-as-you-go pen sion sys tem was trans formed into a multi-pil lar pen sion scheme in two steps. Pub lic and pri vate pen sions were ex pect ed to fi nance a fu ture re tire ment ben e fits. The pres ent pa per ex tends the mod el to the case where in di vid u als live lon ger but the num ber and ra tio of ear ly re tired, dis abled per sons are still high. The prob lem is twofold, in creas ing de mand for pen sion and de creas ing con-tri bu tion from the em ployed per sons. In the oth er hand the at tempt to raise rev enue in or der to fi nance cur rent pen sions was not suc cess-ful. The labour force par tic i pa tion rates are low er for both sex af ter the tran si tion pe ri od. So cial trans fers are not enough to sup port dis abled per sons in Hun gary. The ma jor pur pose of the pa per is to es ti mate this pen sion gap. Meth od smod el was set up and test ed us ing de mo graph ic and macroe co nom ic Hun gar i an data to mea sure the ef fect on pen sion schemes. The base year is 2004, pro jec tion is pre pared for 50 years. Anal-y sis will be un der tak en to ob serve the ef fect of chang ing the bench mark as sump tions on par tic i pa tion rate, ear ly re tire ment, re place ment ra tios and mor tal i ty re duc tion.

0177

Man aged care and a pro cess of in te gra tion in health care sec tor. A case study from PolandKowal s ka K. (De part ment of Eco nomics, War saw Uni ver si ty, Poland)

The aim of the pa per is to iden ti fy a caus al nex us be tween con tract type (fi nanc ing rules) and ten den cy to wards in te gra tion be tween Pol ish health care providers. Af ter re forms in 1999, in the con text of un der de-vel oped in for ma tion sys tems and poor en force ment mech a nisms, unit fi nanc ing rules proved to be one of the weak ness es of the Pol ish health care sys tem. By the way of en hanc ing struc ture-dis in te grat ing pro cess, cost-per-case con tracts de stroyed those of or ga ni za tion al and pro fes-sion al net works (both for mal and in for mal ones) that used to im prove the qual i ty and ef fec tive ness of health care pro cess. From the oth er hand, in 2002, two of the sev en teen Sick ness Funds im ple ment ed con trac tu al ar range ments typ i cal for the man aged care sys tem. The pri ma ry care providers who re al ized so called Pi lot Pro gramme, took on re spon si bil-i ty for co or di nat ing treat ment of the en rolled pa tients and for man age-ment of fi nan cial re sources as signed for the health care pack ages broad-er than usu al in Poland. Cap i ta tion pay ment was the ma jor tech nique of fi nanc ing those providers. By the use of a case-study de scrip tive anal-y sis it is ar gued here that cap i ta tion prospec tive pay ment for wide pack-ages of health care en cour ages spon ta ne ous (bot tom-up) in te gra tion be tween pri ma ry and sec ond ary care providers.

0202

The di rect and in di rect costs at tributable to al co hol con sump tion in Ger manyKonnop ka A. (Health Eco nomics Re search Unit, De part ment of Psy chi a try, Uni ver si ty of Leipzig, Ger many)König HH.

This study aims to es ti mate di rect and in di rect costs caused by mor-bid i ty and mor tal i ty at tributable to al co hol con sump tion in Ger many in 2002 from a so ci etal per spec tive. Meth ods: Us ing the con cept of at tributable risks and the prev a lence-based ap proach, age- and gen der-spe cif ic al co hol-at tributable mor bid i ty and mor tal i ty was cal cu lat ed from neo plasms, en docrino log ic, al co hol ic, ner vous, car di o log ic, di ges-tive, skin and peri na tal dis or ders, in juries and poi son ings. The lit er a-ture pro vid ed data on drink ing prev a lence by age, gen der and dose in Ger many and rel a tive risks. Di rect costs were cal cu lat ed based on rou-tine uti li za tion and ex pen di ture sta tis tics. In di rect costs were cal cu lat-ed based on the hu man cap i tal ap proach us ing a dis count rate of 5%. Re sults: 5.5% of all deaths and 970,000 years of po ten tial life lost were at tribut ed to al co hol con sump tion. To tal costs were 24,398 mil lion EUR, equalling 1.16% of Ger many’s gross do mes tic prod uct. Di rect med i cal and non-med i cal costs were 8,441 mil lion EUR. In di rect costs were 15,957 mil lion EUR (69% mor tal i ty and 31% mor bid i ty costs). In con-trast, pro tec tive health ef fects of al co hol con sump tion saved 4,839 mil-lion EUR. Con clu sion: The mag ni tude of al co hol at tributable health dam age and costs de mands more pre ven ta tive ef forts.

0206

Va lid i ty of the time trade-off meth od of util i ty as sess ment in pa tients with men tal dis or ders König HH. (Health Eco nomics Re search Unit, Uni ver si ty of Leipzig, Ger many)Roick C., Gün ther O., Anger mey er MC.

To an a lyze fea si bil i ty, dis crim i na tive abil i ty and va lid i ty of the time trade-off (TTO) meth od of util i ty as sess ment in pa tients with men tal dis or ders. Meth ods: In 172 pa tients with af fec tive, 166 with schizo phren-ic and 160 with al co hol-re lat ed men tal dis or ders TTO util i ties were ad min is tered through a stan dard ized in ter view. Mea sures of qual i ty of life (EQ-5D, WHO QOL-BREF), sub jec tive (SCL-90R) and ob jec tive (CGI-S) psy cho pa thol o gy, and func tion ing (GAF, GARF, SO FAS, HoN-OS) pro vid ed com par i son. Fea si bil i ty was as sessed by com ple tion rates. Dis crim i na tive abil i ty was an a lyzed by as sess ing fre quen cy dis tri bu tions of TTO util i ties. Va lid i ty was an a lyzed by as sess ing the cor re la tion of TTO util i ties with all oth er scores. Re sults: Of pa tients with af fec tive/schizo phren ic/al co hol-re lat ed men tal dis or ders, 89/86/91% com plet ed the TTO elic i ta tion. 29/43/28% of the re spon dents were not will ing to trade a re duc tion in their length of life for an im prove ment of health sta-tus. The mean TTO util i ty was 0.66/0.75/0.61, me di an 0.85/0.95/0.75. In pa tients with af fec tive and al co hol-re lat ed men tal dis or ders, TTO util i ties were sig nif i cant ly cor re lat ed (most ly mod er ate: 0.3<r<0.5) with all oth er scores. How ev er, in schizo phren ic pa tients TTO util i ties were only lit tle cor re lat ed with oth er sub jec tive mea sures and not cor re lat ed with ob jec tive mea sures. Con clu sions: In pa tients with af fec tive or al co-hol-re lat ed men tal dis or ders TTO util i ties showed a mod er ate ceil ing ef fect, but seem rea son ably valid. How ev er, in schizo phren ic pa tients va lid i ty was not dem on stra ted.

Eur J Health Econom Suppl 1 · 2006 | S55

0259

Ad ver tis ing and Ge ner ic Mar ket En tryKönig bauer I. (Uni ver si ty of Mu nich, De part ment of Eco nomics, Mu nich, Ger many)

The ef fect of pure ly per sua sive ad ver tis ing on ge ner ic mar ket en try and so cial wel fare is anal y sed. Ad ver tis ing in the eth i cal phar ma ceu ti cal mar-ket is gen er al ly al lowed, if tar get ed to wards physi cians, on the grounds that it pro vides nec es sary in for ma tion which might dom i nate the down-sides of ad ver tis ing. This pa per, how ev er, em pha sizes the per sua sive as pect of ad ver tis ing and thus the neg a tive as pect of ad ver tis ing and shows that, as in the lit er a ture on in for ma tion al ad ver tis ing, ad ver tis-ing is no bar ri er to mar ket en try. Ad ver tis ing cre ates prod uct dif fer en-ti a tion and can in duce ge ner ic mar ket en try which is de terred with out dif fer en ti a tion due to strong Bertrand com pe ti tion. This ad van tage can dom i nate the neg a tive brand-loy al i ty. Hence, the per sua sive as pect of ad ver tis ing can con tribute fur ther to the wel fare which is gained from the in for ma tion al con tent. It is anal y sed un der which cir cum stances this is the case and how these con di tions can be pos i tive ly in flu enced by the health au thor i ties.

0234

The Ger man Way of Man aged CareKuchinke B.A. (Il me nau Uni ver si ty of Tech nol o gy, Il me nau, Ger many)

Un der the giv en reg u la tion one can find sep a rat ed, ver ti cal ly not in te-grat ed providers for phy si cian, hos pi tal and re ha bil i ta tion ser vices in the Ger man health care sys tem. These three lev els of med i cal treat ment have been large ly sep a rat ed ver ti cal ly for his tor i cal rea sons. Nowa days in Ger many the need of man aged care and ver ti cal ly in te grat ed providers of med i cal ser vices are dis cussed and po lit i cal ly pushed. So far first steps have been made in Ger many. Some sorts of co-op er a tion be tween providers such as physi cians and hos pi tals or hos pi tals and re ha bil i ta tion fa cil i ties are al lowed by law. In this pa per the eco nom ic ef fects of ver ti-cal ly in te grat ed health care providers un der the giv en reg u la tion in Ger-many are worked out the o ret i cal ly. In the ex ist ing lit er a ture es pe cial ly the po ten tial pos i tive ef fects of such sys tems are point ed out. For ex am-ple the trans ac tion and pro duc tion costs may fall. The qual i ty of care could be high er. Ad di tion al ly in this pa per it is shown that these pos i tive ef fects are just one side of the same medal and have to be seen in com par i-son to the po ten tial neg a tive ef fects. For ex am ple the free dom of pa tients will fall po ten tial ly be cause they are not free in choos ing a doc tor or a hos-pi tal and the prob lem of mar ket pow er may oc cur. As a con clu sion the giv en reg u la tion is dis cussed and it is shown that a re-reg u la tion has to be made to im ple ment an ef fi cient health care provider sys tem.

0136

Eco nom ic tran si tion and the health fi nanc ing re form im per a tive in the for mer So vi et UnionKutzin J. (World Health Or ga ni za tion/EURO, Copen hagen, Den mark)

Ob jec tives: The aims of this study are to demon strate how the health fi nanc ing sys tem in her it ed by the suc ces sor states of the USSR was not able to cope ef fec tive ly with the eco nom ic and fis cal im pacts of tran si-tion; the as so ci a tion be tween the mag ni tude of fis cal con trac tion and the share of health spend ing com ing from out-of-pock et pay ments; the as so ci a tion be tween eco nom ic tran si tion, fis cal con trac tion, and the mix of health sys tem in puts fund ed from pub lic sources; and the ex pe ri-ence of se lect ed coun tries with com pre hen sive health fi nanc ing re forms that have mit i gat ed some of these neg a tive trends and en abled im prove-ments in health sys tem ef fi cien cy, eq ui ty, and trans paren cy. Meth o dol o gy: The ap proach com bines con cep tu al and em pir i cal anal-y sis. The con cep tu al ap proach is based on ap ply ing the frame work of

health fi nanc ing func tions (col lec tion, pool ing and pur chas ing) to the “Se mashko” health sys tem in her it ed from the USSR, as well as to the im ple men ta tion of piece meal re form in Kaza khstan and com pre hen-sive re forms in Kyr gyzs tan and Moldo va. The em pir i cal work in cludes anal y sis of cross-coun try data re lat ing the ex tent of fis cal con trac tion (both lev els and chang es in to tal gov ern ment ex pen di ture as a per cent of GDP) and the share of health spend ing com ing in the form of out-of-pock et pay ments. Ad min is tra tive data from Kaza khstan and Moldo va, as well as ex ten sive house hold and hos pi tal pa tient sur vey data from Kyr-gyzs tan, is used to an a lyze the ef fects of fi nanc ing re forms in these three coun tries. The ad min is tra tive data are com bined with a de scrip tion of re form im ple men ta tion to ex am ine the im pact of re form on the lev el of pub lic fund ing for health in the 3 coun tries. Be cause the Kyr gyz re forms were phased in over sev er al years and the data sets en able oblast-lev el com par isons, a com bined cross-sec tion al lon gi tu di nal ap proach is used to as sess the ef fects of the re forms on the ef fi cien cy of in put mix (chang-es in the mix of fixed and vari able costs over time), the mag ni tude and fre quen cy of in for mal pay ments, and the tar get ing of ben e fits to vul ner-a ble groups. The as so ci a tion of re forms with chang es in eq ui ty in the use of ser vices is also ex plored. Re sults: The cross-coun try anal y sis il lus trates the rad i cal ly dif fer ent con text faced by the coun tries of the Cau ca sus and some coun tries in Cen tral Asia (Tajik istan and to some ex tent Kyr gyzs tan) that ex pe ri-enced ex treme con trac tion of the state, as com pared to some oth er coun-tries that ex pe ri enced more mod est lev els of con trac tion (Kaza khstan, Uzbek istan, Moldo va, Ukraine, Rus sia), and one that has had es sen tial-ly no tran si tion (Be larus). There is a clear pos i tive re la tion be tween the ex tent of fis cal con trac tion and the share of health spend ing com ing in the form of out-of-pock et pay ment. Hence, much of the dif fer ence in the fund ing mix that we ob serve in these coun tries can be ex plained by this as pect of the mac ro con text. How ev er, there re mains con sid er able un ex plained vari a tion for coun tries with sim i lar ly sized pub lic sec tors, sug gest ing that dif fer ences in pol i cy as well as the ex tent to which gov-ern ments pri or i tize health in re source al lo ca tion make an im por tant dif fer ence. The anal y sis of se lect ed re form ex pe ri ences sug gests that the in tro duc tion of a new fund ing source (pay roll-tax es for com pul so-ry health in sur ance) by it self may have a neg a tive im pact on the over-all fi nanc ing sys tem un less it is co or di nat ed with ex ist ing bud get funds and com bined with a fun da men tal change in the way that pub lic funds for health are pooled and the way ser vices are pur chased from these funds. In Kyr gyzs tan, the change in pool ing and pur chas ing meth ods led to a sub stan tial re duc tion in fixed costs and a re duc tion in in for mal pay ments, while also be ing as so ci at ed with im proved eq ui ty in the uti li-za tion of care across in come groups.Con clu sions: The eco nom ic tran si tion cre at ed spe cif ic chal lenges to the in her it ed Se mashko health fi nanc ing sys tem. Fis cal con trac tion led to a grow ing share of out-of-pock et pay ments in the health fi nanc ing mix, while the wider shift to a more mar ket-based econ o my also led to in creased prices for key in puts such as en er gy and medicines. This change ne ces si tat ed coun tries to re duce the fixed in puts costs of the sys-tem or be faced with an ever-de creas ing amount of pub lic funds avail-able to sup port di rect pa tient treat ment in puts. The ex pe ri ence of the CIS coun tries that are on the lead ing edge of re form (Kyr gyzs tan and Moldo va) sug gests that a pri or i ty for fi nanc ing re form is to re place the frag men ta tion and du pli ca tion in her ent in the Se mashko sys tem with a more cen tral ized pool ing of funds (at least at oblast lev el, and po ten tial-ly at na tion al lev el, de pend ing on pop u la tion size), the fi nan cial sep a ra-tion of pur chas er from providers and use of out put-based pur chas ing meth ods (i.e. an end to the hi er ar chi cal line item in put-based bud get-ing pro cess), and the ad just ment of the wider pub lic fi nance sys tem to ac com mo date these chang es in the health fi nanc ing sys tem.

S56 | Eur J Health Econom Suppl 1 · 2006

0520

Coun try-lev el cost-eff ec tive ness anal y sis us ing who-choice: An ex am ple of al co hol in ter ven tions from Es to niaLai T. (De part ment of Pub lic Health, Uni ver si ty of Tar tu, Es to nia)Reinap M., Habicht J., Chisholm D.

Aim: To adapt WHO-CHOICE ap proach for coun try-lev el use and as sess the pop u la tion-lev el costs, ef fects and cost-ef fec tive ness of dif fer-ent al co hol con trol stra te gies in Es to nia. De sign: Re gion al cost-ef fec tive ness es ti mates from the WHO’s CHOICE pro ject were used as a start ing point for the con tex tu al i sa tion and re gion-al data was sub sti tut ed to bet ter re flect the sit u a tion in the coun try. Pop-u la tion-spe cif ic data on Es to ni an de mog ra phy, al co hol epi de mi ol o gy, in ter ven tion costs and ef fec tive ness was in clud ed. A sim pli fied mod-elling frame work of WHO-CHOICE was used to es ti mate the to tal costs and ef fects of in ter ven tions com pared to a sit u a tion in which no in ter ven tions are im ple ment ed. Costs were as sessed in Es to ni an Kroon (EEK) for the year 2000 (Eu ros were also com put ed), while ef fects were ex pressed in dis abil i ty-ad just ed life years (DALYs) avert ed.Re sults: Most cost ef fec tive in ter ven tions to re duce bur den of dis ease from haz ardous al co hol con sump tion is in creased ex cise tax. In creas-ing tax a tion costs 759 EEK (€49) per DALY avert ed to re duce haz-ardous al co hol con sump tion. Adding an oth er in ter ven tion costs 1331 EEK (€85) for ev ery ad di tion al DALY avert ed from haz ardous al co hol con sump tion. The first choice to be added would be ad ver tis ing ban. Com pared to WHO base line es ti mates of the anal y sed in ter ven tions there was a con sis tent de crease in in ter ven tion costs re sult ing in more favourable CER in all cas es.Con clu sions: All in ter ven tions anal y sed were found to be cost-ef fec-tive with pop u la tion-wide mea sures like tax a tion hav ing the best CER in Es to nia. Per son al in ter ven tions such as brief ad vice to heavy drinkers are ef fec tive but much more cost ly and there fore less cost-ef fec tive. The dif fer ences be tween WHO pri ors and ad just ed re sults un der line the im por tance of con tex tu al is ing WHO-CHOICE re sults for small coun-tries like Es to nia as more ac cu rate data on cost-ef fec tive ness of in ter ven-tions al lows bet ter health pol i cy de ci sions on na tion al lev el.

0056

Ad just ment of ex ist ing EQ-5D TTO val ue sets for use of an EQ-5D fi ve lev el de scrip tive sys temLamers L. (iMTA, Eras musMC, Rot ter dam, Nether lands)

The Eu ro Qol Group start ed to de vel op a five lev el EQ-5D (EQ-5D-5L), which can be de signed by adding a lev el 1½ and 2½ be tween the ex ist-ing lev els. Since EQ-5D is of ten used to cal cu late QALYs, the ob jec tive of this study is to es ti mate decre ments for lev el 1½ of a 5L ver sion us ing the Dutch ex ist ing EQ-5D-3L TTO val ue set as the start ing point.In the Dutch 3L val u a tion study 17 health states were di rect ly val ued. In this study two mod er ate state, two se vere and the worst EQ-5D state from this sub set were se lect ed for di rect val u a tion as well as 12 mild states, which were cre at ed by chang ing lev els 1 and/or lev els 2 into 1½ of (very) mild states of the Dutch 3L sub set. 100 stu dents val ued these health states us ing TTO. The com bined TTO dataset of this 5L study and the Dutch 3L val u a tion study was used to es ti mate a ran dom ef fects re gres sion mod el.The es ti mat ed co ef fi cients for lev el 1½ were only sig nif i cant dif fer ent from zero for the di men sions self care and anx i ety/de pres sion. The re sults showed a con text de pen den cy ef fect for TTO val u a tion. The prac-ti cal im pli ca tions of our re sults for fur ther ad just ments of ex ist ing TTO val ue sets will be dis cussed.

0232

Choice, Price Com pe ti tion and Com plex i ty in Mar kets for Health In sur anceLami raud K. (In sti tute for Health Eco nomics and Man age ment (IEMS), Lau sanne, Switzer land)Frank R.G. Lami raud K.

This pa per ex am ines choice ex er cise and price com pe ti tion in health in sur ance mar kets. Switzer land of fers a unique op por tu ni ty to con duct such an anal y sis as nu mer ous sick ness funds pro vide com mu ni ty-rat ed pre mi ums, ho mog e nous ben e fits, open en rol ment and get risk-ad just-ed pay ments. Quite un ex pect ed ly one ob serves low rates of switch ing and lit tle price con ver gence. We ex am ine whether some ex pla na tions ground ed in be hav ioral eco nomics could help us un der stand such a puz zle. We make use of pub licly re port ed data in Switzer land in com bi-na tion with a sur vey of in sured house holds. Our re sults are con sis tent with the pres ence of both de ci sion mak ing over load and sta tus quo bias in health in sur ance mar kets. Con sumers fac ing large num bers of health plan choic es were less like ly to switch health plans. So were peo ple with lon ger pe ri ods of at tach ment to a par tic u lar plan. More over, peo ple mak-ing new health plan choic es chose to en roll in dif fer ent funds than those who had not switched in some time. At a mo ment in his to ry where more and more na tions are think ing of fa vor ing con sumer choic es in health in sur ance mar kets our re sults may of fer some cau tions re gard ing the needs for de ci sion sup ports and mech a nisms that sim pli fy such choic es if the de sired price and qual i ty out comes are to be en cour aged.

0116

An Eco nom ic Anal y sis of the Eff ects of Obe si ty on WagesLange R. (U.S. Food and Drug Ad min is tra tion, Col lege Park, USA)

Sev er al economists have con nect ed obe si ty to wage penal ties, par tic u lar-ly for wom en. This anal y sis ex tends pre vi ous lit er a ture ex am in ing the ef fects of body mass in dex (BMI) on in come. This anal y sis im proves on pre vi ous work by us ing a dataset that can al low health ef fects to be bet ter ex am ined. the first se ries of re gres sions, log wage in come is re gressed on a se ries of vari ables in clud ing BMI. The co ef fi cient on BMI is sig-nif i cant, neg a tive, and very small. Sep a rat ing the sam ple into men and wom en and run ning sep a rate re gres sions on the two groups yields in ter-est ing re sults. Body mass in dex has no sig nif i cant ef fects on the wages of ei ther gen der.sec ond se ries of re gres sions re places the BMI vari able with BMI cat e gor i cal vari ables un der weight, nor mal, over weight and obese. In the re gres sion run only on wom en, over weight wom en ex pe ri-ence only a very slight wage penal ty, but it is not sig nif i cant by con ven-tion al mea sures. By con trast, un der weight and obese wom en do ex pe ri-ence sig nif i cant wage penal ties. Obese men also ex pe ri ence sig nif i cant wage penal ties. Giv en these re sults, it is pos si ble that any sig ma as so ci-at ed in the past with be ing over weight, at least with re gard to in come, has sub sid ed. How ev er, be ing obese does ap pear to hurt both men and wom en.

0278

A Mod el of the Eff ects of Pa tient Com fort on the De ci sion to Seek Treat mentLari N. (North Car oli na State Uni ver si ty, Raleigh, NC, USA)

Di a be tes is a com mon chron ic dis ease that leads to se ri ous com pli ca-tions when in ap pro pri ate ly treat ed. Ba sic care in cludes a com plete phys-i cal exam once each year and HbA1c test ing ev ery three months. Di a bet-ics have a greater risk for de vel op ing dam age to the eyes, kid neys, ner-vous sys tem, car dio vas cu lar and cir cu la to ry sys tems. Pa tients must also mon i tor symp toms of such dam age. Thus, the phy si cian plays an im por-tant roll in the pa tient’s fu ture health. As the lev el of com fort with the

Eur J Health Econom Suppl 1 · 2006 | S57

phy si cian in creas es and the op por tu ni ty cost of vis its de clines, pa tients are more like ly to vis it their phy si cian. This pa per at tempts to mod el the ef fects of ‘pa tient com fort’ among pe di at ric di a be tes pa tients and in ves ti-gate the ef fects of com fort on their fu ture health. In creased pa tient com-fort, which in cludes fac tors such as com fort with the phy si cian and his/her staff, ease of mak ing and at tend ing ap point ments, lan guage and cul-tur al bar ri ers, etc., is ex pect ed to im prove the pa tient’s long-term health as the pa tient seeks rou tine care and/or care when symp toms first pres-ent them selves.

0082

Do Health Shocks Lead to Ear li er Re tire ment When Work ers are Uni ver sal ly In sured?Lar sen M. (The Dan ish Na tion al In sti ti tute of So cial Re search, Copen-hagen, Den mark)Gup ta N.D.

Health shocks sig nif i cant ly al ter work ers’ re tire ment plans, more than ex ist ing health con di tions. The labour sup ply re sponse fol low ing a health shock de pends on ac cess to pen sions and/or pub lic/ pri vate in sur ance. With in an em ploy ment-con tin gent health in sur ance sys tem as in the U.S., in di vid u als may have to con tin ue work ing to be able to pay the costs of their treat ment. When work ers are uni ver sal ly in sured, no such mit i gat ing ef fect on labour sup ply can be ex pect ed. There fore, health shocks would trig ger greater re tire ment in a gen er al tax-fi nanced health-care sys tem with uni ver sal ac cess and may be one rea son be hind the ear li er re tire ment of work ers in such economies. We ex plore this ques tion by es ti mat ing pan el re tire ment age mod els of the ef fect of new health dis tur bances on data drawn from the Dan ish Lon gi tu di nal Reg-is ters. Our aim is to com pare the re tire ment ef fects of neg a tive health shocks in a uni ver sal ly-in sured health care sys tem to those found in U.S. stud ies for sim i lar ly de fined health con di tions. We ap ply tru ly ob jec tive health mea sures based on med i cal di ag noses made at the time of hos-pi tal dis charge from the Dan ish Na tion al Pa tient Reg is try records. As ob jec tive mea sures need not nec es sar i ly cor re late with work in ca pac i-ty, we fo cus only on di ag noses for acute dis charges that im pose se ri ous work lim i ta tions.

0266

The eff ect of price and qual i ty on health in sur er choiceLaske-Alder shof T. (Eras mus Uni ver si ty, Rot ter dam, Nether lands)

Aim: In 2005, the gov ern ment pub lished com par a tive in for ma tion about health in sur ers on the In ter net. In or der to mon i tor the sen si tiv-i ty of con sumers to pre mi um and qual i ty dif fer ences, a base line study is per formed in 2004. Meth od: Two datasets from 2004, con cern ing health plan choice of sick-ness fund en rollees (n =1,100) and in di vid u al mem ber sat is fac tion rat-ings on sev er al qual i ty as pects (n = 4,000), were com bined. For each sick-ness fund we con struct ed an over all qual i ty rat ing. We es ti mat ed a pro-bit mod el of sick ness fund choice with pre mi um, qual i ty as pects, age, gen der, ed u ca tion lev el, fam i ly size, and health sta tus as the most im por-tant ex plana to ry vari ables. Re sults: There ap pears to be lit tle vari a tion in sat is fac tion rat ings be tween sick ness funds. The pro bit es ti ma tion re sults show that there is no sig nif i cant ef fect of qual i ty on health in sur er choice, but peo ple who pay high er con tri bu tion rates are more like ly to switch to a cheap-er fund. Fur ther more, the de ci sion to switch is sig nif i cant ly neg a tive ly re lat ed to age and fam i ly size and is sig nif i cant ly pos i tive ly re lat ed to knowl edge of the health in sur ance.Con clu sion: In 2004 peo ple were sen si tive to pre mi um dif fer ences, but not to qual i ty dif fer ences.

0335

Pol i cy mak ing for rare child hood dis easesLeal J. (Health Eco nomics Re search Cen tre, De part ment of Pub lic Health, Uni ver si ty of Ox ford, Eng land)Wordsworth S., Gray A., Oer ton J., Philips P., Deza teux D.

Me di um chain acyl-CoA de hy dro ge nase de fi cien cy (MCADD) is a rare in her it ed er ror of fat ty acid me tab o lism, with high mor tal i ty and mor-bid i ty which may be eas i ly pre ventable through ear ly di ag no sis and treat ment. Sev er al Eu ro pean coun tries are al ready pro vid ing uni ver-sal MCADD new born screen ing. The UK Na tion al Screen ing Com mit-tee (UKN SC) is cur rent ly re view ing its pol i cy for MCADD. Our study ex am ines the cost-ef fec tive ness of uni ver sal MCADD screen ing com-pared to no-screen ing and is part of a larg er eval u a tion fund ed by the UK De part ment of Health. A Markov mod el ex am ines the life time costs (screen ing, di ag no sis, mor bid i ty and treat ment) and ef fects (sur vival) of the two stra te gies. Unit costs were de rived from ref er ence costs, pub-lished lit er a ture and pri ma ry data col lec tion. Ef fec tive ness data were ob tained from a cur rent UK MCADD screen ing pi lot and sur veil lance study, in ter na tion al prospec tive stud ies, and the lit er a ture. Prob a bilis-tic sen si tiv i ty anal y sis was used to ex plore mod el un cer tain ty. We pres-ent the mod el re sults and dis cuss the chal lenges in us ing out comes mea-sures, in par tic u lar QALYs, in eval u at ing new born screen ing. We con-sid er the im pli ca tions of un cer tain ty for a po ten tial de ci sion of im ple-ment ing MCADD screen ing for UKN SC. Fi nal ly, we con sid er whether screen ing for rare child hood dis eases needs to be eval u at ed dif fer ent ly from screen ing for more com mon dis eases.

0400

Mul ti level anal y sis vs oth er meth ods – ex pen di tures on health pro mo tion in PolandKra jew s ki-Siu da K. (Fac ul ty of Pub lic Health, Med i cal Uni ver si ty of Sile sia, By tom, Poland)Ro ma niuk P., Hu bic ki L., Ko ciel P.

Back ground: Self-gov ern ments has be come since 1999 re spon si ble for re al-i sa tion of health pro mo tion and pre ven tion pro grammes, al though this task is non-obli ga to ry for the units. The sur vey is an at tempt to re sume coun ties’ ex pe ri ence con cern ing health pro mo tion and pre ven tion. Aim: The aim of pre sent ed re search is to an a lyse data con cern ing coun-ties’ ex pen di tures on health pro mo tion and pre ven tion pro grammes in 1999 – 2004.Meth ods: The ques tion naire was send to all units via e-mail. Ex pen di-tures were cor rect ed by (health) in fla tion rates. The ex pen di tures per cap i ta and per cent age of to tal bud get were a de pen dent vari able in the mul ti var i ate anal y sis. The t-test, GLM (gen er al lin ear mod el) and MLA (mul ti level anal y sis) were adopt ed to val i date whether the choice of sta-tis ti cal tech nique can mod i fy fi nal con clu sions. Re sults: The re sponse rate (af ter one year) was 197/380 (52%). The re sults of mul ti var i ate anal y sis (both GLM and MLA) are not co her ent with the re sults from t-test in this par tic u lar study. The sig nif i cance lev-el of the re gion, time and type of unit (ru ral/ur ban) var ied from not sig-nif i cant up to high sig nif i cant (p<0.00000001). The re sults from GLM and MLA were simil lar.Con clu sions: A multi-lev el anal y sis should be con sid ered in health ac counts re search.

0419

Mea sure ment of Pub lic Ser vice Pro duc tiv i tyLee P. (The Offi ce for Na tion al Sta tis tics, Lon don, Unit ed King dom)

A great deal of work has been car ried out on im prov ing mea sures of in puts, out put and pro duc tiv i ty of the health ser vice in the UK in re cent

S58 | Eur J Health Econom Suppl 1 · 2006

years by the Of fice for Na tion al Sta tis tics (ONS), the De part ment of Health for Eng land, and a pro ject group in volv ing the Na tion al In sti-tute for Eco nom ic and So cial Re search and the Cen tre for Health Eco-nomics at the Uni ver si ty of York. This work has been sup port ed and in many in stances driv en by Sir Tony Atkin son’s Re view of the Mea-sure ment of Gov ern ment Ac tiv i ty for the Na tion al Ac counts.ONS pub-lished a first ar ti cle en ti tled Pub lic Ser vice Pro duc tiv i ty Health in Oc to-ber 2004, and a sec ond ar ti cle on health is sched uled for pub li ca tion in 2006. The ar ti cle is de signed to ex plore pub lic ser vice pro duc tiv i ty with-in the con text of the UK Na tion al Ac counts, draw ing on oth er in for ma-tion to paint a more de tailed pic ture of pub lic ser vice out put and pro-duc tiv i ty than the Na tion al Ac counts them selves.con fer ence pa per will pres ent the work car ried out by the ONS to im prove ex ist ing mea sures, fo cus ing in par tic u lar on health ser vice in puts, out put and pro duc tiv i ty as es sen tial ma te ri al for pub lic ac count abil i ty and bet ter man age ment of the UK health ser vice.

0164

The Mi gra tion of High ly-Skilled Work ersLéger P.T. (HEC Mon tréal at Uni ver sité de Mon tréal, CIRA NO and CIR PÉE, Mon tre al, Can a da)Dostie B.

The the o ret i cal and em pir i cal eco nom ic lit er a ture on who and where in di vid u als mi grate is quite vast. At its most ba sic form, the eco nom ic mod el of mi gra tion posits that in di vid u als will mi grate if the ex pect ed ben e fits of mov ing to an al ter nate lo ca tion are greater than the ex pect ed ben e fits of re main ing in their cur rent lo ca tion (net of trans ac tion costs). This mod el sug gests that in di vid u als will mi grate if they can ex pect to earn more in an al ter nate lo ca tion than in their cur rent lo ca tion, where the choice of lo ca tion will be the one that max i mizes ex pect ed earn ings. Viewed in this way, mi gra tion is sim ply an in vest ment in hu man cap i tal. In a het er og e nous pop u la tion, how ev er, the re turns to mi gra tion (i.e., the re turns to in vest ment in hu man cap i tal) are also like ly to be het er og-e nous. As a re sult, the ba sic mod el of mi gra tion can be aug ment ed to al low for sort ing based on skills. Ac cord ing to Bor jas and al (1992) dif-fer ent lo ca tions (in their case, U.S. states) are char ac ter ized by their own wage gen er at ing pro cess. Con se quent ly, high ly-skilled in di vid u als will wish to mi grate to re gions with a high-skills pre mi um (i.e., with a rel a-tive ly large vari ance in wages con di tion al on mean wages) where as low-skilled in di vid u als will wish to mi grate to re gions with a rel a tive ly low-skills pre mi um (i.e., with a rel a tive ly small vari ance in wages con di tion-al on mean wages). Al though the link be tween skills and mi gra tion is an im por tant one, our un der stand ing of this re la tion ship is lim it ed for sev-er al rea sons. First, there are very few stud ies which ex am ine this is sue em pir i cal ly, part ly be cause of a lack of suit able data. More over, there is lit tle con sen sus as to what con sti tutes a high ly-skilled work er. The o ret i-cal ly, a high-skilled in di vid u al is de fined sim ply as be ing more pro duc-tive. Be cause of a lack of suit able data on in di vid u al-spe cif ic pro duc tiv-i ty, high ly-skilled work ers are of ten de fined by their lev el of ed u ca tion and/or their pro fes sion and/or their wage. How ev er, none of these mea-sures are en tire ly sat is fac to ry as they only take into ac count ob serv able dif fer ences which may not ac cu rate ly or ful ly re flect pro duc tiv i ty dif fer-ences be tween work ers. Fur ther more, the is sue of un ob served skill dif-fer ences be tween work ers who leave and work ers who stay is com plex, and ul ti mate ly dif fi cult to re solve (Card, 2003). In re sponse to these lim i ta tion we wish to con tribute to the re cent em pir i cal lit er a ture on sort ing of work ers (via mi gra tion) based on skills and lo ca tion-spe cif-ic re turns to skills (Bor jas, 1987). How ev er, un like many oth er pa pers (Hunt and Mueller, 2004 and Chiquiar and Han son, 2005), we con sid er not only ob serv able skills but also un ob serv able skills (and their re spec-tive lo ca tion-spe cif ic re turns). In do ing so, we will also con tribute to the lit er a ture on the fun da men tal drivers of mo bil i ty of high ly-skilled work-ers. In or der to do so, we fo cus on the in ter-provin cial mi gra tion pat-terns of Cana di an physi cians. We choose this par tic u lar group for sev-

er al rea sons. First, physi cians (es pe cial ly spe cial ists) are of ten sin gled out, in Can a da, as a high ly-ed u cat ed group who fre quent ly ex pe ri ence both in ter na tion al and in ter-provin cial mi gra tion. Fur ther more, fo cus-ing on physi cians al lows us to study the mi gra tion de ci sions of a rel a-tive ly ho mog e nous set of work ers in terms of for mal ed u ca tion. Fi nal-ly, Cana di an physi cians are gen er al ly paid on a fee-for-ser vice (i.e., a fee-per-con sul ta tion) ba sis which are set at the provin cial lev el. Thus, wage rates (or fees) can be con sid ered ex og e nous to both ob serv able and un ob serv able in di vid u al char ac ter is tics as they re flect ex clu sive ly the phy si cian_spe cial ty and province of prac tice. Con se quent ly, we can use the phy si cian_to tal billings as a mea sure of his or her out put. Be cause of this en vi ron ment, we are able to of fer a pre cise def i ni tion of a high ly-skilled phy si cian (or work er) a phy si cian who has greater billings (i.e., has a greater out put of health-care ser vices) than would oth er wise be pre dict ed by his or her ob serv able char ac ter is tics and their cor re spond-ing ex og e nous wage-rate. In oth er words, we con sid er a phy si cian to be more skilled (or equiv a lent ly, more pro duc tive) if they have greater to tal billings than ob serv ably iden ti cal physi cians. Fi nal ly, be cause (i) in ter-provin cial mi gra tion is much more fre quent than in ter na tion al mi gra-tion, (ii) health care is a provin cial re spon si bil i ty in Can a da, and (iii) we ob serve we ob serve physi cians pri or-to and post in ter-provin cial mi gra-tion, we de vel op a two-stage mod el of wage de ter mi na tion and mi gra-tion de ci sions. In the econo met ric sec tion pro vid ed be low, we first es ti-mate province-spe cif ic earn ings equa tion and use the es ti mat ed pa ram-e ters to pre dict the phy si cian_po ten tial earn ings for each po ten tial des-ti na tion (i.e., for each of the oth er provinces). We then es ti mate a con-di tion al-log it mod el with un ob served het ero ge ne ity to ex am ine the ef fects of in di vid u al and des ti na tion-spe cif ic char ac ter is tics (par tic u lar-ly earn ing dif fer en tials) on the choice of phy si cian lo ca tion. Our set up also al lows us to ex am ine whether dif fer ences in the re turns to ob served hu man cap i tal and un ob served skills across dif fer ent provinces are an im por tant fac tor in phy si cian mo bil i ty.

0557

The as sess ment of drug ben e fi t by the Ger man In sti tute for Qual i ty and Effi cien cy in Health Care (IQEH) in an in ter na tion al per spec tive: what role for health eco nomics?Lei dl R. (In sti tute for Health Eco nomics and Health Care Man age ment, GSF-Na tion al Re search Cen ter for En vi ron ment and Health, Neuher berg, Ger many)

In Ger many, the Fed er al Joint Com mit tee (FJC) de cides whether or not new drugs are clas si fied into ref er ence pric ing groups. On de mand by FJC, the new ly cre at ed IQEH car ries out drug ben e fit as sess ments. This ren ders the ev i dence ba sis for the clas si fi ca tion de ci sion. FJC rules for the as sess ment, IQEH study scopes de rived at the be gin ning of the pro-cess, and first as sess ment ex am ples pro vide the ba sis for an anal y sis of this reg u la to ry pro ce dure. By law, eco nomics is not part of the as sess-ment, but in di ca tors used be long to both the cost and the ef fect side of an eco nom ic eval u a tion. Find ings con trast strong ly the high ly trans par ent pro ce dure used in the British Na tion al Health Ser vice, but also de ci sion mak ing in the bet ter com pa ra ble Dutch health in sur ance sys tem. Meth-ods and re sults of the as sess ment of se lect ed drugs are com pared across the three sys tems. For Ger many, it is sug gest ed to ex tend IQEH’s re spon si-bil i ty to eco nom ic as sess ment, and to stan dard ize the meth o dol o gy used there fore. Fea tur ing a very com pre hen sive task, this will pro vide bet ter trans paren cy in the over all re sult when as sess ing cost and ef fect im pacts of a drug. In an in ter na tion al per spec tive, re duc ing reg u la to ry va ri ety would like ly di min ish costs and reg u la to ry un cer tain ty to in no va tors.

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0407

Work ing con di tions and health sta tus of old er work ersLengagne P. (IRD ES, Par is, France)De brand T.

To pre serve health of old er work ers is a ma jor is sue to health and so cial pol-i cy in Eu ro pean coun tries, be cause suc cess of poli cies con sist ing in in creas-ing la bor force par tic i pa tion rate among age ing peo ple de pends on it.Even if the re la tion ship be tween health sta tus and par tic i pa tion in the la bor mar ket ap pears ob vi ous, the caus al re la tion ship is not clear. Two con tra dic to ry ef fects seem to op er ate: on one hand ar du ous work may re sult in worse health, par tic u lar ly to wards the end of work ing life, and on the oth er poor health may re sult in ear ly de par ture from the la bor mar ket.Sev er al stud ies show that health sta tus mod i fies la bor par tic i pa tion of old er work ers. But few ar ti cles in tro duce work ing con di tions as a de ter-mi nant of health, and thus, la bor sup ply. In this pa per, us ing the data from SHARE (Sur vey on Health Age ing and Re tire ment in Eu rope – which rep re sents the pop u la tion of in di vid u als aged 50 and over for ten coun tries on the Eu ro pean con ti nent), we mea sure the im pact of work-ing con di tions on sev er al health in di ca tors: self-as sessed health, long-term ill ness, lim it ed ac tiv i ties…

0531

EF PIA HTA Key Prin ci ples: A Pay er Per spec tiveLengyel G. (Na tion al Health In sur ance Fund Ad min is tra tion, Bu dapest, Hun gary)

Health tech nol o gy as sess ment is a manda to ry re quire ment in the re im-burse ment ap pli ca tion pro cess of a new med i cine since May 2004 in Hun-gary and the re quire ments of the anal y sis are of fi cial ly stat ed (Di rec tive of the MoH: Cost-ef fec tive ness anal y sis guide line, is sued in 2001). As HTA be came a for mal el e ment in re im burse ment de ci sion mak ing it helps to max i mize the health-gain of re im bursed med i ca tions. HTA out comes can be im ple ment ed in the de ci sion mak ing pro cess only if the in put data is lo cal and the anal y sis is adopt ed to the lo cal set tings. The po ten tial po si-tion ing of the new drug in the clin i cal prac tice and in the dis ease man age-ment may de fine its re im burse ment op por tu ni ties. Be sides clin i cal ben-e fits the cost of the new ther a py is crit i cal as the fi nan cial re sources are lim it ed. In no va tive drugs bring ther a peu tic ad van tages but af ford abil i ty is al ways the key ques tion and po ten tial sav ings may be re al ized only in the long term or they fall out side the health care sec tor. In or der to re ward the added val ue the pay er has to re-al lo cate the re sources or the bud get will be over spent. The most dif fi cult and most in ter est ing ques tion is how to fi nance in no va tion and man age fi nan cial con cerns at the same time, in par al lel with serv ing the so ci etal health-care de mands.

0037

Com plex i ty and Eco nom ic Eval u a tion in Health CareLessard C. (Uni ver si ty of Mon tre al, Que bec, Ca n a da)

With the growth of health care costs, man agers and pol i cy mak ers turn to wards health tech nol o gy as sess ment, with a fo cus in the area of health eco nomics. De spite the aes thet ics of mod els and the pre ci sion of com pu-ta tion, de ci sion anal y ses may over sim pli fy com plex health care de ci sions. These anal y ses of ten ig nore im por tant health con se quences, con tex tu al el e ments, re la tion ships or oth er rel e vant mod i fy ing fac tors, which might not be ap pro pri ate in a mul ti ob jec tive, mul ti stake hold er is sue. One so lu-tion would be to de vel op a new paradigm based on the is sues of per spec-tive and con text. Com plex i ty the o ry may pro vide a use ful con cep tu al frame work for eco nom ic eval u a tion in health care. Com plex i ty think-ing con tributes to de vel op aware ness of is sues in clud ing un cer tain ty, con-tex tu al is sues, mul ti ple per spec tives, broad er so ci etal in volve ment, and

trans dis ci plinar i ty. For the health eco nom ic field, the use of com plex i ty the o ry will in volve the ac knowl edge ment of com plex, in ter de pen dent re la tion ships with broad er con tex tu al, eco nom ic, so cial, cul tur al, po lit-i cal and oth er non-tech ni cal fac tors. This would lead the field to wards an ac count abil i ty and epis te mol o gy based on plu ral ism and un cer tain-ty, re quir ing new forms of lay-ex pert en gage ment and roles of lay knowl-edge into de ci sion-mak ing pro cess es. A turn to wards com plex i ty the o ry would pro vide the ba sis for the en gage ment of health eco nomics and pol-i tics, and eco nom ic eval u a tion knowl edge and broad er so ci ety.

0217

Con tract set ting in health care when qual i ty de pends on an ir re vers ible in vest ment de ci sionLev ag gi R. (Di par ti men to di Scien ze Eco nomiche, Uni ver si ty Degli Stu di di Bres cia, Italy)Moret to M.

The cost and qual i ty trade-off in con tracts for hos pi tal care is stud ied by as sum ing that qual i ty is a run ning cost. We ar gue that qual i ty is the re sult of an in vest ment de ci sion. This as sump tion shifts the fo cus of the in cen-tive-com pat i ble con tract from cost rev e la tion to in tertem po ral in vest-ment de ci sions. Lev ag gi and Moret to (2004) shows that to in cen ti vate qual i ty the pur chas er should set an in tertem po ral pur chas ing rule al low-ing hos pi tals to in crease their ac tiv i ty only if they in vest when the tech-nol o gy is new.study the game be tween the pur chas er and the provider of health care that de ter mines the best price and qual i ty con tract giv en that the pur chas er faces a trade off be tween price, qual i ty ver i fi a bi ly and hold up prob lems.use a two-pe ri od mod el &agrave; la Abel et al. (1996) where the hos pi tal can ex pand its ca pac i ty by mak ing an in vest ment now or in the fu ture through a real op tion ap proach. The tech nol o gy is in no-va tive only at the be gin ning of its life when learn ing costs are high er and fu ture op er at ing costs are not known. In sub se quent pe ri ods the tech nol-o gy is con sol i dat ed and the hos pi tal that has in vest ed in the first pe ri od pro duces a pos i tive ex ter nal i ty to the sys tem.

0527

Gov er nance and Cor rup tion in Health Care Sys tems in Tran si tion and De vel op ing Coun triesLew is M. (Cen ter for Glob al De vel op ment, Wash ing ton D.C., USA)

This pa per de fines gov er nance and cor rup tion in health care, and then re views the am ple if frag ment ed ev i dence. Cross coun try re gres sions, and data from in sti tu tion al and gov er nance sur veys on the per cep tions of cor rup tion in the sec tor pro vide a con text for the sum ma ry of ev i-dence on the per for mance of health care sys tems. Draw ing on com par-a tive quan ti ta tive mea sures such as ab sen teeism, pet ty theft, in for mal pay ments and leak age of pub lic funds the pa per re views ev i dence at the coun try lev el. Ef fec tive coun try poli cies and ini tia tives that have bol stered ac count abil i ty and im proved per for mance are re viewed to guide pol i cy.

0251

Vari a tions in the Pre scrib ing Pat terns of StatinsLink C. (Uni ver si ty of Delaware, Newark, Unit ed States)Condliff e S.

Ra tio nale: The iden ti fi ca tion of high cho les ter ol as a risk fac tor for cor-o nary heart dis ease (CHD) has prompt ed im ple men ta tion of pre ven-tion pro grams, with statins play ing a ma jor role. Stud ies have shown for many drugs that dis par i ties in pre scrib ing pat terns ex ist that are un re lat-ed to clin i cal guide lines. (e.g., across in sur ance types, re gions, and var i-ous de mo graph ic char ac ter is tics).

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Ob jec tive: The ob jec tive of the pa per is to es ti mate multi no mi al log it mod els of the de ter mi nants of pre scrib ing pat terns for statins for per-sons hav ing CHD and dys lipi demia. The key ques tion, do the above men tioned dis par i ties ex ist for statins? Three large data bases pro vide so cioe co nom ic, de mo graph ic, and di ag nos tic in for ma tion. These in clude of fice-based phy si cian set tings (Na tion al Am bu la to ry Med i-cal Care Sur veys) and hos pi tal set tings (Na tion al Hos pi tal Am bu la to ry Med i cal Care Sur veys). The Med i cal ex pen di ture Pan el Sur vey (MEPS), a pan el, has rich er so cioe co nom ic data about re spon dents. Re sults based on NAM CS and NHAM CS: Pre lim i nary re sults found vari a tions across mi nori ties, re gions of the US, and in sur ance cat e gories. It is ev i dent that vari a tions do ex ist. Be tween 1992 and 2002 statin us age in creased by be tween one and five per cent per year. We are in the pro-cess of run ning the anal y ses for 1996 through 2002 us ing the Med i cal Ex pen di ture Pan el Sur vey (MEPS).

0288

Eff ect of the ge ner ic sub sti tu tion pol i cy on en try, prices and ex pen di tures of phar ma ceu ti calsLin nos maa I. (De part ment of Health Pol i cy and Man age ment, Uni ver si ty of Kuo pio, Fin land)Kan gashar ju A., Val to nen H.

Ob jec tive of this study is to ex am ine the im pact of the ge ner ic sub sti tu-tion pol i cy on the en try of ge ner ic phar ma ceu ti cals, prices and ex pen-di tures of phar ma ceu ti cals in the Finnish phar ma ceu ti cal mar kets. We use quar ter ly sales data for in di vid u al phar ma ceu ti cal prod ucts in sev-en ATC groups for the years 1997-2005. Ge ner ic sub sti tu tion is al lowed for drugs in four ATC groups (drugs used to treat axid re lat ed dis or ders (ATC group A02B), high cho les ter ol (ATC group C10A), high blood pres-sure (ATC groups C07-C09), and de pres sion (ATC group N06A)). Ge ner-ic sub sti tu tion is not al lowed in three ATC groups (drugs used to treat psy-cho sis (ATC group N05A), de pres sion (ATC group N06A), and epi lep sy (ATC group N03)). The three lat ter groups are used as a con trol group in the study. use pan el data mod els to study the in flu ence of the ge ner ic sub-sti tu tion pol i cy on the en try of ge ner ic phar ma ceu ti cals, prices and ex pen-di tures of phar ma ceu ti cals. En dog e nous vari ables are re gressed on the dum my vari able, in di cat ing the time of in tro duc ing the pol i cy, vari ables char ac ter iz ing mar kets and oth er rel e vant co vari ates. Ap pro pri ate es ti ma-tion tech niques, like the in stru men tal vari able es ti ma tion tech nique, will be ap plied to solve any prob lems due to en dog e nous ex plana to ry vari-ables. Re sults and con clu sions will be pre sent ed at the con fer ence.

0192

A mul ti level anal y sis on di a be tes care prac tices in pri ma ry careLip pi Bruni M. (De part ment of Eco nomics, Uni ver si ty of Bologna, Italy)No bilio L., Ugoli ni C.

In rec og ni tion of their ge ner ic po ten tial to in flu ence doc tor be hav iour, bonus es paid over and above the phy si cian_base in come have been in creas ing ly in tro duced in pri ma ry care to try and im prove al loca tive ef fi cien cy and qual i ty of care. Al though many stud ies have con firmed that physi cians re spond to fi nan cial in cen tives, there is scarce em pir i cal ev i dence on how such schemes in flu ence qual i ty of treat ment. This prob-lem re flects the lack of em pir i cal data but also the com plex i ty of gen er-al prac tice in which many con found ing fac tors are like ly to in flu ence phy si cian be hav iour. Giv en this back ground, we in ves ti gate the im pact on care qual i ty of hav ing in tro duced eco nom ic in cen tives in the pri ma-ry care con tracts in the Ital ian re gion Emil ia Ro magna. We con cen trate on the treat ment of pa tients af fect ed by di a be tes mel li tus type 2 and we test the hy poth e sis that, oth er things equal, lo cal health au thor i ties that in tro duced fi nan cial in cen tives aimed to in crease pri ma ry care as sump-tion of these pa tients were more like ly to reg is ter a de crease in hos pi tal

ad mis sions for hy per gly ce mic emer gen cies and in be lat ed hos pi tal iza-tions. To this end, we ex am ined the com bined in flu ence of phy si cian, or gan i sa tion al and pa tient fac tors through the use of mul ti level mod-elling. Es ti ma tions are based on the year 2003.

0315

The in ter gen er a tional trans mis sion of healthLlena-Nozal A. (Fac ul ty of Eco nomics, Uni ver siteit Ams ter dam, The Nether lands)Lin de boom M., Klaauw B.

This pa per in ves ti gates how much of health is trans mit ted across gen er-a tions through ge net ics and how much through be hav ior and so cio-eco-nom ic sta tus (SES). Low SES chil dren start adult hood with low er ed u-ca tion and health and this may con strain their eco nom ic po si tion in adult hood. The in ter gen er a tional cor re la tion of in come may be linked to health but it is not clear what mech a nisms are driv ing this. Low SES par ents may face fi nan cial con straints that low er pa ren tal in vest ment, they may have low er par ent ing skills, or they may have worse health out-comes that con straint eco nom ic op por tu ni ties and these may be trans-mit ted across gen er a tions. Both un ob served het ero ge ne ity and pa ren tal health need to be ac count ed for in or der to dis en tan gle the cor re la tion. We use a co hort study, the Na tion al Child De vel op ment Study, which fol lows in di vid u als since their birth in 1958 un til their 40s. We ex ploit the rich ness of the data and in cor po rate in for ma tion on twins, adoptees and the co hort mem bers’ own chil dren to dis en tan gle the na ture and nur ture com po nents. Our find ings sug gest that in come is im por tant for the child’s health but this ef fect dis ap pears when we con trol for pa ren tal health and time in vest ment. On the oth er hand, when fi nan cial dif fi cul-ties are used to mea sure pov er ty, the ef fects per sist.

0584

Eff ec tive ness, Effi cien cy and Eq ui ty to ac com plish the Mil len ni um Goals in CubaPar do C.M.L. (Ha bana Uni ver si ty, Fac ul ty of Eco nomics, Cuba)

In the World Health Re port 2003, the World Health Or ga ni za tion pre-sents the MDGs that re fer to health, with its goals and in di ca tors. From all in di ca tors (6 in to tal) are ex am ined, re gard ing their ac com plish ment in the case of Cuba, the fol low ing: re duce child mor tal i ty, im prove ma ter-nal health and com bat HIV/AIDS, ma lar ia and oth er dis eases. It is dem-on stra ted that Cuba has showed high ef fec tive ness (un der stood by the achieve ment of the de fined goals), ef fi cien cy (con sid er ing the re la tion-ship be tween re sults and re sources) and eq ui ty (ac cord ing to the ter ri to-ri al dis tri bu tion) in the ac com plish ment of the ob jec tives con sid ered in the con text of Latin Amer i ca and the Caribbean, Can a da and the Unit ed States. This pre sen ta tion also dis cuss es that, in terms of the anal y sis, in di-ca tors to quan ti fy ef fec tive ness, ef fi cien cy and eq ui ty has been built.

0494

EF PIA HTA Key Prin ci ples: An In dus try Per spec tiveLoth K. (No var tis In ter na tion al AG, Brus sels, Bel gium)

Health Tech nol o gy As sess ment (HTA) is an im por tant means of en abling gov ern ments and oth er health pay ers to de vel op mech a nisms for eval u at ing the clin i cal and cost-ef fec tive ness of medicines and oth-er health tech nolo gies. This pre sen ta tion, il lus trat ed by ex am ples, fo cus-es on three key prin ci ples. First, that as sess ments should be based on a clear, so phis ti cat ed and dif fer en ti at ed view of what con sti tutes val ue. A nar row def i ni tion of val ue that does not in cor po rate the per spec tive of pa tients, car ers, health care pro fes sion als, and ig nores cost im pli ca tions else where in the sys tem, whether per son al or pub lic, dis torts the true

Eur J Health Econom Suppl 1 · 2006 | S61

val ue of a med i cal in ter ven tion. Sec ond ly, any as sess ment or ap praisal must be trans par ent and bal anced and should con form to the prin ci pals of the Eu ro pean Trans paren cy Di rec tive i.e. the pro cess must be non dis crim i na to ry, be based on ob jec tive and ver i fi able cri te ria and there must be a right to ap peal a de ci sion. HTA should be im ple ment ed as a means to achieve bet ter health out comes, not to de lay or ex clude new medicines from reach ing pa tients. Third ly, the ap praisal pro cess should re main sep a rate from the reg u la to ry re view pro cess. The de ci sion on whether to fund a med i cal in ter ven tion re mains a sub jec tive one, based on so ci etal val ues and the lo cal fund ing sit u a tion. As long as mem ber states re tain the re spon si bil i ty for health care, na tion al au thor i ties or politi cians must re main ac count able for the de ci sions on whether a med-i cal in ter ven tion is deemed to be cost ef fec tive.

0179

Iden ti fy ing con structs in mea sur ing pa tient em pow er mentLoukano va S. (Uni ver si ty of Hei del berg, Ger many)Bridg es J.F.P.

Pa tient em pow er ment is a key is sue in health care qual i ty im prove-ment. There is a need for a val i dat ed in stru ment for pa tient em pow er-ment as sess ment. The prin ci ple aim of this re search is to de fine pa tient em pow er ment and to iden ti fy con structs in mea sur ing em pow er ment. An ex pert pan el of key in for mants was formed to iden ti fy their views of em pow er ment from a wide range of per spec tives. In-depth in ter-views were con duct ed with se lect ed in for mants to ex plore their opin-ion about what is im por tant in terms of pa tient em pow er ment. Data were an a lyzed us ing the Frame work anal y sis. Ini tial dis cus sion was con-cen trat ed on two sets of fac tors, in flu enc ing em pow er ment – hu man cap i tal (health and health care sta tus, own er ship and re spon si bil i ty, lit-er a cy, health out comes), and health care sys tem re sources (ac cess, ad vo-ca cy, de ci sion mak ing). Fur ther anal y sis sug gest ed more con cep tu al con-structs. The re sult in di cat ed that em pow er ment is the state of con trol over own’s health through a dy nam ic, mul ti di men sion al pro cess of tak-ing re spon si bil i ty to be in volved in de ci sion mak ing and treat ment. To be em pow ered, pa tients need their hu man cap i tal and a pa tient ori ent ed health care sys tem that ac cepts (le gal izes) their in volve ment. This def i-ni tion should be used as a base for de vel op ment of em pow er ment mea-sure in stru ment among pa tient groups.

0454

Do diff er ent mod els pro vide diff er ent ev i dence? Im pli ca tions for pol i cy mak ing.Lourenço O. (Fac ul dade de Econo mia da Uni ver si dade de Coim bra and CEIS-UC, Coim bra, Por tu gal)Quin tal C., Fer reira P.L. Bar ros P.P.

The ro bust ness and sound ness of em pir i cal ev i dence pro vid ed by health eco nomics may af fect the way how pol i cy mak ers use it to de ci sion mak-ing. How ev er, the out put of re search might de pend on the meth o dol o-gy and hy pothe ses adopt ed. It is there fore im por tant to as sess the sta bil-i ty of re sults across mod els.Our ob jec tives are: to com pare the re sults of dif fer ent re gres sion mod-els that as sess the im pact of so cio-eco nom ic vari ables in health care uti li-za tion in Por tu gal, these mod els be ing the NEG BIN, Hur dle and La tent Class mod els (LCM). Our data comes from the lat est Na tion al Health Sur vey. The re sults sug gest that LCM mod els per form bet ter than the oth-ers; re gard ing ag gre gate re sults for the whole pop u la tion, dif fer ent mod-els gen er ate re sults that are quan ti ta tive ly sim i lar; the two class es, de rived from the LCM mod el, di verge in terms of the eco nom ic ef fects of re gres-sors in the uti li za tion of care: con trar i ly to low users, where most of non-health vari ables are eco nom ic and sta tis ti cal ly sig nif i cant, in the high users class, most of non-health vari ables are not sta tis ti cal ly sig nif i cant.

Re sults for the pop u la tion are sim i lar for the three mod els, sug gest ing some con sis ten cy, still, LCM mod els, by al low ing us to iden ti fy la tent class es of users, gen er ate more de tailed in for ma tion rel e vant for pol i-cy mak ing.

0338

The im pact of smok ing re stric tions on smok ing prev a lenceLud brook A. (Health Eco nomics Re search Unit, Uni ver si ty of Ab erdeen, Scot land)Bird S.

A num ber of coun tries across Eu rope have ei ther planned or im ple ment-ed re stric tions on smok ing in pub lic places. Apart from the health gains from re duced ex po sure to en vi ron men tal to bac co smoke, such re stric-tions may have the po ten tial to con tribute to re duc ing smok ing prev-a lence. How ev er, de ter min ing whether and by how much prev a lence has been or will be re duced as a re sult of this pol i cy in ter ven tion is dif-fi cult and pro vides an ex am ple of the prob lems which will be en coun-tered more gen er al ly in eval u at ing pol i cy in ter ven tions.avail able ev i-dence re lat ing to smok ing prev a lence is drawn from stud ies of work-place smok ing bans and clean air laws. A va ri ety of study de signs have been em ployed, some more ro bust than oth ers. The pa per dis cuss es the po ten tial sources of bias in the dif fer ent study de signs and the prob-lems of at tempt ing to pool data from dif fer ent types of study in quan ti-ta tive meta-anal y sis. A num ber of es ti mates for prev a lence ef fects are pro duced and trans lat ed into health gains. The pa per ar gues that in a con text where &#8216;gold stan dard’ RCT data are not avail able, care-ful anal y sis can en sure that pol i cy im pacts are es ti mat ed with suf fi cient pre ci sion for pol i cy mak ing and pol i cy eval u a tion pur pos es.

0306

In ju ry Sever i ty and Com pen sa tionLuke C. (The Uni ver si ty of Queens land, Bris bane, Aus tralia)

In this pa per we an a lyse the claims ac tiv i ty and claims out comes for com-pens able in di vid u als who have been in jured in au to mo tive ac ci dents in the State of Queens land for the pe ri od 1999–2004. We in ves ti gate the im pact of a range of co vari ates, in clud ing in ju ry sever i ty (as mea sured by the New In ju ry Sever i ty Score), de mo graph ic char ac ter is tics, in come, re ha bil i ta tion treat ments and ex pen di tures, as well as data on claims man age ment pro-cess es and de mo graph ic fac tors on (i) claims propen si ty, (ii) claims suc cess, and (iii) pay out mag ni tudes. Our study is some what unique in the sense that it in cludes ob jec tive (i.e., non-self-re port ed) data on in ju ry sever i ty as well as the usu al fields that are avail able un der com pen sa tion schemes of this kind. Our re sults shed some light on an im por tant, but some what ne glect ed field with in health eco nomics, i.e. the eco nomics of health and health care un der com pen sa tion and com mon law schemes.

0350

In for mal and for mal care among sin gle-liv ing el der ly in Eu ropeLund borg P. (Lund Uni ver si ty Cen tre for Health Eco nomics (LUCHE), Lund, Swe den)Lind gren B., Bolin K.

The aims of this study were (1) to an a lyse whether in for mal care, pro-vid ed by chil dren or grand chil dren to their el der ly par ents, and for mal health care are sub sti tutes or com ple ments, and (2) whether this re la tion-ship dif fers be tween dif fer ent parts of Eu rope. The anal y ses were based on the new ly de vel oped SHARE (Sur vey of Health, Age, and Re tire ment in Eu rope) database. We found (1) that in for mal- and for mal home care are sub sti tutes, while in for mal care is a com ple ment to doc tor- and hos-

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pi tal vis its, and (2) that these re la tion ships in some cas es dif fer among the Eu ro pean coun tries that were stud ied.

0565

Health Care Or ga ni za tion and Fi nanc ing of End Stage Re nal Dis ease: The Span ish Mod elLuño J. (Hos pi tal Gen er al Uni ver si tario, Madrid, Spain)Marañón G.

Re nal re place ment ther a py in Spain is com plete ly cov ered by the uni ver sal and free Na tion al Health Ser vice. While the prev a lence of ESRD in Spain is high (925 peo ple per mil lion), the in ci dence (130 peo ple per mil lion) is only a third of the US ESRD in ci dence and is sim i lar to Eu rope’s av er age in ci dence. Spain’s re mark able rate of ca dav er ic or gan do na tion, 35 per mil-lion pop u la tion in 2004, is the high est in the world. Where as most Eu ro-pean coun tries have a re nal trans plant in ci dence rate of only 30 trans plants per mil lion, Spain’s is 50 per mil lion. Spain spends rel a tive ly lit tle on gen-er al health care (1319 Eu ros per cap i ta), com pared to oth er coun tries, but ESRD care rep re sents a larg er por tion of the over all bud get (7.7% of the Gross Do mes tic Prod uct). Qual i ty of care in the NHS is not de ter mined by free com pe ti tion or per for mance re wards; in stead, it is mon i tored by sev-er al health agen cies. Nev er the less, nephrol o gists with low salaries have rel-a tive ly few pro fes sion al and eco nom ic in cen tives to im prove qual i ty. One may won der whether the Span ish sys tem can be sus tained at salaries that re pres ent only a third of the in come re ceived by the nephrol o gists of the oth er coun tries and with out stronger pro fes sion al in cen tives.

0347

In ter na tion al com par isons of health sys tem per for mance with ag gre gate dataLu o ma K. (Gov ern ment In si tute for Eco nom ic Re search, Helsin ki, Fin land)Räty T.

We as sess the per for mance of health care sys tems with data en vel op ment anal y sis (DEA) us ing dif fer ent sets of out put and in put vari ables avail-able in OECD Health Data and data on mor tal i ty ame na ble to health care. We in ves ti gate how sen si tive ef fi cien cy scores and rank ings are with re gard to which in put and out put mea sures are in clud ed in the anal-y ses. In al ter na tive mod el spec i fi ca tions out put is mea sured ei ther by life ex pect an cy at birth, in fant mor tal i ty, mor tal i ty ame na ble to health care, dis abil i ty ad just ed life ex pect an cy or some com bi na tions of them. The al ter na tive in put vari ables in clude to tal health ex pen di ture, health em ploy ment, the num ber of doc tors and nurs es. In most of the anal y-ses we use pooled data for 24 OECD coun tries from years 1998-2002. The anal y ses which use mor tal i ty ame na ble to health care as an out put vari able use only 1998 data. DEA re sults and coun try rank ings based on them proved to be quite sen si tive to which in put and out put vari ables were in clud ed in the mod el. In ap ply ing DEA for as sess ing the per for-mance of health care sys tems one should be care ful and par si mo nious in se lect ing in put and out put vari ables. The ex cess num ber of vari ables and vari ables loose ly con nect ed to health sta tus tend to in flate ef fi cien cy scores and many coun tries can be deemed to be ef fi cient by de fault.

0188

The im pact of ser vice pro vi sion on pa tient move ments in a list pa tient sys temLu raas H. (Health Ser vice Re search Unit,Uni ver si ty Hos pi tal, Loren skog, Nor way)Iversen T.

In the Nor we gian list pa tient sys tem gen er al prac ti tion ers (GPs) are paid by a mix of cap i ta tion and fee-for-ser vice. Some GPs ex pe ri ence

that their pre ferred num ber of pa tients is greater than the num ber they ac tu al ly have on their lists. In pre vi ous work we have shown that fee-for-ser vice en cour ages these GPs to in crease the ser vice pro vi sion to their pa tients. In par tic u lar, we find that they pro vide the bet ter paid con sul ta-tion of a long du ra tion more fre quent ly than GPs with enough pa tients. In the pres ent pa per we fo cus on a re lat ed eco nom ic mo tive If pa tients pre fer many ser vices rather than few, the pro vi sion of ex tra ser vices may dis cour age pa tients from switch ing to oth er GPs. By means of Gen er al-ized Least Squares Re gres sion that both takes un ob served het ero ge ne-ity and het eroskedas tic i ty into ac count, this hy poth e sis is test ed on pan-el data cov er ing all Nor we gian GPs dur ing the pe ri od 2001-2004. We are not able to show any ef fect of ser vice pro vi sion on pa tient switch ing. Hence, ex tra ser vice pro vi sion does not com pen sate for neg a tive char ac-ter is tics (pa tients’ im pres sion of com pe tence, em pa thy etc) of less pop-u lar GPs. Hence, pa tients’ re vealed pref er ences show that ben e fits are less than costs at the mar gin, and we con clude that ex tra ser vice pro vi-sion is so cial ly in ef fi cient.

0433

Ex pen di ture, Or ga ni za tion and Out comes in Health. Amer i ca and Eu ropeMa ceira D. (Cen ter for the Study of State and So ci ety (CEDES), Buenos Aires, Ar genti na)Bar bi eri E., Lignel li B.

Health care sys tems wid ly dif fer in their cov er age, fi nanc ing and out-comes, since they are as so ci at ed with the av er age rich ness of each na tion and its dis tri bu tion. As a re sult, the ob jec tive is to com pare health care sys tems in four dif fer ent re gions: Latin Amer i ca, Unit ed States and Can-a da, West ern and East ern Eu rope, iden ti fy ing the main char ac ter is tics re lat ed with the so cioe co nom ic con text rul ing in each re gion. The pa per also anal y ses the as so ci a tion be tween in come and par tic i pa tion of the pub lic fi nanc ing and pro vid ing of health care ser vices. The re sults sup-port the hy pothe ses of the pos i tive as so ci a tion be tween the GDP per cap i ta and the health care sys tems per for mance. In this way, the ef fec-tive ness of the health care sys tems in poor na tions is ques tioned, tak ing them to face two chal lenges in light of rich coun tries’ ex pe ri ence: (I) to build a health care struc ture that com pen sates the fi nan cial lim i ta tions giv ing the best ser vices and (II) to en force the in sti tu cional ca pa bil i ty of the state to guar an tee the good work ing of the health care sec tor, eq ui ty in the ac cess and qual i ty to all the users.

0002

De vel op ment of a Cap i ta tion Scale for IDF Ca reer Sol diers in Is raelMag nezi R. (De part ment of Health Sys tems Man age ment, School of Health Sci ences, The Ariel Col lege of Judea and Samaria, Med i cal Ser vices and Sup ply Cen ter, Med i cal Corps, Is rael De fense Forces, Is rael)Weiss Y., Co hen Y., Shmueli A.

The Is raeli Na tion al Health In sur ance Law al lo cates a na tion al health-care bud get to the sick ness funds, which pro vide the med i cal care the civil ian pop u la tion. Med i cal care for mem bers of the IDF is fi nanced through the bud get of the Min istry of De fense and is not in clud ed in the na tion al health care bud get. Ben e fits pro vid ed to sol diers serv ing in the per ma nent forces are far more ex ten sive than those pro vid ed to civil ians. Be cause of no co-pay ments, poor man age ment, and the cost-based bud get, mil i tary health care costs in Is rael are ex pect ed to ex ceed civil ian health care costs, ad just ing for age and sex. The pres ent pa per de rives age- and sex-based cap i ta tion rates for mil i tary per son nel, and com pares mil i tary and civil ian age-based ex pen di ture and cap i ta tion rates. The study pop u la tion com prised ca reer sol diers and civil ians aged 21–54 years. Ex pens es of ca reer sol diers were cal cu lat ed to pro vide in for-

Eur J Health Econom Suppl 1 · 2006 | S63

ma tion on the fi nan cial costs of med i cal ser vices for each age group in 2003. Over all ex pens es for wom en were high er than for men in all age groups. As ex pect ed, the old er the group, the high er the to tal ex pen-di ture for both men and wom en. In-pa tient care rep re sent ed a high er per cent age of the to tal costs for men (28.3%) than for wom en (22.1%). Emer gen cy room care was high er for wom en in the 22–24 age group but com pa ra ble to that of men in high er age groups. Spe cial ist vis its rep re sent ed a sig nif i cant ly high er per cent age of the to tal costs for wom-en than for men in the 22–24 and 25–34 age groups (by 6% and 15%, re spec tive ly). The dif fer ence de creased to 13% in the 35–44 age groups and, in the 45-54 age group, the dif fer ence for men was 14% high er than for wom en. Mil i tary costs were sim i lar to civil ian costs in the 22–24 age groups, high er in the fol low ing two groups, and low er in the 45–54 age group. Like in oth er or ga ni za tions, mil i tary health care ser vices might ben e fit from out sourc ing. The in equal i ty in med i cal ser vices to sol diers and civil ians, the over-use of the mil i tary health care sys tem, and the de crease of stan dards and bud getary re sources will com pel the es tab lish-ment of more cre ative means of pro vid ing these ser vices through con-tracts and agree ments, per haps through the civil ian sick ness funds.Key words: Cap i ta tion; Health Ser vices; Is rael De fense Forces (IDF)

0607

The cost-eff ec tive ness of in fl ix imab fro rheu ma toid ar thri tis in Hun garyMá jer I. (Corv i nus Uni ver si ty of Bu dapest, Hun gary)Brod szky V., Pén tek M., Gulác si L.

Ob jec tive: To es ti mate the cost-ef fec tive ness of in flix imab plus methotrex at (MTX) com pared with MTX plus pla ce bo in the treat ment of rheu ma toid ar thri tis in Hun gary. Meth ods: Markov sim u la tion mod el was adapt ed to as sess costs and qual i ty-ad just ed life-year (QALY) val ues in the long run. Base line dis-tri bu tion of can di dates for bi o log ic ther a py ac cord ing to the Hun gar i an guide lines, util i ty and costs of each dis ease sever i ty state were ob tained from a mul ti cen tric cross sec tion al sur vey in Hun gary. Pub lished tran si-tion prob a bil i ty data of the ARAMIS (Ar thri tis Rheu ma tism and Ag ing Med i cal In for ma tion Sys tem) co hort and the AT TRACT (Anti-Tu mor Ne cro sis Fac tor and Con com i tant Ther a py) in flix imab clin i cal tri al were used. Sen si tiv i ty anal y sis was per formed to as cer tain the vari abil-i ty of the re sults.Re sults: As sum ing 54 weeks of treat ment the in cre men tal QALY was 0,263 in the first year and 0,493 on life time ho ri zon with an in cre men-tal cost of 12,390 € and 12,080 € re spec tive ly, re sult ing in 45,355 €/QALY or rather 24,485 €/QALY. Ap ply ing oth er mod elling as sump tions ac cord-ing to cost sce nar ios, dis count and mor tal i ty rates, the in cre men tal cost-ef fec tive ness ra tios (ICERs) re mained in a rea son able range.Con clu sion: Com pared with oth er pub lished re sults, ICERs based on Hun gar i an data were low er that sug gests low er Hun gar i an costs and re source use.

0485

So cial class and men tal health of the UK pop u la tion 1993–2000Man ga lore R. (Lon don School of Eco nomics, Lon don, Unit ed King dom)Knapp M.

This pa per anal y ses the dis tri bu tion of men tal health prob lems and use of ser vices in the UK, by so cial class es, us ing data from Psy chi at ric Mor bid i ty Sur veys 1993 and 2000. The aim is to pres ent the chang es be tween the two years, es ti mate the ex tent of un met needs and ev i dence of in equity in the sys tem. Con cen tra tion in dex ap proach is used for the anal y sis of eq ui ty is sues. A dis tinc tion is made be tween self-per ceived and clin i cal ly as sessed men tal health prob lems as the rules of in ter na-tion al clas si fi ca tion sys tems for psy chi at ric dis eases set thresh olds of dis-

ease sever i ty that equate to lev els that a psy chi a trist would re gard as a case like ly to re quire treat ment and ex clude many with men tal health prob lems. Peo ple with symp toms be low this thresh old of ten suf fer dis-tress and im pair ment of func tion ing and many of these may not have ac cess to men tal health care. Their needs are the ‚hid den needs’ which are rarely tak en into con sid er a tion in the plan ning of men tal health ser-vices. Re sults show that while there is in equal i ty in the dis tri bu tion of men tal health prob lems among so cial class es, there is no clear ev i dence of in equity in the use of ser vices. The de gree of as so ci a tion be tween psy-chi at ric mor bid i ty and so cial class es varies be tween di ag nos tic groups and the gap be tween self-per ceived and clin i cal ly as sessed needs and util i sa tion of ser vices is re mark able.

0276

For which high risk adults is a catch-up HBV vac ci na tion cam paign cost-eff ec tive?Man gen M.J. (Na tion al In sti tute for Pub lic Health and the En vi ron ment, Bilthoven, The Nether lands)De Wit G.A., Kret zschmar M.

The aim of this study was to eval u ate a four year catch-up hep a ti tis B vi rus (HBV) vac ci na tion cam paign for high-risk adults at risk-group lev el, start ing in the Nether lands in 2002. Groups con sid ered were men hav ing sex with men, het ero sex u als with a high rate of part ner change (HRP), com mer cial sex work ers and hard drug users (HDU). Based on ob served data col lect ed in the first two years, and ex trap o lat ing these data for the two fol low ing years, to tal num ber of par tic i pants and pro-gram costs were es ti mat ed. By ap ply ing lin ear re gres sion to the data col-lect ed on anti-HBc prev a lence, the prob a bil i ty of sus cep ti ble in di vid u als in risk group i to be come in fect ed with HBV in their re main ing life was es ti mat ed. Cor rect ing for ob served vac ci na tion com pli ance, the num ber of fu ture HBV in fec tions avoid ed was es ti mat ed per risk-group. By com-bin ing these num bers with es ti mates of life years lost, qual i ty of life loss-es and health care costs of HBV in fec tions, the ben e fits of the cam paign were es ti mat ed for each risk-group. The pro gram was cost-ef fec tive in all four risk groups. Vac ci nat ing HDUs was most cost-ef fec tive with € 6,700 per QALY gained, where as vac ci nat ing HRPs was least cost-ef fec-tive (€ 15,200 per QALY gained).

0354

Pro pos al for an un con ven tion al risk-ad just ed cpi ta tion for mu la for al lo cat ing funds to re gions in ItalyMapel li V. (Uni ver si ty of Mi lan, Italy)

Cur rent for mu lae for al lo cat ing re sources from a cen tral fund to sub-na tion al gov ern ments or to health schemes are based on mul ti var i ate re gres sion mod els that ad just for risk or need, but fail to con sid er the vari abil i ty of the av er age costs of ser vices pro vid ed, thus end ing up by “re dis tribut ing” in ef fi cien cies and wastes across health au thor i ties. The pro posed for mu la for the Ital ian NHS ex plic it ly con sid ers the de ter mi-nants of health ex pen di ture in the fol low ing way: C = π · f · q · c, where C is cap i ta tion, π is the prob a bil i ty of be ing (chron i cal ly) ill, f is the fre-quen cy or propen si ty to use spe cif ic ser vices when ill, q is the quan ti ty and c is the unit cost of ser vices used. Epi demi o log i cal stud ies show that al most 80% of ex pens es is de ter mined by chron i cal ly ill and by dead. The cap i ta tion can be cal cu lat ed ei ther at an ag gre gate lev el, by mul ti-ply ing the re gion al prev a lence rates of 15 ma jor chron ic dis eases times the na tion al av er age treat ment cost (f · q · c) for each dis ease, thus rec-og niz ing the dif fer ence in re gion al risks/needs; or at an an a lyt i cal lev-el by set ting stan dard or tar get val ues for (f), (q), and (c), thus cor rect-ing also for ex ces sive fre quen cies, in ap pro pri ate quan ti ties or un nec es-sary costs. The ba sic in for ma tion for the for mu la can be de rived from ad min is tra tive data bases con tain ing in di vid u al records on chron ic dis-eases and ex pen di ture.

S64 | Eur J Health Econom Suppl 1 · 2006

0414

Vol un tary Pri vate Health In sur ance and Eq ui ty in ac cess to health careMargheri ta G. (De part ment of Eco nomics, Fi nance and Sta tis tics, Uni ver si ty of Pe ru gia, Italy)Masse ria C.

As in most EU coun tries, the last ten years have been char ac ter ised by a trend in shift ing health care costs from the state to in di vid u als. The Ital-ian health care sys tems (SSN) pro vides com pre hen sive health care cov-er age. De spite this, health care ex pen di tures have been char ac ter ised by the in creas ing im por tance of the pri vate com po nent, in clud ing Vol un-tary Health In sur ance (VHI). There is ev i dence at EU lev el that ac cess to com ple men ta ry VHI is prob lem at ic for peo ple with low in comes.aim of the pa per is to mea sure, in come-re lat ed hor i zon tal in equity in the ac cess to vol un tary health in sur ance in Italy. In or der to stan dard-ise for in di vid u al needs we use a mea sure of in equity which is based on the in di rect stan dard iza tion ap proach pro posed by Wagstaff and Van Doorslaer (2000). The data are tak en from the Mul ti scopo sur vey, 1999-2000. In come in for ma tion, was im put ed by us ing the Eu ro stat sur vey (1999) for Italy. Hor i zon tal in equity in dices for VHI are gen er at ed com-par ing them across re gions. Re sults show that ac cess to VHI is sub ject to in come-re lat ed in equity in most Ital ian re gions. We mea sured the rel-a tive con tri bu tion of VHI to in equity in ac cess to in pa tient, GP and spe-cial ist ser vices. It ap pears that VHI ac cess is a source of in equity. This should raise con cerns on in creas ing the role of VHI in Italy.

0066

Giv ing greater in de pen dence to providers: does it make a diff er ence?Mari ni G. (Cen tre for Health Eco nomics, Uni ver si ty of York, UK)Ja cobs R., Mari ni G.

Foun da tion hos pi tals are a new type of or ga ni sa tion in tro duced into the En glish Na tion al Health Ser vice in 2003. Foun da tion sta tus of fers hos pi tals fi nan cial and man age ri al in de pen dence. The ra tio nale is that giv ing hos pi tals more self-de ter mi na tion will pro vide in cen tives to im prove per for mance. Foun da tion hos pi tals are be ing in tro duced in a phased man ner – only the high est per form ing hos pi tals are al lowed to be come foun da tion hos pi tals. At pres ent there are 25 foun da tion hos pi-tals (from a to tal of 173 acute hos pi tals), but with in 5 years the gov ern-ment ex pects all acute hos pi tals to be per form ing at lev els high enough to qual i fy for foun da tion sta tus.pan el data for En glish acute hos pi tals from 2000/01 to 2004/05, we in ves ti gate the char ac ter is tics of the “ear-ly-adopters” : those hos pi tals that are in the first and sec ond waves of re form : with those of oth er hos pi tals. Dif fer ence in dif fer ence meth ods are used to ex am ine the dif fer ence be tween hos pi tals be fore and af ter the adop tion of foun da tion sta tus on a range of char ac ter is tics. The foun da tion hos pi tal scheme has been crit i cised for gen er at ing in equal-i ty in the dis tri bu tion of health care sup ply (a “two-tier” sys tem). Our anal y sis sheds light on this and is gen er al is able to oth er de volved sys-tems in which hos pi tals achieve more in de pen dence and free dom from cen tral con trol.

0590

Eco nom ic Costs and Im pact of Non-Com mu ni ca ble Dis eases: Ex pe ri ence from Rus siaMar quez P. (WHO)Shurke M.

This pa per would pres ent re sults on costs and eco nom ic growth im pact of NCDs in Rus sia. Costs are es ti mat ed at 3 per cent of GDP and, at its cur rent pace, NCDs could have a pro found im pact on GDP growth in

the next 20 years. The pa per looks at op tions for pol i cy and macroe co-nom ic in ter ven tions to im prove per for mance rel a tive to sta tus quo.

0558

The use of Pa tient-Re port ed Out comes to sup port a reg u la to ry claim in the USA and Eu ropeMar quis P. (Mapi Val ues, Bos ton, USA)

The ob jec tive of this ses sion will be to pres ent FDA and EMEA pa tient-re port ed out come (PRO) sub mis sions and re views. Ar eas of con ver-gence and di ver gence will be iden ti fied and dis cussed. The cre ation of the Study End points and La bel De vel op ment group (FDA/CDER/OND/SEALD) three years ago and the de vel op ment of a draft PRO guid ance doc u ment il lus trate the US reg u la tors’ com mit ment to wards de vel op ing and main tain ing con sis tent cri te ria for re view of PRO and oth er study end point eval u a tions. In the mean time, the EMEA has de vel oped a re flec tion pa per on health-re lat ed qual i ty of life. So the FDA and EMEA have both gained ex pe ri ence in re view ing PRO and health-re lat ed qual-i ty of life eval u a tions. Dur ing the pre sen ta tion, an em pha sis will be put on prac ti cal ex pe ri ences when as sess ing and sub mit ting PRO/health-re lat ed qual i ty of life data at dif fer ent stag es of the clin i cal pro gram, with a fo cus on ear ly phas es (e.g. de vel op ment of hy pothe ses, de vel op ment/val i da tion of ques tion naires, strat e gy for anal y sis and in ter pre ta tion). Al though most of the rec om men da tions when im ple ment ing PROs in glob al clin i cal de vel op ment pro grams are agreed upon by dif fer ent reg u-la tors, is sues re lat ed to def i ni tion of con cepts, PRO paradigms, PROs as pri ma ry end-points, role in eval u a tion of treat ment risk/ben e fit, cross-cul tur al is sues, and clin i cal sig nif i cance, mer it fur ther dis cus sion.

0575

An eco nom ic eval u a tion of phys i cal ac tiv i ty in ter ven tionsMarsh K. (Ma trix Re search and Con sul tan cy Ltd., Lon don, UK)

Ob jec tive: NICE com mis sioned Ma trix RCL to de ter mine the cost ef fec-tive ness of four types of in ter ven tion aimed at in creas ing phys i cal ac tiv i-ty lev els: brief in ter ven tions in pri ma ry care; pe dome ters; ex er cise re fer-ral; and walk ing and cy cling pro grammes in the com mu ni ty.Meth od: A re view of ef fec tive ness stud ies was used to iden ti fy the re source use and change in phys i cal ac tiv i ty re sult ing from the in ter-ven tions. An eco nom ic mod el was con struct ed to mea sure the health ben e fits of the chang es in phys i cal ac tiv i ty lev els, and the con se quent im pact on par tic i pants’ qual i ty of life and NHS cost sav ings. Re sults: Defin ing costs as just those in curred im ple ment ing the in ter-ven tions, the mod el found that the cost per QALY gained es ti mates for the in ter ven tions var ied from c£20 to c£470 (when com pared with ‘usu-al care’). When costs are de fined to in clude the fu ture health care costs saved as a re sult of health states avoid ed, the in ter ven tions dom i nate usu-al care, both im prov ing health out comes and be ing less cost ly. The most cost-ef fec tive in ter ven tions are ex er cise pre scrip tion or in ter views. Dis cus sion: A num ber of im por tant lessons are drawn for un der tak ing eco nom ic eval u a tions of pub lic health in ter ven tions. A key chal lenge is the epi demi o log i cal mod elling re quired to de ter mine long-term health im pacts of pub lic health in ter ven tions. A num ber of pieces of in for ma-tion are cru cial to this part of the mod el: an ac cu rate mea sure of base-line risk of suf fer ing health states; change in risks as a re sult of the in ter ven tion; and the im pact of this change on risk of suf fer ing health states.

Eur J Health Econom Suppl 1 · 2006 | S65

0084

On in sur ance and the cost-shar ing of phar ma ceu ti cal R&DMar tinez-Gi ralt X. (Uni ver si tat Au tono ma de Barcelona, Bel later ra, Spain)Bar ros P.P.

An old de bate that is be ing de vel oped since the late 1950s, is the link be tween the lev el of prof its of a com pa ny (and thus, its monopoly pow er in the mar ket) and the source of fund ing of R&D ac tiv i ties. The re cent years have wit nessed the up ris ing of the glob al iza tion of eco nom ic ac tiv-i ties in the de vel oped world. To geth er with glob al iza tion, in creas ing costs as so ci at ed with the pace of tech no log i cal change force com pa nies to re view their R&D or ga ni za tion and spend ing. Di Masi et al. (2003) es ti mate the to tal R&D cost per new drug in 2001 at $802 mil lion. The Tufts Cen ter for the Study of Drug De vel op ment (2003), in creas es the es ti mate fur ther to $897 mil lion in 2003.The sharp in crease in R&D ex pens es com bines in the case of the phar ma-ceu ti cal in dus try, with the tra di tion al dif fer ences of drug prices across coun tries due to a num ber of fac tors. Among them, dif fer ent reg u la to ry regimes and in sur ance sys tems, to geth er with the fact that gov ern ments are usu al ly monop sony buy ers of drugs.In re ply to this new en vi ron ment, com pa nies have re act ed de vel op ing part ner ships, and propos ing a sin gle price across coun tries (at least with-in the EU). On their part, gov ern ments in high price coun tries have also re act ed by in tro duc ing these prices dif fer ences as an el e ment in their ne go ti a tions with phar ma ceu ti cal cor po ra tionsWe pro pose to fo cus on the is sue of how to im pute the over all R&D costs in the phar ma ceu ti cal in dus try across coun tries. Ram sey pric ing has been pro posed in the phar ma ceu ti cal in dus try as a mech a nism to price dis crim i nate among mar kets while al low ing to re cov er the (fixed) R&D cost (see e.g. Dan zon and Towse, 2003). How ev-er, such anal y ses ne glect the role of in sur ance and the as so ci at ed moral haz ard dis tor tion of (the elas tic i ty of) de mand. By in cor po rat ing this new el e ment, we aim at pro vid ing some build ing blocks to wards an eco nom ic the o ry merg ing Ram sey pric ing, eq ui ty con cerns by gov ern-ments and the strate gic in cen tives, as gov ern ments also de ter mine the re im burse ment lev el in coun tries with a NHS-like sys tem.

0111

Eval u a tion of co mor bid i ty in dices in risk ad just ment mod els for in pa tient mor tal i tyMar tins M. (Na tion al School of Pub lic Health/Os wal do Cruz Foun da tion (Brazil) and Med i cine School/Mon tre al Uni ver si ty, Can a da)Blais R.

Ob jec tive: To eval u ate the va lid i ty of sever i ty mea sures based on co mor-bidi ties, com par ing the Charl son co mor bid i ty in dex (CCI) to a new em pir i cal ly de vel oped in dex.Meth o dol o gy: The re search de sign was a ret ro spec tive cross-sec tion al study. The study was lim it ed to the Ribeirão Pre to re gion in the State of São Paulo, Brazil, from Jan uary 1996 to De cem ber 1998. We used in for-ma tion from the database on hos pi tal iza tions of Ribeirão Pre to Uni ver-si ty, cov er ing 100% of hos pi tal ad mis sions in the re gion. We in clud ed only ad mis sions in which the prin ci pal di ag noses were res pi ra to ry and cir cu la to ry dis eases. Hos pi tal ad mis sions of pa tients less than 18 years of age were ex clud ed from the anal y ses. Based on these cri te ria, the fi nal sam ple con sist ed of 69,302 hos pi tal iza tions.Re sults: Eval u a tion of the CCI in di cates that re vi sion of the clin i cal con-di tions stud ied by Charl son, as well as their weights, in creased mor tal i ty mod el pre dic tive ca pac i ty. In ad di tion, the de vel op ment of a new in dex through the uti li za tion of oth er co mor bidi ties ex clud ed from the orig i-nal CCI al lowed the im prove ment of the mod els’ dis crim i na tion. Con clu sions: The re sults of the va lid i ty anal y sis for co mor bid i ty in dices fa vor the uti li za tion of em pir i cal ly de vel oped in dices. How ev er, age and prin ci pal di ag no sis are the most im por tant pre dic tors of mor tal i ty risk.

0282

Sources of small area vari a tions and the eff ects of self-dis pens ing prac tices in the use of an tibi otics in the com mu ni tyMasiero G. (Fac ul ty of Eco nomics of Lugano, Switzer land)Fil ip pi ni M., Masiero G., Moschet ti K.

Health au thor i ties world wide are con cerned with the in creas ing ef fects of bac te ri al re sis tance and the in ap pro pri ate use of an tibi otics. Wide dif-fer ences in the uti li za tion of an tibi otics in am bu la to ry care are ob served across Eu ro pean re gions. Fil ip pi ni, Masiero and Moschet ti (Health Pol i-cy, forth com ing) re cent ly in ves ti gat ed the fac tors af fect ing re gion al vari-a tions in out pa tient an ti bi ot ic use in Switzer land. How ev er, the lit er a-ture lacks em pir i cal ev i dence on the de ter mi nants of small area vari a-tions. We in ves ti gate the sources of small area vari a tions in out pa tient an ti bi ot ic use and ad dress the is sue of in duce ment in an ti bi ot ic pre scrip-tions by self-dis pens ing prac tices. We sketch a the o ret i cal mod el of the de mand for an tibi otics cap tur ing the in ter ac tion be tween pa tients and gen er al prac ti tion ers in dif fer ent mar ket ar eas. The main hy pothe ses are test ed us ing an econo met ric mod el. The de pen dent vari able is the per cap i ta out pa tient an ti bi ot ic sales (240 Swiss ar eas for the year 2002, quar ter ly data) where as the ex plana to ry vari ables in clude so cioe co nom-ic and epi demi o log i cal fac tors, ac cess to prac tices and to an ti bi ot ic treat-ment, and as pects of prac tice reg u la tion and prac tice style. We find that not only do self-dis pens ing prac tices im prove ac cess to health care ser-vices, but they may in duce high er lev els of an ti bi ot ic con sump tion in the com mu ni ty. Fol low ing Phelps and Par ente (1990) we then es ti mat-ed that the wel fare loss from small area vari a tions in the use of an ti bi ot-ic is in deed re mark able.

0200

In equal i ty in health in 10 Eu ro pean coun triesMasse ria C. (Lon don School of Eco nomics and Po lit i cal Sci ence, LSE Health and So cial Care, Lon don, UK)Allin S.

Us ing a unique, com pre hen sive dataset across 10 Eu ro pean coun tries, Sur vey on Health Age ing and Re tire ment in Eu rope (SHARE), this pa per mea sures so cio-eco nom ic in equal i ties in health among the over 60 across 10 Eu ro pean coun tries, high light ing the role of dif fer ent de ter-mi nants such as gen der, ed u ca tion, in come, wealth and par tic i pa tion in so cial ac tiv i ty. This study aims also at ad dress ing a main method olog i-cal is sue the choice of an ap pro pri ate in di ca tor in the anal y ses of in equal-i ties in lat er life among in come, ed u ca tion and wealth. re sults show that in equal i ties in health do not dis ap pear in lat er life. Health sta tus de te ri o-rates when age in creas es and wom en tend to re port worse health sta tus than men. Smok ing and BMI are sta tis ti cal ly sig nif i cant de ter mi nants of lim i ta tions in dai ly ac tiv i ty in many coun tries, while par tic i pa tion in so cial ac tiv i ty (vol un tary work, car ing ac tiv i ty, com mu ni ty life, cours es, sports, etc.) is a pro tec tive fac tor. In di vid u als with high er ed u ca tion lev-el en joy bet ter health in all coun tries, and the in equal i ty is par tic u lar ly large in Den mark, Greece and Aus tria. In come and wealth are im por-tant de ter mi nants of health dis par i ties among old er peo ple as well. The in dex of in come-re lat ed in equal i ty is pos i tive ev ery where, and par tic u-lar ly so, in Den mark and Swe den. Sim i lar re sults are found for wealth-re lat ed in equal i ty.

S66 | Eur J Health Econom Suppl 1 · 2006

0214

So cioe co nom ic and ge o graph i cal diff er ences in an te na tal screen ing prac tice in ItalyMasse ria C. (Lon don School of Eco nomics and Po lit i cal Sci ence, LSE Health and So cial Care, Lon don, UK)

So cioe co nom ic dif fer ences in health care use have been the fo cus of sev er al stud ies, but an te na tal care has not re ceived suf fi cient at ten tion. How ev er, in equal i ties in ac cess to health care in the an te na tal and peri-na tal pe ri od are like ly to con tribute to health in equal i ties in lat er life. The aim of this study is to in ves ti gate the role of moth er’s ed u ca tion lev el and re gion of res i dence in the take-up of an te na tal screen ing in Italy us ing data from the Mul ti scopo sur vey. An te na tal screen ing has be come more com mon in re cent years. Na tion al guide lines are vague, and each re gion de cides its an te na tal screen ing pro gram; large vari a-tions are found across ge o graph i cal ar eas. An te na tal screen ing is more com mon in the North 90% of preg nant wom en un der took mor pho log-ic-fe tal ul tra sound in the North com pared to only 76% in the South. Fur-ther dis crep an cies are found across re gions in each ge o graph i cal area. More over, it ap pears that preg nant wom en with high er lev el of ed u ca-tion have al most four times greater prob a bil i ty of re ceiv ing in for ma tion about avail able screen ing tests, and are more like ly to un der take tests such as am nio cen te sis, tri-test and fe tal ul tra sound than wom en with low er lev el of ed u ca tion across all ages and re gions.

0157

Per verse in cen tives from wait ing list man age ment pro grammes : ev i dence based on DRG data Ma teus C. (Es co la Na cional de Saude Pub li ca, Lis boa, Por tu gal)Bar ros P.P.

Wait ing lists are pres ent in many west ern coun tries, and in gen er al con-sti tute a ma jor po lit i cal is sue. Gov ern ments are pressed to find some so lu tion. One such so lu tion was im ple ment ed in Por tu gal batch es of the wait ing list were auc tioned. Both pri vate and pub lic fa cil i ties were al lowed to en ter the auc tion. In par tic u lar, pub lic hos pi tals hold ing wait-ing lists were not ex clud ed from treat ing their own pa tients, out side the nor mal sched ule of course. Nat u ral ly, treat ing these pa tients was paid on top of the typ i cal fixed salary (which is in de pen dent of the lev-el of ac tiv i ty). It is clear to see that per verse in cen tives may set in, with pos si ble re duc tions in nor mal ac tiv i ty in or der to treat the more com-pen sat ing “wait ing list” cas es. We term this ef fect “crowd ing-out”. We em pir i cal ly eval u ate whether this is the case, or not. We make use of a de tailed data set, based on DRG ac tiv i ty, for both nor mal and “wait ing list pro gramme” treat ments in pub lic hos pi tals. Our econo met ric anal-y sis shows that in deed crowd ing out was pres ent. This has, of course, strong pol i cy im pli ca tions for wait ing list man age ment pro grammes.

0541

Two decades of case mix in Por tu gal: where are we now? Céu M. (Na tion al School of Pub lic Health, Nova Uni ver si ty of Lis bon, Por tu gal)

In 1984 DRGs were for mal ly in tro duced in Por tu gal and the aim was the de vel op ment and im ple men ta tion of a ful ly in te grat ed in for ma tion sys-tem for the man age ment and fi nanc ing of hos pi tals. Por tu gal, as oth er Eu ro pean coun tries, faced rais ing costs and in creas ing pres sures from the de mand side in the hos pi tal sec tor when it was de cid ed to adopt DRG as a man age ment and pay ment tool. Adop tion was de cid ed at the MoH and a top-down ap proach prof it ing from a very cen tral ized po lit i-cal sys tem was cho sen. It is sought to pres ent the ra tio nales be hind the op tion for a prospec tive pay ment sys tem us ing DRGs, as well as some re sults and con tro ver sies re lat ed to the im ple men ta tion of such sys tem.

Ma jor achieve ments of im ple ment ing DRGs are more re lat ed to ben e-fits in the man age ment of hos pi tals and build ing of a na tion al database with de mo graph ic and clin i cal data. The Por tuguese ex pe ri ence shows that to im ple ment a PPS more is re quired be sides DRGs. A case mix cul-ture has been cre at ed but fur ther de vel op ments will de pend on the sup-port by the MoH to re search in this area.

0093

Rus sian health care re form dur ing the 1990s – what lead to the in sti tu tion al trap?Math ivet B. (Uni ver si ty Par is I Pan theon Sor bonne, Par is, France)

Our main goal is to un der stand why, af ter more than ten years of in tro-duc tion of the re formed mech a nisms, the Rus sian health care sys tem is un able to cope with the san i ta ry chal lenges of the eco nom ic tran si tion, and in some cas es even con tribut ed to wors en the sit u a tion.re form was dual and con sist ed first in the de cen tral iza tion of the for mer cen tral-ly and bud getary fi nanced sys tem to the re gion al and lo cal au thor i ties. The sec ond as pect of the re form was to in tro duce a dif fer ent source of fi nanc ing (pay roll) and new means of co or di na tion in the sys tem in clud-ing the in tro duc tion of mar ket reg u la tion (with pri vate in sur ance com-pa nies as the main ac tors of the Manda to ry Health In sur ance Sys tem). This sys tem was sup posed to quick ly sup ply the ma jor i ty of the nec es-sary re sources. Mar ket mech a nisms were also sup posed to be able to en sure both qual i ty and cost-con trol of med i cal prac tices.an a lyze the con fron ta tion with ini tial con di tions (main char ac ter is tics of the for mer sys tem, and so cio-eco nom ic con di tions at the date of in tro duc tion of the new sys tem), in or der to show that it in evitably lead to an in sti tu tion-al trap, with lack of in cen tives, few san i ta ry im prove ment, and a wors-en ing of in equal i ties of ac cess to health care. paths for fu ture re forms are pro posed.

0365

Do new tech nolo gies cost more? Out come and eco nom ic re sults of the GERSH WIN-Study (Ger man Stent Health Out come and Eco nomics With in Nor mal Prac tice), a con trolled eval u a tion of drug-elut ing ver sus bare-met al stents for the re duc tion of cor o nary re ste no sis Mc Bride D. (Char ité Uni ver si ty Med i cal Cen ter of So cial Med i cine, Epi de mi-ol o gy and Health Eco nomics, Ber lin, Ger many)Brüggen jür gen B., Willich S.N.

Ob jec tive: To eval u ate long-term im pli ca tions of drug-elut ing stents (DES) vs. bare-met al stents (BMS) in the treat ment of cor o nary ar tery dis ease (CAD).Meth od: In this prospec tive in ter ven tion study in 35 hos pi tals in Ger-many, CAD pa tients un der go ing PCI were treat ed with BMS or DES. Stan dard ized pa tient and phy si cian ques tion naires 3, 6, and 12 months fol low ing PCI doc u ment ed ma jor ad verse car di ac events (MACE), dis-ease-re lat ed costs and pa tient qual i ty of life.Re sults: 602 pa tients were treat ed with DES (mean age 63±9, 87% male) and 295 with BMS (mean age 65±10, 79% male). There were no sig nif-i cant base line dif fer ences in car dio vas cu lar risk fac tors and sever i ty of CAD. Af ter 12 months, 18% DES vs. 30% BMS pa tients had suf fered MACE (p<0.05). Ini tial hos pi tal costs were high er with DES than with BMS (5,939±85 vs. 3,730±78 Euro), but re spec tive 12-month fol low-up di rect and in di rect costs were low er (5,052±642 vs. 6,052±590 Euro and 753±459 vs. 2,013±422 Euro). Over all, dis ease-re lat ed costs were sim i lar in both groups (DES 11,765±827, BMS 11,826±760, p = ns). Con clu sions: Com pared to pa tients with BMS, pa tients with DES ex pe-ri enced con sid er ably few er MACE dur ing 12-month fol low-up. De spite the high er ini tial costs as so ci at ed with DES com pared to BMS, the over-all costs 12 months fol low ing PCI were sim i lar.

Eur J Health Econom Suppl 1 · 2006 | S67

0456

Health care Out put and Pro duc tiv i ty Mea sure mentMc Cormick B. (De part ment of Health, Lon don, UK)

The De part ment of Health in Eng land pub lished a pa per in De cem ber 2005 re port ing work to im prove mea sures of health out put, used in the Na tion al Ac counts, to in clude mea sure ment of qual i ty change. This was a re sponse to the Atkin son Re port on Mea sure ment of Gov ern ment Out-put and Pro duc tiv i ty for the Na tion al Ac counts (Jan uary 2005).The DH pa per, Ac count ing for Qual i ty Change, com bined a sum ma ry of re search com mis sioned from York/NIESR (sep a rate ECHE sub mis-sion) with pro pos als for oth er qual i ty ad just ments, in clud ing an nu al rise in val ue of health in line with GDP per head, a val ue (rather than cost) weight for pre scribed statins, ev i dence of clin i cal im prove ments in pri ma ry care, sur vey ev i dence of im proved pa tient ex pe ri ence and lon ger term sur vival from heart at tacks. Mea sures were ac knowl edged as pro vi sion al and in some cas es con tro ver sial. Fur ther de vel op ment plans were de scribed.A pre sen ta tion at Bu dapest would also re port on sub se quent work and dis cus sions, with links to sep a rate pro pos al by the UK Cen tre for the Mea sure ment of Gov ern ment Ac tiv i ty.

0535

Eval u at ing the cost eff ec tive ness of sui cide pre ven tion stra te gies: prac ti cal and method olog i cal chal lengesMc Daid D. (LSE Health and So cial Care, Lon don School of Eco nomics and Po lit i cal Sci ence, Lon don, UK)Knapp M., Hal l i day M, Mack en zie M., Max well M., Mc Col lam A., Mc Lean J., Platt S., Wood house A.

Re duc ing the sui cide rate is a key pub lic health tar get across Eu rope, where it is no co in ci dence that the high est sui cide rates in the world can be found. A sys tem at ic re view was un der tak en to iden ti fy in for ma tion on the de vel op ment of na tion al and area based sui cide pre ven tion stra-te gies world wide, as cer tain the ex tent to which they had been sub ject to any type of eco nom ic eval u a tion, and con sid er in the ab sence of such in for ma tion how best to aid pol i cy mak ers in as sess ing the val ue for mon-ey of such pro grammes. Re sults in di cate that few area based ini tia tives to tack le sui cide had been im ple ment ed. Few er still have been sub ject ed to eval u a tion ei ther of ef fec tive ness or cost ef fec tive ness al though some ev i-dence is be gin ning to emerge. Thresh old anal y sis how ev er in di cates that if mod est suc cess can be achieved in re duc ing sui cides then many pro-grammes have the po ten tial to be high ly cost ef fec tive. A num ber of prac-ti cal and method olog i cal chal lenges for the use of eco nom ic eval u a tion in this area are dis cussed. As with many oth er ar eas of pop u la tion lev el pub lic health in ter ven tions cost ben e fit anal y sis may well be the most suit able ap proach to adopt. Much may also be learnt by com par ing long term trends in sui cide with chang es in so cio-eco nom ic risk fac tors such as eco nom ic re ces sion and struc tur al tran si tion with in coun tries.

0329

Vis it ing the Doc tor, Noise and Self-As sessed HealthMc Gre gor P. (School of Eco nomics and Pol i tics of Ul ster, Belfast, Ire land)Mc Kee P., Neill C.

Self-as sessed health (SAH) is fre quent ly used as a noisy, sca lar mea sure of health sta tus. This pa per ex am ines its role in a mod el of GP uti li za-tion in Eng land em ploy ing data from the British House hold Pan el Sur-vey (BHPS). The frame work de vel oped is one of util i ty max i miza tion with in which SAH is treat ed as a mea sure of util i ty, con di tioned upon health sta tus. This pro vides a dif fer ent ra tio nale for the in clu sion of so cio-eco nom ic vari ables than in con ven tion al anal y sis.of SAH re quires an al ter na tive and more &#8216;ob jec tive’; mea sure of health sta tus to

purge the er rors in the for mer. This is pro vid ed by self-re port ed health con di tions (of which there are 15 in the BHPS) and whether the in di-vid u al at tend ed hos pi tal out-pa tients. In the UK the GP acts as a gate-keep er for such con sul ta tions and thus at ten dance im plies that a thresh-old lev el of sever i ty of the con di tion has been ex ceed ed. em pir i cal ex er-cise con sists of a si mul ta ne ous mod el of GP uti li za tion where SAH and out-pa tient at ten dance com prise the ad di tion al equa tions. This al lows health sta tus to be mea sured by two vari ables in the GP uti li za tion equa-tion since the ef fects of the in di vid u al con di tions is now con tained in these vari ables. The re sults sug gest that SAH is the dom i nant in flu-ence and that the role of so cio-eco nom ic vari ables has im por tant con se-quences for the con sid er a tion of in equity in uti li za tion.

0385

Us ing a dis crete choice ex per i ment to de sign a treat ment pro fi le for pe riph er al neu ro path ic pain McIn tosh E. (Uni ver si ty of Ox ford, In sti tute of Health Sci ences, Eco nomics Re search Cen tre, Ox ford, UK)Ossa D.F., Brig gs A., Dworkin R., Col lett B., Marcini ak A.

As part of the de vel op ment of new treat ments for a dis ease, the im pact of the dis ease and its treat ment on pa tients’; health-re lat ed qual i ty of life should be ex plored. The aim of this study was to es ti mate the val ue of hy po thet i cal treat ments for pe riph er al neu ro path ic pain (PNP) in terms of at tributes im por tant to clin i cians and pa tients. A dis crete choice ex per-i ment (DCE) was de signed and ad min is tered to a sam ple of clin i cians and pa tients in the US and UK. At tributes re lat ed to PNP were iden ti fied from a lit er a ture re view and through in ter views with clin i cal ex perts and pa tients. Fi nal at tributes for the DCE, which were the most im por tant to pa tients, in clude pain, qual i ty of sleep, gen er al ac tiv i ty, mood, con cen-tra tion, day time drowsi ness, diz zi ness and nau sea. In ad di tion, an out-of-pock et cost at tribute was in clud ed in or der to es ti mate will ing ness-to-pay val ues. The sur vey re turned 354 ques tion naires. Fi nal anal y ses were per formed on 10,620 ob ser va tions that showed con sis ten cy, re li abil i ty and face-va lid i ty us ing a ran dom-ef fects pro bit mod el. Most at tribute lev-els were sig nif i cant pre dic tors of choice with non-lin ear ef fects ob served across dif fer ent at tribute lev els. These re sults could be used to aid de ci-sions re gard ing op ti mal de sign of a treat ment for PNP, or as a ba sis for a cost-ben e fit anal y sis with in clin i cal tri als.

0361

The ge ner ic cost-eff ec tive ness of health careMeerd ing WJ. (De part ment of Pub lic Health, Rot ter dam, Nether lands)Mack en bach JP.

Ob jec tive: To as sess the ge ner ic cost-ef fec tive ness of health care.Meth ods: We as sessed the con tri bu tion of pre ven tion and med i cal care to wards pop u la tion health, their costs and cost-ef fec tive ness, for se lect-ed dis ease clus ters: in fec tious dis eases, can cers, and car dio vas cu lar dis-eases. The cur rent bur den of dis ease (BoD) was cal cu lat ed us ing the GBD meth o dol o gy, com bin ing in ci dence, prev a lence, mor tal i ty, and dis-abil i ty weights into DALYs. Epi demi o log i cal es ti mates were made in ter-nal ly con sis tent with ad vanced in ci dence-prev a lence-mor tal i ty mod-elling tech niques (DIS MOD2). We then cal cu lat ed the BoD in a ‘null’ sit u a tion with out pre ven tion and med i cal care with use of his tor i cal data and lit er a ture on in ci dence, sur vival, mor tal i ty, and prev a lence of risk fac tors, com bined with trend anal y sis, and ac count ing for the role of au ton o mous fac tors (e.g. im prove ments in hous ing and nu tri tion). The dif fer ence be tween the cur rent and ‘null’ BoD was com bined with cost of ill ness data to es ti mate the ge ner ic cost-ef fec tive ness of med i cal care for the se lect ed dis ease clus ters. Re sults: avail able in due course.Con clu sions: The re sults main ly de pend on the def i ni tion of med i cal care, and the es ti mat ed con tri bu tion of au ton o mous trends.

S68 | Eur J Health Econom Suppl 1 · 2006

0582

The An swer of Health Uni fi ed Sys tem in Brazil and its fi nanc ing chal lenges to achieve the Mil le ni um De vel op ment Ob jec tives Mendes Á. (Fac ul ty of Eco nomics of Faap, Sao Pao lo, Brazil)Mar ques R.M.

Brazil is achiev ing rapid progress in the di rec tion of the most Mil le ni um De vel op ment Ob jec tives. The col lect ed data of the na tion al in for ma tion sys tems shows that the coun try will achieve ob jec tives re lat ed to pov er-ty, hun ger, ed u ca tion and its re duc tion of sex dif fer ences, if so cial and eco nom ic poli cies fol low the same way of the pres ent trends. Nev er the-less, the coun try has im por tant chal lenges for the near fu ture, as in the case of health is sue, which de mands hard work, main ly in Health Uni-fied Sys tem (HUS) fi nanc ing. Al h tough the nec es sary ef forts to achieve the main ob jec tives have been drawn, it is im por tant to say that it is not enough to have the pro gramme de fined. It de pends on the fi nan cial re spon s abil i ty of each lev el of gov ern ment – fed er al, state and mu nic i-pal, all HUS man agers –, spe cial ly from the fed er al lev el which ac counts for the biggest par tic i pa tion in the to tal of health pub lic ex pen di ture in the Brazil. Af ter 18 years of Health Uni fied Sys tem in sti tu tion al iza-tion on brazil ian con sti tu tion, its an nu al def i ni tion of fi nanc ing is not free of con flicts. These con flicts take place int the strug gle by re sources be tween the dif fer ent ar eas of So cial Se cu ri ty and / or in the ap peal-ing at tempts of the eco nom ic fed er al gov ern ment team in re duc ing its ex pen di ture or in chang ing the def i ni tion of what is un der stood by pub-lic health ser vices and ac tions. Even af ter the Con sti tu tion al Am mend-ment 29/2000 ap proval, the ob jec tives of the pres ent fed er al gov ern ment eco nom ic pol i cy re strain its de vel op ment, plac ing in schock with the fun da men tals prin ci ples of So cial Se cu ri ty as well as HUS. This pre sen-ta tion tries to dis cuss that Brazil will face dif fi cul ties in achiev ing the goal which refers to health is sue be cause it de pends on the def i ni tion of HUS in sti tu tion al fi nan cal rules, in or der to garan tee the re spon s abil i ty of fed er al gov ern ment in the sys tem fi nanc ing.

0532

Eco nom ic Eval u a tion for Co lo rec tal Can cer Screen ing Men ni ni F. (Uni ver si ty of Rome Tor Ver ga ta, Italy)Palaz zo F., Fe deri ci A.

The aim is a cost ef fec tive ness study. The pop u la tion sub ject ed to the screen ing is for all three mod els from 50 to 64 years of age. A study mo dal i ty has been adopt ed that refers to a Qual i ty Man age-ment (QM) sys tem un re lat ed to the study ty polo gies pre vi ous ly in di-cat ed. The screen ing stra te gies have been com pared util is ing thresh old anal y sis, to iden ti fy val ues of cer tain pa ram e ters and make the choice of screen ing strat e gy in dif fer ent com pared with any oth er. The mod el that we are im ple ment ing has char ac ter is tics in com mon with the most im por tant stud ies analised even if adapt ed to the Ital ian sys tem. The aim is to use cost for life gained. Lat er, should the na ture of the in for ma tion per mit us to use QALY, it would also be fea si ble. It can be con firmed that the aim is a cost ef fec tive ness study.

0602

DRGs in Italy: per spec tives and prob lemsMen ni ni F.S. (Uni ver si ty of Rome Tor Ver ga ta, Italy)Span donaro F.

In Italy a fi nanc ing sys tem based on DRGs was in tro duced in 1992. A Fed er al/Re gion al pro cess (2001) shift ed upon Re gions the bur den to man age the fee sys tem.The use of that sys tem dur ing the last ten years per mits us to eval u ate:1) the ef fects of DRG sys tem on hos pi tal ac tiv i ty;

2) the ef fects on the in te gra tion of sup ply;3) the dif fer ences of im pact as a con se quence of the pub lic struc ture of

NHS in Italy vs the pri ma ry ex pe ri ence in USA;4) the re la tion ship be tween age ing and hos pi tal ad mis sion with the

DRG sys tem;5) the use of fee poli cies, au tonomous ly, from Re gions to guar an tee

fi nan cial sta bil i ty of the Re gion al health sys tems.In con clu sion it is pos si ble to ar gue that:a) the Ital ian DRG sys tem ap plied upon pub lic health sys tem has not

cre at ed such com pe ti tion as in USA;b) the sup ply in te gra tion goes slow ly in re spect of the ex pec ta tions with

neg a tive re laps es, par tic u lar ly for the el der lies;c) Re gions use the fee sys tem to cre ate dump ing;d) the in tro duc tion of the DRG sys tem in creased the at ten tion to ward

the eco nom ic as pects of health sys tem;e) the DRG sys tem rep re sents an im por tant in stru ment to in crease hos-

pi tal pro duc tiv i ty.

0493

Mea sur ing peo ple’s pref er ences for dis tri bu tion of health. On the meth o dol o gy.Mes tad O. (Chr Michelsen In sti tute, Bergen, Nor way)Norheim O.F.

Sev er al em pir i cal stud ies have dem on stra ted that peo ple do not eval u ate health pro grammes sole ly based on ag gre gate health gains they also care about the dis tri bu tion of health. Dis tri bu tion al con cerns can be in cor-po rat ed into cost-ef fec tive ness anal y sis by us ing dis tri bu tion al weights, but ex ist ing em pir i cal stud ies pro vide lit tle guid ance on how this can be done in prac tice. In this pa per, part of the rea son for the weak link be tween the em pir i cal lit er a ture and ap plied cost-ef fec tive ness anal y sis is as cribed to the lack of a co her ent an a lyt i cal frame work that can build this bridge. For in stance, sev er al em pir i cal stud ies fail to dis tin guish ap pro pri ate ly be tween mar gin al and in fra-mar gin al health gains. We show that this fail ure may lead to se ri ous ly mis lead ing es ti mates of dis tri-bu tion al weights, and we pro pose a way of deal ing with the prob lem.

0391

Phy si cian au thor i ty un der man aged care: A the o ry of uti li za tion re viewMey er E. (LMU München, Abteilung für Ver sicherungswis senschaft, München, Ger many)

Uti li za tion re view (UR) is an im por tant in stru ment used by man aged care plans and oth er health in sur ers to mon i tor physi cians’ use of health care ser vices. It is widespread in the US, but also es tab lished in sev er al Eu ro pean health care sys tems. For ex am ple, in terms of prospec tive UR, physi cians need in sur er au tho riza tion for hos pi tal iza tions or oth er high-cost treat ments. Some times, pa tients who seek sur gery are also re quired to ob tain a sec ond opin ion.In the US, these prac tices have aroused physi cians’ and pa tients’ anger about in ter ven tions into med i cal de ci sion mak ing, re sult ing in the so-called man aged care back lash. De spite the at ten tion paid to it, em pir i-cal stud ies sug gest that the cost-re duc ing ef fect of UR is rather low and that many in sur ers pre fer a non-in tru sive re view style with low de ni-al rates. Build ing on the prin ci pal-agent the o ry of au thor i ty in tro duced by Aghion and Ti role (1997), this pa per pro pos es an ex pla na tion for the em pir i cal facts. The mod el is adapt ed to a con text of man aged care, con-sid er ing the phy si cian’s di ag no sis and re fer ral be hav ior un der a stan-dard cost-shar ing con tract.It is shown that the in sur er’s (or a third-par ty re view er’s) ef fort to iden-ti fy un nec es sary re fer rals will have a neg a tive ef fect on the phy si cian’s ini tia tive, as mea sured by his di ag no sis ef fort. There fore, it is ef fi cient

Eur J Health Econom Suppl 1 · 2006 | S69

for the in sur er to com mit to a low er lev el of mon i tor ing. This can be achieved, for ex am ple, by del e ga tion to a third par ty who has weak er in cen tives to mon i tor.

0075

Does in sur ance make us blind?Mil cent C. (PSE, Par is, France)

How the vari a tion of in sur ance cov er age and the in sur ance regime can af fect the con sumer_search be hav ior of the drug price ? In France, 64 % of in di vid u als de clare they do not know the price of the use of health-care. Here, the ef fort is de fined by the con sumer_search be hav ior. With-out in sur ance, the ef fort is op ti mal and we show that the pres ence of in sur ance mar ket de te ri ores this lev el of ef fort that cor re sponds to the moral haz ard phe nom e na. The dis tor sion due to the moral haz ard is the part of the price that the agent do not re alise to spend, a sort of a blind ness due to the in sur ance. What ev er the form of or ga ni za tion, this dis tor sion is al ways high er for the high-risk type in pres ence of in sur ance mar ket. The over all drug ex pen di ture is also af fect ed by the moral haz ard due to the pres ence of the health in sur ance mar ket and its forms of or ga ni za tion. The ex tra over all drug ex pen di ture is the part of the price that agents would not spend with out in sur ance mar-ket. This ex tra over all ex pen di ture de pends on the par tic i pa tion of the high risk and low risk types. With a vol un tary in sur ance mar ket, the high-risk can be the only type to have ac cess to the pre scrip tion drug. There fore, this ex tra over all ex pen di ture leads to an in crease un der a com pul so ry in sur ance sys tem and may lead to a de crease un der a vol-un tary one.

0517

Hos pi tal debts in Poland – pub lic as sis tance – at tempt of struc tur al so lu tionMiskiewicz P. (WHO Coun try Offi ce in Poland, War saw, Poland)Kuszews ki K.

In 1999 Poland in tro duced uni ver sal health in sur ance sys tem. Be fore that, state liq ui dat ed all hos pi tals’ debts but not the main caus es. Most un for tu nate ly Bill on “203”(Growth of Av er age Wages in En ter pris es) 2001 passed through Par lia ment, with out in di cat ing source of fi nanc-ing. Apart from in crease of la bor costs, costs of med i cal pro ce dures, cost of phar ma ceu ti cals in creased as well and re sult ed in run ning hos pi tals into debts again, gen er at ing ad di tion al cred it in ter est rate bur den. Hos-pi tal debts reached in mid dle 2005 val ue of 6 bil lion PLN. Par lia ment ap proved the bill on “Pub lic Aid and the Re struc tur ing of Pub lic Health Care Es tab lish ments”. The bill reg u lat ed the is sue of deal ing with pub lic law li a bil i ties, civ il law li a bil i ties and in di vid u al claims of em ploy ees. To ap ply for pub lic sup port hos pi tals were obliged to de vel op and pres ent the re struc tur ing plan. Funds se cured for pub lic help were ap prox i mate-ly 2.2 bil lion PLN. From 740 hos pi tals one third was in good con di tion, 240 were hold ers of 80% of debts. Anal y sis of debts struc ture, man age-ment, re struc tur i sa tion and lev el of con tract ing with Na tion al Health Fund will en able to ass es weath er pub lic sup port is help ing hos pi tal to func tion and how many hos pi tals will in re al i ty ben e fit from it. Ra tio-nal iza tion el e ments are hos pi tal net work, change in fi nanc ing EMS and op ti mal i sa tion of drug pur chas ing.

0444

Cost ing hos pi tal ser vices in the Eu ro pean Union: re sults from the Health Bas ket pro ject on the re view of con cepts, meth ods, and fea si bil i tyMo gy orosy Zs. (Cen tre for Health Eco nomics, Uni ver si ty of York, UK)Smith P.C.

Aims and ob jec tives: One of the aims of the EU-fund ed Health bas ket pro ject is to pro vide a com pre hen sive as sess ment of best prac tice in cost ing health ser vices with a spe cial fo cus on in ter na tion al com par a-tive stud ies. Meth ods: En glish lan guage pu bli ca tions were iden ti fied and crit i cal ly ap praised us ing pre-set qual i ty cri te ria through search es of elec tron ic data bases, In ter net web sites, lo cal li bra ry files and ref er ence lists of pub-lished ar ti cles and books.Re sults: The re view re vealed that the choice of cost ing meth ods is guid-ed by mul ti ple cri te ria, and ac count ing cost is fre quent ly used as an es ti-mate of op por tu ni ty costs. A top-down cost ing ap proach can be rea-son ably ac cu rate for ser vices where mar ket ed health tech nolo gies are re spon si ble for most of the re source use, where as a bot tom-up or mixed ap proach is to be pre ferred when ser vice pro vi sion is based on com plex or gan i sa tion al ar range ments. Fur ther more, ac cu rate cross-coun try cost com par i son can be com pro mised by dif fer ences in ac count ing sys tems, na tion al cost ing guide lines, provider pay ment sys tems, and the lack of stan dard ized unit cost data bases. Con clu sions: Re searchers and de ci sion-mak ers should care ful ly con sid-er the trade-offs be tween in for ma tion ac cu ra cy, com pa ra bil i ty, and the costs of se cur ing that in for ma tion, in or der to as sess whether the val ue of de tailed cost data jus ti fies the ad di tion al costs of ob tain ing them.

0521

Pa tients’ pref er ences for Choice of Hos pi talMon stad K. (The Nor we gian School of Eco nomics and Busi ness Ad min is tra tion, Bergen, Nor way)

What de ter mines pa tients’ choice of hos pi tal, in a set ting where hos pi-tal stays are ra tioned by wait ing lists and where trav el dis tances with in the coun try are sub stan tial? Through a re form im ple ment ed in 2001, Nor we gian pa tients are giv en gen er ous for mal rights to choose hos pi-tal for elec tive treat ment through out the coun try. This pre sen ta tion is an at tempt to in fer the will ing ness to pay for short er waits by study-ing the ob served al lo ca tion of op er a tions. The trade-off be tween dis-tance and qual i ty is like ly to dif fer ac cord ing to pa tient char ac ter is tics and so cio-eco nom ic back ground. Pa tients’ pref er ences are ex am ined us ing a unique data set with in di vid u al pa tient data on one spe cif ic pa tient group, name ly elec tive hip re place ments in Nor way dur ing the years 2001-2003. Af ter a dis cus sion of the in sti tu tion al set ting, the pa per fo cus es on the trade-off that the pa tients make be tween dis tance and wait ing time, and ex plores whether qual i ty com pe ti tion may be traced in the Nor we gian hos pi tal sec tor. The main re sults are that dis tance and wait ing time are both high ly sig nif i cant at tributes, and that pa tients are will ing to wait a con sid er able length of time to avoid trav el ling. Pref er-ences are found to vary over time and ac cord ing to age and gen der.

0309

ACE-Obe si ty: Pri or i ty set ting for obe si ty pre ven tionMood ie M. (The Uni ver si ty of Mel bourne, Vic to ria, Aus tralia)Haby M., Swin burn B., Mark wick A., Mag nus A., Tay-T.K., Sach T., Carter R.

The ACE-Obe si ty study uses an ev i dence-based ap proach to eval u ate in ter ven tions aimed at re duc ing the prev a lence of obe si ty in Aus tralian youth. It in forms de ci sion-mak ers about the ben e fits of in di vid u al in ter-

S70 | Eur J Health Econom Suppl 1 · 2006

ven tions and the pack ag ing of a co her ent strat e gy for obe si ty pre ven tion and man age ment.To avoid method olog i cal con found ing, the ap proach em ploys stan-dard ised meth ods in clud ing a two stage con cept of ben e fit; a com mon com par a tor, set ting and de ci sion con text; Aus tralian data; and ex ten-sive prob a bilis tic un cer tain ty test ing. The tech ni cal cost-ef fec tive ness re sults (cost per DALY) for each of the se lect ed in ter ven tions will be re port ed. Mod elling is un der tak en to con vert chang es in be hav iour to BMI out comes and then to DALYs, and is sues of the at tri bu tion of costs across mul ti ple ob jec tives arise. Due pro cess is achieved by in volv ing stake hold ers on a Work ing Group, and by con sid er a tion of sec ond stage fil ters (such as eq ui ty, ac cept abil i ty and fea si bil i ty).The re sults are brought to geth er in a ‘league ta ble’ in which all the in ter ven tions are ranked in or der of eco nom ic mer it with out the usu al method olog i cal con cerns about re sults drawn from stud ies lack ing in com pa ra bil i ty. In pack ag ing in ter ven tions to meet par tic u lar bud get al lo-ca tions, the di vis i bil i ty, mu tu al ex clu siv i ty and re turns to scale of in di-vid u al in ter ven tions are con sid ered, as well as is sues of pro gram log ic, tar get group cov er age and a range of set tings.

0384

Vari a tions in Health Ex pen di ture Growth Trends across OECD Coun tries, 1992 – 2003Mor gan D. (Or ga ni sa tion for Eco nom ic Co-op er a tion and De vel op ment, Par is, France)Orosz E.

This pa per, based on OECD Health Data 2006, dis cuss es ex pen di ture trends from a per spec tive of the pres sure on gov ern ments to ad just pub lic ex pen di ture on health to eco nom ic growth. Pub lic ex pen di ture on health over the pe ri od 1997 to 2003 in creased on a year ly av er age by 4.7% across OECD coun tries – twice the rate of eco nom ic growth – re sult ing in a con sid er able in crease in the ra tio of health ex pen di ture to GDP. This com pares to the pre ced ing pe ri od (1992–1997) when the an nu al growth rate of pub lic health ex pen di ture was 2.4% – the very same as that of the econ o my as a whole. The first part of the pa per ex am-ines the cross-coun try vari a tions and the dif fer ent caus es be hind these trends de lib er ate stra te gies to re lieve ten sions aris ing out of tough cost-con tain ment poli cies adopt ed in the ear ly to mid nineties; the fail ure of cost-con tain ment poli cies in some coun tries; and, a third pat tern in Ger many, slow pub lic health ex pen di ture growth (1.5%) ac com pa nied by even slow er eco nom ic growth. sec ond part of the pa per looks at the links – and pos si ble ex pla na tions – be tween the growth in pub lic ex pen-di ture on health and GDP by com par ing the Eu ro pean Union and the Unit ed States. Whilst the last decade has seen sim i lar over all growth rates in health ex pen di ture, the short term fluc tu a tions in the an nu al growth rate have fol lowed the chang es in eco nom ic growth more close-ly in the Eu ro pean Union than is the case in the Unit ed States.

0394

Es ti mat ing pa tients’ will ing ness to trav el for high er qual i ty hos pi tal careMoschet ti K. (Uni ver si ty of Lugano, Lugano, Switzer land)Bal san D., Rochaix L.

This pa per aims at de vel op ing a meth o dol o gy to es ti mate pa tients’ will-ing ness to trav el for high er-qual i ty hos pi tal care. The es ti ma tion meth-od uses as de pen dent vari able the ad di tion al dis tance that pa tients are will ing to trav el to reach such a hos pi tal when a sim i lar ser vice in terms of DRG com pe tence is of fered near er to their homes. The will ing ness to trav el is mod elled as re sult ing from a two stage de ci sion pro cess or from one stage de ci sion pro cess. Re fer ring to these two al ter na tive hy pothe-ses, we ap ply a gen er al ized To bit mod el and sim ple To bit mod el to a large French database con tain ing mi cro-lev el data of hos pi tal dis charges

for both the pri vate and pub lic sec tors. Be cause France does not rely on a gate keep ing sys tem to ac cess sec ond ary care, and af ter ex clud ing emer gen cy cas es and trans fers, one may le git i mate ly as sume that the choice of hos pi tal is made pri mar i ly by pa tients them selves. Un like pre-vi ous stud ies, we use all DRGs to give an across the board es ti mate of pa tients’ will ing ness to trav el for qual i ty. The study pro vides es ti mates of dis tance ver sus qual i ty elas tic i ties and shows that per ceived qual i-ty sig nif i cant ly af fects pa tients’ will ing ness to trav el. In so do ing, our work con tributes to a bet ter un der stand ing of pa tients’ pref er ences con-cern ing hos pi tal care and the role they may play in qual i ty com pe ti tion among hos pi tals.

0530

EF PIA HTA Key Prin ci ples: A Pa tient Per spec tiveMoss man J. (Kil ma colm, UK)

As new ther a peu tic ap proach es to dis ease man age ment are de vel oped, they need to be test ed in ro bust clin i cal tri als to as sess their ef fec tive ness. In creas ing ly, in an en vi ron ment where health care costs are capped, the em pha sis is on cost ef fec tive ness in ad di tion to clin i cal ef fec tive ness. In cor po rat ing health eco nomics into the data col lec tion of clin i cal tri als has large ly ig nored the pri or i ties which pa tients and their car ers would as sign to the ben e fits and un want ed ef fects of the treat ments be ing test-ed. The data may be sta tis ti cal ly re li able but may be ir rel e vant to the de ci sions pa tients make when faced with treat ment op tions. The di verse range of fac tors which in flu ence pa tients might be dif fi cult to as sess in the ro bust way in which sur vival is able to be judged, but is nev er the-less im por tant if pa tients are to ad here to the treat ment pro to cols which will max imise the clin i cal ef fec tive ness. There is, there fore, an im per a-tive for re searchers to take more no tice of what mat ters to pa tients. Ide-al ly, pa tients should be in volved in the health tech nol o gy as sess ment pro cess from the tri al de sign stage through to the for mal as sess ment of ef fi ca cy and ef fec tive ness thus en sur ing that de ci sions on which treat-ments of fer val ue for mon ey re flect the val ue pa tients put on qual i ty of life and sur vival ben e fits. Pa tients un der stand the prob lems of a lim it ed bud get and are well placed to judge the rel a tive mer its of dif fer ent treat-ments. The chal lenge is: how to achieve in put from pa tients and car ers that is use ful in the HTA pro cess.

0395

In ter na tion al com par i son of skillmix be tween GPs and nurse in pri ma ry careMousques J. (IRD ES (In sti tut de Recherche et Doc u men ta tion en Economie de la San té), Par is, France)Bour gueil Y.

The aims of this study is to ex am ine ways in which some coun tries de fine the roles and skill of nurse in pri ma ry care and what kind of chang es have tak en place over re cent decades in terms of co op er a tion, del e ga tion and sub sti tu tion be tween GPs and nurs es. How these chang es have been im ple ment ed, and what im pact they have had on the health care sys-tem. This in ter na tion al com par i son was based on lit er a ture re view and struc tured ques tion naire and/or in ter views of re searchers, stake hold ers and health care pro fes sion als. This study show that close col lab o ra tion be tween GPs and nurs es is not a stan dard. Where this mod el does ex ist, whether in an ex per i men tal form (Italy, On tario, Que bec, the Nether-lands, Ger many), or more gen er al ly (UK, Swe den, Fin land), this is as a re sult of con cert ed pol i cy on the part of the state to de vel op the pro fes-sions’ tra di tion al modes of work ing. Or gan i sa tion al mod el move away from the -in te grat ed health cen tre- op tion to wards col lab o ra tive prac-tice in a self-em ployed group prac tice set ting. Nurs es’ par tic i pa tion in pri ma ry care is also evolv ing through the de vel op ment of new tasks in this set ting of col lec tive or gan i sa tions, rather than through the di rect trans fer of tasks pre vi ous ly car ried out by GP.

Eur J Health Econom Suppl 1 · 2006 | S71

0124

All-Pay or Hos pi tal Rate Set ting in Mary landMur ray R. (Health Ser vices Cost Re view Com mis sion, Bal ti more, Mary land, USA)

Ra tio nale: US health re form has been char ac ter ized by vac il la tions from heavy-hand ed reg u la tion in the 1970s, to an em pha sis on mar ket-based stra te gies in the 1990s. Ex treme ap proach es have failed to ra tio-nal ize the mar ket for health ser vices. Per for mance in achiev ing oth er pol i cy goals (ac cess, eq ui ty and pub lic dis clo sure/trans paren cy) has also been dis ap point ing. Ob jec tives: To pres ent a de scrip tion of the Mary land Hos pi tal Rate Sys-tem and il lus trate how a reg u la to ry struc ture can be craft ed to com bine both reg u la to ry and com pet i tive forces, to cor rect for mar ket fail ure and bet ter achieve key health pol i cy ob jec tives. Re sults: The Mary land sys tem, it has out per formed the rest of the US in the ar eas of cost con trol, ac cess, eq ui ty, ac count abil i ty and fi nan cial sta bil i ty: 1) the low est rate of growth in hos pi tal costs of any state over the pe ri od 1976 – 2003; 2) fi nanc ing of $550 mil lion of un com pen sat ed care an nu al ly, ob vi at ing the need for pub lic hos pi tals; 3) eq ui table pay-ment with no cost shift ing; 4) high er de grees of pub lic ac count abil i ty/trans paren cy than in oth er states or coun tries; and 5) stan dard iza tion of billing for pay ers and fi nan cial sta bil i ty for hos pi tals. Hos pi tal Rate Set-ting also holds great promise in a num ber of im por tant ar eas in clud ing the de vel op ment of a com pre hen sive “Pay for Per for mance” ini tia tive.

0529

Treat ment costs of diff er ent phas es of breast can cer in Hun garyMuszbek N. (MED TAP In sti tute at UBC, As traZeneca, Lon don, Unit ed King dom)Bene dict Á., Horváth K.

Ob jec tives: The ob jec tive of the study is to de ter mine the breast can cer treat ment costs of dif fer ent phas es of breast can cer in Hun gary. Meth ods: Re source use and costs were col lect ed ret ro spec tive ly on three co horts: ear ly breast can cer (EBC) pa tients, pa tients with lo cal re gion-al re cur rence (LRR) and meta stat ic breast can cer. Data were ob tained from the On col o gy Re port, the in pa tient, out pa tient and the phar ma-ceu ti cal database of the Na tion al Health In sur ance Fund. Co horts were de ter mined us ing ICD, WHO, ATC, TNM and oth er codes. Age above 55 served as a proxy for post meno paus al sta tus. Pa tients re ceiv ing hor-mon al ther a py were as sumed to be hor mon al re cep tor pos i tive. The three co horts con sist ed of the first 100 rel e vant pa tients in each cat e go-ry en ter ing the On col o gy Re port database in 2003 and were fol lowed up for min i mum 1 year. Rel e vant re sources were pre de ter mined with the help of treat ment guide lines, on col o gists and cod ing ex perts.Re sults: The fi nal co hort in cludes 86 pa tients with in ci dent EBC, 80 LRR, and 100 meta stat ic breast can cer pa tients. The fre quen cy and type of di ag nos tic and sur gi cal pro ce dures, con sul tant vis its, pre scrip tions will be sum ma rized in nat u ral units. To tal cost/pa tient will be pre sent ed based on Hun gar i an na tion al fee sched ules. Mul ti var i ate anal y sis will be car ried out us ing de mo graph ic and hos pi tal char ac ter is tics.

0489

DRGs in fo cus of re im burse ment of acute hos pi tal care – Hun gar i an ex pe ri encesNagy J. (Na tion al Health In sur ance Fund Ad min is tra tion, Bu dapest, Hun gary)Dózsa Cs., Bon cz I., Borc sek B.

DRGs in fo cus of re im burse ment of acute hos pi tal care – Hun gar i an ex pe ri ences.

Back ground: The Hun gar i an ad ap ta tion of DRGs have been used for re im burse ment hos pi tal care since 1st of July 1993. It was in 1986 when the vi a bil i ty of a case-mix clas si fi ca tion meth od for health care pro vi sion be gan to be dis cussed in Hun gary. There was a grow ing de mand for health care ac tiv i ties and per for mance to be mea sur able and ap prais able. Be tween 1987 and 1991 data was col lect ed from an full-scale(?) range of sources. More than 18 hos pi tals par tic i pat ed in the mi cro) cost study. Hun gary de vel oped in for ma tion sys tem, groupers, de fine the re im burse-ment pa ram e ters, rules. Ob jec tives: The launch of case-mix de vel op ment was clear ly mo ti vat-ed by its ap pli ca tions in the area of re im burse ment. Health pol i cy-mak-ers sought a ra tio nal fi nanc ing meth od re plac ing the tra di tion al ly used in put fi nanc ing sys tem which would: 1.en sure the cost-ef fec tive ness of treat ment, 2.bring the al lo ca tion of re sources into line with per for mance, 3.pro vide in cen tives to im prove care, 4.en sure the sus tain abil i ty of avail-able re sources. Pres ent sys tem Hun gary ap ply the DRGs sys tem for re im-burse ment of all acute hos pi tal cas es as a prospec tive pay ment sys tem: a. The rel a tive weights are na tion al ly uni form. b. The trim-points of du ra tion for each group are de ter mined tak ing the guar an tee cri te ria into con sid er a-tion. c. The base-rates are na tion al ly uni form, and pre de ter mined. The pre-dictabil i ty of the sys tem has in creased sub stan tial ly. d. The ba sic fee does not cur rent ly cov er the amor ti za tion cost of the equip ments only the op er-at ing costs. How ev er, it also – put a cov er on the pay ment of physi cians.Re sult: The DRGs sys tem in Hun gary lived up to ex pec ta tions since it is ca pa ble of pre cise ly ex press ing the com pe ten cies of hos pi tal care, it is suit able for de ter min ing out put and can be linked up in cen tive rules in the in ter ests of op ti mis ing the use of re sources or achiev ing pro fes-sion al goals.

0548

De vel op ment of a risk ad just ment and risk shar ing scheme for Hun gar i an Man aged Care Or ga ni za tionsNagy B. (Unit of Health Eco nomics and Health Tech nol o gy As sess ment De part ment of Pub lic Pol i cy and Man age ment Corv i nus Uni ver si ty of Bu dapest, Hun gary)Bon cz I., Falusi Zs., Gu lac si L., Resze gi Cs.

In tro duc tion: In the Hun gar i an Man aged Care Pro gram 16 health plans cov er a wide range of health care ben e fits for 2,3 mil lion peo ple. The an nu al bud get is al lo cat ed by the Na tion al Health In sur ance Fund through cap i ta tion. The cap i ta tion for mu la is not ac cu rate enough to ful-fil the re quire ments of eq ui table and ef fi cient re source al lo ca tion. Mean-while the fi nan cial pres sure on health plans not to ex ceed the cap i ta-tion can be sub stan tial. There fore, the im prove ment of the cap i ta tion for mu la with risk ad just ment and also the use of risk shar ing ar range-ments are re quired.Meth od: The cur rent sys tem to han dle risk is a mix ture of ru di men ta-ry risk ad just ment and a high lev el of risk shar ing. The cap i ta tion for-mu la is weight ed by three vari ables age, sex (R2=4,57%), and chron ic di al y sis con di tion (R2=18,65%). Risk shar ing in cor po rates out li er risk shar ing where sur plus es and deficits are han dled in a sol i dar i ty fund. Also carve outs with high cost, high risk ser vices are es tab lished to pre-vent ex treme vari a tions in the health plan’s bud gets. These el e ments are un der in ves ti ga tion.Re sults: Pre lim i nary re sults show that the im prove ment of risk ad just-ment scheme is an op ti mal choice to im prove both eq ui table and ef fi cient re source al lo ca tion. For this pur pose, in di vid u al lev el di ag noses, phar ma-ceu ti cal data and ag gre gate lev el so cioe co nom ic data are scru ti nized. These pro vide a good hy brid sys tem of health based and non-health based risk ad justers. We demon strate that risk shar ing is sup ple men tary along with risk ad just ment, since this meth od suc cess ful ly eas es the fi nan cial pres sure on health plans but also re duces in cen tives to con trol ex pen di tures.Con clu sion: Pri or i ty on risk ad just ment is rec og nized and that the im prove ment of risk ad just ed cap i ta tion has to be bal anced in line with the re duc tion of risk shar ing ar range ments.

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0568

Ver ti cal eq ui ty – mea sure ment and im pact on health re lat ed de ci sion mak ing of the Hun gar i an GPs.Nagy L. (MSD Hun gary Ltd., Bu dapest, Hun gary)Kovács F., Erdész D.

One of the fac tors that may ex plain the lim it ed im pact of eco nom ic eval u a tions is that de ci sion-mak ers be lieve that non-pref er ence based out come mea sures (i.e. QALYs) fails to ad dress many po ten tial ly rel e-vant di men sions of health care de ci sions. Ex ter nal i ties, like op tion val ue which are typ i cal ly non-health ef fects of health care play an im por tant role in de ter min ing peo ple’s dis tri bu tion al judg ments. Ev i dence shows a re jec tion of health max imi sa tion as the sole cri te ri on for al lo cat ing re sources sev er al oth er fac tors ex ist like: pa tient age, so cioe co nom ic sta-tus, prev a lence of the dis ease, sever i ty of dis ease, type of ill ness (acute vs. chron ic), time ho ri zon of health gain, dis tri bu tion of fu ture health gain, num ber of peo ple treat ed. Ex ist ing stud ies pro vide in di ca tions that peo-ple may make trade-offs, but do not pro vide use able eq ui ty weights. The pres ent pa per ex plores the po ten tial to in cor po rate the eq ui ty di men sion into health care de ci sion-mak ing. As a pi lot study in a face to face in ter-view a Choice Based Con joint meth od was used in a ran dom ly se lect ed strat i fied GP pop u la tion (200 physi cians) to de ter mine eq ui ty weights of the at tributes de scribed above. As a re sult we sug gest to scale down the nor ma tive am bi tions of eco nom ic eval u a tions, at least un til these can be based on sol id ev i dence about peo ple’s pref er ences and val ues.

0581

Mea sur ing the out puts and pro duc tiv i ty of long term careNet ten A. (PSS RU, Uni ver si ty of Kent, Eng land)

In re sponse to in ter na tion al re quire ments to im prove the ba sis of Na tion-al Ac counts an ap proach is be ing de vel oped in the UK to re flect ing the wel fare gain from care ser vices. The aim is to use rou tine sources as far as pos si ble in an in dex that is de signed to re flect chang es in char ac ter is-tics of ser vices, of ser vice users and qual i ty of care. The pre sen ta tion will demon strate the ap pli ca tion of the the o ret i cal ly ground ed ap proach to the mea sure ment of out puts of long term care ser vices for old er peo ple. Ser vices are de scribed in terms of the ca pac i ty of ser vice users to ben e fit from them and a qual i ty mea sure ap plied to re flect the de gree to which ser vices do ac tu al ly de liv er this ben e fit. Na tion al sur veys of user sat is-fac tion and reg u la tor re ports of care home stan dards pro vide the ba sis of the qual i ty mea sures. Data from re search stud ies are used to ad just data from rou tine sources to re flect the chang ing con tri bu tion of wel-fare re sult ing from chang es in pat terns of pro vi sion and in creased tar get-ing of ser vices. The ap proach has po ten tial for a num ber of pol i cy and prac tice ap pli ca tions in clud ing fa cil i tat ing in ter na tion al com par isons of the pro duc tiv i ty and ef fi cien cy of long term care of old er peo ple.

0106

Mea sure ment of in for mal care giv ing time in a study with de men tia pa tients.Neu bau er S. (GSF – Forschungszen trum für Umwelt und Gesund heit, In sti tut für Gesund heit sökonomie und Man age ment im Gesund heitswe sen (IGM), Neuher berg, Ger many)Gräßel E., Holle R., Großfeld-Schmitz M.

Back ground and aim: Due to the ris ing life ex pect an cy in de vel oped coun tries the prev a lence of de men tia is in creas ing. One aim of de men-tia care is to post pone or avoid in sti tu tion al care. Per form ing an eco nom-ic eval u a tion of in ter ven tions with this aim from a so ci etal per spec tive has to in clude in for mal care. We re port on our con cept and prac ti cal ex pe ri ences in mea sur ing these costs.

Meth ods: With in the Ger man IDA study (‘Ini tia tive De men zver-sorgung in der All ge mein medi zin’) three in ter ven tion groups are to be com pared with re spect to time to in sti tu tion al care over a pe ri od of two years. In for mal care is mea sured by a Ger man ad ap ta tion of the RUD Lite ques tion naire, which dis tin guish es three cat e gories of in for mal care ac tiv i ties: ADL, IADL, and su per vis ing. The in for mal care giv er has to state the num ber of days and av er age hours per day of care pro vid ed to the pa tient dur ing the last four weeks. In ad di tion to the orig i nal ver sion, we try to in clude the time of all in for mal care givers who are in volved in car ing for the pa tient. The ques tion naire is ap plied as a com put er-as sist-ed tele phone in ter view with the pri ma ry care giv er.Re sults: Our first ex pe ri ences show that most care givers are will ing and able to an swer the ques tion naire. We will re port on our find ings from the base line as sess ment of care giv er time and de scribe fac tors in flu enc-ing the com plete ness and plau si bil i ty of the data.

0237

Should one brush twice a day? De ter mi nants of den tal health among young adultsNguyen L. (Cen tre for Health Eco nomics – CHESS, Na tion al Re search and De vel op ment Cen tre for Wel fare and Health (STAKES), Helsin ki, Fin land)Häkki nen U., Knu ut ti la M.

The aim of this pa per is to ex plore the de ter mi nants of den tal ill-health with a fo cus on the oc cur rence of car ies. De rived from health pro duc-tion and de mand the o ry, we em ployed a re cur sive two-equa tion pro-bit mod el that con sists of a pro duc tion func tion of den tal health and a de mand func tion of den tal care. The data are from a lon gi tu di nal study of the North ern Fin land 1966 Birth Co hort that had the lat est fol low-up when the co hort reached the age of 31 (n=5020). The fac tors con trolled for re lat ed to birth, youth, the liv ing con di tion of the fam i ly, and so cioe-cononom ic vari ables. The to tal ef fects of the ex plana to ry vari ables on the oc cur rence of car ies were com put ed for the re cur sive pro bit mod-el. Fac tors among fe males that in creased car ies were a body mass in dex and the in take of al co hol, sug ar and soft drinks. Among males, car ies was pos i tive ly re lat ed to the metropoli tan res i dence and neg a tive ly re lat-ed to good diet and cur rent ed u ca tion. Smok ing in creased car ies, where-as brush ing teeth at least twice a day, vis it ing the den tist reg u lar ly and us ing den tal care re duced car ies. The find ings sug gest that to pre vent car ies, at ten tion should be fo cused on ap pro pri ate poli cies aimed at pro-vid ing di e tary ad vice as well as rais ing den tal ed u ca tion. Brush ing twice a day is a use ful and ob vi ous cost-ef fec tive means of self-care that all adults should be en cour aged to adopt.

0390

Elic it ing pref er ences of meno paus al wom en for a Hor mone Re place ment Ther a py us ing Dis crete Choice Ex per i ments Nguyen F. (GRE SAC, Lyon, France)Moumjid N., Bré mond A., Car rare MO.

All wom en ex pe ri ence meno pause af ter their re pro duc tive years, and eighty per cent of them suf fer from symp toms that may af fect their qual-i ty of life hot flush es, os teo po ro sis. Af ter 70 years, frac tures of the fem-o ral neck oc cur in one out of six wom en.or der to al le vi ate these symp-toms and risks, 30 to 50% per cent of wom en be tween 48 and 64 years of age use Hor mone Re place ment Ther a py (HRT). But re cent stud ies have shown that HRT is also as so ci at ed with in creased risks of heart dis ease, pul mo na ry em bo lism and breast can cer.HRT pre sents (1) risks, (2) ben-e fits and (3) mon e tary costs, the aim of our study is to an a lyse wom en’s pref er ences for HRT, us ing Dis crete Choice Ex per i ments (DCE). The meth od con sists in build ing hy po thet i cal sce nar ios with dif fer ent treat-ment char ac ter is tics, and pre sent ing them to wom en from a rep re sen-ta tive sam ple who then in di cate their pref er ences.this study, we will be

Eur J Health Econom Suppl 1 · 2006 | S73

able not only to spec i fy the in flu ence of ben e fits, risks and mon e tary costs of HRT on wom en_choice to use this treat ment or not, but also to de ter mine the po ten tial i ties of DCE as a sup port to col lec tive de ci sion-mak ing for al lo cat ing col lec tive health re sources.

0564

Uni ver sal Cov er age with As pects of Ra tioning and Per for mance: The Case of Eng land and WalesNichol son T. (Pub lic Health Sci ences & Med i cal Sta tis tics, Uni ver si ty of Southamp ton, UK)Rod er ick P.

Eng land and Wales are com par a tive ly high cost chron ic kid ney dis-ease coun tries. Health care pro vi sion is pre dom i nant ly pub licly fund-ed through a tax based Na tion al Health Ser vice (NHS). Re nal ser vices have ex pand ed sig nif i cant ly in the last decade, par tic u lar ly hos pi tal haemodial y sis (HD). Here pub lic funds have been used in some ar eas to com mis sion pri vate providers of sat el lite HD, though such fa cil i ties have NHS med i cal in put and are linked to NHS re nal units. Re gion al vari a tions do ex ist, part ly driv en by his tor i cal pat terns and in re sponse to pop u la tion need (e.g. eth nic mi nor i ty pop u la tions). Whilst ac cep-tance rates onto re nal re place ment ther a py (RRT) are low by in ter na tion-al stan dards, they are com men su rate with many oth er north ern Eu ro-pean coun tries. There is no ex plic it ra tioning of care, and no ro bust data on mis match be tween the in ci dence of es tab lished re nal fail ure and ac cep tance onto ther a py. How ev er, the lat ter is like ly to be most ap par ent in old er ages and in those with sig nif i cant co-mor bid i ty. Cur-rent ly, for mal pal lia tive care pro vi sion is low but grow ing, of fer ing an al ter na tive to RRT. Health out comes ap pear to be im prov ing in Eng land and Wales. This should con tin ue through the re cent es tab lish ment of a Re nal Ser vices Na tion al Ser vice Frame work that sets out stan dards and mark ers of good prac tice. Mon i tor ing is pos si ble through clin i cal gov er-nance frame works and the UK Re nal Reg is try (that cov ers ap prox i mate-ly 90% of pa tients on RRT).

0585

How can the pop u lar health in sur ance pro gramme sup port the achieve ment of MDGs in Mex i co?Ni gen da G. (Na tion al In sti tute of Pub lic Health, Cuer nava ca, Mex i co)González L.M., González M.C.

In Mex i co, a heavy bur den of dis eases is still posed on the poor est pop u-la tions de spite the gov ern ment´s ef forts to achieve uni ver sal health cov-er age. The re cent ly launched Pop u lar Health In sur ance Pro gramme is the first pro gramme in the coun try´s his to ry to pro vide in sur ance to the job less and poor pop u la tions us ing fresh pub lic funds. Var i ous stra-te gies have been im ple ment ed along side the pro gramme to tar get the most vul ner a ble pop u la tions and deal with their most rel e vant dis eases. The im pact on the im prove ment of health con di tions in these pop u la-tions is es ti mat ed to re duce in fant and ma ter nal mor tal i ty in the fol low-ing years, two in di ca tors that are key to achieve MDGs in health in Mex-i co. The way this strat e gy is be ing im ple ment ed to im prove these in di ca-tors is the ob jec tive of the pre sen ta tion. The pa per shows the amount of hu man and fi nan cial re sources in volved in the pro duc tion of ser vices, the groups of pop u la tion that have been most ben e fit ed, the ar tic u la tion be tween lev els (fed er al, state and mu nic i pal) of gov ern ment to achieve the strat e gy goals and the per spec tive of man agers and providers in the progress made so far to achieve tar gets.

0086

Com par ing the cen tral lim it the o rem and boot strap meth ods for es ti mat ing in cre men tal net ben e fi tNixon R. (MRC Bio sta tis tics Unit, Cam bridge, UK)Won der ling D., Grieve R.

An in creas ing ly com mon ap proach in cost-ef fec tive ness anal y sis on in di-vid u al pa tients in a sin gle ran dom is ed con trolled tri al is to es ti mate the in cre men tal net ben e fits (INB), along with its 95% con fi dence in ter-vals, and com pute cost-ef fec tive ness ac cept abil i ty curves and con fi-dence el lipses.Two com mon al ter na tive non-para met ric meth ods for es ti mat ing INB are to em ploy the cen tral lim it the o rem or a boot strap meth-od. Both these meth ods are de scribed and the va lid i ty of their un der-ly ing as sump tions dis cussed. Nei ther meth od is ex act. How ev er, both meth ods give un bi ased es ti mates of the in cre men tal net ben-e fit, but give dif fer ent es ti mates for the vari ance of this es ti mate.We used Monte Car lo sim u la tion to com pare the two tech niques, as sum-ing the pop u la tion ef fect to be nor mal ly dis tribut ed and costs gam ma dis tribut ed. We re peat ed this ex per i ment a num ber of times vary ing the sam ple size, skew ness, and will ing ness-to-pay thresh old. In al most ev ery ex per i ment the vari ance of the es ti mat ed in cre men tal net ben e-fits was bet ter es ti mat ed us ing cen tral lim it the o rem than the boot strap, lead ing to bet ter cov er age of the con fi dence in ter vals and con fi dence el lipses, and more ac cu rate CEACs.

0334

Eval u at ing the lev el of gen er al is abil i ty of eco nom ic eval u a tion stud iesNixon J. (Cen tre for Re views and Dis sem i na tion, York, Unit ed King dom)Ul mann P., Déméoth is C., Ser ri er H., Rice S., Drum mond M., Pou vourville de G.

Ob jec tives: In a pre vi ous ly pub lished study we re port ed the pre lim i nary val i da tion of the EU RON HEED trans fer abil i ty check list. The aim of the pres ent study is to re port the re sults of a val i da tion sur vey con duct ed with French and UK de ci sion-mak ers.Meth ods: Postal sur vey of a pan el of 40 promi nent health economists and health care de ci sion mak ers in France, which was matched for the UK. The sur vey in stru ment asked re spon dents to choose items that they con sid ered to be im port in the as sess ment of gen er al is abil i ty. They then as signed a weight (1, 2 or 3) to each se lect ed item, which re flect ed its rel-a tive im por tance. Qual i ta tive com ments were also sought con cern ing the check list, and sug ges tions for fur ther items that were not in clud ed in the pres ent ver sion.Re sults: The re sponse rate was 75% in France and 65% in the UK. The sur vey re sults pro vid ed a good lev el of val i da tion of the check list, which can now po ten tial ly be mod i fied to pro duce a weight ed so lu tion. Dis cus sion: Dif fer ences among the re spon ders, in con junc tion with their qual i ta tive com ments, sug gest that more anal y sis and re search is need ed re gard ing de ci sion-mak ers’ knowl edge and un der stand ing of eco nom ic eval u a tions. The EU RON HEED check list is close to be com-ing a vi a ble in stru ment to as sess the trans fer abil i ty of pub lished eco-nom ic eval u a tions.

0193

A Com par i son of GP Vis it ing in North ern Ire land and the Re pub lic of Ire land Nolan A. (Eco nom ic and So cial Re search In sti tute, Dub lin, Ire land)Mc Gre gor P., Nolan B., Oill C.

In North ern Ire land, all res i dents are en ti tled to free GP ser vices while in the Re pub lic of Ire land, only the 30 per cent of the pop u la tion who

S74 | Eur J Health Econom Suppl 1 · 2006

qual i fy on the ba sis of an in come means test are en ti tled to free GP ser-vices. Giv en the sim i lar i ty in the in sti tu tion al fea tures of GP ser vices in North ern Ire land and the Re pub lic, this al lows us to an a lyse the im pact of charges on GP use. use com pa ra ble data from the 2001 North ern Ire-land House hold Pan el Sur vey and the 2001 Liv ing in Ire land Sur vey to es ti mate pooled cross-sec tion mod els of GP ser vices use con trol ling for a va ri ety of in di vid u al and house hold de mo graph ic and so cio-eco nom-ic char ac ter is tics. We es ti mate five sep a rate or dered pro bit mod els for each in come quin tile, with a dum my in di ca tor vari able for those who live in the Re pub lic. re sults in di cate that for those in the low est in come quin tile in North ern Ire land and the Re pub lic, there is no sig nif i cant dif-fer ence in vis it ing be tween North ern Ire land and the Re pub lic (be cause the ma jor i ty of those in the low est in come quin tile in the Re pub lic are el i gi ble for free GP care). How ev er, for the sec ond, third and fourth in come quin tiles, vis it ing is sig nif i cant ly low er in the Re pub lic (where the ma jor i ty must pay), and for the fifth (and high est) in come quin tile, vis it ing is also sig nif i cant ly low er in the Re pub lic, but not to the same ex tent as for the mid dle in come quin tiles. This sug gests that the ef fect of charges in the Re pub lic is im por tant, al though less so for those in the high est in come quin tile.

0152

An Eco nom ic Eval u a tion of the In cred i ble Years Child-Par ent ing Pro grammeÓ’Céil leachair A. (Canol fan Economeg a Pholisi Iechyd, Ban gor, Wales)Ed wards RT., By wa ter T., Hutch ings J.

Back ground: Con duct dis or der is es ti mat ed to af fect 10% of chil dren in the UK and has both short and long-term cost im pli ca tions for fam i-lies, pub lic ser vices and so ci ety.Ob jec tives: To in ves ti gate the rel a tive cost-ef fec tive ness of the In cred i-ble Years Child-Par ent ing Pro gramme com pared with a six-month wait-ing list con trol.De sign: An in cre men tal cost-ef fec tive ness anal y sis of a ran dom is ed con-trol tri al.Set ting: Sure-Start ar eas in north Wales, mid Wales and Bor ders.In ter ven tion: 116 chil dren aged 36-59 months with con duct dis or der as mea sured by the Ey berg Child Be hav iour In dex (ECBI) were ran dom-is ed to ei ther a group re ceiv ing the child-par ent ing pro gramme or to a six-month wait ing-list con trol.Pri ma ry Out come Mea sure: In cre men tal cost per unit of im prove ment on the in ten si ty score of the ECBI.Re sults: We cal cu lat ed an ICER point es ti mate of £23 per one point im prove ment on the in ten si ty score of the ECBI (95% con fi dence in ter-val –£1–£51). With a Cost-Ef fec tive ness Ac cept abil i ty curve cost ceil ing of £45 there is a 93.9% chance of the in ter ven tion be ing cost-ef fec tive.Con clu sions: The In cred i ble Years Child-Par ent ing pro gramme im proves child be hav iour as mea sured by the in ten si ty and prob lem scores of the ECBI at a small ad di tion al cost and con se quent ly could be cost-ef fec tive as com pared with cur rent ly pro vid ed in ter ven tions.

0280

Pa tient Mi gra tion in Cen tral Eu rope: The Case of Den tal CareOester le A. (Vi en na Uni ver si ty of Eco nomics, Vi en na, Aus tria)Del ga do J.

With re cent ECJ de ci sions, pa tient mi gra tion be came a top pri or i ty is sue in Eu ro pean health pol i cy. Apart from pa tient mi gra tion in the con text of re gion al co-op er a tions, den tal care is one of the few health sec tors in Eu rope where cross-bor der mi gra tion of pa tients has al ready reached con sid er able lev els. The pa per stud ies the de ter mi nants of cross-bor-der den tal care in Cen tral Eu rope by fo cus ing on re spec tive mi gra tion flows be tween Aus tria and Hun gary. The un der ly ing hy poth e sis is that,

in this par tic u lar sec tor, in di vid u al ex pens es to be borne by pa tients work as a de ci sive fac tor for mi gra tion de ci sions. Start ing from pre vi ous work on pa tient mi gra tion us ing choice mod els, the study iden ti fies four ma jor de ter mi nants: qual i ty of care, ser vice qual i ty, pa tients’ ex pens es for the ser vice pro vid ed and trans ac tion costs. In ves ti gat ing these de ter-mi nants the study uses ad min is tra tive data (which only cov ers those re im bursed by so cial health in sur ance funds) as well as data from in ter-views with pa tients. First re sults con firm that den tal care mi gra tion in Cen tral Eu rope is strong ly pa tient driv en, with prices and ser vice qual i-ty be ing key de ter mi nants for the re spec tive de ci sions.

0297

How good is the qual i ty of health care in France?Or Z. (IRD ES,of Re search on Health Eco nomics, Par is, France)

France has been clas si fied by the WHO as hav ing one of the best health sys tems in the world. How ev er, there is sur pris ing ly lit tle sys tem at ic in for ma tion on the qual i ty and safe ty of health care pro vid ed in France. De spite many re cent ini tia tives to im prove qual i ty and its mea sure ment, the avail able data re main par tial, in con sis tent and not eas i ly ac ces si ble. In or der to ob tain a glob al pic ture of health care qual i ty prob lems and to de vel op qual i ty-im prove ment stra te gies, it is im por tant to col lect na tion-al data on a con sis tent ba sis with in a co her ent frame work. How ev er, un like in most En glish-speak ing coun tries, no at tempt has been made in France to de vel op a na tion al re port ing sys tem on qual i ty. This pa per pools to geth er both pub lished and un pub lished data from many dif fer-ent sources on the qual i ty of care in France us ing the in ter na tion al ly-re cog ni sed frame work de vel oped by the U.S. In sti tute of Med i cine. The di men sions cov ered are safe ty, ef fec tive ness, ap pro pri ate ness, re spon-sive ness and ac ces si bil i ty. Where pos si ble, com par isons are made with the sit u a tion in oth er OECD coun tries. This pa per thus pro vides an overview of what is known about the qual i ty of health care de liv ered in France with in an in ter na tion al per spec tive, and aims to iden ti fy the ma jor de fi cien cies in terms of mea sur ing and re port ing qual i ty.

0012

Per son trade-off in QALY and DALY mod elsØs terdal L.P. (Uni ver si ty of Copen hagen, Den mark)

A con sid er able num ber of pa pers have pro posed, or have been in.uenced by, a speci.c meth od for in te grat ing so cial pref er ences in the QALY frame work (e.g. Nord 1992, 1994, 1995, 1996, Nord et al. 1993, Rich-ard son and Nord 1997, Dolan and Green 1998, Ubel et al. 2000, and Schwarzinger et al 2004). In this meth od the qual i ty-ad just ment fac tor is es ti mat ed from per son trade-o¤ scores, i.e. as sess ments of the num ber of peo ple that should re ceive a speci.ed health im prove ment (for ex am-ple one ex tra life year at a cer tain health state) so that it is so cial ly equal-ly pre ferred to axed num ber of oth er peo ple re ceiv ing a giv en health im prove ment (for ex am ple one ex tra life year in per fect health). Like-wise, the DALY mod el used by WHO for as sess ment of re gion- and dis-ease-speci.c bur den of dis ease is also based on dis abil i ty weights es ti mat-ed by per son trade-o¤ pro to cols (WHO 2004) (for de tails, see Mur ray and Lopez 1996). De spite the pop u lar i ty of qual i ty-ad just ment in dices based on per son trade- o¤s, the o ret i cal sup port for its use in a QALY frame work has not been in ves ti gat ed (Dolan 1998, Green 2001, Mans-ley and El basha 2003). In this pa per, we show that if the qual i ty-ad just-ment fac tor is con struct ed from per son trade-o¤ scores, then any eval u-a tion cri te ri on based on QALYs (or DALYs) gen er al ly vi o lates the Pare-to prin ci ple.

Eur J Health Econom Suppl 1 · 2006 | S75

0324

Ex plain ing the Diff er ences in Kid ney Or gan Do na tions Across Coun triesOs terkamp R. (Ifo In sti tute for Eco nom ic Re search, Mu nich, Ger many)Roehn O.

The scarci ty of kid ney or gans with re sult ing wait ing lists for kid ney trans plants is a key health sec tor prob lem in near ly all in dus tri alised coun tries. The main di men sions of the prob lem are in di vid u al pain and high so cial costs, both due to di al y sis. How ev er, do na tion fig ures per mil lion pop u la tion and p.a. dif fer wide ly across coun tries. The ar ti-cle asks for the rea sons of the dif fer ences and whether a best prac tice can be iden ti fied. With in a multi-vari ate pan el anal y sis for 25 in dus tri-al coun tries sev er al pos si ble de ter mi nants are ex plored. Fac tors con sid-ered are the le gal frame work for or gan do na tion, cen tral i ty of the clin i-cal sys tem, den si ty of in ten sive care units (ICU), avail abil i ty of “in cen-tive” per son nel in clin ics with ICU, fa tal traf fic ac ci dents, prev a lence of obe si ty, prac tis ing di al y sis spe cial ists, do na tion-re lat ed spend ing for pro-fes sion al and pub lic ed u ca tion, the in ter ac tion be tween ca dav er ic and liv ing do na tion. The el e ments of a best prac tice sys tem can be iden ti fied. Spain seems to be near est to best prac tice.

0088

Sup ple men tary health in sur ance as a tool for risk-se lec tion in manda to ry ba sic health in sur ance mar ketsPaoluc ci F. (iBMG – Eras mus Uni ver si ty, Rot ter dam, Nether lands)Schut E., Beck K., Vo orde C., Greß S., Zmo ra I.

Ab stract this pa per, we ex am ine the role of sup ple men tary health in sur-ance (SHI) as a po ten tial tool for risk-se lec tion in five coun tries with a com pet i tive ba sic health in sur ance (BHI) mar ket Bel gium, Ger many, Is rael, the Nether lands and Switzer land. We as sess the po ten tial role of SHI as a se lec tion de vice in each of these coun tries by in ves ti gat ing the po ten tial gains from risk-se lec tion, the mar ket share of SHI and the links be tween ba sic and sup ple men tary health in sur ance mar kets. From this anal y sis we con clude that SHI is a pow er ful se lec tion tool in Switzer-land, while in the Nether lands in cen tives to use SHI for risk-se lec tion are in creas ing. In Ger many and Is rael, in cen tives for risk-se lec tion are strong but op por tu ni ties for us ing SHI to at tract favourable risks are severe ly re strict ed by reg u la tion and the pre vail ing mar ket struc ture. In Bel gium, there are am ple op por tu ni ties to use SHI as a se lec tion de vice but the in cen tives to do so are lim it ed though in creas ing.

0016

Pa tient tra jec to ries and Health ar easPar ent O. (Uni ver sité de Saint-Eti enne, France)Boureille B., Nor mand M., Trombert-Paviot B.

This study at tempts to an a lyse the tra jec to ries of pa tients with in the French health care sys tem. The sys tem of pa tient tra jec to ries has vari-able fea tures, spe cif ic de ter mi nants, and con se quences on peo ple_health that should be in ves ti gat ed in a re gion al per spec tive. We pres-ent a tra jec to ry-based an a lyt i cal ap proach to as sess ing pat terns, de ter-mi nants, and out comes of health care with ap pli ca tion to breast can cer.. The ap proach uses eco nom ic and sta tis ti cal meth ods for sam ple se lec-tion and anal y sis, as well as sta tis ti cal meth ods con cern ing mod el fit-ting and val i da tion strat e gy. It also uses spa tial econo met rics meth ods al low ing pa tient tra jec to ry iden ti fi ca tion.. Us ing a new dataset of the French Na tion al Case Mix Database over the pe ri od 2003 – 2004 for the Rhône-Alpes re gion, we find dif fer ent pa tient tra jec to ries for breast can-cers pa thol o gy. Dif fer ences be tween the Loire area (with 2,129 pa tients and 70 hos pi tals and med i cal cen ters) and a metropoli tan city Lyon

(with 1,210 pa tients and 44 med i cal cen ters) are set forth.. We il lus trate the fea si bil i ty and prof itabil i ty of the pa tient tra jec to ry sys tem to iden-ti fy pat terns, de ter mi nants, and con se quences of re gion al ized health care sys tem. This ap proach could be used to an a lyse oth er patho log i cal health-care sys tems.

0571

Health eco nomics from the con sumers’ per spec tive; a study of con sumers’ pref er ence for cor o nary heart dis easeParsa A.D. (Di vi sion of car dio vas cu lar med i cine, Uni ver si ty of Not ting ham, UK)Gray D.

Ev ery health care sys tem in the world is strug gling to meet de mand for health care. Health sys tems through out the world face es ca lat ing health care costs and pri ori ti sa tion of health care is sues is one ap proach to cost-con tain ment. Will ing ness to pay (WTP) is in creas ing ly be ing used as a mea sure of val u a tion in health tech nol o gy as sess ment. Will ing ness-to-pay stud ies have as sessed the val ue of a par tic u lar in ter ven tion or to com pare the rel a tive val ue of dif fer ent treat ments. Specif i cal ly, will-ing ness to pay (WTP) may be used as a guide to re source al lo ca tion. WTP im plies that con sumers of health ser vices can ex press their pref er-ences through their abil i ty and will ing ness to pay for ser vices, whether pre ven tion or treat ment of CHD. It can be used to ex plore the re la tion-ship be tween sup ply and de mand for both ex ist ing ser vices and new ser vices. Ob jec tives: Dif fer ent groups of ser vices con sumers may re act dif fer-ent ly to price in creas es. The main ob jec tive of this study is to find out peo ple’s will ing ness and abil i ty to pay for treat ment and pre ven tion of CHD among British and Ira ni an pop u la tion (peo ple in volved with CHD and with out CHD in volve ment). The in flu ences of age, gen der, so cioe co nom ic group, ex tent of knowl edge of dis ease and its treat ment, ge o graph ic lo ca tion and ed u ca tion al lev el have been as sessed. Meth ods: De sign The study has been un der tak en in both quan ti ta tive and qual i ta tive set ting. Set ting and Sam pling: Data have been col lect ed from the study pop-u la tion in dif fer ent ge o graph i cal ar eas of Iran (Tehran, Abad dan and Ahavaz) and in the UK (Not ting ham). This study is based on data from main ly a self ad min is tered ques tion naire, and part ly in ter views will be con duct ed for tar get pop u la tion. The study pop u la tion com pris es of about 500, pa tients with di ag no sis of CHD or pre vi ous di ag no sis of CHD who had at tend ed car di ol o gy clin ic or ad mit ted in the Uni ver si-ty hos pi tal in Not ting ham and Iran ver sus heal thy vol un teers (with no pre vi ous ex pe ri ences of heart at tack). Par tic i pants in vol un teers group are se lect ed ran dom ly but will be strat i fied ac cord ing to age, sex and so on. Ad di tion al ly it is pro posed to in clude non-En glish speak ing (Far si) par tic i pants (Ira ni an) due to un der tak ing part of study in Iran. Num ber of pre dic tor vari ables, in clud ing age, gen der, eth nic i ty, em ploy ment sta-tus, house hold in come has been ex am ined. The for mat con sist ed of two ways a self-ad min is tered ques tion naire and a face-to-face in ter view. Per spec tive: The per spec tive of study is so ci etal and the re sults will be rel e vant to de ci sion mak ing with in the Ira ni an health sys tem. Data anal y sis: Both quan ti ta tive and qual i ta tive anal y sis us ing SPSS and AN OVA are used. Dis cus sion: un for tu nate ly we have not got all data yet but it is more like-ly to get the fi nal re sult be fore the con fer ence date. Con clu sion: Till now, it is ex pect ed that there are sig nif i cance dif fer-ences in val u a tion of heal thy heart and risk re duc tion pro gramme in se lect ed pop u la tions. This study stress es that cor o nary heart dis ease is a main pri or i ty not only among pa tients but also all oth er peo ple in both de vel op ing and de vel oped coun tries.

S76 | Eur J Health Econom Suppl 1 · 2006

0615

Overview of pri or i ty set ting, pri or i ty set ting meth ods and the use of PBMA: re sults from in ter na tion al re searchPea cock S. (British Columbia Can cer Agen cy & Uni ver si ty of British Columbia, Can a da)Don ald son C., Bate A.

The de vel op ment of frame works to al low de ci sion-mak ers to man age scarce re sources is one of the most im por tant chal lenges fac ing health eco nomics. Man ag ing re source scarci ty in volves mak ing choic es about which types and amounts of health care to pro vide for dif fer ent in di vid-u als and pop u la tions from a giv en bud get. This pa per de scribes an eco-nom ic ap proach to pri or i ty set ting – Pro gramme Bud get ing and Mar gin-al Anal y sis (PBMA) – to as sist de ci sion-mak ers in mak ing these choic-es. PBMA has been used in over 70 pri or i ty set ting ex er cis es in Aus-tralia, Can a da, and the UK. It is based on three con cepts: the need to con sid er op por tu ni ty costs; the need for mar gin al anal y sis of costs and ben e fits; and, the ex is tence of a fixed bud get which im plies that some ser vices must be con tract ed if oth ers are to be ex pand ed. Re cent de vel-op ments in PBMA will be de scribed, which have fo cussed on the com-plex na ture of both ob jec tives and con straints in pri or i ty set ting. De vel-op ments in clude mod elling de ci sion-mak ers’ ob jec tives us ing mul ti at-tribute util i ty the o ry, in cor po rat ing eth ics into eco nom ic ap proach es, and ex am in ing the con straints of po lit i cal econ o my and or gan i sa tion al con text that de ci sion-mak ers face in set ting pri or i ties.

0601

Trans fer abil i ty of util i ty re sults of rheu ma toid ar thri tis cost-eff ec tive ness mod els into Hun gary Pén tek M. (Rheu ma tol o gy, Flór Fer enc Coun ty Hos pi tal, Kistarc sa, Hun gary)Brod szky V., Má jer I., Ro jkovich B., Pol gár A., Szekanecz Z., Poór Gy., Czir ják L., Gen ti Gy., Ko belt G., Gulác si L.

Ob jec tives: Sev er al mod els have been de vel oped to study the cost-ef fec-tive ness of new ther a pies in rheu ma toid ar thri tis but the de gree of util-i ty chang es and the meth ods used were dif fer ent. Ad ap ta tion of in ter-na tion al re sults is cru cial in Hun gary once there is a lack of epi demi o-log i cal data and cost-ef fec tive ness anal y sis is re quired for re im burse-ment. The aim of our study was to as sess the trans fer abil i ty and adapt-abil i ty of util i ty re sults of rheu ma toid ar thri tis cost-ef fec tive ness mod-els into Hun gary. Ma te ri als and meth ods: A cross-sec tion al sur vey was per formed by hos pi tal based rheuma tol o gists from June to Au gust in 2004 in volv ing 255 rheu ma toid ar thri tis pa tients. Dis ease ac tiv i ty (DAS), self-com plet-ed ques tion naires (HAQ, EQ-5D, RAQoL) were used and vi su al an a-logue scale (VAS) to mea sure health sta tus, pain, pa tient’s and physi-cians’ glob al as sess ment. Sta tis ti cal anal y sis was per formed to an a lyze cor re la tions. Util i ty on dif fer ent dis ease stag es was stud ied. Re sults: Cor re la tion be tween EQ-5D, HAQ, RAQoL, DAS and pain-VAS was sig nif i cant. Util i ty equa tions were: EQ-5D=0,85-0,282×HAQ (R2 0,413); EQ-5D=0,895–0,027×RAQoL (R2 0,427); EQ-5D=0,841-0,0081×painVAS (R2 0,312). Dis ease ac tiv i ty cor re la tion was: EQ-5D=1,014–0,25×HAQ–0,041×DAS (R2 0,44). Us ing 6 HAQ states, mean EQ-5D was 0,784; 0,576; 0,504; 0,367; 0,211; 0,022 (p<0,01), mean RAQoL scores were: 6,7; 12,23; 16,05; 20,96; 23,29; 22,37.Con clu sion: Util i ty equa tions can be set up in the Hun gar i an sam ple but the dif fer ence can achieve the clin i cal ly min i mal im por tant lev el in com par i son with mod els. Co in ci dent ly with Ko belt’s pre vi ous study, dis-ease ac tiv i ty has im pact on util i ty loss in de pen dent ly from HAQ, pain seems to have key role. Us ing HAQ based Markov mod el stag es the EQ-5D change was sig nif i cant but not con sis tent, the great est loss was de tect ed in the mildest groups. Dis ease spe cif ic qual i ty of life was con-stant once a se vere func tion al dis abil i ty was achieved. Our cross-sec tion-al sur vey cov er ing sev er al dis ease pa ram e ters of fer com pa ra ble re sults

to mod els in volv ing ob ser va tion al co horts. Coun try-spe cif ic data might have im pact on QALY gain spe cial ly in Markov mod els.

0430

In come-re lat ed in equal i ty in health care in re la tion to in equal i ties in needPereira J. (Es co la Na cional de Saúde Públi ca, Nova de Lis boa, Por tu gal)Lopes S.

Ob jec tives: To as sess in come-re lat ed in equities in the de liv ery of health care in Por tu gal.Meth ods: Study draws on a meth od pro posed by Wagstaff and van Doorslaer. Data are from the 1998/99 Por tuguese Na tion al Health In ter-view Sur vey. Spe cial ist and GP vis its, as well as lab tests, are used as mea-sures of health care uti li za tion. Sev er al in di ca tors of ill-health are used as pre dic tors of need.Re sults: Find ings pro vide ev i dence of un equal treat ment for equal need. In equity in dices re veal that the worse-off use more GP vis its and the bet-ter-off use more spe cial ist care and lab tests, even af ter tak ing need into ac count. The most sig nif i cant in equities in health care are in spe cial ist vis its. The dis tri bu tion of GP vis its slight ly favours the poor er in come groups. Al though these find ings ap ply to all mor bid i ty mea sures used in the pre dic tion of need, when a mea sure of self-as sessed health sta-tus is used, health care pro vi sion ap pears con sid er ably more favourable to the rich.Con clu sions: The na ture of health care pro vi sion in Por tu gal very like-ly the main rea son for dif fer en tial uti li za tion of ser vices be tween worse-off and bet ter-off. A ma jor find ing is that lev els of mea sured in equity are par tic u lar ly sen si tive to the need in di ca tor that is used, with self-as sessed health show ing very pro-rich in equity. This ques tion has im pli-ca tions for cross-coun try com par isons.

0218

Mis lead ing cost es ti mates when ne glect ing the cen tre eff ect in mul ti cen tre RCTsPetrin coa M. (De part ment of Pub lic Health and Mi cro bi ol o gy and De part ment of Sta tis tics and Ap plied Maths “Diego de Cas tro”, Uni ver si ty of Turin, Italy)Paganob E., Fer ran dob A., Big ic R., Desiderid A., Gre gorie D.

In mul ti cen tre RCTs the cost eval u a tion is af fect ed by the het ero ge ne ity in the sub jects’ clin i cal fac tors (be tween-pa tient sam pling vari abil i ty) and in the cost struc ture of each cen tre (be tween-lo ca tion vari abil i ty) (Man ca et al.,2003). To avoid mis lead ing con clu sions the cen tre ef fect needs to be ap pro pri ate ly con sid ered. We anal y sed cost data from the COSTA MI tri al: an in ter na tion al RCT eval u at ing al ter na tive dis charge stra te gies in the post in farc tion. 10 cen tres (8 Ital ians and 2 Turk ish-es) par tic i pat ed (main dif fer ences in to tal and car di o log ic hos pi tal i sa-tions and in in ten sive-care beds). Treat ments costs were mod elled as func tion of pa tients re lat ed co vari ates (age, sex, pre vi ous isch emic his-to ry, co mor bidi ties) with a Cox pro por tion al haz ards mod el. The cen-tre ef fect was mod elled as shared frailty from Klein (1992) and Nielsen (1992). Frailty es ti mate was ob tained by ap ply ing the Th erneau penal-ty func tion (2000). The ear ly dis charge strat e gy showed a cost-ra tio of 0.598 (95%CI: 0.48–0.74) when mod elled with the ad just ed mar gin al Cox mod el. The es ti mat ed cost-ra tio for the cen tre ef fect, based on the gam ma frailty, turned out to be high er (0.783; 95%CI: 0.65–0.95) than the ef fect of the dis charge strat e gy.In mul ti cen tre tri als, to avoid mis lead ing con clu sions in com par ing ser-vices costs and re lat ing the re sults to clin i cal char ac ter is tics, the cen tre ef fect should to be eval u at ed.

Eur J Health Econom Suppl 1 · 2006 | S77

0290

In vest ments in med i cal tech nol o gy and the role of doc torsPig nataro G. (Uni ver si ty of Cata nia, Italy)

A the o ret i cal mod el is de vel oped to study the de ter mi nants of hos pi-tals’ choic es on how much to in vest in med i cal tech nolo gies. A two-stage pro cess is mod elled: in the first stage, the man ag er of a hos pi tal has to choose how much to in vest in med i cal equip ment. In a sec ond stage, doc tors use the equip ment, to max imise their ob jec tive func tion, de fined ac cord ing to a work-pref er ence as sump tion. Med i cal tech nol o-gy can be used by doc tors to serve two dif fer ent pur pos es: 1) in creas-ing the num ber of treat ments; and 2) al low ing more com plex cas es to be treat ed, or more “so phis ti cat ed” treat ments to be pro vid ed. They will choose how much ef fort to put in us ing this equip ment for treat ing more pa tients and how much ef fort to de vote in us ing the tech nol o-gy for treat ing more com plex cas es (or pro vid ing more “so phis ti cat ed” treat ments). The man ag er max imis es rev enues (pos i tive ly re lat ed to the num ber of pa tients treat ed in the hos pi tal, as weight ed by the com plex i-ty of treat ments), net of in vest ments op por tu ni ty costs.First, the amount of in vest ment cho sen by man agers is char ac ter ized in terms of doc tors’ pref er ences for the dif fer ent ways of us ing tech nol o gy, the hos pi tal’s re mu ner a tion sys tem, doc tors’ ef fort pro duc tiv i ty. Sec ond, the re sults are ex tend ed in an asym met ric in for ma tion con text, where hos pi tals’ man agers are un cer tain about doc tors’ pref er ences.

0580

The in fl u ence of the ra tio bias on the val ue of a sta tis ti cal lifePrades J.L.P. (Uni ver si tat Pom peu Fab ra, Barcelona, Spain)Pérez J.E.M., Per piñan J.M.A.

Ob jec tive: to test the con sis ten cy of val ues of a sta tis ti cal life (VOSL) us ing the Stan dard Gam ble-Con tin gent Val u a tion (SG-CV) meth od. We an a lyze if these val ues can be in flu enced by the Ra tio Bias.Back ground: the SG-CV meth od has been pro posed as a meth od more con sis tent than the tra di tion al one in or der to es ti mate VOSL. We re fer to the “tra di tion al” meth od as that one that es ti mates the VOSL ask ing will ing ness to pay (WTP) ques tions for very small (usu al ly X in 100.000) risk re duc tions. The SG-CV meth od is a two stage pro ce dure. First, sub-jects are asked WTP and will ing ness to ac cept (WTA) ques tions for a health state un der cer tain ty. Us ing the re sponse to the WTP and WTA ques tions, the Mar gin al Re la tion of Sub sti tu tion (MRS) be tween risk and mon ey is es ti mat ed. Sec ond, the SG meth od is used to es ti mate the rel a tive val ue (RV) of a health state in re la tion to death. Us ing these two ques tions, the VOSL is es ti mat ed as MRS x RV. The ra tio bias (RB) con sists in the ten den cy of sub jects to con cen trate on the ab so lute num-ber of events (the neg a tive part of the nu mer a tor) when they do judg-ments about risk, not giv ing enough weight to the de nom i na tor (the base of the risk).Meth ods and re sults: 180 sub jects where in ter viewed us ing the CV-SG meth od in or der to es ti mate the VOSL. In this group, we asked the SG ques tion us ing 1000 as the de nom i na tor. We then asked the risk of death that sub jects would ac cept in or der to get rid of health states X and Y as the num ber of cas es out of 1000. We also asked for WTP and WTA for health states X and Y. Us ing this meth od, we es ti mat ed a VOSL of about 9 mil lion eu ros. In a sec ond group (n=102), we repli cat ed the same meth o dol o gy us ing 500 as the de nom i na tor. We then asked the risk of death that sub jects would ac cept in or der to avoid health states X and Y, as the num ber of cas es out of 500. We found that sub jects were not very sen si tive to the change in the base of risk (from 1000 to 500). This re duced the rel a tive val ue (RV) of the health states in re la tion to death and then the VOSL. We found a VOSL of about 4.5 mil lion eu ros if the SG ques tions were asked as num ber of events out of 500 (in stead of 1000 as be fore).

Con clu sion: the SG-CV avoids some of the prob lems ob served in the lit er a ture re lat ed to the dif fi cul ty of con vey ing small prob a bil i ties to sub-jects. How ev er, it is not a meth od free of bi as es. We have shown that the Ra tio Bias can have a dra mat ic in flu ence on the VOSL es ti mat ed us ing this meth od. The CV-SG meth od should be im proved in or der to pro-vide more con sis tent es ti mate of the VOSL.

0286

Health care net work: im pli ca tions for Ital ian lo cal health au thor i ties Pi raino N. (Po litec ni co di Mi lano, De part ment of Man age ment, Eco nomics and In dus tri al En gi neer ing, Mi lano, Italy)Masel la C., Pi raino N.

The Ital ian Health Care Sec tor is char ac ter ized by a num ber of re forms that have deeply mod i fied its man age ri al and or ga ni za tion al set tings. Cur rent ly the Ital ian health care sys tem is high ly de cen tral ized: there are many types of health care or ga ni za tions and dif fer ent co or di na tion mech a nisms (hi er ar chy, mar ket and net work) are im ple ment ed.The aim of the pa per is to an a lyse dif fer ent types of net work im ple ment-ed in the Ital ian health care sec tor and to as sess the im pact of co or di-na tion mech a nisms adopt ed on lo cal health au thor i ties, from an or ga-ni za tion al and man age ri al point of view. On the ba sis of the the o ry of net work-based or ga ni za tions, two case stud ies are con duct ed con sid er-ing two main units of anal y sis: 1) the net work and 2) the lo cal health au thor i ties. The scope is to as sess em pir i cal ly how the net work af fects the man age ri al prac tices of the lo cal au thor i ties, for ex am ple in terms of new mod els of gov er nance and ac count abil i ty ar range ments. The health care net works anal y sed are two pi lot ex pe ri ences, car ried out in Re gione Marche (ASUR-net work) and Re gione Toscana (So ci età del la Salute), and the lo cal health au thor i ties in volved are, re spec tive ly, ASUR-Marche and Azien da USL 10 di Firen ze.The re search could pro vide a use ful con tri bu tion for health in sti tu tions to im prove their per for mances and to un der stand the ef fects of re gion-al health pol i cy, par tic u lar ly in the light of the lat est chang es in Ital ian Health care sys tem.

0604

Pub lic Health Eco nomics in The Nether landsPold er J. (Na tion al In sti tute for Pub lic Health and the En vi ron ment (RIVM), Bilthoven, Nether lands,)Klazin ga N.

The con tri bu tion of health eco nomics to the pub lic health de bate is steadi ly in creas ing. In this pre sen ta tion the Dutch ap proach will be high-light ed. We will start with de scrip tive stud ies on health ex pen di ture and pop u la tion health. Cost-of-ill ness fig ures will we pre sent ed and the role of the last year of life will be dis cussed, as well as the in flu ence of de ter-mi nants (like hy per ten sion and obe si ty) and un healthy be hav ior (smok-ing, phys i cal in ac tiv i ty, drink ing too much, eat ing un healthy things).In the week pre vi ous to this con fer ence, the new edi tion of the Dutch Pub lic Health Fore casts re port will be launched. In this pre sen ta tion the main con clu sions will be sum ma rized from an eco nom ic per spec tive.

0130

Age ing im pact on elas tic i ty of Health Care Ex pen di turePolis te na B. (Uni ver si ty of Rome Tor Ver ga ta, Rome, Italy)Rat ti M., Span donaro F.

Fore word stud ies, us ing cross-sec tion and pan el data, com pare the evo-lu tion of the health care ex pen di tures in dif fer ent coun tries. Com mon fac tors in these stud ies are the spec i fi ca tion of the vari ables ex plain ing

S78 | Eur J Health Econom Suppl 1 · 2006

health care ex pens es, as well as the eval u a tion of the elas tic i ty of health ex pen di tures to per cap i ta GDP.pi o neer ing re sults ob tained by New-house (1977) and those ob tained by Abel Smith in their re search es on a sam ple of OCSE coun tries, show an elas tic i ty greater than 1, while Hi tiris e Pos nett (1992), in tro duc ing de mo graph ic vari ables in the anal y sis, eval-u ate an elas tic i ty very close to 1.of the study study anal y ses the im pact of the in tro duc tion of de mo graph ic fac tors into the pre dic tion mod els of the in ci dence of the health care ex pen di ture on GDP, in a fast age ing coun try like Italy.con text of this anal y sis is some how pe cu liar, be cause of the re dis tribu tive ef fects in duced by the fund ing rules of re gion al Health Sys tem in Italy sol i dar i ty mech a nisms tend to in vert the re la tion be tween the GDP share ab sorbed by health care, and av er age per cap i ta GDP.and Method ol o gy anal y sis is con duct ed on so cio eco nom ic ex pen di ture data at lev el of the Ital ian re gions, through re gres sion mod els on pan el data.

0169

Health Care Cost Anal y sis for Heart Fail ure Pa tients in Marche Re gionPoli ti C. (Azien da San i taria Uni ca Re gionale, Re gione Marche, An cona, Italy)Deales A., Mar co bel li A., Ci c chitel li F., Stanis lao F.

Ob jec tives: To es ti mate health care costs for heart fail ure (HF) pa tients in Marche re gion in 2004 through record link age of ad min is tra tive and de mo graph ic data bases. To up date and com plete a pub lished ear ly ver-sion of the study. Meth ods: Pa tients hos pi talised in 2001-2004 with HF as pri ma ry or sec ond ary di ag no sis and those with co-pay ment ex emp tion due to HF are iden ti fied. Their health care con sump tions in 2004 are re trieved by record link age of ad min is tra tive data bases; costs are es ti mat ed by DRGs, out pa tient tar iffs and drug gross ex pen di ture. To tal costs, av er age costs per pa tient, con sump tions pat terns by age and sex are anal y sed.Re sults: 21.071 pa tients out of 1,5 mil lion in hab i tants in Marche re gion are record ed with HF (1,4% prev a lence rate). In 2004 to tal health care costs are es ti mat ed around 41.4 mil lion € (1,7% of the re gion al pub-lic health ex pen di ture). Hos pi tal care, drugs and out pa tient care cov er re spec tive ly 80%, 18% and 2% of the to tal costs. The av er age cost per pa tient is 1.964 €. Old er pa tients reg is ter on av er age low er unit costs, in par tic u lar for drugs and out pa tient ser vices. Males record high er av er-age costs per pa tient than fe males. Con clu sions: Find ings con firm the rel e vance of HF and high light dif fer-ent pat terns of ac cess to health care ac cord ing to age and sex. Work is in progress to ex tend the anal y sis to oth er Ital ian re gions.

0216

Health Ser vices Ac cess and Uti li za tion in BrazilPor to S. (Es co la Na cional de Saúde Públi ca, FIOCRUZ, Na tion al School of Pub lic Health, Rio de Janeiro, Brazil)

Brazil ian health re form sta b lished the im ple men ta tion of so cial and eco-nom ic poli cies in or der to guar an tee uni ver sal and igual i tar i an acess to health ser vices.re sults of the house hold sur vey that has been ac com-plished in 2003 showed that there still are im por tant in equal i ties in the ac cess and uti li za tion of health ser vices in Brazil, but that there are im prove ments in sev er al in di ca tors be tween 1998 and 2003, such as Per cent age of the pop u la tion which uses reg u lar ly one health ser-vice; Per cent age of per sons which had at least one med i cal con sul ta tion in the pre vi ous year; Per cent age of per sons that de mand ed some kind of health ser vice in the pre vi ous 15 days.sur vey also showed a de cline at the per cent age of per sons that eval u at ed their health sta tus as bad or very bad.anal y sis of these data showed that the mod i fi ca tion of the health ser vices de liv ery mod el and of its fi nanc ing mech a nisms con-tribut ed to the im prove ment of ac cess con di tions. 1998 pri ma ry health care pro gram has been pri or i tized and it has been sta b lished that its

fi nanc ing should reach a sit u a tion of ex pen di tures per cap i ta equal i ty. There have also been cre at ed in cen tives for the de vel op ment of the “Fam-i ly Health Pro gram” (Pro gra ma de Saúde da Família) and com mu ni ty health agents.pa per dis cuss the con tri bu tion of pri ma ry health ser vices to the im prove ment of health ser vices ac cess and uti li za tion in di ca tors.

0366

Ear ly life eff ects on In di vid u al Mor tal i tyPor trait F. (Vri je Uni ver siteit, Ams ter dam, Nether lands)Por trait M. Lin de boom G.B.

On av er age be ing born in a re ces sion in creas es the mor tal i ty rate lat er in life. We ex am ined the role of nu tri tion and of ex po sure to dis eases dur-ing child hood in ex plain ing this re sult. We have in di vid u al data records from Dutch reg is ters of birth, mar riage, and death cer tifi cates, cov er ing an ob ser va tion win dow of un prece dent ed size (1812–2000). These are merged with his tor i cal data on re gion al agri cul tur al prices and mor tal i-ty in di ca tors, and with na tion al mac ro-eco nom ic out comes. We cor rect for sec u lar chang es over time and oth er mor tal i ty de ter mi nants. We es ti-mate du ra tion mod els where the in di vid u al’s mor tal i ty rate de pends on cur rent con di tions, con di tions ear ly in life, in di vid u al char ac ter is tics in clud ing land own ing sta tus and in ter ac tions terms. The re sults in di-cate that ex po sure to dis ease dur ing in fan cy in creas es mor tal i ty at all ages and that farm ers ben e fit from high er agri cul tur al prices.

0490

Cost of qual i ty and non-qual i ty in care pro vid ed by health care or gan i sa tions – Cur rent sit u a tion and pro pos alsPréaubert-Hayes N. (HAS/ Haute au torité de San té (French na tion al au thor i ty for health), Saint-De nis la Plaine Cedex, France)Sail lour-Glénis son F., Préaubert-Hayes N.

Pur pose: To make pro fes sion als in health care or gan i sa tions (HCOs) aware of the eco nom ic di men sion of qual i ty, and to pro vide in for ma-tion on the cost of qual i ty and non-qual i ty.Meth ods: Sys tem at ic search on data bases, use ful web sites and the grey lit er a ture (1990–2003). A crit i cal lit er a ture re view re port was pro duced and dis cussed with a work ing group at 4 meet ings.Re sults: 1-Fre quen cy of de fi cien cies of qual i ty of care. The data avail-able for French HCOs pin point the most com mon ar eas of non-qual i-ty that re pres ent po ten tial sav ings through im prove ments in qual i ty of care: ad verse events, un jus ti fied in ter ven tions and hos pi tal stays. 2-Cost of de fi cien cies. There are very few data for French hos pi tals. For eign stud ies have shown that the de fi cien cy-re lat ed ex cess costs vary ac cord-ing to type of de fi cien cy. The most ex pen sive are: post op er a tive in fec-tions bac ter aemia, pneu mo nia, drug-re lat ed ad verse events, hos pi tal i sa-tions and in ap pro pri ate pre scrib ing. 3- Pos i tive im pact of in ter ven tions to pre vent de fi cien cies. Stud ies pub lished in France and abroad agree that the fol low ing may be use ful: qual i ty im prove ment pro grammes, pre-ven tion of in fec tions, and cost ra tio nal i sa tion pro grammes.Look ing ahead: To rem e dy the lack of in for ma tion and to en sure the per-ma nence of qual i ty func tions in HCO’s, stud ies must be car ried out to mea-sure the cost of the main de fi cien cies, the cost of in vest ing in qual i ty.

0588

Health Sys tems and Fi nanc ing Chal lenges in New Ac ces sion Coun triesPrek er A. (World Bank)

A group of ECA coun tries have re cent ly been ad mit ted to the EU and oth ers are lined up to join. Al though the EU char ter has few spe cif ic pro-

Eur J Health Econom Suppl 1 · 2006 | S79

vi sions on health broad er Eu ro pean leg is la tion have a sig nif i cant im pact on the health sec tor of the new ac ces sion coun tries. This pa per re views the course of health care re forms in the ac ces sion coun tries and chal-lenges faced by the new mem bers in mod ern iz ing their health sys tems and health care fi nanc ing.

0284

Sur gi cal vol ume-out come eff ectsRaik ou M. (Lon don School of Eco nomics, Lon don, UK)McGuire A.

There is a wide ly held view that as sur gi cal vol ume in creas es there is an im prove ment in out come. There are two pos si ble ex pla na tions for this ef fect; a learn ing by do ing ef fect and a se lec tive re fer ral ef fect, where by hos pi tals with bet ter out comes re ceive high er re fer rals. The em pir i cal lit er a ture on the sub ject is mixed how ev er. In this pa per a com pet ing risks mod el, with shared frailty to con trol for un ob serv able pa tient het-ero ge ne ity, is de vel oped us ing lon gi tu di nal data over the pe ri od 1989 to 2002 for pri ma ry hip re place ment (ap prox. 50,000 in ci dent cas es) and pri ma ry knee re place ment (ap prox. 20,000 in ci dent cas es). The mul ti-ple out comes are de fined as with in hos pi tal mor tal i ty, 30-day mor tal i ty, 1-year mor tal i ty and re-ad mis sion for re vi sion. Fixed ef fects are used to con trol for se lec tive re fer ral ef fects, al low ing anal y sis to con cen trate on the learn ing by do ing hy poth e sis. By link ing the pa tient lev el data to an oth er data set con tain ing hos pi tal re source in for ma tion it is pos si-ble to con trol for vary ing sur gi cal in put lev els. A small but sig nif i cant learn ing by do ing ef fect is cal cu lat ed for both pro ce dures im ply ing that the vol ume-out come re la tion ship is dom i nat ed by the se lec tive re fer ral ef fect. A squared vol ume ef fect is found to be sig nif i cant in di cat ing an up per bound to the learn ing by do ing ef fect.

0115

Anal y sis of the age ing im pact of phar ma ceu ti cal ex pen di ture in ItalyRat ti M. (Uni ver si ty of Rome Tor Ver ga ta, Roma, Italy)Polis te na B., Span donaro F.

Fore wordI taly, ac cord ing to IS TAT the el der ly peo ple will con sti tute the 34% of the to tal in hab i tants in 2050. pa tient’s age is very im por tant in the al lo ca tion of per cap i ta phar ma ceu ti cal pub lic ex pen di ture from 38,7 euro for child un til four year pro gres sive ly to climb up to 585,9 euro for the pa tients with age above than the 75 years. In to tal the pop-u la tion with more than 65 year in clude 60% of the ex pen di ture and pre-scrip tion in Italy.of the studyaim of the work is to es ti mate the age ing im pact on the Ital ian phar ma ceu ti cal pub lic and pri vate ex pen di ture.mul ti var ied fore cast mod el has been con struct, on the re gion al pan el data. The led anal y sis to put in ev i dence the crit i cal as pect to the age-ing, be sides to eval u ate the ef fect of the phar ma ceu ti cal and in dus tri al poli cies. In par tic u lar, we eval u ate the ef fects of the re cent reg u la tion re ferred to the phar ma ceu ti cal sec tor like dif fer ent sys tem of price re duc-tion, in tro duc tion co pay ment and lim i ta tion to the pre scrip tions, whose ef fect are to be dis cuss.

0345

The long run pro duc tiv i ty de vel op ment in Finnish pri ma ry care and its cor re latesRäty T. (Gov ern ment In sti tute for Eco nom ic Re search (VATT), Helsin ki, Fin land)Lu o ma K., Aal to nen J., Järviö M.L.

We mea sure pro duc tiv i ty chang es of pri ma ry care in Fin land as a ra tio of key ser vices pro duced and real op er at ing costs. It is nec es sary to

im prove this mea sure in or der to slow down the ex pect ed fu ture growth in to tal health care ex pen di ture. Our data cov er all the health cen tres that pro duced both in pa tient and out pa tient care in 1997–2003. We use the new ly de vel oped tech niques to cor rect asymp tot ic bias in non-para-met ric ef fi cien cy scores and boot strap the con fi dence in ter vals for the ex plana to ry mod el pa ram e ter es ti mates. The bias es ti mate of ef fi cien-cy scores is on av er age 2.8%, the amount with which the reg u lar scores over es ti mate ef fi cien cy. The av er age pro duc tiv i ty de clined 13.7% over the whole pe ri od; the re sult is in sen si tive to es ti mat ed bias. Even if the stan dard para met ric con fi dence in ter vals do not gen er al ly ap ply when ef fi cien cy scores are re gressed, our boot strapped in ter vals are al most equal to para met ric ones. Of the cor re lates used the in creased mu nic i-pal tax es ac count ed for 3% of the pro duc tiv i ty in crease. The cor re lates, that are ex pect ed to de crease the need of pri ma ry care ser vices, have had neg a tive im pact on pro duc tiv i ty, im ply ing that health cen tres have not been able to ad just their ex pen di tures cor re spond ing ly. The or gan-i sa tion al chang es that have tak en place with in pri ma ry care have not re sult ed in the de sired pro duc tiv i ty im prove ments.

0376

Full eco nom ic eval u a tions of di ag nos tic stra te gies: a sur vey of pu bli ca tions iden ti fi ed us ing the NHS Eco nom ic Eval u a tion Database (NHS EED)Re dekop K. (Eras mus MC, In sti tute for Med i cal Tech nol o gy As sess ment, Rot ter dam, Nether lands)

Ob jec tive: To con duct a lit er a ture sur vey of pub lished full eco nom ic eval u a tions (EEs) of di ag nos tic stra te gies and con sid er im pli ca tions for the fu ture.Meth ods: Pu bli ca tions from 1995–2004 were iden ti fied us ing the NHS EED database (York, UK). Var i ous study char ac ter is tics were ex am ined and chang es over time were test ed.Re sults: 612 EEs were iden ti fied, in volv ing var i ous dis eases (most fre-quent: neo plasms (27%), di ges tive dis eases (16%), bac te ri al in fec tions/my coses (13%)). A slight in crease in cost-util i ty anal y ses was seen (6% (1995–99), 13% (2000–2004), p=0.010). Amongst 391 stud ies ex am in-ing only di ag nos tic in ter ven tions, ben e fit was based pri mar i ly on di ag-nos tic/clin i cal out comes (43%), and sel dom on QALYs (9%). Mod elling was fre quent (usu al ly de ci sion mod els), and use in creased over time (34% (1995-99), 44% (2000– 2004), p=0.006). Dis cus sion: Most eco nom ic eval u a tions of di ag nos tic stra te gies still base ben e fit on di ag nos tic or clin i cal out comes. While in cor po ra tion of health out comes and mod elling is favourable, com plex i ty of the study in creas es, ne ces si tat ing greater vig i lance about the qual i ty of the study. The NHS EED and sis ter pro jects (EU RON HEED, CODECS) help not only to iden ti fy rel e vant pu bli ca tions but also to ap praise their qual i ty. Au ton o mous de vel op ments (STARD state ment for re port ing di ag nos tic stud ies, sys tem at ic re views) should also im prove qual i ty of pu bli ca tions and pro vide bet ter es ti mates of di ag nos tic ac cu ra cy.

0245

The Care QolBrouw er W. (De part ment of Health Pol i cy and Man age ment Uni ver si ty Rot ter dam, Nether lands)Re dekop K., Brouw er WBF., Exel NJA., Gorp B.

The so ci etal per spec tive in eco nom ic eval u a tions dic tates that costs and ef fects of in for mal care are in clud ed in the anal y ses. How ev er, this in cor po ra tion de pends on prac ti cal ly ap pli ca ble, re li able and valid meth-ods to reg is ter the im pact of in for mal care. Wethe con cep tu al i sa tion and a first test of the Care Qol in stru ment, aimed at mea sur ing care-re lat ed qual i ty of life in in for mal care givers. The in stru ment com bines the in for ma tion den si ty of a bur den in stru ment (en com pass ing sev en im por tant bur den di men sions) with acom po nent (a VAS scale for hap-

S80 | Eur J Health Econom Suppl 1 · 2006

pi ness). in stru ment was test ed in a Dutch sam ple of het ero ge ne ous care-givers (n=175) ap proached through re gion al care giv er sup port cen tres. This first test de scribes the fea si bil i ty as well asand clin i cal va lid i ty of the Care Qol in stru ment. The sev en bur den di men sions re lat ed well with dif-fer ences in VAS scores. In all in stances, the av er age Care Qol-VAS scores de creased as the sever i ty of prob lems in creased. Mul ti var i ate anal y ses showed that the sev en bur den di men sions ex plained 37% to 43% of the vari a tion in Care Qol-VAS scores, de pend ing on the mod el used. The Care Qol seems a promis ing new in stru ment to reg is ter the im pact of in for mal care givers in eco nom ic eval u a tions.

0507

An as sess ment of the abil i ty of con tin gent val u a tion (CV) to elic it pa tients’ pref er ences for the or ga ni sa tion of home care: the case of blood trans fu sion (BT).Re mon nay R. (GRE SAC Cen tre Leon Be rard, Lyon, France)Morelle M., De vaux Y., Car rere MO.

Ob jec tive: The pur pose of this pi lot study was to test the abil i ty of CV to elic it can cer pa tients’ pref er ences for BT, ei ther at home or in the hos pi tal. Meth ods: All pa tients re ceiv ing BT were en rolled in a prospec tive study, in 2002. In face to face in ter views, there were asked if a fu ture BT was nec es sary, (1) whether there would pre fer to re ceive it at home or in the hos pi tal, (2) what they would be will ing to pay (WTP) and (3) will ing to ac cept (WTA), for their pre ferred trans fu sion place. A bid ding al go-rithm with two dif fer ent first bids was used. Var i ous pa tients’ data was col lect ed: pre vi ous ex pe ri ence of can cer care, per son al char ac ter is tics, qual i ty of life... Re sults: Forty-four pa tients were en rolled and forty ac cept ed to par tic i-pate. Of 40 pa tients, 32 (80%) ex pressed a pref er ence for home BT. On the sam ple of 32 pa tients, no protest re sponse was ex pressed for WTP, where as most WTA re spons es were protest re spons es. WTP was re lat-ed to some so cio-de mo graph ic char ac ter is tics (house hold in come, dis-tance from hos pi tal, stage of dis ease...). We also ob served a first bid bias. Con clu sion: The use of WTP seems ap pro pri ate for elic it ing pa tients’ pref er ences in this con text, con trary to WTA. These re sults should be con firmed on a larg er sam ple of pa tients who are be ing en rolled.

0608

Eco nom ic as sess ment of in no va tion in ra dio ther a py: im pact of FDG PET scan on treat ment de ci sion and tar get vol ume in lung can cer and Hodg kin’s dis easeRe mon nay R. (GRE SAC Cen tre Leon Be rard, Lyon, France)Morelle M., Gi ammar ile F., Car rie C., Car rere MO.

Con text: PET scan is an in no va tive im ag ing tool. As so ci at ed with to mod en sit o m e try (TDM), it al lows a bet ter def i ni tion of the ra di a tion treat ment, com pared with TDM only.Ob jec tive: To as sess the ef fects of Pet scan on re source al lo ca tion (costs and sav ings) and on the choice of the fol low ing treat ment.Meth od: In 2004 and 2005, 209 pa tients were en rolled (97 pa tients with Hodg kin’s dis ease and 112 with non small cell lung can cer) in a na tion-al, prospec tive, non ran dom is ed study con duct ed in 8 hos pi tals. Two treat ment de ci sions made on the ba sis of TDM only or on PET scan, were com pared.The di rect med i cal cost of us ing PET scan was as sessed by mi cro-cost-ing, us ing data col lect ed from spe cif ic ques tion naires. The costs of new ex ams and the costs and sav ings as so ci at ed with chang es in the cho sen treat ment were cal cu lat ed on the ba sis of re im burse ment rates.Re sults: The mean cost of us ing PET scan, cor re spond ing to an ex tra cost, was ap prox i mate ly 800 € (50% for FDG). Treat ments were mod-i fied for only 10% of pa tients with Hodg kin’s dis ease with a mi nor

im pact on costs, ver sus 40% of pa tients with lung can cer with a re duc-tion in mean cost of more than 500 €.Dis cus sion – Con clu sion: The use of PET scan for ra dio ther a py de ci-sion-mak ing seems more ef fec tive for lung can cer than for Hodg kin’s dis ease, both in terms of costs and out comes. This re sult might help pol-i cy mak ers for pri ori ti sa tion.

0591

Im pact of NICE on up take and diff u sion of new drugs: em pir i cal studyAtun R.A. (Im pe ri al Col lege Lon don, Cen tre for Health Man age ment, Lon don, UK)Dan tas A., Gurol-Ur gan ci I.

Back ground: Health tech nol o gy as sess ment is in creas ing ly used in health sys tems to in form re im burse ment de ci sions and guide health-care pro fes sion als about clin i cal and cost ef fec tive ness of new drugs and tech nolo gies. How ev er, few em pir i cal stud ies ex ist to demon strate the ef fect of or ga ni za tions such as NICE on the up take and dif fu sion of in no va tions. Avail able stud ies have fo cused on the ex tent of and prob-lems re gard ing the im ple men ta tion of NICE guid ance, us ing a va ri ety of tech niques such as de scrip tive anal y sis, be fore-and-af ter stud ies, in ter-rupt ed time se ries and sur veys. There is a need to ex plore whether NICE guid ance has suc ceed ed or had a del e te ri ous ef fect in im prov ing pa tient ac cess to cost-ef fec tive and in no va tive drugs.Meth ods: The im pact of NICE guid ance on the num ber of pre scrip tions for drugs in sev en drug class es (ACE In hibitors, Alz hei mer’s, Anti-ag gre-gants, Beta-block ers, Cox II In hibitors, Di a be tes, Obe si ty) were anal y-sed us ing pan el data re gres sion meth ods, con trol ling for cost per unit and var i ous de mand side char ac ter is tics, such as dis ease prev a lence and num ber of hos pi tal con sul ta tions. Quar ter ly data cov ers Eng land, for the pe ri od April 2000 to March 2005. Re sults: Anal y sis shows that pre scrip tion lev els are in flu enced by prev-a lence lev els, re spec tive health util i sa tion mea sures for the dis ease cat e-gories and a lin ear time trend. The im pact of NICE guid ance is in signif-i cant. Con clu sions: NICE in ter ven tions have lim it ed suc cess in in creas ing pre scrib ing lev els for cost-ef fec tive drugs. Pre scrib ing for cost-ef fec tive drugs in Eng land strict ly fol lows de mand.

0326

A com par i son of the re source use, costs and health out comes of en dovas cu lar coil ing ver sus sur gi cal clip ping of sub arach noid aneurysms in the UKRivero-Arias O. (Health Eco nomics Re search Cen tre, Uni ver si ty of Ox ford, Unit ed King dom)Wol sten holme J., Gray A., Molyneux A., Kerr R.

Back ground: The In ter na tion al Sub arach noid An eu rysm Tri al (ISAT), a multi na tion al clin i cal tri al in clud ing eight Eu ro pean coun tries, has re cent ly shown that en dovas cu lar coil ing yields bet ter health out comes at one year than neu ro sur gi cal clip ping for the treat ment of rup tured in tra cra ni al aneurysms. How ev er, data on cost-ef fec tive ness have not been re port ed for any of the coun tries par tic i pat ing in the tri al. Ob jec-tive: To per form an eco nom ic eval u a tion of en dovas cu lar coil ing com-pared to neu ro sur gi cal clip ping us ing data col lect ed along side ISAT for the UK set ting.Meth ods: 2143 pa tients in 11 coun tries with rup tured in tra cra ni al aneurysms were ran dom is ed to coil ing (n=1073) or clip ping (n=1070). Di rect health ser vices re source use and em ploy ment-re lat ed data were col lect ed prospec tive ly along side the study. Mul ti level mod elling was used to an a lyse re source use data be cause of its in ter na tion al na ture. A de tailed cost ing anal y sis was per formed in the sub-sam ple of 1644 UK pa tients to val i date the over all re sults achieved by the mul ti level mod-

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el. Ef fec tive ness data will be ex pressed as life years and qual i ty ad just-ed-life years. The eco nom ic eval u a tion will be pre sent ed as with in tri al anal y sis up to two years fol low-up. Re sults: The en dovas cu lar in ter ven tion was more ex pen sive than neu-ro sur gery due to the costs of coils. How ev er, these costs were off set by the lon ger in pa tient length of stay of pa tients in the neu ro sur gery group. The mean (SD) over all to tal cost per pa tient at 24 months fol low-up was es ti mat ed to be £16199 (£14635) and £17643 (£17711) in the en dovas cu lar and neu ro sur gery groups re spec tive ly, a non sig nif i cant dif fer ence of –£1444 with as so ci at ed 95% non para met ric con fi dence in ter val from –£3191 to £389. These re sults will be pre sent ed with ef fec-tive ness data to pro vide with in tri al in cre men tal anal y sis es ti mates at 24 months fol low-up.Con clu sion: En dovas cu lar coil ing ap pears to have slight ly but not sta tis-ti cal ly sig nif i cant low er costs than neu ro sur gery at 24 months fol low-up. The fi nal with in tri al eco nom ic anal y sis will pro vide use ful in for ma tion for de ci sion mak ers in UK as well as oth er coun tries in Eu rope.

0351

Eval u a tion: Stat ic or dy nam ic? Does it mat ter how we mod el the cost-eff ec tive ness of chla myd ia screen ing?Rob erts T. (Health Eco nomics Fa cil i ty of Birm ing ham, UK)Bar ton P., Rob in son S., Bryan S., Low N.

The ap pro pri ate ness of dif fer ent mod elling ap proach es to use in eco-nom ic eval u a tions of in fec tious dis eases such as chla myd ia is be com-ing in creas ing ly con tro ver sial. In a re cent sys tem at ic re view we found that the ma jor i ty of eco nom ic eval u a tions on Chla myd ia screen ing used de ci sion an a lyt ic mod els, re ferred to as ‘stat ic’ be cause they as sume a con stant force of in fec tion. Very few stud ies had used a trans mis sion ‘dy nam ic’ mod el, in cor po rat ing the ef fects on screen ing out comes of on go ing trans mis sion of in fec tion in the pop u la tion. The is sue is con tro-ver sial: some ex perts ar gue that stat ic mod els give bi ased re sults of the im pact of screen ing, while oth ers be lieve that a sim ple stat ic ap proach is ad e quate, avoid ing the com plex i ties of dy nam ic mod elling.We com pared the re sults of eco nom ic eval u a tions us ing iden ti cal data in both dy nam ic and stat ic mod els. The Chla myd ia Screen ing Stud ies (ClaSS) pro ject in the UK in ves ti gat ed pop u la tion screen ing and gen er at-ed em pir i cal data. We eval u at ed the cost-ef fec tive ness of this screen ing ap proach us ing dis crete event sim u la tion: a dy nam ic mod el: In a par al-lel eval u a tion we are now con duct ing a stat ic de ci sion anal y sis, which uses iden ti cal data as far as pos si ble. The full ex tent of the dif fer ences, if any, in the re sults of the two ap proach es will be pre sent ed and dis-cussed in July 2006.

0348

Test-retest Re li abil i ty of Time Trade off and Per son Trade Off Rob in son S. (Health Eco nomics Fa cil i ty of Birm ing ham, UK)Bryan S., Free man T.

Eco nom ic anal y sis is in creas ing ly be ing em ployed in for mal re source al lo ca tion de ci sion-mak ing pro cess es in health care. The con se quence is that the meth ods be ing em ployed by eco nom ic an a lysts are in creas ing-ly sub ject to close scruti ny. One such area of meth o dol o gy con cerns the in stru ments used to elic it pref er ences for var i ous health states for use in the con struc tion of qual i ty-ad just ed life years (QALYs). There are a num ber of tech niques, which can be used to elic it pref er ences with dif-fer ent tech niques pro duc ing dif fer ent re sults. The ob jec tive of this study is to ex plore the test-retest re li abil i ty of two tech niques Time Trade Off (TTO) and Per son Trade Off (PTO). study con ducts a re view of the lit er-a ture on test-retest re li abil i ty of health state val u a tion tech niques. It also re ports the re sults of an em pir i cal study which anal y sed the test-retest re li abil i ty of both TTO and PTO val u a tions col lect ed by a gen er al pop-

u la tion postal sur vey. to tal of 798 re spon dents re turned ques tion naires. The in tra class cor re la tion co ef fi cients ranged from 0.32-0.84 for TTO and, 0.17 : 0.82 for PTO, with the ma jor i ty of co ef fi cients be ing >0.50. The health states with low co ef fi cients var ied be tween tech niques. The re li abil i ty co ef fi cients var ied be tween tech niques and health states, with the TTO tech nique tend ing to pro duce high er co ef fi cients.

0349

A qual i ta tive in ves ti ga tion to ex plore the va lid i ty of the vi su al an a logue scale, time trade off and per son trade off tech niquesRob in son S. (Health Eco nomics Fa cil i ty of Birm ing ham, UK)Free man T., Bryan S.

There are a num ber of tech niques that can be used to elic it in di vid u al’s health state pref er ences, with dif fer ent tech niques of ten yield ing dif fer-ent re sults. There has been very lit tle re search around the cog ni tive pro-cess which re spon dents un der take in or der to reach their val u a tions. this study, qual i ta tive meth ods were used to pro vide a greater un der-stand ing of the pro cess in di vid u als use and the ex pe ri ence they face when par tic i pat ing in health state val u a tion ex er cis es. Semi struc tured in ter views were un der tak en with re spon dents who had par tic i pat ed in an ear li er health state val u a tion ex er cise which in volved valu ing health states us ing the Vi su al An a logue Scale (VAS), Time Trade Off (TTO) and Per son Trade of Tech niques. in ter views ex plored a num ber of ar eas that are rel e vant to as sess ing the va lid i ty of the in stru ment and pro cess of elic i ta tion. The PTO ex er cise was gen er al ly re ferred to as the most dif fi cult of the three ex er cis es. Re spon dents ex pe ri enced more dif fi cul-ty valu ing the lives of oth ers, as in PTO, rather than valu ing time for them selves i.e. life years in TTO. There was ev i dence that some re spon-dents were em ploy ing heuris tics (cog ni tive short cuts) in or der to sim-pli fy the de ci sion mak ing pro cess. The im pli ca tions of these and oth er find ings were also ex plored.

0487

Do mem bers of the pub lic wish to give more weight to some QALYs than oth ers?: Re sults of pi lot stud ies.Rob in son A. (Uni ver si ty of East An glia, Nor wich, UK)Bak er R., Bate man I., Don ald son C., Loomes G., Pin to J.L., Ryan M., Shack ley P., Smith R., Sug den B.

The Na tion al In sti tute for Health and Clin i cal Ex cel lence (NICE) makes rec om men da tions to the NHS on the adop tion (or con tin u a tion) of ther a pies. This re quires judge ments about whether the val ues/weights at tached to gains in qual i ty and length of life should vary ac cord ing to the char ac ter is tics of the pa tients re ceiv ing them, and how much the NHS should be spend ing (at the mar gin) to achieve such gains. This pa per dis cuss es an on go ing re search pro ject that sets out to in form such judge ments. One aim of the pro ject is to es ti mate the rel a tive weights to be at tached to a qual i ty ad just ed life year (QALY) ac cord ing to the type of gain (for ex am ple, life ex tend ing ver sus qual i ty of life en hanc-ing) as well as the char ac ter is tics of the re cip i ents of these gains. We re port the re sults of pi lot stud ies car ried out us ing both ‘match ing’- or per son trade off- and dis crete choice ap proach es pri or to con duct ing val-u a tion stud ies in rep re sen ta tive pop u la tion sam ples. Re sults show that mem bers of the pub lic can un der stand com plex in for ma tion con cern-ing QALY gains when those gains are rep re sent ed di a gram mat i cal ly and are will ing to dif fer en ti ate be tween ‘types’ of QALYs. We also re port the progress of the main study, in volv ing 600 mem bers of the pub lic, due to com mence in spring 2006.

S82 | Eur J Health Econom Suppl 1 · 2006

0539

From a case mix ad just ed bud get al lo ca tion with in a na tion al hos pi tal ser vice into a US type Prospec tive Pay ment Sys tem to cre ate mar ket com pe ti tion?Ro drigues J.M. (Uni ver si ty of Saint-Eti enne, France)

If the first DRG pi lot tests were pro cessed 21 years ago (1983) in France, the real im ple men ta tion be gan only 7 years ago (1997) with a mod est DRG/GHM ad just ed bud get ing based on re dis tri bu tion of re sources be tween and with in France 22 re gions. Dur ing the 2003 fall the French gov ern ment passed a new fund ing act in the house fore cast ing a PPS like pay ment for pub lic hos pi tals start ing in 2004 and ex pect ed to reach 50 % of the to tal re sources based on re im burse ment to in tro duce mar-ket com pe ti tion be tween pub lic and pri vate for prof it hos pi tals us ing the French DRG sys tem named GHM in 2012 The pa per re calls the DRG/GHM bud get al lo ca tion with in the French na tion al hos pi tal ser-vice ap plied from 2007 and 2003, the ap proved new PPS sys tem for the com ing years and the back ground of the 2 con tra dic to ry health care re forms of 1996 and 2004. It ad dress es the or ga ni za tion al and cul tur al suc cess fac tors for this new stage for the French DRG PMSI pro ject by iden ti fy ing the char ac ters and pro cess es of the French health care frag-men ta tion and of po lit i cal sys tem sup port ing the so cial mod ern iza tion the o ry of en light ened despo tism pro posed dur ing the XVI II cen tu ry by Voltaire for the King of Prus sia, the Em press (Tsa ri na) of Rus sia and the King of France be fore the French rev o lu tion

0030

Are fi xed-term jobs bad for your health? A com par i son be tween Spain and Ger manyRomeu Gor do L. (Max Planck In sti tute for Hu man De vel op ment, Ber lin, Ger many)Gash V., Mertens A., Gor do L.R.

In this pa per we an a lyse the health ef fects of fixed-term con tract sta-tus for men and wom en in West-Ger many and Spain us ing pan el data. This pa per asks whether chang es in the em ploy ment re la tion ship, as a re sult of the lib er al i sa tion of em ploy ment law, have al tered the pos i tive health ef fects as so ci at ed with em ploy ment (Gold smith et al. 1996; Ja ho-da 1982). Us ing in for ma tion on switch es be tween un em ploy ment and em ploy ment by con tract type we an a lyze whether tran si tions to dif fer-ent con tracts have dif fer ent health ef fects. We find that un em ployed work ers show pos i tive health ef fects at job ac qui si tion, and also find the pos i tive ef fect to be small er for work ers who ob tain a fixed-term job. We also es tab lish sur pris ing dif fer ences by gen der and coun try, with wom en less like ly to re port pos i tive health ef fects on job ac qui si tion in Spain.

0005

Effi cien cy ver sus qual i ty in the Por tuguese NHSGi raldes M.R. (Gen er al Di rec torate for Health Min istry of Health, Lis bon, Por tu gal)

The ob jec tive of this pa per is to pres ent the meth o dol o gy used in the eval u a tion of the Por tuguese NHS in an ef fi cien cy and qual i ty per spec-tive. A com pos ite Ef fi cien cy and Qual i ty In di ca tor has been used, which in clud ed ef fi cien cy in di ca tors re lat ed with the main hos pi tal ac tiv i ties (in pa tient care, out pa tient care, day-hos pi tal and emer gen cy care) and with the aux il ia ry sec tions of clin ic sup port and the ho tel sup port ser-vices, weight ed ac cord ing to the rel e vance of its ex pen di ture in to tal ex pen di ture, and qual i ty in di ca tors. In a qual i ty per spec tive two pro cess in di ca tors, the per cent age of surg eries in am bu la to ry care and of ce sar i-ans in to tal de liv er ies and an out come in di ca tor, the num ber of episodes of in pa tient care due to no so co mi al in fec tion in to tal days of in pa tient

care, have been con sid ered. A case-mix in dex has also been con sid ered to cor rect all the in di ca tors used in the com pos ite in di ca tor of ef fi cien-cy. The com pos ite Ef fi cien cy and Qual i ty In di ca tor re sult ed from the mean of the Com pos ite In di ca tor of Ef fi cien cy and the Com pos ite In di-ca tor of Qual i ty, this last one in an in verse ba sis. The re sults should be com pared only for hos pi tals with in the same group of hos pi tals, with a sim i lar num ber of beds and of treat ed pa tients. Al cobaça (Group I), San-to Tir so (Group II), Por ti mao (Group III), San tarém (Group IV), Uni-ver si tary Hos pi tal of Coim bra (Group V), and the Gama Pin to In sti tute (Group VI) are the most ef fi cient and with bet ter qual i ty.A sim i lar meth o dol o gy has been ap plied to the health cen tres.

0432

The im pact of EU anti dis crim i na tion reg u la tion on pri vate sup ple men tary health in sur ance in Ger many. Will uni sex tar iff s be come manda to ry?Roth gang H. (Cen tre for So cial Pol i cy Re search, Uni ver si ty of Bre men, Ger many)

The EU Coun cil Di rec tive 2004/113/EC of 13 De cem ber 2004, which has to be im ple ment ed into na tion al law with in 3 years, rules that from De cem ber 21st 2006 on wards, sex as a fac tor in the cal cu la tion of pre-mi ums is only per mit ted where the use of sex is a de ter min ing fac tor in the as sess ment of risk based on rel e vant and ac cu rate ac tu ar i al and sta-tis ti cal data. It is up to in sur ance in dus try to prove this. More over, any sex dif fer en ti a tion of pre mi ums based on preg nan cy and ma ter ni ty is for bid den. this pa per for the first time re spec tive cal cu la tions for Ger-many are pre sent ed, us ing cost pro file data from both pri vate and pub lic health in sur ance and life ta bles used by pri vate in sur ance com pa nies. As the cal cu la tions demon strate, high er pre mi ums for wom en can be jus ti-fied ac tu ar i al. How ev er, sex-based dif fer ences in costs van ish if costs of preg nan cy and ma ter ni ty are ex clud ed. Thus, uni sex tar iffs be come nec-es sary. tar iffs, how ev er, bear dan gers with re spect to cream skim ming by in sur ance com pa nies and ad verse se lec tion be hav iour by men. Thus, a risk equal i sa tion scheme is sug gest ed which guar an tees both, equal pre-mi ums for men and wom en to pay, but sex-spe cif ic pre mi ums for in sur-ance com pa nies to re ceive.

0134

Health, hu man cap i tal and the in ter gen er a tional trans mis sion of pov er tyRun go P. (A Coruna Uni ver si ty, A Coruna, Spain)Cur rais L., Rivera B.

This Pa per de vel ops a the o ry of fer til i ty and choice be tween in vest ment in ed u ca tion and health-re lat ed spend ing. Fer til i ty dif fer en tial are gen er-at ed by the as sump tion that par ents’ pro duc tiv i ty as teach ers in creas es with their own hu man cap i tal. The ex is tence of a fixed time-cost of rear-ing a child de ter mines a trade-off be tween quan ti ty and qual i ty of chil-dren. Qual i ty (hu man cap i tal) de pends both on ed u ca tion and phys i cal sta tus, which may be con trolled by par ents through health-re lat ed spend-ing (nu tri tion). Tak ing into ac count the ef fects of health on hu man cap i-tal, the mod el shows that a min i mum phys i cal sta tus is nec es sary be fore par ents op ti mal ly choose to in vest in ed u ca tion. Fur ther more, health-re lat ed spend ing above cer tain lev el, even with no in vest ment in ed u ca-tion, may lead an econ o my to a high hu man cap i tal and low fer til i ty equi-lib ri um. The mod el also gen er ates a pov er ty trap re lat ed with a low lev-el of hu man cap i tal and a con se quent in suf fi cient ex pen di ture in nu tri-tion and health-re lat ed spend ing.also test the role of health sta tus in the in ter gen er a tional trans mis sion of pov er ty. We use the Na tion al Health Span ish Sur vey in or der to link the health sta tus of chil dren and their fu ture in come with the health sta tus and hu man cap i tal of par ents. We find strong ev i dence that sup port the the o ret i cal find ings.

Eur J Health Econom Suppl 1 · 2006 | S83

0418

In di vid u al health ex pen di ture and in comeRuz Tor res R. (De part ment of Ap plied Eco nomics, Uni ver sité Li bre de Brux elles, Brus sels, Bel gium)

The cur rent Bel gian risk ad just ment for mu la is based on in di vid u al data. Dif fer ent so cio-eco nom ic sta tus vari ables are in clud ed. Be cause it was not avail able for ev ery in di vid u al, in come is not, in come is gen er al ly seen as an in di ca tor of abil i ty to ad dress the need for health ex pen di ture, and as a fac tor in in flu enc ing health sta tus. The hy poth e sis, there fore, is that in come and health ex pen di tures are re lat ed. use cross-sec tion al in di vid u al data for 1998 to ex plore the re la tion ship be tween in come and health ex pen di tures. Anal y sis of the resid u als of the re gres sion used in the risk ad just ment scheme re veals a non lin ear re la tion ship with in come. The cur rent risk ad just ment mod el’s pre dic tions un der es ti-mate health ex pen di tures for low in come in di vid u als. The mod el is also less pre cise for low in come in di vid u als, sug gest ing that mor bid i ty re lat-ed vari ables are mis sing.a risk ad just ment set ting, these find ings im ply in cen tives for the in sur ers to risk se lect against low in come in di vid u als. The cur rent risk ad just ment mod el needs im prove ment, by re fin ing the so cio-eco nom ic vari ables in clud ed, and by adding di ag nos tic-re lat ed vari ables.a risk ad just ment set ting, these find ings im ply in cen tives for the in sur ers to risk se lect against low in come in di vid u als. The cur rent risk ad just ment mod el needs im prove ment, by re fin ing the so cio-eco-nom ic vari ables in clud ed, and by adding di ag nos tic-re lat ed vari ables.

0090

Ac count ing for diff er ences be tween EQ-5D and SF-6D scores in a sam ple of the gen er al pop u la tionSach T. (Uni ver si ty of Not ting ham, Uni ver si ty Park, Not ting ham, Unit ed King dom)Bar ton GR.

Ob jec tive: To iden ti fy when, and to what ex tent, the EQ-5D and SF-6D give dif fer ent util i ty es ti mates.Meth ods: In for ma tion on six per son al char ac ter is tics (age, gen der, eth-nic i ty, smok ing sta tus, body mass in dex and oc cu pa tion al skill lev el), ten health con di tions (back pain, hip pain, knee pain, heart dis ease, stroke, asth ma, can cer, di a be tes, rheu ma toid ar thri tis and os teo ar thri-tis), the EQ-5D and SF-6D was re quest ed from 2770 pa tients aged ≥45 years in one gen er al prac tice. Re gres sion anal y sis was used to es ti mate vari a tion in the dif fer ence be tween the EQ-5D and SF-6D scores, the six per son al char ac ter is tics and ten health con di tions act ed as ex plana-to ry vari ables.Re sults: The EQ-5D es ti mat ed the mean util i ty of pa tients in the best health state (with the most favourable per son al char ac ter is tics and none of the ten health con di tions) to be 0.096 high er than the SF-6D. Con-verse ly, com pared to the SF-6D, the EQ-5D es ti mat ed the mean loss in util i ty as so ci at ed with back pain, hip pain, knee pain and os teo ar thri tis to be sig nif i cant ly (p<0.01) greater, and the mean util i ty of less heal thy pa tients to be up to 0.274 low er over all. Con clu sion: There is the po ten tial for the EQ-5D and SF-6D to give quite dif fer ent util i ty es ti mates, par tic u lar ly for in di vid u als at ei ther end of the health spec trum.

0208

Costs and ben e fi ts of nurs ing home careSadi raj K. (SEO Eco nom ic Re search of Ams ter dam, Nether lands)Kok L., Stevens J., Gameren E., Woit tiez I.

The pa per de scribes a cost-ben e fit anal y ses of nurs ing home as op posed to el der ly liv ing in their own home. The anal y sis is based on sur veys of

el der ly liv ing at home and el der ly liv ing in a nurs ing home. The sur vey con tains de tailed in for ma tion on the phys i cal and men tal dis abil i ties of the el der ly as well as de mo graph ic and so cial char ac ter is tics. The cost-ben e fit anal y sis re quires that the two groups have sim i lar char ac ter is tics. We achieve this by first, es ti mat ing a mod el that ex plains the prob a bil i-ty whether an el der ly lives at home or in a nurs ing home, giv en in di vid-u al’s (health, so cial and de mo graph ic) char ac ter is tics. Then we use this mod el to pre dict for each el der ly his/her pre ferred state. El der ly that ac tu al ly lived in a nurs ing home but were pre dict ed by the mod el as liv-ing at home is the com par i son group to the el der ly liv ing at home. We cal cu late for these two (com pa ra ble) groups pub lic health costs re lat ed to liv ing in a nurs ing home or at home, costs for the el der ly them selves (in clud ing dif fer ences in hap pi ness) and oth er so cial costs like rent sub-si dies and in for mal care. We con clude that nurs ing home care is much more ex pen sive for the so ci ety as a whole then the costs made for el der-ly liv ing at home. For the el der ly in di vid u als there is no sig nif i cant dif-fer ence in costs be tween the two groups.

0332

Pre dict ing hos pi tal length of stay and treat ment cost un der ca pac i ty con straintSaka O. (King’s Col lege Lon don, Di vi sion of Health and So cial Care Re search, Lon don, UK)McGuire A., Bonet M.J., Rudd A., Wofe C.

Length of stay is com mon ly tak en adopt ed as a per for mance mea sure with in the hos pi tal sec tor. How ev er length of stay may be an en dog e-nous vari able in flu enced by, for ex am ple, ca pac i ty con straints and dis-charge poli cies. This pa per mod els uses pa tient lev el data on stroke in a sur vival mod el to es ti mate the con di tion al length of stay in a stroke unit. The mod el anal y ses the in flu ence of the re spon sive ness of So cial Ser vices and/or pri ma ry care in mak ing ar range ments for dis charge and the fluc tu a tions in the num ber of beds avail able in the stroke unit on the prob a bil i ty of dis charge. The in flu ence of a num ber of fac tors, in clud ing chang es in dis charge fac tors (ca pac i ty, ear ly dis charge pol i cy, bed trans fers, so cial ser vice re spon sive ness and mor tal i ty rates) on the cost of run ning ser vices and the out comes is also as sessed. It is not ed that the prob a bil i ty of dis charge is cor re lat ed with fac tors be yond the con trol of the hos pi tal, such that dis charge pol i cy may be con sid ered part ly ex og e nous. There ap pears to be a wider vari a tion in dis charge prob a bil i ty the clos er a pa tient comes to end of hos pi tal stay, re flect ing an in creas ing un cer tain ty of place ment at the in di vid u al lev el for spe-cif ic case types.

0015

Tech ni cal Effi cien cy, Economies od Scale, Own er ship and Man age ment in The Brazil ian Hos pi tal Sys temSam paio de Sousa M.C. (Uni ver si dade de Brasília, Brazil)Proite A.

In this pa per, we es ti mate DEA (Data En vel op ment Anal y sis) tech ni cal ef fi cien cy scores for 1170 Brazil ian hos pi tals in clud ed in the SUS (Cen-tral Health Sys tem) us ing a re cent ly pro posed meth od that com bines boot strap and jack knife re sam pling to elim i nate the in flu ence of out-liers and pos si ble mea sure ment and record ing er rors in the data. We use the vari able re turns to scale vari ants of the DEA meth od. Af ter com-put ing the ef fi cien cy scores, we use quan tile re gres sion, to in ves ti gate the de ter mi nants of those scores. Our re sults con firm the im por tance of the scale ef fect (mea sured by the to tal num ber of ser vices) over the tech ni cal ef fi cien cy of this sec tor, con trolled by the av er age per ma nence in the hos pi tal, its av er age costs and hu man cap i tal vari ables. Re gard ing hos pi tal’s man age ment, we high light the neg a tive ef fects of non-prof it or ga ni za tions over the ef fi cien cy, which dif fers from the em pir i cal lit er-a ture. Ex ces sive spe cial iza tion also has a neg a tive ef fect over the ef fi cien-

S84 | Eur J Health Econom Suppl 1 · 2006

cy scores, point ing out the ex is tence of an op ti mal mix be tween spe cial-iza tion and gen er al iza tion hos pi tals’ char ac ter is tics. As for prop er ty, pri-vate hos pi tals have its per for mance neg a tive ly af fect ed for those units over the 30th ef fi cien cy quan tile, sug gest ing that mar ket fail ure ef fects are im por tant in this sec tor.

0420

So cial Cap i tal and Health in Eng land. Sas si F. (De part ment of So cial Pol i cy, Lon don School of Eco nomics and Po lit i cal Sci ence, Lon don, Unit ed King dom)

A grow ing body of lit er a ture sug gests that as pects of so cial cap i tal are strong ly as so ci at ed with health and heal thy lifestyles. How ev er, large-scale stud ies are of ten hin dered by the lim it ed avail abil i ty of valid and rel e vant mea sures of so cial cap i tal.pooled 2000-03 Health Sur vey for Eng land (HSE) data we as sessed the im pact of four di men sions of so cial cap i tal (trust, so cial sup port, in di vid u al and com mu ni ty par tic i pa tion in mem ber ship or gan i sa tions) on a range of health in di ca tors. de vel-oped a multi-lev el lo gis tic mod el, ac count ing for the con tri bu tion of in di vid u al and area-lev el vari ables (in clud ing dep ri va tion, in come dis tri-bu tion and res i den tial seg re ga tion) on per ceived health, psy cho-so cial health, lim it ing long-stand ing ill ness, and car dio vas cu lar dis ease. A nov-el em ploy ment-based in dex of so cial cap i tal (de rived from An nu al Busi-ness In quiry data) was used to as sess com mu ni ty par tic i pa tion in mem-ber ship or gan i sa tions. Oth er so cial cap i tal in di ca tors were drawn di rect-ly from HSE.so cial cap i tal ap pears more strong ly re lat ed to health than com mu ni ty so cial cap i tal. In both cas es, how ev er, the re la tion ship is not lin ear and health ap pears to im prove first and then de cline slight ly as so cial cap i tal reach es high er lev els. This may be con sis tent with an in verse re la tion ship be tween “bond ing” and “bridg ing” so cial cap i tal at such high lev els.

0198

Fi nanc ing Health Care in Ger manySauer land D. (WHL Grad u ate School of Busi ness and Eco nomics, Lahr, Ger many)

The on go ing po lit i cal dis cus sion about health care re forms to en sure a sus tain able fi nanc ing mode for health ex pen di tures is fo cused on two pro pos als: a statu to ry in sur ance with flat rate pre mi ums vs. a statu to ry in sur ance with in come re lat ed pre mi ums.Ob jec tives: This pa per of fers a pro jec tion of the fu ture de vel op ment of health care ex pen di tures in the Statu to ry Health In sur ance sys tem. It out lines the fi nanc ing bur den for the in sured in case of the two pro-pos als dis cussed. Meth ods: OLS re gres sions are used to find out the de ter mi nants of real per cap i ta SHI ex pen di tures. Based on the best long-run es ti ma tion, the de vel op ment of fu ture ex pen di tures is fore cast ed. Re sults: The fore cast shows an in crease in ex pen di tures to about 500 bill. € in the year 2040. The fore cast ed flat rate pre mi um goes up to about 700 € per cap i ta. In case of in come re lat ed pre mi ums, an an nu-al in crease in in come of about 4 per cent is nec es sary to en sure sta ble pre mi um rates.Con clu sion: The driv ing de ter mi nants of SHI ex pen di tures, i.e. a high-er in come, an age ing pop u la tion and the tech ni cal progress, are not changed by the dif fer ent ways of fi nanc ing dis cussed. How ev er, an on go-ing eco nom ic de vel op ment with low GDP growth rates will make the fi nanc ing bur den even high er.

0143

The Role of Com mu ni ty So cial Cap i tal in the Re duc ing the Prev a lence of Se ri ous Men tal Ill nessScheffl er R. (Uni ver si ty of Cal i for nia at Berke ley, USA)Brown T.T.

We show that lagged com mu ni ty so cial cap i tal is strong ly and in verse-ly re lat ed to the prev a lence of se ri ous men tal ill ness and also ex hibits strong di min ish ing re turns. We es ti mate a men tal health pro duc tion func tion, which con trols for sex, age, race/eth nic i ty, mar i tal sta tus, ed u-ca tion, and in di vid u al so cial cap i tal, as well as un ob served area-lev el het-ero ge ne ity us ing three years (1999–2001) of U.S. data on 48,222 adults. The pres ence of men tal health is mea sured us ing a valid and re li able in di ca tor of se ri ous men tal ill ness the Kessler K6. Our mea sure of com-mu ni ty so cial cap i tal is a new val i dat ed eco log i cal mea sure of com mu-ni ty so cial cap i tal, the Petris So cial Cap i tal In dex. We es ti mate that an in crease of 0.4% in com mu ni ty so cial cap i tal in se lect ed com mu ni ties would re duce the num ber of in di vid u als with se ri ous men tal ill ness in the U.S. by ap prox i mat ley 29,000.

0398

Se lec tion or in cen tive? An anal y sis of the eff ect of choice of health in sur ance de ductibles on phy si cian vis its us ing match ing tech niquesSchell horn M. (GSF – Na tion al Re search Cen ter for En vi ron ment and Health, In sti tute of Health Eco nomics and Health Care Man age ment, IGM, Neuher berg, Ger many)Gerfi n M.

In Switzer land, ba sic health in sur ance is manda to ry and each in di vid-u al is in sured sep a rate ly. The in sur ance pre mi um varies by re gion of res i dence but is in de pen dent of in come and risk. The in sured face a min i mal an nu al de ductible. An nu al ly, they are giv en a choice of high er de ductibles to re duce their in sur ance pre mi um by a reg u lat ed per cent-age. The choice of a high er de ductible sets in cen tives for a more cau-tious uti li za tion of health ser vices. Clear ly, the choice is made based on ex pect ed health ser vice uti li za tion. In this pa per, the ef fect of the choice of a high er than the min i mal de ductible on phy si cian vis its is an a lyzed. To dis en tan gle in cen tive from se lec tion ef fects we em ploy propen si ty score match ing tech niques for the choice of de ductible to con trol for the en do gene ity of this choice. We dif fer en ti ate be tween the ef fects of the de ductible on the prob a bil i ty and fre quen cy of pri ma ry care phy-si cian and spe cial ist vis its. We use data from the 2002 Swiss Health Sur vey which con tains in for ma tion on the rel e vant health, health care uti li za tion and in sur ance sta tus vari ables for the cur rent and pre vi ous year al low ing us to ad e quate ly mod el the choice of de ductible and sub-se quent phy si cian vis its. The main find ing is that about two thirds of the ob served low er uti li za tion for in di vid u als with a high in sur ance de ductible is caused by se lec tion ef fects. In cen tive ef fects have a big ger im pact on the prob a bil i ty of vis its than on their (con di tion al) fre quen-cy. Pre lim i nary find ings in di cate no sig nif i cant dif fer ence be tween pri-ma ry care phy si cian and spe cial ist vis its.

0307

The Glob al Health Fi nanc ing En vi ron mentSchieber G. (World Bank, Wash ing ton D.C., USA)Lan gen brun ner J.

This pre sen ta tion as sess es the glob al health fi nanc ing sit u a tion and its im pli ca tions for health re forms for the low and mid dle in come coun tries in the Eu rope Cen tral Asia (ECA) Re gion. The huge glob al in equities in dis ease bur den ver sus health spend ing, the dif fi cult trade-offs faced by coun tries in terms of pro vid ing uni ver sal ac cess to an es sen-

Eur J Health Econom Suppl 1 · 2006 | S85

tial pack age of ser vices as well as fi nan cial pro tec tion to their pop u la-tions, and the crit i cal fis cal and macroe co nom ic di men sions of scal ing up health sys tems are dis cussed. First, the glob al health fi nanc ing sit u a-tion is as sessed in terms of dis ease bur den and health ex pen di ture pat-terns. Sec ond, the im por tance of out-of-pock et spend ing, the need to im prove risk pool ing and meth ods for im prov ing risk pool ing are high-light ed. Third, the im por tance of ex ter nal as sis tance and the need to re form the in ter na tion al aid ar chi tec ture are as sessed. Fourth the im por-tance of fis cal space in or der to ac com mo date in creased spend ing is an a lyzed along with meth ods to in crease it. Fifth, the crit i cal epi demi-o log i cal, de mo graph ic, eco nom ic, and po lit i cal di men sions for health fi nanc ing re form poli cies in ECA low and mid dle in come coun tries are dis cussed.

0156

Co-pay ments and risk ad just mentVan de Vo orde C. (Catholic Uni ver si ty of Leu ven, Bel gium)Schokkaert E.

Out-of-pock et pay ments by pa tients play an im por tant role in the Bel-gian sys tem of com pul so ry health in sur ance (a) They are set by the cen-tral reg u la tor and dif fer en ti at ed for dif fer ent health care items with the pur pose of in flu enc ing pa tient be hav ior. This fea ture is ne glect ed in the risk ad just ment sys tem. (b) Weak er so cial groups are part ly ex empt ed. A uni form max i mum billing sys tem has been in tro duced with an in come-de pen dent ceil ing. Sick ness funds are ful ly com pen sat ed for the re sult ing high er costs.an a lyze these pol i cy op tions us ing a database with in di vid u-al ob ser va tions for the Bel gian pop u la tion. Al though the pol i cy op tion with re spect to (b) re moves all in cen tives for the sick ness funds to fight moral haz ard among the weak er so cial groups, it can be de fend ed on eq ui-ty grounds. Dif fer en ti at ed co-pay ments are a rel a tive ly ef fi cient way to im prove ac ces si bil i ty, if they are ful ly com pen sat ed for in the risk ad just-ment sys tem. At the same time, it could be ad vis able to give the funds more free dom to vary the co-pay ments for dif fer ent health care items in or der to stim u late be hav ioral chang es by the pa tients. The re sult ing cost dif fer ences should not be com pen sat ed for through risk ad just ment.

0442

The use of cost ing method olo gies to de ter mine prices for in pa tient health ser vices: a re view of nine Eu ro pean coun triesSchreyögg J. (De part ment for Health Care Man age ment, In sti tute for Tech nol o gy and Man age ment, Ber lin Uni ver si ty of Tech nol o gy, Ger many)

Ob jec tives: For eco nom ic eval u a tions as well as cross-coun try cost com-par isons it is use ful to know to which ex tent prices and ac tu al costs dif-fer in each coun try. This pa per com pares cost ing prac tices to de ter mine prices for in pa tient health ser vices be tween nine EU mem ber states (Den mark, France, Ger many, Hun gary, Italy, the Nether lands, Poland, Spain and Unit ed King dom). It is in ves ti gat ed how cost ing in for ma tion is de rived to de ter mine prices, how prices are set and to which ex tent prices re flect the ac tu al costs in curred. Meth ods: Part ners of the EU Health Bas ket pro ject in each coun try were asked to pro vide de tailed de scrip tions and anal y ses of cost ing prac tices and price set ting in each coun try. Re sults were com pared ac cord ing to de fined cri te ria in or der to re veal com mon al i ties or dis crep an cies.Re sults: Al though most coun tries use DRG-sys tems, cost ing method-olo gies large ly dif fer re gard ing sam ple size, data qual i ty and sta tis ti cal ap proach es. This es pe cial ly ap plies to the num ber of hos pi tals in clud ed in the sam ple to de rive cost data vary ing from 8 in Italy to 221 in Ger-many. There is a trade-off be tween the rep re sen ta tive ness of the data sam ple and the data qual i ty de ter min ing the ex tent to which prices re flect the ac tu al costs in curred.

Con clu sion: Re searchers should care ful ly dis tin guish be tween prices and costs and con sid er that there might be large dif fer ences be tween them de pend ing on the coun try.

0465

The im pact of co-pay ments on pa tient be hav iour: ev i dence from a nat u ral ex per i ment in Ger manySchreyögg J. (De part ment for Health Care Man age ment, In sti tute for Tech nol o gy and Man age ment, Ber lin Uni ver si ty of Tech nol o gy, Ber lin, Ger many)Grab ka M., Busse R.

Ob jec tives: As part of the Statu to ry Health In sur ance Mod ern iza tion Act a co-pay ment of €10 per quar ter for the first vis it at a phy si cian’s or a den tist’s of fice has been in tro duced with ef fect of 1st Jan uary 2004. The study in ves ti gates whether co-pay ments changed pa tient be hav iour with out dis crim i na tion of cer tain pop u la tion groups. Meth ods: Data of the Ger man So cio Eco nom ic Pan el (SOEP) from 1995-2004 (n=20.821) is used for the study. Two lo gis tic re gres sion mod-els are per formed con sid er ing so cioe co nom ic vari ables as well as the state of health. Two con trol groups are con struct ed and com pared by in de pen dent t-tests. Re sults: Phy si cian vis its de clined in the year 2004 com pared to the year 2003 and be fore. The de cline was sig nif i cant ly high er for in sured af fect-ed by co-pay ments than for those which were not af fect ed. How ev er the share of those pa tients who at least had one phy si cian vis it in both years re mained sta ble. The re gres sion mod els point out that no dis crim i na-tion of per sons with low so cial sta tus, dis abil i ties or poor health could be ob served. Con clu sion: It seems plau si ble, that the in tro duc tion of co-pay ments has con tribut ed to a re duc tion of phy si cian vis its with out dis crim i na-tion of cer tain groups.

0576

The eu ro pean col lab o ra tion on as sess ment for re im burse ment: achieve ments and futher chal lengesSchu ur man A.R. (Head of the Re im burse ment De part ment of the Health Care In sur ance Board (CVZ), Brus sels, Nether land)

The are grow ing pos si bil i ties for Eu ro pean co-op er a tion – and the ne ces-si ty of such co-op er a tion – in as sess ing drugs for re im burse ment. The col lab o ra tion is be tween the na tion al com pe tent phar ma ceu ti cal au thor-i ties re spon si ble for the as sess ment of (new) medicines for re im burse-ment and/or for def i ni tions, pric ing and re im burse ment con di tions.The main tasks for the as sess ment of medicines:Mon i tor ing (new) drug as sess ments in all (30) coun tries, and ex chang-ing in for ma tion on these cur rent as sess ments on a week ly ba sis.Ex plor ing and de vel op ing the meth o dol o gy and cri te ria for the as sess-ment of drugs for re im burse ment.Re view ing ex ist ing guide lines for as sess ing medicines for re im burse-ment and ex plor ing the pos si bil i ties for har mon is ing these guide lines, start ing with the area of clin i cal ef fec tive ness. Dis cussing cri te ria for the re-as sess ment of medicines for re im burse-ment in the light of new in for ma tion on clin i cal ef fec tive ness and in di-ca tions, and shar ing in for ma tion on the re view of na tion al re im burse-ment de ci sions.Dis cussing cri te ria for ther a peu tic equiv a lence and in ter change abil i ty.Col lab o rat ing on the post-list ing re views (for ex am ple, Vioxx, Cele brex) and ad just ing in di ca tions. Dis cussing ar range ments for Ref er ence pric ing and (ther a peu tic) clus-ter ing.How the re sults of an as sess ment will be used is of course the re spon si bil-i ty of the na tion al au thor i ties, ac cord ing to the sub sidiar i ty prin ci ple.The per spec tive of com mon, ad e quate as sess ments low ers the so called 4e hur dle to a small hick up.

S86 | Eur J Health Econom Suppl 1 · 2006

0095

HEE-GER: A sys tem at ic re view of Ger man health eco nom ic eval u a tionsSchwap pach D.L.B. (Uni ver si ty Wit ten-Herdecke, Wit ten, Ger many)Bolu arte T.

Ob jec tive: HEE-GER is a sys tem at ic lit er a ture re view that an a lyzes health eco nom ic stud ies that as sessed health care un der coun try spe cif-ic set tings for Ger many. We pro vide an overview of the char ac ter is tics of the re viewed eval u a tions and their quan ti ty and qual i ty. A cen tral part of the study is the ex trac tion of tech niques and sources used to de rive QALYs in pub lished cost-util i ty stud ies. Meth ods: We searched ge ner ic and spe cif ic data bases in April 2005 for rel e vant jour nal ar ti cles pub lished be tween 1990-2004 us ing “high sen-si tiv i ty” search strings. The ref er ences of re trieved ar ti cles and rel e vant Ger man lan guage jour nals were man u al ly searched for ad di tion al ma te-ri al. Ger man ex perts and rec og nized au thors were asked to pro vide bib-li o graph ic data. Stud ies were in clud ed in the re view if they ful filled a set of in clu sion cri te ria. The full texts of re trieved stud ies were as sessed by two in de pen dent re view ers us ing a data ex trac tion sheet. We col lect-ed de tails on study ob jec tive, in ter ven tion type and dis ease cat e go ry, de sign, meth o dol o gy and back ground data. Data re lat ing to health and pref er ence mea sure ment meth o dol o gy were ex tract ed in de tail. Re sults: The sys tem at ic lit er a ture search ini tial ly iden ti fied 2,158 ar ti-cles of which 734 stud ies were in clud ed in the crit i cal ap praisal. The re sults of the quan ti ta tive as sess ment of the char ac ter is tics of these stud-ies are re port ed.

0189

Does rel a tive pay in fl u ence short ages of doc tors and nurs es? Im pli ca tions for the cross-na tion al mo bil i ty of health pro fes sion als.Scott A. (Mel bourne In sti tute of Ap plied Eco nom ic and So cial Re search, Mel bourne, Aus tralia)El liott R., Skatun D., Iken wi lo D., Bell D., Rob erts E.

The im pact of pay on the re cruit ment and re ten tion of health pro fes sion-als has been cit ed as a key fac tor in mo ti vat ing doc tors and nurs es to change jobs or al ter their labour sup ply. This pa per re ports the re sults of a study in the UK NHS that ex am ined the im pact of pay dif fer en-tials across ge o graph i cal ar eas on va can cy rates for doc tors and nurs es in those ar eas. The econo met ric re sults show that rel a tive pay is im por-tant for nurs es but not for doc tors. This sug gests that nurs es sup ply their labour to de fined lo cal labour mar kets, where as doc tors are more like ly to work in a na tion al labour mar ket. The re sults have im pli ca tions for the type of poli cies used to in flu ence re cruit ment and re ten tion. Nurs es’ em ploy ers are like ly to com pete with oth er lo cal ly-based em ploy ers and so flex i bil i ty in set ting pay is im por tant in ad dress ing short ages. How ev-er, the na ture of com pe ti tion in the doc tors’ labour mar ket is like ly to be based on train ing op por tu ni ties and rep u ta tion al con cerns that re quire a dif fer ent type of pol i cy re sponse. Dif fer ent sets of fac tors are there fore like ly to in flu ence the cross-na tion al mo bil i ty of doc tors and nurs es, in clud ing the lev el and flex i bil i ty of re mu ner a tion and the com pet i tive-ness of with in coun try labour mar kets, in ad di tion to oth er fac tors such as rel a tive li cens ing and train ing re quire ments and qual i ty of life.

0598

Pol i cy ex ter nal i ties – the health eff ects of agri cul tur al, trade and for eign aid poli ciesScott G. (De part ment of Ap plied and In ter na tion al Eco nomics, Massey Uni ver si ty Welling ton Cam pus, New Zealand)Scott H.

Back ground: Health, agri cul tur al, trade and for eign aid poli cies are fre-quent ly for mu lat ed and im ple ment ed in iso la tion and by dif fer ent peo-ple with dis sim i lar ob jec tives and knowl edge sets.Aims: To in ves ti gate the im pact that agri cul tur al sup port and pro tec-tion of do mes tic pro duc tion and as so ci at ed trade and for eign aid poli-cies may have on health out comes and so cial wel fare.Meth od: The lit er a ture is re viewed and a num ber of cas es se lect ed that il lus trate ac tu al and pos si ble pub lic pol i cy link ages be tween health and agri cul tur al re lat ed sup port and pro tec tion.Re sults and con clu sions: Three groups of coun tries cat e gorised by the de gree of gov ern ment in ter ven tion in agri cul tur al mar kets and eco nom-ic de vel op ment were iso lat ed. These groups of agri cul tur al pro duc ers were; de vel oped econ o my price set ters, de vel oped econ o my price tak-ers, and de vel op ing econ o my price tak ers. Re sults sug gest that the “iso-la tion ist” ap proach to agri cul tur al pol i cy de vel op ment and im ple men-ta tion may re sult in un in tend ed del e te ri ous do mes tic and in ter na tion-al health ef fects. Pub lic pol i cy mak ing re quires an in te grat ed ap proach and in formed trade offs be tween pol i cy and po lit i cal ob jec tives.

0599

The eco nom ic cost of treat ed and un treat ed sleep ap noea to New ZealandScott H. (Scot tE co nomics, Welling ton, New Zealand)Scott G., Mi haere K., Gan der P.

Back ground: The con se quences of sleep ap noea range from loss of pro-duc tiv i ty, co-mor bid dis ease, in ju ry and death. While there is a grow ing body of knowl edge on the prev a lence of sleep ap noea in New Zealand lit-tle is known about the eco nom ic cost ef fects. Prev a lence and cost in for-ma tion pro vide es sen tial com po nents of the data re quired to con duct cost-ef fec tive ness anal y sis and for mu late ap pro pri ate poli cies.Aims: To in ves ti gate the eco nom ic cost of treat ed and un treat ed sleep ap noea.Meth od: The prev a lence of sleep ap noea, the prob a bil i ty of each out-come and unit costs of each out come was used to cal cu late the to tal eco nom ic and so cial cost of the con di tion. An out come tree was de vel-oped where the pop u la tion with sleep ap noea were tracked as to like-ly de ci sions, the usu al treat ment choic es avail able in Welling ton, New Zealand, and out comes. A prob a bil i ty and cost were at tached at each out come event which en abled us to cal cu late the costs for the un treat-ed and treat ed arms. Monte Car lo sim u la tion was used to take ac count of un cer tain ty in the es ti mates of prev a lence, prob a bil i ty of out comes and unit costs.Re sults and con clu sions: In ter im re sults sug gest that the costs of sleep ap noea and the dif fer ences in cost be tween treat ed and un treat ed in di-vid u als are such that treat ment stra te gies and pro to cols should be de vel-oped.

0603

Reg u lat ing qual i ty in health care – the is sues fac ing the en glish na tion al health ser viceScrivens E. (Health Care Stan dards Unit, Keele Uni ver si ty, UK)

The NHS in Eng land is un der go ing con sid er able struc tur al change to in tro duce more lo cal ly ac count able hos pi tals, greater pa tient choice, pay-ment by re sults and lo cal Gen er al Prac tion er based com mis sion ing of

Eur J Health Econom Suppl 1 · 2006 | S87

ser vices. There is a need to en sure that the re formed NHS pro vides in cen tives for ser vice im prove ment, whilst at the same time main tain-ing con sis ten cy in ac cess to ser vices and the safe de liv ery of ser vices. The UK gov ern ment is com mit ted to re duc ing bu reau cra cy and the de mands for data col lec tion, which is based upon as so ci at ed re quire-ments to re duce the over all costs of reg u la tion, whilst in creas ing the ac count abil i ty of health ser vices.This re quires a new ap proach to reg u-la tion, with uni ver sal na tion al tar iff set ting to equalise the dis tri bu tion of re sources, whilst bal anc ing a stan dard ised con cept of qual i ty with in cen tives to en cour age lo cal in no va tion in ser vice de sign and de liv ery. This pa per ex am ines the cur rent costs of ex ist ing reg u la tion, the is sues that need to be con sid ered in the de sign of such a reg u la to ry sys tem which must op er ate at re duced costs, and in par tic u lar the com pares the costs and im pact of dif fer ent mod els of reg u la tion us ing stan dards and qual i ty as sur ance pro cess es and their con tri bu tion to the im prove-ment in reg u la tion.

0378

Re port ing Het ero ge ne ity and So cial Health In equal i ties in FranceSer met C. (IRD ES, Par is, France)De brand T., Ju sot F. Ser met C.

Mea sur ing health is a cru cial is sue to un der stand so cial health in equal i-ties. Do so cial vari a tions in re port ed health sta tus re flect dif fer ences in “true health” or are they due to re port ing het ero ge ne ity? Re cent lit er a-ture sug gests that for the same “true” health sta tus, re port ing of health de pends on age, gen der, ed u ca tion, oc cu pa tion, eth nic i ty and coun try.the “true” health sta tus can not be ob served, we pro pose to ap proach it by a la tent vari able es ti mat ed by a mul ti ple in di ca tors mul ti ple caus-es struc tur al equa tions mod elling (Shmueli, 2003). This la tent vari able is mea sured by the three health in di ca tors pro mot ed by the Eu ro pean Of fice of WHO self-as sessed health, long-term ill ness and lim it ed ac tiv i-ties. More over, this mod elling al lows to dis tin guish the im pact of so cioe-co nom ic char ac ter is tics on “true” health sta tus from the re port ing bias in duced by so cioe co nom ic char ac ter is tics on each health in di ca tor.the 2002 French Health Sur vey, we es ti mate this mod el to com pare the health in equal i ties with this la tent health sta tus in di ca tor and with the three usu al health in di ca tors.

0053

Diff u sion of med i cal in no va tionsSer ra-Sas tre V. (LSE Health and So cial Care, Lon don, UK)

Tech no log i cal change has been iden ti fied as a lead ing fac tor ex plain-ing in creas ing health care ex pen di ture in a num ber of OECD coun tries over the past few decades. This has gen er at ed a grow ing in ter est in the adop tion and dif fu sion pro cess of in no va tions in the health care sec tor. There have been few em pir i cal stud ies an a lys ing this pro cess. The aim of this pa per is to pro vide ev i dence on the adop tion pro cess of new drugs with in the UK NHS pri ma ry care sec tor. Specif i cal ly, a pan el data mod-el is pre sent ed to con sid er the de ter mi nants of the dif fu sion of statins, a class of cho les ter ol-low er ing drugs that pro tect against car dio vas cu-lar dis ease in tro duced into the UK in the ear ly 1990s.dif fu sion pro cess is ex am ined at the mi cro lev el. It is hy poth e sized that, con trol ling for so cioe co nom ic in cen tives and de mo graph ic char ac ter is tics of the mar-ket where po ten tial adopters op er ate, char ac ter is tics of GP firms play a ma jor role. The anal y sis pro vides ev i dence on the de gree of sub sti tu-tion and ex pan sion of statins over the pe ri od 1992-2004. The find ings sug gest that spe cif ic reg u la to ry fac tors in flu ence dif fu sion but that par-tic u lar in di vid u al GP prac tice char ac ter is tics are of greater im por tance. The pa per thus of fers guid ance on which fac tors to tar get if pol i cy-mak-ers wish to in flu ence the dif fu sion pro cess.

0044

Ap ply ing Be hav ioral Eco nomics to Chang ing Health Be hav ior: the case of Weight-Loss Man age mentHesh mat S. (Uni ver si ty of Illi nois at Spring fi eld, USA)

Ra tio nale: Amer i cans spend in the ag gre gate many bil lions of dol lars each year try ing to lose weight through di et ing or ex er cise, in di cat-ing the na tion’s de sire to slim down. De spite doc u ment ed short-term suc cess, di et ing has a very low suc cess rates, most di eters re gain their weight back with in 3-5 years.Ob jec tives: This pa per pre sents some in sights from be hav ioral eco-nomics to the var i ous as pects of overeat ing, di et ing, and the re lapse as dis cussed in the weight-loss lit er a ture. The ob jec tive of this pa per is to dis cuss why peo ple fail to stick to their goal for eat ing heal thy diet in or der to lose weight. The un der stand ing what drives these de ci sions is a crit i cal part of health pre ven tion. Meth o dol o gy: The pa per pro vides a re view of past stud ies from the health eco nomics and be hav ioral eco nomics lit er a tures. The pur pose is not to pro vide an ex haus tive sum ma ry of the vast lit er a ture re lat ing to this is sue, but rather to pro vide a frame work in which to take a fresh look at a per sis tent pub lic health chal lenge. Con clu sions: Be hav ioral eco nomics takes the premise that many of the fac tors that lead to re lapse stem from faulty log ic, and ir ra tional as sump-tions, lead ing to in con sis tent be hav ior. Di et ing be hav ior ap pears to be prime can di date for ben e fit ing from be hav ioral eco nomics, such as how peo ple deal with out comes that are un cer tain and how they dis count de layed costs and ben e fits. The prev a lence of these bi as es sug gests that there is room for im prove ment. Sim i lar ly, the knowl edge of these bi as-es should help di eters to de vel op prob lem-solv ing skills in weight man-age ment. This pa per demon strates the role of be hav ioral eco nomics in chang ing peo ple be hav ior to ward bet ter eat ing habits, and sug gests how to put that in sight to work in pro grams that tack le weight loss pro-gram

0331

Op ti mal age group ing for cap i ta tion con tractsShmueli A. (He brew Uni ver si ty of Pub lic Health, Jerusalem, Is rael)Ber nice Ober man M.A, Zmo ra I.

Age re mains a cen tral risk-ad juster in many sys tems. Most coun tries use 5- or 10-year age-co horts, fol low ing the tra di tion al prac tice in de mo-graph ic pop u la tion ac counts (“con ven tion al age group ing”). The ob jec tive of this study is to de rive an op ti mal age group ing for cap-i ta tion con tracts, which will ex haust the in for ma tion em bed ded in the data on med i cal cost by age, for the to tal pop u la tion, for men and wom-en. Cost data were col lect ed for a sam ple of over 100,000 in surees of Clalit Health Ser vices, the biggest sick ness fund in Is rael, in the year 2004. We use Clas si fi ca tion And Re gres sion Trees (CART) to sep a rate out op ti-mal age groups. Sev er al mea sures are used to eval u ate the re sult ing clas-si fi ca tions in com par i son with the con ven tion al group ings.The main char ac ter is tics of the op ti mal group ing rel a tive to the con ven-tion al one are the sin gle-year group fol low ing birth (age 0-1), fol lowed by rel a tive ly large groups at young ages, nar row ing un equal ly with ad vanced age. The op ti mal group ing is dif fer ent for men and wom en. Con ven tion al age group ing for cap i ta tion con tracts re sults in sub-op ti-mal age group ing. Cap i ta tion con tracts based on con ven tion al group ing might have ad verse in cen tives for risk se lec tion.

S88 | Eur J Health Econom Suppl 1 · 2006

0370

Pri vate health ex pen di tures in so cial health care sys temsShmueli A. (He brew Uni ver si ty of Pub lic Health, Jerusalem, Is rael)Bernar di B., End veld M., Achdut L., At til la V.

Pri vate out-of-pock et health spend ing is an ex pres sion of con sumers’ sovereign ty, try ing to achieve bet ter health fac ing the pub lic pack age of ben e fits. How ev er, since there is nei ther cross-sub si diza tion nor sol i-dar i ty in pri vate out-of-pock et ex pen di ture, it has al ways been an open so cial and eq ui ty is sue in so cial health care sys tems. The pres ent anal y sis uses na tion al Fam i ly Ex pen di ture Sur veys from 2000/1 to ex am ine pri vate health ex pen di tures in a com par a tive three (UK, Italy and Is rael) so cial health care sys tems con text. It uses na tion-al age-based cap i ta tion rates to pro vide a re li able mea sure of the house-holds’ health needs, al low ing us to fo cus on hor i zon tal and ver ti cal (in)eq ui ty in the con sump tion of six types of pri vate health ex pen di-tures: to tal health ex pen di ture, vol un tary in sur ance pre mi ums, to tal ex clud ing in sur ance, op ti cal ex pen di ture, ex pen di ture on med i cal and den tal care, and ex pen di ture on med i ca tions. The cross-coun tries dif fer-ences are re lat ed to the va ri ety of the health care sys tems: an old NHS in the UK, a new NHS in Italy, and a com pet i tive so cial in sur ance in Is rael.

0339

Is wait ing-time pri ori ti sa tion wel fare im prov ing?Si cil iani L. (Eco nomics De part ment, Uni ver si ty of York, UK)Grav elle H.

Ra tioning by wait ing time is com mon ly used in health care sys tems with zero or very low mon ey prices. Some sys tems pri ori tise par tic u-lar types of pa tient and of fer them low er wait ing times. We in ves ti gate whether pri ori ti sa tion is wel fare im prov ing when ex pect ed ben e fits vary across pa tients and are the sum of ob serv able and un ob serv able com po-nents. If the ob serv able com po nent is di choto mous (for ex am ple gen-der) pri ori ti sa tion is wel fare im prov ing only if the de mand elas tic i ty of the group with high er ex pect ed ben e fit is low er (in ab so lute terms) than the de mand elas tic i ty of the oth er group. If the ob serv able com po-nent is con tin u ous (for ex am ple de pends on age, which en ters neg a tive-ly in the util i ty func tion), wait ing-time pri ori ti sa tion is wel fare im prov-ing if the mean age (or ob serv able ben e fit) of the pa tients who are in dif-fer ent (be tween re ceiv ing the treat ment or not) is high er than the mean age of the pa tients who re ceive the treat ment. This is cer tain ly the case if the joint den si ty of ob serv able and un ob serv able com po nents is uni-form or nor mal (it has no ef fect if den si ty func tion is neg a tive ex po nen-tial). We also show that a more ex treme form of pri ori ti sa tion, where pa tients whose ob serv able com po nent is be low a thresh old are de nied treat ment, can fur ther in crease wel fare. Key words: wait ing times, pri ori ti sa tion, ra tioning.

0340

Op ti mal con tracts for health ser vices in the pres ence of wait ing times and asym met ric in for ma tionSi cil iani L. (Eco nomics De part ment, Uni ver si ty of York, UK)

This pa per pre sents a mod el of op ti mal con tract ing for health ser vices in the pres ence of ex cess de mand and wait ing times. We as sume that i) hos pi tals dif fer in their de mand for treat ment; ii) po ten tial de mand is pri vate in for ma tion of the provider; iii) spe cial ists can dump pa tients; iv) ac tiv i ty and wait ing times are con tractible; v) providers are semi-al tru is tic.show that if dif fer ences in po ten tial de mand be tween hos pi-tals are vis i ble to the pur chas er, then the op ti mal con tract is for the pur chas er to of fer a trans fer to the provider in ex change for the pro vi-sion of the de sired lev el of ac tiv i ty and wait ing time, with out leav ing

any rent to the provider. Also a mix of im plic it ra tioning (through wait-ing time) and ex plic it ra tioning (through dump ing) may be op ti mal. Ra tioning by wait ing alone in duces ex ces sive disu til i ty for the pa tients, while ra tioning by dump ing alone gen er ates ex ces sive disu til i ty for spe-cial ists and ex ces sive costs. the more re al is tic as sump tion of asym met ric in for ma tion, a sep a rat ing equi lib ri um ex ists when it is op ti mal for the pur chas er to con tract more ac tiv i ty and lon ger wait ing times to those hos pi tals with high er de mand. If disu til i ty from dump ing is high (low) com pared to the de gree of al tru ism, hos pi tals with low (high) de mand gain in for ma tion al rents. A pool ing equi lib ri um may also oc cur.

0614

Re port on UK work to mea sure health care out put, and pro duc tiv i ty, through an ag gre gate mea sure which in cor po rates some qual i ty ad just ments, with pro pos als for fu ture im prove mentsSimkins A. (De part ment of Health, Lon don, UK)

Re port on UK work to mea sure health care out put, and pro duc tiv i ty, through an ag gre gate mea sure which in cor po rates some qual i ty ad just-ments, with pro pos als for fu ture im prove ments.Ob jec tive/Aims: The ob jec tive of this pre sen ta tion is to pres ent the prin-ci ples and meth ods used by the UK De part ment of Health to im prove the mea sure of NHS out put used in the Na tion al Ac counts and in ONS pro duc tiv i ty mea sure ment, fol low ing the Atkin son Re port (ONS, Jan-uary 2005) on mea sure ment of gov ern ment out put and pro duc tiv i ty. Fig ures pub lished by DH in De cem ber 2005 and ONS in Febru ary 2006 have shown a rise in qual i ty ad just ed pro duc tiv i ty, on cer tain as sump-tions, but some of these are con tro ver sial and fur ther de bate and de vel-op ment is re quired.Meth od: The DH pa per, Ac count ing for Qual i ty Change, com bined a sum ma ry of re search com mis sioned from York/NIESR (sep a rate ECHE sub mis sion from An drew Street) with pro pos als for oth er qual i ty ad just-ments. The main el e ments were:

Rate of mor tal i ty with in 30 days of hos pi tal ad mis sion;Es ti mat ed ben e fits of val ue from hos pi tal treat ment;Chang es in av er age wait ing time for elec tive treat ment;Sur vey ev i dence of im proved pa tient ex pe ri ence (ac cess, in volve-ment in de ci sions etc);Im proved blood pres sure con trol in pri ma ry care;Us ing a val ue weight rather than a cost weight to re flect lives saved by pre scrib ing statins;An nu al rise in val ue of health in line with GDP per head.

Re sult: The com bined meth ods added 2.7% a year, on av er age, to out-put growth. The largest items were the ‘val ue of health’ and the val ue weight for statins. How ev er, there are large data gaps in clud ing lack of rou tine in for ma tion about the ben e fits from treat ment. Sep a rate anal y-sis by the Of fice for Na tion al Sta tis tics (ECHE sub mis sion from Phillip Lee) which com pared out put growth with growth in de flat ed in puts, us ing the same qual i ty ad just ments as DH, gave a range of es ti mates of pro duc tiv i ty change up to 1.6% a year – but with many qual i fi ca tions on in ter pre ta tion. Con clu sion/dis cus sion: Mea sure ment of ag gre gate health care out put and pro duc tiv i ty, for Na tion al Ac counts or linked pur pos es of pub lic ac count abil i ty, re quires meth ods which take ac count of qual i ty. Qual i-ty of health care has sev er al dif fer ent do mains and there are chal leng ing is sues on mea sure ment and in ter pre ta tion. How ev er, the pa per demon-strates that as sump tions can be made which en able par tial in for ma-tion to be com bined into an over all as sess ment of pro duc tiv i ty change. Fur ther de vel op ment work is re quired, and would ben e fit from wider de bate on con cepts and ap proach es. It would be very ben e fi cial if sim i lar meth ods could be used in dif fer ent coun tries, both to as sist in method-olog i cal im prove ments and to al low for com par isons in the ef fi cien cy of dif fer ent health care sys tems and the suc cess of dif fer ent ap proach es to im prov ing their per for mance and pro duc tiv i ty.

Eur J Health Econom Suppl 1 · 2006 | S89

0427

Com par ing the prop er ties and per for mance of ge ner ic, sin gle in dex num ber HRQoL in stru mentsSin to nen H. (Uni ver si ty of Helsin ki, Dept.of Pub lic Health and Fi nO H TA, Helsin ki, Fin land)9

There are a few ge ner ic, sin gle in dex num ber HRQoL in stru ments like 15D, AQoL, EQ-5D, HUI and SF-6D, but none of them can claim a gold stan dard sta tus. To be suit able for QALY cal cu la tions, the scores they pro duce should re flect a cred i ble trade-off be tween length and qual i ty of life. There are some the o ret i cal com par isons be tween the in stru ments, but quite few stud ies com par ing their prop er ties and per for mance e.g. in terms of dis crim i na to ry pow er, re spon sive ness to change and cred i-bil i ty of scores in QALY frame work in dif fer ent pop u la tions, pa tients groups and sit u a tions. The pur pose of this ses sion is to en cour age such com par isons and to bring to geth er em pir i cal find ings from them so that the po ten tial users of the in stru ments would be came more knowl edge-able about the pros and cons of dif fer ent in stru ments.

0322

Em pir i cal anal y sis of chang es in the de mand for prental health ser vices in ru ral ar eas when eco nom ic in cen tives are in tro duced.Sosa-Rubi S.G. (Cen tre for Health Eco nomics, Uni ver si ty of York, UK)

We in ves ti gate the shift in the pat terns of use of pre na tal ser vices in ru ral ar eas af ter the im ple men ta tion of a so cial pro gramme named Pro-gre sa. Cash trans fers in this pro gramme re quire ac tive par tic i pa tion by the re cip i ent house holds in ex change for the ben e fits, such as a min i-mum of num ber of vis its to pre na tal ser vices. Two-part mod el (TPM) is ap plied to show that with a cer tain de gree of ho mo ge ne ity among users and providers such as when a sin gle ep i sode of ill ness is re called could be an ap pro pri ate mod el for study ing the de mand for pre na tal health ser-vices. Good per for mance of TPM-neg a tive bi no mi al mod el was found in the sub-sam ple of preg nan cies re called be fore the ini ti a tion of Pro gre-sa pro gramme. How ev er due to chang es in the dis tri bu tion of the pre na-tal vis its in the sub-sam ple in flu enced by Pro gre sa, dif fi cul ties in iden ti-fy ing the di chot o my be tween zero and non-zero users were found. The in crease of the num ber of vis its to pre na tal ser vices and the re duc tion of the num ber of wom en with out any ap proach to the health ser vices dur ing their preg nan cy was found. This re veals that fi nan cial in cen tives grant ed by Pro gre sa goes be yond the in di vid u al of fam i ly’s con straints to use health ser vices, al low ing moth ers in ru ral ar eas to ac cess ba sic health ser vices dur ing their preg nan cy.

0600

Co lon-rec tal can cer screen ing, di ag no sis, and treat ment guide linesSpan donaro F. (CEIS Cen tre for Health Eco nomics and Man age ment (CHEM), Fac ul ty of Eco nomics, Uni ver si ty of Rome Tor Ver ga ta, Rome, Italy)Rat ti M.

Un til now, Ital ian guide lines have fo cused their at ten tion pre dom i nant-ly on clin i cal/epi demi o log i cal is sues. With the re vi sion of “Co lon-rec-tal can cer screen ing, di ag no sis, and treat ment guide lines”, ASSR and CHEM are aim ing to im prove the role of eco nom ic eval u a tion, and for this rea son have formed a Re search Group (com posed of ex perts from the re gions, Aca dem ic In sti tu tions, and In dus try). The Group de vel oped a method olog i cal eco nom ic eval u a tion frame-work us able for “Co lon rec tal can cer guide lines” and de signed a gen er-al meth o dol o gy ap pli ca ble for fu ture guide lines in Italy, com par ing it with the best In ter na tion al ex pe ri ences on this top ic.

Fur ther more we faced with prob lems de riv ing from the new fed er al is-tic shape of the Ital ian NHS; ev ery as sess ment needs to con sid er re gion-al spec i fic i ty (in ci den tal ly note that the im por tance of ASSR is more and more in creas ing due to that) but, at the same time, must guar an-tee some uni for mi ty and suit able mo bil i ty char ac ter is tics in the place of ap pli ca tion.Fur ther more, the Group ap plied the meth o dol o gy in as sess ing the vir-tu al co lo nos co py tech nol o gy. The aim is to sup port Ital ian re gions in eval u at ing and com par ing costs and out put in health care ac tiv i ties.

0096

Eco nom ic Eval u a tions for Re im burse ment and Pric ing De ci sions in France: Can Phar ma coeco nom ic Eval u a tion Meth ods be trans ferred to Med i cal De vices?Späth H.M. (ISPB – Fac ulté de Phar ma cie, Lyon, France)Taboulet F., Car rere M.O.

Back ground: Phar ma coeco nom ic eval u a tion ac tiv i ties have grown in re cent years, but few eco nom ic eval u a tions (EE) have fo cused on Med-i cal De vices (MD). Nev er the less, the French Au thor i ties sug gest that MD man u fac tur ers in clude EE in re im burse ment and pric ing ne go ti a-tions. This study ad dress es the bar ri ers to con duct ing EE of MD, in com-par i son with phar ma coeco nom ic eval u a tions. Meth ods: First, we stud ied the dif fer ences be tween MD and drugs that im pact on the com ple tion of EE. Then, we anal y sed items of the French “Guide lines for EE of Health Care Tech nolo gies” that might be bar ri ers to EE of MD, as com pared to drugs. Re sults: The six most im por tant bar ri ers to EE of MD are re lat ed to: (1) the fea si bil i ty of clin i cal tri als, (2) the dif fi cul ty to de fine a com par a-tor, (3) the fact that MD ef fec tive ness of ten de pends on the op er a tor; (4) the short life cy cle of MD, (5) the pro fes sion al cul ture of en gi neers, (6) costs of EE ac tiv i ties. At the con fer ence, we will pres ent an anal y sis of these bar ri ers, and rec om men da tions al low ing to over come them.Con clu sion: We rec om mend set ting up mul ti dis ci plinary groups of en gi neers, health care pro fes sion als and economists from the be gin ning of MD de vel op ment; and defin ing MD to be eval u at ed in pri or i ty, on which EE meth ods should be test ed be fore be ing ap plied to oth ers.

0253

Re form ing Long-term Care in Ger manySper mann A. (Cen tre for Eu ro pean Eco nom ic Re search (ZEW), Mannheim, Ger many)Arntz M., Michae lis J.

Giv en pro jec tions re gard ing the num ber of ben e fit re cip i ents in the long-term care so cial in sur ance (LTC-SI) in Ger many, cost pres sures are ex pect ed to rise con tin u ous ly. Thus, re form ing the LTC-SI ap pears to be the only pos si ble route in or der to en sure cur rent care lev els for fu ture gen er a tions of the frail el der ly with out strong ly in creas ing the so cial con tri bu tion rates for the LTC-SI. Since, from the LTC-SI per-spec tive, nurs ing home care is much more ex pen sive than home care, in duc ing a high er share of ben e fit re cip i ents to stay at home be comes a nat u ral start ing point in or der to re duce cost pres sures. Thus, one main ob jec tive of the re form of the LTC-SI is a high er de gree of flex i bil i ty in the LTC-trans fer sys tem that al lows for more sta ble home care ar range-ments. One way to in tro duce more flex i bil i ty to the cur rent sys tem is to al low for a match ing trans fer in ad di tion to the cur rent ly avail able in-kind trans fers and lump-sum trans fers. A match ing trans fer al lows for an ex tend ed spec trum of care ser vices and also pro vides a sup port ive case man age ment. The pa per looks at the match ing trans fer from a the-o ret i cal per spec tive us ing a sim ple house hold bar gain ing ap proach and pre sents pre lim i nary find ings from so cial ex per i ments in sev en sites in Ger many.

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0160

Health Care Re form in UkraineStaat M. (Uni ver si ty of Mannheim, Ger many)Pilyavsky A.

We an a lyze the tech ni cal ef fi cien cy and ef fi cien cy change for 193 com-mu ni ty hos pi tals and poly clin ics across Ukraine, for the years 1997 to 2001. These fa cil i ties are a sub set of the cen tral med i cal in sti tu tions in ru ral Ukraine; they have an iden ti cal func tion in the health sys-tem and share the same de part men tal struc ture. The data com prise the num ber of staff in the de part ments as well as the poly clin ics, the num ber of pa tient days, in pa tient and out pa tient ad mis sions as well as the num ber of sur gi cal pro ce dures, lab tests and x-rays per formed. Fi nal ly, the num ber of deaths and deaths af ter sur gery are used as qual i ty prox ies. We em ploy an out put-ori ent ed or der-m es ti ma tor, a ro bust non para met ric tech nique, to as sess the ef fi cien cy of health care providers and chang es of their pro duc tiv i ty. The ef fi cien cy scores are close to uni ty for hos pi tals where as poly clin ics are some what less ef fi-cient. The Malmquist-in dex ex ceeds uni ty for three out of four pe ri-ods for both hos pi tals and poly clin ics in di cat ing im proved pro duc tiv i-ty on av er age. Where as progress for hos pi tals is in the range of 2% to 4.5%, the in dex in di cates progress for poly clin ics in ex cess of 10% for the fi nal pe ri od. This is the only re sult in di cat ing a sub stan tial ef fect of the re forms tak ing place.

0151

The Eco nom ic Im pact of Chron ic Dis easesStan ci ole A.E. (De part ment of Eco nomics and Re lat ed Stud iesof York, UK)Abe gunde D.

Chron ic dis eases are a ques tion of in creas ing rel e vance for de vel op ing coun tries. The pro cess es of ur ban iza tion and in dus tri al iza tion in de vel-op ing coun tries are as so ci at ed with the in crease of sev er al risk fac tors, such as obe si ty, smok ing and the lack of phys i cal ac tiv i ty. Con se quent ly the al ready high rates of mor bid i ty and mor tal i ty of chron ic dis eases in de vel op ing coun tries are pro ject ed to in crease even more in the com ing years.pa per ex plores the ef fect of chron ic dis eases on house holds us ing mi cro data from the Liv ing Stan dards Mea sure ment Stud ies (LSMS) of the World Bank for Brazil (1996), In dia (1997) and Rus sia (from 2000 to 2003). We es ti mate the mar gin al ef fects of chron ic dis eases us ing Gen-er al ized Lin ear Mod els, which con trol for the prob lems of high rates of non-re sponse and skew ness in the data.main con clu sion of the pa per is that chron ic dis eases are sig nif i cant ly as so ci at ed with high er lev els of health care ex pen di tures and, to a less er ex tent, with pro duc tiv i ty loss es re flect ed in low er labour sup ply and labour in come. On the oth er hand, we can not re ject the hy poth e sis that house holds are able to in sure non health con sump tion against chron ic dis eases. This leaves the ques tion of how they man age to do so, since there is no ev i dence of in creased trans fers from for mal sys tems of so cial in sur ance.

0112

The im pact of cross-ref er ence-pric ing on phar ma ceu ti cal prices – man u fac tur ers’ pric ing stra te gies and price reg u la tionStar gardt T. (De part ment of Health Care Man age ment, Fac ul ty of Eco nomics and Man age ment, Ber lin, Ger many)Schreyögg J.

Ob jec tive: Sev er al EU-coun tries are de ter min ing re im burse ment prices of phar ma ceu ti cals by cross-ref er enc ing to prices of for eign coun tries. Our ob jec tive is to quan ti fy the cross-bor der spill-over ef fects of cross-ref er ence-pric ing schemes on phar ma ceu ti cal prices in the for mer EU-15 coun tries.

Meth ods: An an a lyt i cal mod el was de vel oped es ti mat ing the im pact of phar ma ceu ti cal price chang es in Ger many on phar ma ceu ti cal prices in oth er coun tries in the for mer EU-15 us ing cross-ref er ence-pric ing. We dif fer en ti at ed be tween the di rect im pact (from ref er enc ing to Ger many di rect ly) and the in di rect im pact (from ref er enc ing to oth er coun tries that con duct their own cross-ref er ence pric ing schemes).Re sults: If the re spec tive drug is mar ket ed in all ref er enced coun tries a price re duc tion of € 1.00 in Ger many will re duce max i mum re im burse-ment prices in the Nether lands be tween € 0.27 and € 0.29. In Ire land, in ad di tion to a di rect im pact be tween € 0.21 and € 0.23, ref er enc ing to the Nether lands ex pands the im pact of a price re duc tion in Ger many to a to tal im pact be tween € 0.27 and € 0.29. In Aus tria, the Ger man price re duc tion con tributes to a to tal im pact of € 0.15 a di rect im pact of € 0.07, while € 0.08 are due to ref er enc ing to the Nether lands and Ire land. In Italy the to tal im pact is be tween € 0.33 and € 0.36. Con clu sions: While these re sults might be favourable to the health care sys tem in gen er al, cross-bor der spill-over ef fects of pol i cy in ter ven tions in duce strong in cen tives for strate gic prod uct launch es, lob by ing ac tiv i-ties and af fects the ef fi cien cy of reg u la tion as a whole.

0009

In ter na tion al com par i son of for mal and in for mal long term careStevens J. (So cial and Cul tur al Plan ning Offi ce, Hauge, Nether lands)Pom mer E., Gameren E., Woit tiez I.

We an a lyse the dif fer ences in the amounts of for mal and in for mal long-term care ser vices giv en in nine Eu ro pean coun tries. In for mal care is de fined as care by rel a tives, friends and neigh bours. For mal care is de fined as paid or pro fes sion al care. The ser vices con sid ered in clude nurs ing, per son al care and do mes tic help. anal y sis is based on the Sur-vey of Health, Age ing and Re tire ment in Eu rope (SHARE). In 2004 about 23.000 per sons aged 50 or old er were in ter viewed. The coun tries in clud ed in the anal y sis are The Nether lands, France, Ger many, Aus tria, Den mark, Swe den, Spain, Italy and Greece. fo cus on el der ly with im pair-ments. First we con struct a mea sure of im pair ments based on Mokken scale anal y ses, in clud ing scales for phys i cal and men tal im pair ments. Cross-tab u la tions pro vide in di ca tions of com ple men tar i ty be tween for-mal and in for mal do mes tic help and sub sti tu tion be tween for mal and in for mal nurs ing care. a multi no mi al log it mod el we ex plain the type of for mal care re ceived. Pre lim i nary re sults show that af ter cor rect ing for age, im pair ments, re ceived in for mal care, avail abil i ty of in for mal care and coun try-dum mies, sub sti tu tion be tween in for mal and for mal care varies be tween coun tries and type of care. There re mains a sig nif i cant dif fer ence in the amount of for mal care sup plied im ply ing cul tur al and in sti tu tion al dif fer ences be tween coun tries.

0434

The role of in di rect eff ec tive ness and cost-eff ec tive ness com par isons of health tech nolo gies in health pol i cy Stoyko va B. (Health Eco nomics Re search Group, Brunel Uni ver si ty, Uxbridge, UK)Mu niswamy S., Bux ton M.

Back ground: In HTA, in di rect com par isons of ef fec tive ness and cost-ef fec tive ness of tech nolo gies of ten need to be made, for ex am ple where two com pet ing drugs have been each com pared against pla ce bo/best sup port ive care, or where two new tech nolo gies have been de vel oped in par al lel and each has been com pared to cur rent prac tice. Meth ods: In this pa per we pres ent a case study com par ing the cost-ef fec-tive ness of al ter na tive tests for risk strat i fi ca tion of pa tients with sus pect-ed cor o nary ar tery dis ease based on two RCTs. The first RCT stud ied myo car dial per fu sion im ag ing, and the sec ond RCT stud ied stress echo-car di og ra phy, in each case com par ing them with the cur rent stan dard

Eur J Health Econom Suppl 1 · 2006 | S91

in the UK of ex er cise elec tro car di og ra phy (ETT), which has un sat is fac-to ry sen si tiv i ty and spec i fic i ty.Re sults: Mean costs to di ag no sis (95% CI) in the ETT arms of the tri als were sig nif i cant ly dif fer ent: £490.44 (453.8–527.1) vs. £231.84 (192.3–271.38). Whilst both tri als were com pa ra ble in key as pects of their de sign, com par a tive anal y ses of data from the com mon tech nol o-gy in di cat ed ma jor dif fer ences (e.g. rate of cor o nary an gi og ra phy) con-found ing the in di rect com par i son of re sults, and these in di cat ed the need to ad just the com par i son fo cussing on a com mon com pa ra ble sub-set of pa tients. Con clu sion: In di rect com par isons of costs and in cre men tal cost-ef fec-tive ness ra tios of al ter na tive tech nolo gies need to be ap pro pri ate ly ad just ed. We rec om mend the use of ap pro pri ate mod elling tech niques as the best avail able meth od to in form pol i cy.

0344

Phar ma ceu ti cal Patents: In cen tives for R&D or Mar ket ing?Straume O.R. (De part ment of Eco nomics, Uni ver si ty of Min ho, Bra ga, Por tu gal)Brekke K.R.

We an a lyse how a patent-hold ing phar ma ceu ti cal firm may strate gi cal-ly use ad ver tis ing of ex ist ing drugs to af fect R&D in vest ments in new (dif fer en ti at ed) drugs, and there by af fect the prob a bil i ty dis tri bu tion of fu ture mar ket struc tures in the in dus try. With in a fair ly gen er al mod el frame work, we de rive ex act con di tions for ad ver tis ing and R&D be ing sub sti tute stra te gies for the in cum bent firm and show that it may over-in vest in ad ver tis ing to re duce the in cen tive for an en trant to in vest in R&D, there by re duc ing the prob a bil i ty of a new prod uct on the mar ket. In a more spe cif ic set ting of in for ma tive ad ver tis ing, we show that such over in vest ment in cen tives are al ways pres ent, and that more gen er ous patent pro tec tion im plies that a larg er share of the patent rent is spent on mar ket ing, rel a tive to R&D.

0508

Health: a vi tal in vest ment for eco nom ic de vel op ment and pov er ty re duc tion in East ern Eu rope and Cen tral AsiaSuhrcke M. (World Health Or ga ni za tion, Eu ro pean Offi ce for In vest ment for Health & De vel op ment, Venice, Italy)Mc Kee M., Roc co L.

The re cent health record of sev er al coun tries of East ern Eu rope and Cen-tral Asia (ECA) is un favourable by many stan dards, and some of the coun tries have seen life ex pect an cy de clin ing in re cent years. In light of the rel a tive ly poor health sta tus and giv en the ap par ent low pol i cy pri-or i ty on health in the re gion, this re port seeks to demon strate that by as sign ing a com par a tive ly low im por tance to health, the coun tries are pay ing a pro hibitive price in terms of fore gone eco nom ic de vel op ment. The re port rep re sents the first com pre hen sive ef fort to pro duce new ev i-dence on the eco nom ic im pact of (ill) health in ECA coun tries, both on the mi croe co nom ic (i.e. in di vid u al & house hold) as well as on the macroe co nom ic lev el. Re sults demon strate that ill-health, in par tic u lar in the area of non-com mu ni ca ble dis ease and in juries, has left a sig nif i-cant neg a tive im pact on eco nom ic out comes in ECA coun tries. Re duc-ing the bur den of dis ease is pro ject ed to con tribute sig nif i cant ly to sus-tained fu ture eco nom ic growth in the coun tries. We also an a lyse the role that fac tors be yond a nar row in ter pre ta tion of “health care” have played (and could play) in pro mot ing health in the re gion. In par tic u-lar we quan ti ta tive ly as sess the role of so cial cap i tal and of the qual i ty of gov er nance.

0402

The diff er ent con cep tions of the so cial cost of a risk fac tor: what is the the o ret i cal and eth ic back ground of each method olog i cal op tion ?Bé jean S. (Uni ver sité de Bour gogne, Lab o ra toire d’Economie et de Ges tion, Pole d’Economie et de Ges tion, BP, Di jon, France)Taïeb H.S.

Back ground: The eval u a tion of the so cial cost of a risk fac tor pro vides very valu able in for ma tion for pre ven tion pol i cy de ci sion-mak ing. Sev er-al fields are con cerned: road ac ci dents, ex po si tion to air pol lu tion, ex po-si tion to risk fac tors at work. Ob jec tives, as sump tions: The ob jec tive is to pro duce a se ries of cri te-ria that may help to clas si fy sur veys on so cial costs im putable to a risk fac tor ac cord ing to the meth o dol o gy used. Meth o dol o gy: A re view of lit er a ture of (1) sur veys fo cused on method-olog i cal and eth ic prob lems in cost-ben e fit anal y ses and (2) sur veys mod el ing the so cial cost of a spe cif ic risk fac tor. Re sults: Three types of cri te ria :The type of costs in clud ed in the sur vey (di rect, in di rect, in tan gi ble costs) de pends on the point of view of the anal y sis (pub lic health in sur-ance sys tem, en ter pris es, so ci ety as a whole). As re gards in di rect costs, the Fric tion costs the o ry (Koop man schap 1992) rais es de bat able eth-ic ques tions. The val ue of lost lives im putable to the risk fac tor : is the price of an in di-vid u al dif fer ent dur ing oc cu pa tion al life and re tired life ? on what ba sis can we eval u ate the mon e tary val ue of life (av er age or mean wage, per cap i ta GDP) ? what are the dif fer ent choic es for the ac tu al i sa tion of the val ue of a lost life ? Has the de lay be tween the oc cur rence of a risk fac tor and its con se-quences been tak en into ac count in the sur vey ? The re sults of so cial cost eval u a tions can be very sen si tive to long term health ef fect of risk fac tors (Chanel & Vergnaud, 2004).

0503

Di ver gent Na tion al Stra te gies for an EU-Health Care Pol i cy and their Re sultsSund mach er T. (Uni ver sität Duis burg-Es sen, Cam pus Duis burg, Fach bere ich Be trieb swirtschaft slehre, Lehrge bi et Mikroökonomik, Duis burg, Ger many)

Di ver gent Na tion al Stra te gies for an EU-Health Care Pol i cy and their Re sults An in creas ing in flu ence of EU ac tiv i ties on the na tion al health care pol i cy is per cep ti ble. In deed, this in flu ence is still rel a tive ly low. For the fu ture, dif fer ent re sults are pos si ble. The ques tion aris es, which stra-te gies Eu ro pean gov ern ments will choose and which health care pol i-cy at EU lev el re sults from this. Some rec og niz able strat e gy pat terns are: 1. Preser va tion. Min i mum con ver sion of the pres ent Eu ro pean change im puls es, stress to the na tion al com pe tences, pre ven tion strat-e gy against EU ac tiv i ties; 2. Ero sion. Con ver sion of change im puls es leads to re jec tions which make wider (na tion al) re form steps nec es sary, ’fel low pas sen gers’ at EU lev el, mud dling through “In stru men tal iza tion. Forc ing of change im puls es to stim u late own re form plans, ‚at ten tion-re lat ed’ choice of del e ga tion; 3. Econ o miza tion. EU-health care pol i cy for in ter nal iza tion of cross-bor der ex ter nal ef fects and for the ex ploita-tion of scale ef fects, cost-cut ting del e ga tion strat e gy, rel e vant es pe cial-ly for small er na tions; 4. Ex clu da tion. Del e ga tion of re spon si bil i ties for the (the re elec tion en dan ger ing) health care sys tems to Brus sels (’sys tem agri cul tur al pol i cy’), forc ing of EU com pe tence, no spe cial con tents, del-e ga tion for the rea son of del e ga tion With in the scope of a game the o ry mod el of the EU de ci sion-mak ing pro cess these stra te gies are used and ex am ined un der vari a tions of the gam ing rules. Be sides, learn ing pro-cess es are also tak en into con sid er a tion.

S92 | Eur J Health Econom Suppl 1 · 2006

0504

High In no va tion Dy nam ics and the 4th Hur dle – no Nec es sary Con tra dic tion?Sund mach er T. (Uni ver sität Duis burg-Es sen, Fach bere ich Be trieb-swirtschaft slehre, Lehrge bi et Mikroökonomik, Duis burg, Ger many)

An eco nom ic eval u a tion of phar ma ceu ti cal re im burse ment of ten counts as a bu reau crat ic in no va tion brake. An es sen tial rea son for this ap praisal lies in the trans mis sion of (ear li er) ex pe ri ences of the cen tral, state owned reg is tra tion pro ce dure of phar ma ceu ti cals (the first three hur dles). For the 4th hur dle an al ter na tive so lu tion is in tro duced. In this mod el a de cen tral ized com pet i tive ar range ment is car ried out as far as pos si ble. To do so, a mar ket fail ure anal y sis is car ried out at dif fer ent lev-els (in ex am ple for mar kets for (in no va tive) phar ma ceu ti cals, for in sur-ance mar kets and for eco nom ic eval u a tion mar kets). The in tro duc tion of a prov ing pe ri od be fore start ing the 4th hur dle at tack is an oth er es sen-tial el e ment of the new in sti tu tion al set ting. In this prov ing pe ri od there ex ist in cen tives for the man u fac tur ers to close the col lect ing of eval u a-tion data as quick ly as pos si ble. Fur ther more such a 4th hur dle re quires a sep a ra tion of dif fer ent tar gets of ‚the phar ma ceu ti cal pol i cy’. R&D pol-i cy, health pol i cy or con sumer pro tec tion pol i cy tar gets are in ex am ple most ly not con gru ent. Hence, build ing up on a sys tem ati za tion in stru-ments are dis cussed for tar gets not be ing ad dressed by the health pol i-cy ori en tat ed 4th hur dle. Be sides, these in stru ments should af fect as lit-tle as pos si ble the reach ing of health pol i cy tar gets.

0401

Ac tiv i ty Based Hos pi tal Fund ing in a Cash-Lim it ed Sys tem – Qual i ta tive Anal y sis of ‘Pay ment by Re sults’ in Eng landSus sex J. (Offi ce of Health Eco nomics, Lon don, UK)Far rar S.

Aims: ‘Pay ment by Re sults’ (PbR) is a ma jor change in the sys tem of fund ing hos pi tals in the Na tion al Health Ser vice in Eng land, where by hos pi tals are re mu ner at ed ac cord ing to the type and vol ume of ac tiv i-ty they un der take. The aim of the re search re port ed here, which is part of the na tion al eval u a tion fund ed by the De part ment of Health, is to ex am ine the pro cess of im ple ment ing PbR and an a lyse its ef fects on lo cal health economies. PbR is in tend ed to in cen tivise the sys tem to meet spe cif ic pol i cy ob jec tives and is like ly to have per verse as well as in tend ed ef fects. Meth ods and Data: In ter view-based, qual i ta tive anal y sis. A pur po sive sam ple of se nior lo cal NHS man agers was con tact ed and in ter viewed con fi den tial ly. In ter vie wees were from Foun da tion and non-Foun da-tion NHS Hos pi tal Trusts, Pri ma ry Care Trusts and Strate gic Health Au thor i ties. Semi-struc tured in ter views sought man agers’ knowl edge and ex pec ta tions about the im pact of PbR.Re sults and Con clu sions: The in ter views raised many in ter est ing is sues – some con firm ing, but oth ers con trast ing with, the o ret i cal hy pothe ses as to the in cen tive ef fects of PbR and its im pacts on hos pi tal ac tiv i ty, ef fi-cien cy and com pe ti tion. The quan ti ta tive el e ment of the eval u a tion will be used to test the ro bust ness of these ini tial find ings, some of which will be re turned to in fu ture rounds of qual i ta tive anal y sis.

0320

Lo cal diff er ences in fam i ly doc tor re cruit ment and re ten tion and pat terns of rel a tive re wardsSut ton M. (Health Eco nomics Re search Unit of Ab erdeen, Scot land)El liott R.F., Grav elle H., Hole A.R., Ma A., Mor ris S., Sib bald B., Skatun D.

Ac cess is a key ob jec tive of many health care sys tems. This re quires a dis-tri bu tion of rel a tive re wards that equalis es the net ad van tages to health

care pro fes sion als of lo cat ing in dif fer ent ar eas. The ex is tence of chron-ic prob lems in re cruit ing fam i ly doc tors to par tic u lar ar eas in Eng land sug gests a fail ure in the ex ist ing na tion al pay struc ture. We an a lyse spa-tial vari a tion in fam i ly doc tor re cruit ment and re ten tion and rel a tive re wards across lo cal ar eas in Eng land. The anal y sis uses a unique mi cro dataset com pris ing sev er al in di ca tors of fam i ly doc tor re cruit ment and re ten tion prob lems (in clud ing va can cy rates, va can cy du ra tions and job sat is fac tion), fam i ly doc tor earn ings drawn from tax records, ob ser va-tions of pri vate sec tor pay and job char ac ter is tics at each lo ca tion. The dif fer ence be tween the pay of fam i ly doc tors and that of com par a tor pro fes sions in flu ences area vari a tions in re cruit ment and re ten tion, sug-gest ing the na tion al pay sys tem does not ad e quate ly com pen sate for dif-fer ences in the cost-of-liv ing and the dis ameni ties of lo cat ing in par-tic u lar ar eas. Fea tures of fam i ly doc tor jobs that have no pri vate sec-tor coun ter part also help ex plain lo cal re cruit ment and re ten tion dif fi-cul ties. These fac tors should be re flect ed in the na tion al pay sys tem to equalise net ad van tages across ar eas and en cour age the mi gra tion of fam i ly doc tors.

0069

Qua si-mar kets with fi xed prices – qual i ty-com pe ti tion in el der ly careSvens son M. (IHE, The Swedish in sti tute for health ec, Lund, Swe den)Ede balk P.G.

‘Con sumer choice’ in el der ly care is a sys tem in which the user is free to choose one of at least two providers, one be ing run by the lo cal au thor i-ties. The user, fol low ing an as sess ment of his/her needs, re ceives a vouch-er, which is a doc u ment stat ing that the cho sen provider is en ti tled to com pen sa tion out of pub lic funds. Prices in Swe den are fixed and equal for all providers. ‘Con sumer choice’ is a mul ti faceted con cept. The com-pe ti tion is de pen dent on how the con sumer-choice sys tem has been con-struct ed. For in stance, is there free en try to the mar ket or not? Do the au thor i ty have a ten der ing pro cess to ap prove the providers, or do the provider get au tho riza tion by the au thor i ty? There is a lack of knowl-edge as to how dif fer ent con sumer-choice mod els func tion, seen from a qual i ty-ori ent ed com pet i tive per spec tive.study de scribes what com pe-ti tion with fixed prices in el der ly care is about and how the providers act to com pete. A cen tral ques tion is how the de sign of con sumer-choice mod els in flu ences the com pe ti tion. The study is based on a sur vey in two mu nic i pal i ties in Swe den, with ex pe ri ence of dif fer ent con sumer choice sys tems in el der ly care.

0020

Mea sur ing the True Cost of Med i cal Pro ce duresSz abó T. (Sanigest In ter na tion al, Bratisla va, Slo vakia)Cer cone J., Száz K.

One of the prin ci pal ob jec tives of the cur rent Slo vak health care re form is to in tro duce a per for mance-based fi nanc ing sys tem. For this, it is nec-es sary to mea sure the real costs of med i cal pro ce dures. In ter na tion al ex pe ri ence in this re spect in cludes in di vid u al cost ing per pa tient, av er-age costs per hos pi tal pro ce dure and costs based on treat ment pro to col. the lack of data, none of these mod els could be im ple ment ed as-it-is. A new meth od has been pro posed based on Ac tiv i ty Based Cost ing, ap ply-ing an in no va tive al lo ca tion mod el that al lows as so ci at ing costs to dif fer-ent time episodes of a treat ment, dif fer en ti at ing be tween fixed and vari-able costs, and costs re lat ed to ser vice com po nents. The mod el has been suc cess ful ly test ed in two Slo vak hos pi tals for a to tal of six med i cal pro-ce dures.Slo vakia, med i cal records con tain de tailed data on pa tient treat-ment; but only in pa per form. In for ma tion was ex tract ed by nurs es into a pre-pre pared data col lec tion sheet. Sam ple size was pre-de ter mined us ing a proxy for the ex pect ed cost de vi a tion, which, ex-post, re sult ed to be sur pris ing ly ro bust. A sin gle database was es tab lished to an a lyze

Eur J Health Econom Suppl 1 · 2006 | S93

the in for ma tion and de ter mine the es ti mat ed cost per pro ce dure for each hos pi tal.re sults show a cost vari a tion of be tween 9 and 78 per cent for the same pro ce dure per formed in dif fer ent hos pi tals. The vari a tion is at tribut ed to a high de gree of het ero ge ne ity in treat ment pro to cols. The ABC cost ing was used to demon strate to Slo vak hos pi tal man agers where ef fi cien cy gains are pos si ble for in di vid u al pro ce dures. The de vel-op ment of the al lo ca tion al go rithm will al low for fu ture rep li ca tion of oth er pro ce dures and in oth er fa cil i ties.

0458

Pub lic Health Con cerns on Ir reg u lar Mi gra tion in Eu ropeSzilárd I. (In ter na tion al Or ga ni za tion for Mi gra tion, Brus sels, Bel gium)

With the re cent en large ment of the EU, Hun gary, Poland and Slo vakia now make-up the new EU East ern bor der to Ukraine, Be larus, Ro ma-nia (and Moldo va) and pro vide an even more sus cep ti ble en try space for ir reg u lar mi grants (both through smug gling and traf fick ing in per son) than be fore. The com po si tion of the ir reg u lar mi grant flow, per coun try of or i gin, is very broad with mi grants orig i nat ing from Viet nam, Chi na, Afghanistan, In dia, the Cau cus es, Iraq, and So ma lia etc. IOM es ti mates the vol ume of traf fick ing to the EU from East ern Eu rope and the Balka ns as high as 200 000 wom en and chil dren a year. Ac cord-ing to OSCE chil dren make up more than 30% of all the traf ficked vic-tims.What is known in gen er al about the mi gra to ry pat tern and pro cess shows that ir reg u lar mi grants, ei ther as in de pen dent ly hav ing com mit-ted a crim i nal ac tion (il le gal bor der cross ing), or as vic tims of the crim-i nal act (traf ficked per sons) have, very like ly dur ing their rout ing/jour-ney been ex posed to a range of health-re lat ed prob lems, such as: poor liv ing con di tions – ex po sure to a wide range of dis eases– phys i cal vi o lence – sex u al ex ploita tion and – psy cho log i cal abuse.Pro vid ing ap pro pri ate health pro mo tion and care ser vices for traf ficked per sons is not only a hu man i tar i an obli ga tion, but also a pub lic health con cern for coun tries of or i gin, tran sit and des ti na tion alike. This prob lem does not mere ly ap pear in the con text of spread ing sex-u al ly trans mit ted in fec tions (STIs) and ‘com mon’ in fec tious dis eases, such as the – (re)-emerg ing prob lems of TB, – HIV/AIDS and of – Hep a ti tis B and C. Pos si ble con se quence of the de mol ished pub lic health sys tem in the ma jor i ty of coun tries of or i gin: vac cine pre ventable dis eases are spread to tran sit and des ti na tion coun tries where most physi cians have not been con front ed with these patholo gies be fore.To achieve sig nif i cant ad vances in this field, gov ern ments must har-monise their pub lic health poli cies in clud ing bor der man age ment and ser vice pro vi sion, avail abil i ty of spe cial ly trained prac ti tion ers, and data and in for ma tion shar ing.

0554

Brain-trade; the trends and costs of med i cal mi gra tionEke E. (Sem mel weis Uni ver si ty, Health Ser vices Man age ment Train ing Cen tre, Bu dapest, Hun gary)Sinko E., Szoc s ka M.

Aims: 1. Ex plor ing brain-trade: what are the po ten tial eco nom ic re la tions

and con se quences of brain-drain – gen er al back ground – what fac-tors and fig ures should be in clud ed and why?

2. What can and can not be known about mi gra tion (mean ing out flow) of Hun gar i an med i cal pro fes sion als since the EU ac ces sion of Hun-

gary? What do we know about mi gra tion ten den cies? In tro duc tion of an on go ing mi gra tion re search pro ject and its re sults.

3. What eco nom ic im pacts can be es ti mat ed in re la tion with the cur-rent ly seen and pre dictable mi gra tion trends among Hun gar i an health pro fes sion als?

4. What chal lenges health pol i cy faces re gard ing mi gra tion?Meth ods: 1. Re view of Lit er a ture2. Con sid er a tion and ex plo ra tion of re lat ing eco nom ic fac tors3. Anal y sis of of fi cial data re gard ing mi gra tion of young med i cal doc-

tors4. In tro duc tion and anal y sis of own data re gard ing mi gra tion ten den-

cies among med i cal stu dents and young med i cal doc tors5. Anal y sis of po ten tial eco nom ic re la tions of our re sults6. How can/ should the find ings be in volved into health pol i cy stra te-

giesRe sults: 1. Brain drain in health sec tor has been a long-last ing is sue in the

world, al though it has at tract ed much at ten tion in Hun gary (and sur round ing coun tries) since the EU ac ces sion of our coun try in May1 2004. The pre cise ex tent of mi gra tion of med i cal pro fes sion-als and its con se quences in health-care and health sta tus of the pop-u la tion of fer much to ex plore. The main chal lenge is to see the is sue in an over all eco nom ic con text.

2. Based on avail able lit er a ture, of fi cial data and own data we at tempt to cal cu late the costs of mi gra tion of Hun gar i an health pro fes sion-als, name ly physi cians.

3. Ac cord ing to our study and as sump tions we would like to ex plore what health pol i cy and eco nom ic as pects should be con sid ered and what rec om men da tions can be made for in ter ven tion.

Con clu sion: Mi gra tion and its as pects must be seen, ex plored and han dled in the scope of over all eco nom ic con text. Brain drain also emerges as a work-force mar ket is sue in the form of Brain Trade, so the eco nomics of this trend should also be in ves ti gat ed.

0025

The Eff ect of Pov er ty on the Health of New born Chil dren: Ev i dence from Ger manyTamm M. (RWI Es sen, Ger many)

A high risk of chil dren liv ing in poor fam i lies to at tain poor out comes in var i ous fields is well doc u ment ed. We pro vide new in sights into health out comes of new born chil dren in Ger many and their re la tion to pov er ty sta tus and try to iden ti fy path ways of the ef fect of pov er ty on health.data con sists of 565 new born chil dren and re ports sev er al health out comes (low birth weight, preterm birth, small height at birth, small head cir-cum fer ence at birth, and any con firmed dis or ders) as well as the num ber of doc tor vis its and vis its to a hos pi tal dur ing the first three months af ter birth, which were due to health prob lems and not due to reg u lar med i-cal check-ups. The data is based on a com plete ly new ques tion naire sup-ple ment ing the Ger man So cio-Eco nom ic Pan el (GSOEP) in 2003 and 2004.econo met ric im ple men ta tion is based on com ple men ta ry log-log mod els for the bi na ry health out comes and on hur dle and zero in flat ed neg a tive bi no mi al mod els for the num ber of doc tor vis its and vis its to a hos pi tal.find ings in di cate that there is no sig nif i cant re la tion be tween pov er ty sta tus and most health out comes of new born chil dren. How ev-er, preterm birth is sig nif i cant ly more like ly by more than 20 per cent age points among poor moth ers. Fur ther more, moth er_health sta tus has a sig nif i cant ef fect on a cou ple of as pects of child health, at least moth-er_health dur ing preg nan cy. I.e. there is clear in di ca tion of in ter gen er a-tional trans mis sion of health fac tors to new born chil dren.

S94 | Eur J Health Econom Suppl 1 · 2006

0264

The At tributable Cost and Lenght of Hos pi tal Stay of Cen tral Line As so ci at ed Blood Stream In fec tion in Three In ten sive Care Units and In fec tious Dis eases De part ment in a Teach ing Clin ic in Mi lan, Italy. A Prospec tive, Matched Anal y sis.Tar ri cone R. (Com mer ciale Lui gi Boc coni – CER GAS (Cen tre for Re search on Health and So cial Care Man age ment), Mi lan, Italy)Tor bica A., Musi grave F., Franzetti F., Co ro na A., Rai mon di F., Ro sen thal V.D.

The aim of the study was to es ti mate costs of CVC-as so ci at ed BSI from a hos pi tal per spec tive.2 -year prospec tive nest ed case-con trol study was un der tak en at the three In ten sive Care Units and In fec tious Dis-eases De part ment in a teach ing clin ic in Mi lan. pa tients with BSI (cas-es) and 56 pa tients with out BSI (con trols) were matched for de part-ments, length of stay (LOS), gen der, age, and sever i ty of ill ness score. LOS in the de part ment was ob tained prospec tive ly on dai ly rounds. As to costs eval u a tion, they were es ti mat ed based upon the con sump tion of re sources while in hos pi tal. Unit costs have been cal cu lat ed through a mi cro-cost ing ap proach.mean age of cas es and con trols was 64 and 70 years re spec tive ly.mean LOS of pa tients with and with out BSI was 18 and 7.28 days re spec tive ly. The mean ex tra cost for over heads was € 7.722. Over all, the mean costs of pa tients with and with out BSI were € 17.469 and € 8.279 re spec tive ly. The ex tra cost per case was € 9.191.the pres ent study, pa tients with BSI had sig nif i cant lon ger hos pi tal iza tion, and greater cost. The pres ent study sup ports the need for rou tine uti li-za tion of pre ven ta tive in ter ven tions to re duce CVC-as so ci at ed BSI as a means of re duc ing health care costs.

0132

The change in the doc tor-nurse paradigm, some con di tions and im pli ca tionsTavares A.I. (Uni ver si ty Au tono ma of Barcelona, Spain)

Doc tor-nurse game was first ly iden ti fied by Leonard Stein in 1967. In this game, nurs es were play ing the role of doc tor_third arm. Nurs es weren_high ly ed u cat ed and their pro duc tiv i ty was not very high ei ther. In the 1990 Stein et al. went back to an a lyse this doc tor-nurse game and no ticed that nurs es role had changed. They had be come more ed u cat-ed, their pro duc tiv i ty had in creased and they had be come more au ton-o mous health pro fes sion als. We pro pose a for mal iza tion of this his tor-i cal evo lu tion us ing agen cy the o ry. We de rive im pli ca tions on the doc-tor-nurse in cen tives with in a team and in fere about the va lid i ty of some of the doc tors and nurs es claims.

0540

The fi rst decade of case-mix sys tems in ItalyTedeschi P. (Boc coni Uni ver si ty De part ment: Cen ter for re search in health care man age ment, Mi lan, Italy)

Case-mix sys tems have been in tro duced in the Ital ian na tion al health sys tem since 1994 af ter the Amer i can ex pe ri ence with DRGs and as part of an over all re form pro cess which has de cen tral is ing de ci sion al, or ga-ni za tion al and op er a tional pow er from State to Re gions. While the chal-lenges lead ing to a hos pi tal prospec tive pay ment sys tem were sim i lar to oth er Eu ro pean Coun tries (e.g. in creas ing de mand, rais ing costs), Italy adopt ed a strat e gy of re gion al ad ap ta tion of case-mix es and tar iffs lead-ing through time to in creas ing in ter re gion al dif fer ences. In par tic u lar the in ter ven tion will ad dress the caus es lead ing to the health pol i cy shift to wards DRGs, the goals, de bates, re sults and con tro ver sies re lat ed to the health sys tem evo lu tion un der case-mix sys tems. For sure the Ital ian case high lights that health fi nanc ing based on case-mix es re quires con-

trol tools (both in ter nal and ex ter nal to hos pi tals) in or der to ex ploit the po ten tial of ac tiv i ty re lat ed fund ing while man ag ing the ef fects of par-tial eco nom ic con ve niences (e.g. pri vate hos pi tal pro vid ing con ve nient care, but not nec es sar i ly com ple men ta ry to pub lic of fer and needs). The fu ture of case-mix sys tems in Italy ap pears to be con nect ed with the ca pa bil i ty of com bin ing clin i cal, cost and qual i ty in or der to fos ter con-tin u ous im prove ment in hos pi tal prac tice and or ga ni za tion.

0058

The Im pact of Ag ing on Fu ture Health care Ex pen di tureTelser H. (Uni ver si ty of Zurich, Switzer land)Stein mann L., Zweifel P.

The im pact of ag ing on health care ex pen di ture (HCE) has been at the cen ter of a pro longed de bate. This pa per pur ports to shed light on sev er-al is sues. First, it pre sents new ev i dence on the rel a tive im por tance of the two com po nents of HCE that have been dis tin guished by Zweifel, Felder and Mei er (1999), viz. the cost of mor bid i ty and the cost of mor tal i ty (their red her ring hy poth e sis claims that ne glect ing the mor tal i ty com po-nent re sults in ex ces sive es ti mates of fu ture growth of HCE). Sec ond, it takes ac count of re cent ev i dence sug gest ing that HCE does in crease life ex pect an cy, im ply ing that time-to-death is an en dog e nous de ter mi nant of HCE. Third, it in ves ti gates the con tri bu tion of pop u la tion ag ing to the fu ture growth of HCE. For the case of Switzer land, it finds this con tri bu-tion to be rel a tive ly small re gard less of whether or not the cost of dy ing is ac count ed for, thus qual i fy ing the red her ring hy poth e sis.

0150

Anal y sis of mi gra tion im pact on de vel oped coun triesTesti A. (Uni ver si ty of Gen o va, De part ment of Eco nomics and Quan ti ta-tive Meth ods, Gen o va, Italy)Ival di E., Tan fani E.

In the last decade the move ment of peo ple to de vel oped ar eas high lights new and emer gent is sues, i.e. how to re spond to the health needs of mi grants. More over, the of fi cial data about mi gra tion do not in clude the grow ing ir reg u lar or un doc u ment ed flows. A com mon ly used as sump-tion is that ir reg u lar mi gra tion ac counts for one-third to one-half of new en trants into de vel oped coun tries, an in crease of 20 per cent over the past ten years (IOM Re port, 2003). In Eu ro pean coun tries grow ing at ten tion is fo cused on un der stand ing state gies, poli cies and pro grams aimed at fa cil i tat ing so cial and eco nom ic in te gra tion of mi grants in re ceiv ing ar eas. In this con text a top i cal is sue is to doc u ment the im pact on ac cess and use of health ser vices.ref er ence to the Ital ian Na tion al Health Ser vice the main ob jec tives of this pa per are i) to iden ti fy ma jor prob lems re lat ed to the lack of ho mo ge ne ous and re li able data col lec-tion, in par tic u lar re lat ed to the un doc u ment ed mi grants; ii) to de tect the main health ser vices re quired by mi grants (ex pressed de mand); iii) to high light the mag ni tude of re sources need ed to achieve a pos i tive im pact on the health of the mi grants and to ad dress the ques tion of the best fi nanc ing mech a nism.

0486

Ap proach es to cap i tal in vest ment in the hos pi tal sec tor in Eu ropeThomp son C. (Eu ro pean Com mis sion, DG SAN CO, Lux em bourg)Mc Kee M.

While much has been writ ten about health care fi nanc ing in Eu rope in re cent years, dis cus sion has al most en tire ly fo cused on rev enue. In con trast, there has been re mark ably lit tle writ ten on fi nanc ing of cap i-tal in vest ment in Eu ro pean health care sys tems. Yet ma jor chang es are

Eur J Health Econom Suppl 1 · 2006 | S95

un der way in sev er al coun tries, in par tic u lar in volv ing new forms of pub-lic-pri vate part ner ships (PPP). At the same time, there is grow ing rec-og ni tion of the way in which the in her it ed struc ture of the health care de liv ery sys tem con strains the sys tem’s abil i ty to adapt to chang ing cir-cum stances. This pre sen ta tion re ports the re sults of a sur vey un der tak-en among key in for mants in the mem ber states of the Eu ro pean Union to be gin to as cer tain ex ist ing prac tices and fu ture plans in re la tion to hos pi tal plan ning and fi nanc ing amongst pub lic and pri vate not-for-prof it hos pi tals. The lo cus of hos pi tal plan ning de ci sions re flect the con-sti tu tion al frame work of the coun try in volved, and thus the em pha sis on na tion al or lo cal plans. There has been an ex pan sion of pri vate sec-tor in volve ment, with four ba sic mod els iden ti fied: pri vate loans di rect to the hos pi tal pri vate loans to a re gion al health body a PPP where the pri vate sec tor’s role is to build, de sign and op er ate the non-clin i cal func-tions of the hos pi tal and, fi nal ly, a PPP, where the pri vate sec tor’s in volve-ment also in cludes man age ment of the clin i cal func tions of the hos pi tal. It is too ear ly to say whether these ap proach es will be more suc cess ful than the mod els they are re plac ing.

0033

Pref er ences for Fi nanc ing Long-Term Care in Old AgeTip per A. (Uni ver si ty of Ab erdeen, Scot land)Coast J., Fly nn T.

Lit tle is known about the pub lic_pref er ences for fi nanc ing their own long-term care (LTC) for when they are in old age. There fore a dis crete choice ex per i ment was con duct ed with a ran dom sam ple of the pop u la-tion to es ti mate util i ty val ues for the var i ous at tributes and as so ci at ed lev els of LTC fi nanc ing. at tributes for the ex per i ment, de vel oped from the lit er a ture on fi nanc ing LTC, were risk over cov er ing all ex pen di tures, life span risk, care ac cess, fi nance and qual i ty of care. Two ver sions of the ques tion naire were de vel oped, the first us ing best worst scal ing and the sec ond us ing pair wise com par isons. ques tion naires are be ing ad min-is tered by post to a ran dom smaple (n=2000) of the gen er al pub lic in ear-ly 2006 with the data anal y sis per formed short ly af ter wards. The re sults will be gin to fill the gap in the lit er a ture about the de ci sion mak ing pro-cess that in di vid u als pur sue in fi nanc ing their LTC. The util i ty val ues can be used to de sign a pol i cy for fi nanc ing LTC de fined by the most pref er en tial fea tures of the ex per i ment

0105

De ter mi nants of Pro longed Wait ing Times for Spe cial ized Health Care Ser vices in Can a daTis saaratchy P. (Health Can a da, Ot tawa, On tario, Can a da)

The ob jec tive of this study is to ex plore, us ing re cent Cana di an pa tient sur vey data for 2003 avail able in the Health Ser vices Ac cess Sur vey (source Sta tis tics Can a da), de ter mi nants of pro longed wait ing times for spe cial ized non-emer gen cy ser vices, name ly sur gi cal, spe cial ist, and di ag nos tic. The lo gis tic re gres sion mod els pre sent ed in this study tell us that will ing ness to pay by pa tients for ser vices for which pri vate sec-tor op tions ex ist, pri or i ti za tion of pro ce dures by physi cians, and can-cel la tions by both physi cians and pa tients im pact the length of wait ing. This pa per adds to the ex ist ing body of an a lyt i cal lit er a ture by pro vid-ing some in sights into the im pact of pa tient and phy si cian be hav iour on pro longed wait ing. re sults in di cate that the be hav iour of pa tients and physi cians does in flu ence the length of the wait for a ser vice. For spe cial ized ser vices for which pri vate sec tor op tions ex ist, pa tients in the high est in come quar tile have the low est prob a bil i ty of ex pe ri enc-ing a pro longed wait in di cat ing a high er de gree of will ing ness to pay by such pa tients. For non-emer gen cy di ag nos tic scans, pa tients ob tain ing scans in pub lic in sti tu tions have a high er prob a bil i ty of ex pe ri enc ing a pro longed wait. For all spe cial ized ser vices, di ag nos tic con di tions as so-ci at ed with high er mor tal i ty rates are as so ci at ed with the low est prob-

a bil i ties of a pro longed wait which in di cates the pres ence of pri or i ti za-tion by physi cians/hos pi tals. Can cel la tion of pro ce dures/ap point ments is as so ci at ed with a high er prob a bil i ty of a pro longed wait, par tic u lar ly when the can cel la tion is ini ti at ed by the pa tient which in di cates that the hos pi tal/phy si cian may pri or i tize those who ex pe ri ence can cel la tion for rea sons be yond pa tient con trol. Ex pe ri enc ing bar ri ers to ac cess such as schedul ing dif fi cul ties and avail abil i ty also lead to a high prob a bil i ty of a pro longed wait. Oth er fac tors as so ci at ed with pro longed wait ing as a re sult of bot tle necks pres ent in the sys tem are the lack of a fam i ly phy si-cian and the re quire ment of an overnight hos pi tal stay for a non-emer-gen cy sur gi cal pro ce dure.

0168

The use of Pa tient Re port ed Out comes (PRO) and health eco nomics for reg u la to ry ap proval and re im burse mentTol ley K. (Mapi Val ues, Mac cles fi eld, UK)

Mar ket ac cess for new phar ma ceu ti cals, re quires phar ma ceu ti cal com-pa nies to se cure reg u la to ry ap proval from the FDA (USA)/EMEA (Eu rope). Tra di tion al ly, this in volved com pa nies in clud ing clin i cal end-points and phar ma covig i lance data in phase III tri als to show the ef fi-ca cy/safe ty of their prod uct against pla ce bo. In re cent years there has also been a move to wards the use of pa tient re port ed out come (PRO) end points (e.g. symp tom scales, health re lat ed qual i ty of life mea sures) that can be sub mit ted to FDA/EMEA to sup port a reg u la to ry claim. This has led to a need to en sure PRO mea sures are prop er ly de vel oped and val i dat ed. Be yond reg u la to ry ap proval, mar ket ac cess for new phar-ma ceu ti cals re quires re im burse ment from na tion al and lo cal pay ers. In creas ing ly in Eu rope (and else where) 4th hur dle agen cies such as the Scot tish Medicines Con sor tium, NICE, Com mit tee for Phar ma ceu ti cal Help in the Nether lands are re quir ing ev i dence on cost-ef fec tive ness/bud get im pact to de ter mine re im burse ment sta tus or re im burse ment price. Health eco nom ic based ar gu ments based on ro bust clin i cal tri-al ev i dence are re quest ed by these agen cies. The ses sion will fo cus on com par ing Eu ro pean and USA needs for PRO for reg u la to ry ap proval and com pare dif fer ent coun tries needs for health eco nom ic data for drug re im burse ment.

0559

Rapid health tech nol o gy as sess ment for phar ma ceu ti cal re im burse ment and de ci sion mak ing in Eu ropeTol ley K. (Mapi Val ues, Cheshire, UK)

Health eco nom ic ev i dence needs and the im pact on mar ket ac cess of three in flu en tial Eu ro pean re im burse ment agen cies that ap praise new drugs at launch: the Sin gle Tech nol o gy Ap praisal (STA) of NICE in the UK, the Scot tish Medicines Con sor tium in the UK and the Com mit tee for Phar ma ceu ti cal Help in the Nether lands will be dis cussed. First an up-to-date sta tus re port of the STA pro cess and dif fer ences from a full NICE ap praisal will be pre sent ed, with case stud ies of the first drugs to un der go this pro cess pre sent ed (i.e. do c etax al, pa cli tax el and trastuzum-ab for ear ly breast can cer). There af ter, a brief com par i son of the pro cess of de ci sion-mak ing in volved with each agen cy will be pre sent ed. Also the crit i cal phar ma coeco nom ic ev i dence needs of these agen cies, with a fo cus on the spe cif ic prob lems of choice of the ap pro pri ate com par a-tor, the mea sure ment of health out comes etc. will be con sid ered. This ses sion will con tain an in ter ac tive ex er cise to re view case study ex am-ples of prod ucts that have been ap praised (and for which in for ma tion is pub licly avail able). The im pact of each agen cy on new prod uct re im-burse ment and mar ket ac cess with in the UK and The Nether lands, and more wide ly in Eu rope, will be dis cussed. Some rec om men da tions on best prac tice in op ti mis ing phar ma ceu ti cal com pa ny sub mis sions will be pro vid ed.

S96 | Eur J Health Econom Suppl 1 · 2006

0616

What does in dus try think about a “4th hur dle”?Towse A. (Offi ce of Health Eco nomics, Lon don, UK)

Is sues to be dis cussed:1. Role of eco nom ic eval u a tion is iden ti fy ing val ue in dif fer ent types of

pric ing and re im burse ment sys tems. Is ref er ence pric ing an al ter na-tive to eco nom ic as sess ment? Who sets the price and should there be an ex plic it will ing ness to pay for a QALY?

2. Avail abil i ty of in for ma tion and han dling un cer tain ty. Pay ers don’t want to re im burse prod ucts that are not cost-ef fec tive, but don’t have all of the in for ma tion at launch. What is an ef fi cient way to re solve this dilem ma? How is new in for ma tion best han dled?

3. Cov er age of HTA. Is is “all new medicines?” Is that the best use of HTA re sources?

4. What is a “good prac tice” pro cess for an HTA in sti tu tion al as sess-ment of val ue? For ex am ple, what role do man u fac tur er’s sub mis-sions have? Should there be an ap peal pro cess? And pa tient group in volve ment?

5. Ex tent of pan- Eu ro pean shar ing of as sess ments. What is ef fi cient and not ef fi cient? Can Eu rope’s HTA bod ies pool skills and ef fort or are costs, ef fec tive ness, and will ing ness to pay too dif fer ent across Eu ro pean coun tries?

0271

Pro gramme Bud get ing and Mar gin al Anal y sis (PBMA):a case study of the Greek con textTsoura pas A. (Health Eco nomics Fa cil i ty, Health Ser vices Man age ment Cen tre, Uni ver si ty of Birm ing ham, Unit ed King dom)Frew E.

Back ground: PBMA is a sys tem at ic, ex plic it pri or i ty set ting toolk it, aim-ing to as sist de ci sion mak ers in iden ti fy ing the most ef fi cient use of re sources. It can fa cil i tate pri or i ty set ting by en cour ag ing par tic i pants to iden ti fy de ci sion-mak ing cri te ria and com bine these with the best avail-able ev i dence. To date this tech nique has not been used in Greece.Meth ods: Lit er a ture re view and tape-record ed semi-struc tured in ter-views with se nior med i cal and gov ern ment de ci sion mak ers from Greece, to de ter mine the ac cept abil i ty of PBMA in this con text.Re sults: The lit er a ture demon strates that for the PBMA frame work to work well it is im por tant to have ac tive in volve ment, com mit ment and co-op er a tion from all par tic i pants, es pe cial ly se nior mem bers of an or ga ni sa-tion. Al though in volve ment and com mit ment were ap par ent among some in ter vie wees as a means of ob tain ing more trans par ent pri or i ty set ting, lack of co-op er a tion be tween hos pi tal de part ments would make ap pli ca tion of PBMA dif fi cult. Fur ther more, re cent re forms in tro duc ing re gion al health au thor i ties (RHA) and fu ture re forms in tro duc ing ‘lo cal bud gets’ in the RHAs could fa cil i tate the adop tion of PBMA, but time is need ed for the RHA to gear to the new sit u a tion that ‘lo cal bud gets’ will set.Con clu sion: PBMA may en hance de ci sion-mak ing in Greece, but the cul tur al con text nec es sary for suc cess does not cur rent ly seem to be pres ent.

0145

Health sta tus in adult hood ac cord ing to fam i ly and so cial back ground : in ter gen er a tional trans mis sion of in come-re lat ed health in equal i tiesTubeuf S. (IRD ES, Par is, France)Tran noy A., Rochaix L., Bou vard L.

Ob jec tives: The ob jec tive of this pa per is to ex plore the hy poth e sis of an in ter gen er a tional trans mis sion of health in equal i ties on French data, par tic u lar ly in terms of equal op por tu ni ties.

Sum ma ry: Re search into the de ter mi nants of in equal i ties (both in terms of health sta tus and health care util i sa tion) has shown the im por tance of in come and so cial char ac ter is tics (mea sured by so cial class and ed u ca-tion lev els) – Wagstaff et al. (2001), Kun st et al. (2000), Van Doorslaer and Kool man (2005)–. An oth er line of re search into the de ter mi nants of in come-re lat ed health in equal i ties has con sid ered the whole life cy cle. Wadsworth (1986) has shown the in flu ence of health in child hood on ca reer prospects and the im pact of liv ing con di tions in child hood, even in ute ro, on health sta tus in adult hood (Wadsworth (1999)). This anal y sis ac cord ing to which fam i ly and so cial back grounds in child-hood strong ly in flu ence health in adult hood has not yet been car ried out on in di vid u al French data. In this study, we ex plore the hy poth e-sis of an in ter gen er a tional trans mis sion of health in equal i ties. First, we build dis tri bu tions of health sta tus con di tion al on the fam i ly and so cial back ground, as mea sured by par ents’ so cioe co nom ic sta tus. We then com pare these con di tion al dis tri bu tions of health in or der to ap pre ci ate dif fer ences be tween the French sit u a tion and an ide al of equal op por-tu ni ty. We ap ply the Lefranc-Pis tole si-Tran noy (2004) meth o dol o gy based on non para met ric anal y ses of the dis tri bu tions of health in sto-chas tic term of pre dom i nance to the 2004 Sur vey on Health, Age ing and Re tire ment in Eu rope –SHARE. We then com pare the French sit-u a tion in terms un equal op por tu ni ties for health to the 11 oth er Eu ro-peans coun tries in the sur vey.

0277

Re forms of the Na tion al Health care Sys tem and Dy nam ics of the Hos pi tal Effi cien cyTu rati G. (Uni ver si ty of Turin, Fac ul ty of Eco nomics, Tori no, Italy)Pi a cen za M., Van noni D.

In this pa per we es ti mate cost ef fi cien cy and tech no log i cal char ac ter is-tics of pub lic hos pi tals in Pied mont – a Re gion of the North ern Italy – over the pe ri od from 2000 to 2004. Dur ing the Nineties, dif fer ent reg-u la to ry re forms aim ing at con trol ling health ex pen di ture af fect ed the Ital ian NHS, rang ing from the in tro duc tion of a new re im burse ment scheme for hos pi tals (DRG-based mech a nism) to the im ple men ta tion of fis cal fed er al ism. We ar gue that all these dif fer ent re forms ren dered pro duc ers more prone to con trol costs, in or der to be able to meet fi nan-cial con straints. Our em pir i cal find ings sup port this hy poth e sis: av er age cost in ef fi cien cy scores ob tained es ti mat ing a Translog sto chas tic cost fron tier by the Bat tese and Coel li (1992) meth o dol o gy show a de crease from 2000 to 2004, while the adop tion of more ef fec tive tech nolo gies shift ed up ward the cost fron tier. We also find sig nif i cant economies of scale not ex ploit ed by pro duc ers.

0046

A pro ject port fo lio ap proach to pri or i tize in no va tive tech nol o gy in vest ments in health care or ga ni za tionsTur ra E. (APSS, Tren to, Italy)Ger mana H.R.

In health care or ga ni za tions and hos pi tals there is an in creas ing de mand for uti liz ing health care and in for ma tion tech nolo gies in the man age-ment of change and in no va tion. Faced with the com plex i ty of that ef fort and the in flex i bil i ty of the cap i tal bud gets, com bined with the on go-ing op er a tional needs, a sys tem at ic ap proach has been adopt ed by the Azien da Provin ciale per i Servizi San i tari (APSS) in Tren to for the se lec-tive fund ing of tech nol o gy en abled in no va tion ac tiv i ties. For this, APSS es tab lished pro ject port fo lio man age ment ca pa bil i ties to as sist man age-ment in mak ing the de ci sion on how to al lo cate the dis cre tionary side of the bud getary re sources : that is, the por tion of the bud get not al ready com mit ted to pre vi ous de ci sions. To guide the se lec tion pro cess, a for-mal re view is pe ri od i cal ly per formed to ana lyise and se lect ing those pro-jects, among the sev er al ones which are pro posed by the var i ous de part-

Eur J Health Econom Suppl 1 · 2006 | S97

ments, each com pet ing for grant ing a share of the cap i tal bud get. The goal is to dis cov er those pro posed in no va tion ini tia tives which makes a greater con tri bu tion to the com pa ny ob jec tives based on ex plic it or ga ni-za tion pri or i ties and eva l u ta tion cri te ria. This is also to avoid that ex ist-ing com mit ted pro grams, backed by ex ist ing in ter nal con stituen cies : would be favoured over val ue-adding and in no va tive tech nol o gy ini tia-tives, un pro tect ed by com mit ted stake hold ers.

0129

Health Fund Com pe ti tion in Ger manyUe belmess er S. (CES, Uni ver si ty of Mu nich, Ger many)Beck er B.

In the 1990s, com pe ti tion among pub lic health funds was in tro duced in Ger many. Even though legal ly for bid den, there is an ec dot al ev i dence that funds en gage in ac tiv i ties to se lec tive ly re cruit en rolees. Em pir i cal-ly, it is dif fi cult to sep a rate di rect risk se lec tion of sick ness funds from switch ing which – due to switch ing costs – might be bi ased to wards the young and heal thy. In this pa per, we want to di rect ly ad dress this ques tion by fo cus ing on the ad ver tise ment strat e gy of sick ness funds. So far, this has not been pos si ble due to lack of data. We use a new dataset of all ads placed by pub lic sick ness funds in all Ger man news pa pers and mag a zines be tween 1990 and 2003 as well as man u al ly col lect ed ads placed in the Ger man mag a zine Stern be tween 1992 and 2003.The anal y sis of the ad ver tise ment stra te gies pro vides us with ev i dence to draw first con clu sions about the ef fects of more com pe ti tion. In tro-duc ing more com pe ti tion was in tend ed to in crease the ef fi cien cy of the health funds thus lead ing to low er con tri bu tion rates. We find that the ad ver tise ment ac tiv i ties in gen er al as well as the con tent of the ads placed in the Stern mag a zine are af fect ed by the most rel e vant in sti tu-tion al chang es. Our con tent anal y sis, how ev er, seems to in di cate that the changed con tent can not be tak en as clear ev i dence of risk se lec tion. This points to wards a (more) im por tant role played by the de ci sion of the sick ness funds about where to ad ver tise for an anal y sis of risk se lec-tion.

0155

Qual i fy ing the Re la tion ship be tween Health Care Ex pen di ture and HealthUl mann P. (CNAM, Par is, France)Nixon J.

Pre vi ous em pir i cal re search by the au thors con firmed that, for the Eu ro-pean Union, in creas es in health care ex pen di ture are sig nif i cant ly as so-ci at ed with large im prove ments in in fant mor tal i ty, but only marginal-ly for life ex pect an cy. The find ings, how ev er, were at tached to a num-ber of caveats con cerned with mod el mis spec i fi ca tion is sues and data avail abil i ty, con sis tent with many pre vi ous stud ies in this field.The aim of the pres ent pa per is to re port the find ings of up dat ed and more re li-able anal y ses us ing the lat est OECD health data, aug ment ed by ex plana-to ry vari ables de rived from oth er macroe co nom ic datasets. The study was ex tend ed to cap ture the in flu ence of a) health care sys tem ty pol o gy, b) share of pub lic health ex pen di ture, c) share of pri ma ry care ex pen di-tures, d) pri ma ry pre ven tion, e) ed u ca tion al care ex pen di tures, f) the char ac ter is tics of health care fi nanc ing. Fi nal ly, the di min ish ing in flu-ence of health ex pen di tures on health in de vel oped coun tries was also eval u at ed. This is work in progress and de tailed re sults are not yet avail-able. The re sults, how ev er, will in crease the va lid i ty of our pre vi ous find-ings and are ex pect ed to con firm a sta tis ti cal ly sig nif i cant as so ci a tion be tween health care ex pen di ture and health out comes, and en hance our un der stand ing of the in flu ence of oth er ex plana to ry vari ables that ex plain this re la tion ship.

0158

Com par ing life time health care costs of ma jor risk fac tors: smok ing ver sus obe si ty Van Baal P. (RIVM, Bilthoven, Ned er lands)Feen stra T., Pold er J., Boshuizen H., Hoogen veen R.

Es ti mates of health ex pen di ture at tributable to risk fac tors are usu al ly based on cross sec tion al anal y ses and do not take into ac count health care costs of com pet ing dis eases that might re sult from chang es in lifestyle. Us ing a dy nam ic pop u la tion mod el, we cal cu lat ed in ci dences, preva-lences and health care costs of some ma jor chron ic dis eases con di tion-al on risk fac tors. We com pared life time health care costs of a co hort smok ers and a co hort of obese peo ple to those of a co hort of ‘heal thy’ peo ple. Av er age dis ease costs per pa tient were linked with dis ease prev-a lence’s es ti mat ed with the mod el.At all ages, av er age health care costs were low est for ‘heal thy’ peo ple. Un til age 65, av er age health care costs were high est for obese peo ple. At old er ages, smok ers were most ex pen sive. How ev er, since health care costs in creased rapid ly at old er ages and life ex pect an cy is longest for heal thy peo ple and short est for smok ers, to tal life time costs were high-est for the co hort of heal thy peo ple and low est for the co hort of smok-ers. Re lat ing the dif fer ence in life ex pect an cy to the dif fer ence in health care costs re veals that health care costs per life year gained are low er for pre-ven tion of obe si ty (€1,000) than for pre ven tion of smok ing (€ 5,000).

0567

Or ga ni za tion and Fi nanc ing of ESRD Care in a Mixed Uni ver sal In sur anceVan Biesen W. (Re nal di vi sion, Dept of In ter nal Med i cine, Uni ver si ty Hos pi tal Ghent, Bel gium)Lameire N., Van hold er R.

Bel gian health care is or ga nized as a mixed pri vate/pub lic sys tem: com-pul so ry con tri bu tions and re im burse ments are or ga nized by the state, but the providers are pri vate. There is a fee-for-ser vice sys tem with fixed re im burse ment rates for each med i cal in ter ven tion. There used to be only a few re stric tions on the ser vices pro vid ed, but this is rapid-ly chang ing due to the in creas ing costs of health care. For ESRD, the fee-for-ser vice sys tem dis cour ages the de vel op ment of pre ven tive stra-te gies, ear ly re fer ral to the neph rol o gy unit, and the use of home based ther a pies like peri to ne al di al y sis. The ag ing of the gen er al pop u la tion is re flect ed in the rapid ly in creas ing num ber of very old di al y sis pa tients who tend to have mul ti ple in fir mi ties re quir ing more com pli cat ed care. Al though the cur rent sys tem de liv ers an ac cept able cost-ben e fit ra tio with ex cel lent stan dards of care, one may ques tion whether un re strict-ed ac cess will re main sus tain able in view of the high cost of di al y sis. If re stric tions on ac cess be come nec es sary, how they should be de vel oped and by whom will be the per ti nent ques tions. Nephrol o gists should be aware of fi nan cial and or ga ni za tion al is sues to raise their voic es in this dis cus sion.

0099

Uni ver sal manda to ry pri vate health in sur ance in the Nether landsVan de Ven W. (Eras mus Uni ver si ty, Rot ter dam, Nether lands)Prin sze F.J., Brui jn D., Schut F.T.

Since 1 Jan uary 2006 all cit i zens in the Nether lands are obliged to buy pri vate health in sur ance. There will be an an nu al open en rol ment, com-mu ni ty-rat ed pre mi ums per in sur er, and a risk-equal iza tion sys tem based on age, gen der, dis abil i ty, di ag nos tic cost groups, and phar ma cy-

S98 | Eur J Health Econom Suppl 1 · 2006

based cost groups.this pa per we fo cus on sup ple men tary health in sur-ance as a tool for risk se lec tion. For sup ple men tary in sur ance the in sur-ers are free in pre mi um set ting and un der writ ing prac tices. If an in sur-er re jects an ap pli cant for the sup ple men tary health in sur ance, this con-sumer most like ly will buy the manda to ry ba sic health in sur ance from an oth er in sur er. re sults in di cate that there is a clear sim i lar i ty be tween the ques tions in the health ques tion naires that in sur ers use for ap pli-cants of sup ple men tary health in sur ance and the sub groups of con-sumers who gen er ate a pre dictable loss for the ba sic in sur ance. By the an swers in the health ques tion naires in sur ers can eas i ly di vide their ap pli cants in two groups about one third with an av er age pre dictable loss for the ba sic in sur ance of about 800 euro per year and the oth ers with an av er age pre dictable prof it of about 350 euro per year. There fore risk se lec tion via the sup ple men tary health in sur ance is a very easy and prof itable strat e gy.

0107

Us ing open-end ed fol low-up ques tions to test the va lid i ty of DCE es ti matesVan der Pol M. (Uni ver si ty of Ab erdeen, UK)Shiell A., Au F., Tough S., John ston D.

The Dis crete Choice Ex per i ment (DCE) is be com ing in creas ing ly pop u-lar with in health eco nomics. How ev er, con cerns have been raised over the va lid i ty of the es ti mates pro duced by a DCE. This is in ves ti gat ed in this pa per by test ing the con sis ten cy be tween the es ti mates ob tained from a DCE with those di rect ly ob tained us ing open-end ed ques tions’s pref er ences for com mu ni ty peri na tal care were elicit ed. Face to face in ter views were held with 292 wom en. Con sis ten cy be tween the meth-ods is ex plored by an a lys ing the DCE data ac cord ing to the op ti mal sce-nario iden ti fied in the open-end ed ques tion. lev els of con sis ten cy were achieved when ex am in ing whether par tic i pants chose the pack age in the DCE iden ti fied as their op ti mal pack age in the di rect open-end ed ques tion. How ev er, the mean WTP de rived from the open-end ed CV ques tion is sub stan tial ly low er than the mean de rived from the DCE. The re sults did sug gest that in di vid u als who are will ing to pay rel a tive ly more in the open-end ed CV ques tion were also will ing to make rel a tive-ly larg er trade-offs in the DCE. Re search into the dif fer ent bi as es that are pres ent and may cause the dif fer ence in the WTP es ti mates con tin-ues to be an im por tant line of en quiry.

0108

Is risk at ti tude in health con text spe cifi c?Van der Pol M. (Uni ver si ty of Ab erdeen, UK)Rug geri M.

In tro duc tio n is an on go ing de bate about which health val u a tion meth od is su pe ri or. One of the ar gu ments that is used in favour of the Stan dard Gam ble (SG) meth ods is that it in cor po rates in di vid u als’ pref er ences for risk. This is seen as de sir able be cause most med i cal de ci sions are made un der con di tions of cer tain ty. How ev er, most un cer tain ty is not of the ‘life or death’ form as pres ent in the SG. The ar gu ment there fore only holds if in di vid u als’ risk at ti tude is con stant and does not de pend on the kind of health risk. There is ev i dence in the psy chol o gy lit er a ture that risk at ti tude varies across dif fer ent do mains and sit u a tions. This has not been ro bust ly test ed us ing health out comes. aim of this study is to ex am-ine whether in di vid u als’ risk at ti tude for fa tal chang es in health dif fer from their risk at ti tude for non-fa tal chang es in health. ‘risk at ti tude is mea sured through the use of SG ex er cis es. Two types of health out come are used fa tal chang es (0 ver sus 5 years; and 5 ver sus 15 years) and non-fa tal chang es (amount of time spent in ill-health). In to tal, 102 uni ver-si ty stu dents filled out the web-based ques tion naire.col lec tion has just been com plet ed. Re sults will be avail able soon.

0312

Care for a break? An in ves ti ga tion of in for mal care givers’ at ti tudes to ward respite care Van Exel J. (Eras mus MC, In sti tute for Med i cal Tech nol o gy As sess ment (iMTA) & De part ment of Health Pol i cy and Man age ment (iBMG), Rot ter dam, Nether lands)Brouw er W.B.F.

Pub lic aware ness is grow ing that in for mal care givers should be sup port-ed in their valu able and in dis pens able ef fort to pro vide care to some one in their so cial en vi ron ment. Respite care was shown be an ef fec tive way to al le vi ate care giv er bur den and to re duce the ad verse (health) ef fects from sub stan tial bur den. Yet, lit tle is known about care givers’ needs and de sires re gard ing respite care. con duct ed a Q-method olog i cal study and found three dis tinct groups of care givers in for mal care givers who “need and ask for respite care”, those who “need but won’t ask for respite care”, and those who “do not need respite care”. Care givers in the first two groups ex pe ri ence sub stan tial bur den, while those in the third group en joy suf fi cient sup port and ap pear to man age pret ty well. Care givers in the sec ond and third group de rive con sid er able “pro cess util i ty” from care giv ing. On bal ance, care givers in the first two groups would some-times rather have some one else take over their task, but for care givers in the sec ond group this de sire is frus trat ed by care re cip i ent re sis tance against respite. respite care funds should be tar get ed at care givers in the first two groups, while in the sec ond group ef fort should be di rect ed to both care giv er and care re cip i ent.

0467

The de mand and use for sup port and respite care for in for mal care giversVan Exel J. (Eras mus MC, In sti tute for Med i cal Tech nol o gy As sess ment (iMTA) & De part ment of Health Pol i cy and Man age ment (iBMG), Rot ter dam, Nether lands)

We anal y sed the pref er ences for and use of sup port and respite care in a sam ple of in for mal care givers. Al most 80% of the re spon dents de sire sup-port or respite care in gen er al, some time off is pre ferred by 40% of the re spon dents. The re sults show that care giv er char ac ter is tics, care re cip-i ent char ac ter is tics, el e ments of the care giv ing sit u a tion and in sti tu tion-al vari ables de ter mine the de sire for sup port and respite care. Es pe cial ly the sub jec tive bur den of care giv ing is im por tant, where as the num ber of care giv ing tasks and the time in vest ed (ob jec tive bur den) hard ly af fect the de sire for sup port and respite care. Care givers are rea son ably well in formed about ex ist ing respite ser vices and about one third of care givers made use of respite care. These care givers ex pe ri enced sub stan tial bur den of care giv ing. Most respite care fa cil i ties reach the care givers most in need of sup port, but not all care givers in need make use of respite care. More re search is need ed into the cost-ef fec tive ness of respite care. Ref er encesKoop man schap MA, van Exel NJA, van den Bos GAM, van den Berg B, Brouw er WBF.

The de sire for sup port and respite care: pref er ences of Dutch in for mal care givers.

Health Pol i cy 2004;68:309-20.

Van Exel J, Moree M, Koop man schap M, Schreud er Goed hei jt T, Brouw er W. Re-

spite care: an ex plo rative study of de mand and use in Dutch in for mal care givers.

Health Pol i cy (in press)

0078

The length of wait ing lists for long-term care in the Nether landsVan Gameren E. (So cial and Cul tur al Plan ning Offi ce, Nether lands)

Since many years, the long-term care sec tor in the Nether lands has been char ac ter ised by wait ing lists. Reg u lar counts have been held of the num-ber of peo ple wait ing for the var i ous ser vices, rang ing from home care

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to ad mis sion in a nurs ing home. In this pa per the length of the wait ing lists in 32 re gions (per in hab i tant aged 75 or more) in Oc to ber 2003 is con front ed with sup ply in di ca tors such as the ca pac i ty of nurs ing homes and avail abil i ty of per son nel in a re gion, de mand in di ca tors as the num-bers of el der ly above age 85 and of sin gle-liv ing el der ly, and in di ca tors of the or ga ni sa tion of the care in the re gion. De mand and sup ply fac-tors are gen er al ly pos i tive ly cor re lat ed, in di cat ing that a high er de mand goes with a high er sup ply. Sup ply fac tors gen er al ly neg a tive ly cor re late with the length of the wait ing lists, more sup ply gives short er wait ing lists. For some of the de mand fac tors a (wrong) neg a tive sign is found. It re mains com plex to de ter mine the driv ing forces be hind the wait ing lists. The most ap par ent out come is that the wait ing lists for the var i ous ser vices are high ly in ter con nect ed, be cause some of the ser vices are giv-en as a tem po rary care so lu tion to peo ple wait ing for oth er ser vices.

0137

Eff ects of risk equal iza tion on pre mi um re bates for vol un tary de ductibles in so cial health in sur anceVan Kleef R. (Eras mus Uni ver si ty Rot ter dam, Nether lands)Beck K., Ven W. P.M.M, Vli et R. C.J.A.

With out risk equal iza tion among in sur ers, pre mi um re bates for vol un-tary de ductibles in health in sur ance can be very high due to self-se lec-tion. With risk equal iza tion, the ef fect of self-se lec tion is small er since risk equal iza tion (part ly) cor rects for dif fer ences in risk be tween the con-sumers who choose a de ductible (the rel a tive ly heal thy) and those who do not (the rel a tive ly un healthy). As a re sult, these dif fer ences can not be (ful ly) re flect ed in the pre mi um re bate. study, which is based on data from a Swiss sick ness fund, shows that with out risk equal iza tion the pre-mi um re bate for a vol un tary de ductible of SFr. 1,270 can (the o ret i cal ly) be 86 per cent rel a tive to the ac tu ar i al ly fair pre mi um for full cov er age. With risk equal iza tion based on age, gen der, re gion and med i cal his to ry, the max i mum pre mi um re bate drops to 40 per cent. How ev er, this pre mi-um re bate still ex ceeds the de ductible amount (SFr. 1,270). So, even with com pre hen sive risk equal iza tion, there still is a sub stan tial ef fect of self-se lec tion on the pre mi um re bate, re sult ing in non-op ti mal risk sol i dar i ty. In clud ing the lev el of de ductible as a risk fac tor in risk equal iza tion could op ti mize risk sol i dar i ty, but would also lead to low er re bates and con se-quent ly to a small er num ber of con sumers choos ing a de ductible.

0028

The so cial costs and ben e fi ts of pri or au tho riza tionVarke viss er M. (Eras mus Uni ver si ty Rot ter dam / ECRi, Nether lands)Di jk graaf E., Van der Geest S.

In the Nether lands re im burse ment of new, cost ly med i ca tions aimed at treat ing par tic u lar med i cal con di tions is re strict ed. For some of these drugs pri or au tho riza tion (PA) is com pul so ry, while for oth ers health in sur ers are free to im pose PA. To con trol drug costs, pa tients in creas-ing ly have to seek ap proval from their in sur er. We have iden ti fied the po ten tial so cial costs and ben e fits as so ci at ed with PA for “spe cial” drugs. Eco nom ic ra tio nal in sur ers use PA when pri vate ben e fits ex ceed pri vate costs. PA, how ev er, is a la bor in ten sive ad min is tra tive pro ce dure that rais es costs for all af fect ed par ties. It may also re duce pa tients’ ac cess to ben e fi cial drugs. Es pe cial ly when the re stric tions for re im burse ment that are im posed by the gov ern ment lag be hind clin i cal re search. In it self PA may be use ful to en cour age ap pro pri ate use of cost ly drugs. Be cause its sub stan tial ad min is tra tive costs and its po ten tial ad verse ef fects on health out comes, how ev er, the con se quences for all af fect ed par ties (both health in sur ers, physi cians and pa tients) should be tak en into ac count. It is un like ly that in sur ers will act in this way out of their own ac cord. We ar gue that with in the cur rent Dutch sys tem it is there-fore not en sured that PA will only be used when so cial ben e fits out-weigh so cial costs.

0029

Pa tients’ hos pi tal choice in the Nether landsVarke viss er M. (Eras mus Uni ver si ty Rot ter dam / iBMG, Nether lands)Schut E.

We em pir i cal ly ex am ine pa tients’ hos pi tal choice in the Nether lands, us ing a unique dataset with in di vid u al pa tient lev el hos pi tal util i sa tion data for the year 2003 from a large Dutch health in sur er. If the propen-si ty to trav el dif fers be tween dif fer ent types of pa tients, then the use of cur rent pa tient mi gra tion data to de fine ge o graph ic hos pi tal mar kets, as com mon ly ap plied in an titrust cas es, may lead to in cor rect con clu-sions. First, we an a lyse pa tients’ de ci sions to by pass the near est hos pi-tal. We show that de spite the ab sence of both fi nan cial in cen tives and ob serv able qual i ty dif fer ences be tween hos pi tals a size able per cent age of pa tients was not ad mit ted to the near est hos pi tal. Sec ond, we es ti mate a log it mod el of in di vid u al pa tient hos pi tal choice. Our ap proach fo cus-es on the sub sti tutabil i ty of hos pi tals and is based on a ran dom util i ty mod el in which the in di rect util i ty of a pa tient who vis its a spe cif ic hos pi-tal is a func tion of per son al at tributes, hos pi tal at tributes and at tributes spe cif ic to a giv en pa tient-hos pi tal com bi na tion (e.g. trav el time). Our pre lim i nary es ti ma tion re sults in di cate that al though trav el time and hos pi tal wait ing time per for mance are im por tant ex plana to ry vari ables much of the trav el for hos pi tal care oc curs for id io syn crat ic rea sons such as per ceived qual i ty dif fer ences or per son al pref er ences.

0194

Cost-eff ec tive ness anal y sis of the screen ing of he red i tary hemocro mato sis: How many al ter na tives are pos si ble?Vi cente A. (Ser vi cio Aragonés de la Salud, Aragón, Spain)Garuz R., Misiego A., Or te ga M.

In tro duc tion: He red i tary He mo chro ma to sis (HH) is a ge net ic dis ease with an au to som ic re ces sive pat tern that caus es an ex ces sive gas tro in tes-ti nal ab sorp tion of iron, es pe cial ly he pat ic. Prev a lence of the dis ease in Spain is be tween 1/1000 and 3/1000 but it is still not well de fined, as well as its ge net ic ex pres siv i ty. Ear ly de tec tion is ba sic to stop the de vel-op ment of an ir re vers ible dis ease. Screen ing is per formed by means of ser ic iron stud ies: Trans fer rin Sat u ra tion In dex (TSI) and plas ma tic fer-ri tin. If high val ues are found, a con fir ma tion ge net ic test is per formed (not re quir ing liv er bi op sy). We have un der tak en a cost-ef fec tive ness test to de ter mine the best screen ing strat e gy: Op por tunist screen ing of men > 30 years or screen ing of close rel a tives of HH pa tients (sib lings & off spring).Ma te ri al and meth ods: The uti lized costs have been the di rect; Ge net-ic test, an a lyt i cal de ter mi na tions, the phle bot o my and the HH’s com-pli ca tions, spe cial ly give them cir rho sis. They have been the mea sure of ef fect uti lized the years of life earned (AVG) and to es ti mate the life ex pect an cy in the gen er al pop u la tion in peo ple and with HH, the same way that the ben e fits uti lized Markov’s mod els them selves. The data of mor tal i ty come from the I.N.E and the sup po si tions of the mod el (the HH’s prev a lence, prob a bil i ty of de vel op ment HH) are ex tract ed of the in ter na tion al lit er a ture. The adopt ed per spec tive matched her so cial and the an nu al rate of dis count of the 5 %. Re sults: The best choice cost cash the strat e gy went from screen ing in broth ers of peo ple af fect ed of HH (with an in cre men tal cost of 2,281 eu ros for AVG). Screen ing’s strat e gy in chil dren of peo ple af fect ed of HH (with an in cre men tal cost of 18,838 eu ros for AVG). Screen ing’s strat e gy opor tunis tic in males of over 30 years (with an in cre men tal cost of 23,794 eu ros for AVG). The re sults of the sen si tiv i ty anal y sis demon-strate con sis ten cy in a gen er al way for all of the in ter vals of moral val-ues of the as sumed vari ables.Con clu sion: The screen ing to de tect ho mozy gotes for mu ta tion c282y of the gene HFE in first-de gree rel a tives (broth ers) with HH is the best choice cost cash. Our rec om men da tion is of ex pec tant pru dence to the

S100 | Eur J Health Econom Suppl 1 · 2006

hour to im ple ment screen ing’s pro grams of the HH in males of gen er al pop u la tion with out symp toms in our Na tion al Health Sys tem.

0296

Dy nam ic be hav ior of di ag nos tic im ag ing ser vices provi-ders un der a fee-for-ser vice re im burse ment Vieira M. (HPA-Hos pi tal Par tic u lar de Al ma da, Lis boa, Por tu gal)Bar ros P.P.

We aim at iden ti fy ing both sup ply and de mand side de ter mi nants of ex pen di tures growth with di ag nos tic im ag ing ser vices. In the Por-tuguese mar ket, prices are ex oge nous ly fixed un der a fee-for-ser vice regime, there fore pri vate providers com pete in oth er di men sions, and trends to wards high er con cen tra tion in the sup ply side could be as so ci-at ed with high er growth in to tal de mand.Our data is con sis tent with the com mon per cep tion of a gen er al trend in ex pen di tures in creas ing with med i cal tech nol o gy, due to a grow ing uti li za tion of di ag nos tic tech nol o gy, most ly linked to a ris ing share of more cost ly tech nol o gy.The in crease in an nu al in voice amounts is not even ly dis tribut ed across the sam ple of providers ob served. Clas si fy ing providers ac cord ing to their an nu al pro duc tion, show us that those with in in ter me di ate class-es have big ger an nu al pos i tive vari a tion of pro duc tion, sug gest ing that they are the main drivers of ex pense in crease from the sup ply side.Providers dy nam ic re vealed to wards a mix of in crease of scale and scope is the re sult of a sur vival req ui site de rived from the com pe ti tion among di ag nos tic ser vices com pa nies.The dis tinc tion be tween de mand and sup ply side de ter mi nants is cru-cial to as sess whether we wit ness in creased sat is fac tion of un met needs, or whether some sort of in duced de mand for these ser vices ex ist.

0057

Is there a thresh old eff ect in the re la tion ship be tween in come and health ?Vuilleu mi er M. (In sti tut de Recherch es Economiques, Neuchâ tel, Switzer land)

Many em pir i cal stud ies have in ves ti gat ed the re la tion ship be tween in come and health. They found a sig nif i cant log a rith mic as so ci a tion which re flects the ef fect of de creas ing mar gin al re turns of ma te ri al is-tic re sources on health. How ev er, the in come and health re la tion ship can also be seen as a suc ces sion of dif fer ent lin ear regimes sep a rat ed by thresh olds. In that case, we ob serve a lin ear ef fect of in come on health in each regimes, but with a de creas ing ef fect in high er regimes. mak ing the as sump tion that the in come and health as so ci a tion can be di vid ed into two dif fer ent regimes, the aim of this study is to de tect an em pir i cal thresh old on Swiss data us ing Quandt meth o dol o gy. This meth o dol o gy pro pos es a max i mum like li hood pro ce dure to de tect the switch ing point into a lin ear re gres sion sys tem obey ing two sep a rate regimes. We also com pute a like li hood func tion of a re cur sive re gres sion mod el which de pends only on the thresh old. Fi nal ly, we de rive a con fi dence in ter val us ing boot strap sim u la tion to test ro bust ness of the thresh old de tect ed.use the “Self As sessed Health” (SAH) and an equiv alised mea sure of house hold in come. Data are grouped into nine ty in come cat e gories of same length and we es ti mate the health mean in each cat e go ry. Re sults: We find that the thresh old which pro posed the best ad just ment of data is the 2900-3000 CHF in come cat e go ry. Ef fect of in come on health is clear ly high er be low the thresh old be cause of the sig nif i cant dif-fer ence be tween the in come co ef fi cients of each regimes. How ev er, the re sult of the boot strap es ti ma tion show that the thresh old is not ro bust. The con fi dence in ter val is too large for claim ing that there is a thresh old ef fect in the re la tion ship be tween in come and health.)

0223

Per sons With out Health In sur ance in Ger many: Sta tus Quo and Pol i cy Op tionsWal endzik A. (In sti tute for Health Care Man age ment, Uni ver si ty Duis burg/Es sen, Ger many)Greß S., Wasem J.

Per sons With out Health In sur ance in Ger many : Sta tus Quo and Pol-i cy Op tion s Ger many more than 99 per cent of the pop u la tion is cov-ered ei ther by so cial health in sur ance or by al ter na tive pri vate health in sur ance. Nev er the less, since the ear ly 1990s, struc tur al chang es on the labour mar ket have led to a larg er share of low-in come self-em ployed per sons and more low-in come em ploy ees. At the same time, the leg is-la tor has re strict ed ac cess to so cial health in sur ance. As con se quence, the num ber of the unin sured has dou bled to al most 200,000 per sons in 2003. By us ing rep re sen ta tive cen sus data we were able to iden ti fy groups of per sons who run a high er than av er age risk to be come unin-sured. These groups con sist main ly of low-in come self-em ployed and low-in come em ploy ees, per sons who got di vorced, uni ver si ty stu dents and for eign ers. Avail able ev i dence from the US shows quite clear ly that the unin sured have a high er risk to be come severe ly ill or to die pre ma-ture ly than per sons with health in sur ance. We con clude that this can be avoid ed by in tro duc ing manda to ry health in sur ance for the en tire pop u-la tion. The same has been done re cent ly in the Nether lands and ten years ago in Switzer land. Al ter na tive ly we sug gest to im prove ac cess in so cial health in sur ance as well as in al ter na tive pri vate health in sur ance.

0279

Tar get pay ment and Gen er al Prac ti tion ers’ Ser vice Ac tiv i ty in the UK NHSWang Q. (Uni ver si ty of York, UK)May nard A.

Back ground: In or der to im prove GPs per for mance, the tar get pay ment pol i cy was in tro duced by the UK NHS in 1990. Tar get pay ment re mu-ner ates health care ser vice providers only if they pro vide an agreed lev-el of care. Since 1990, there are two lev els of tar get for child hood im mu-ni sa tion (low er tar get 70% and high er tar get 90%) and cer vi cal cy tol o-gy (50% and 80%). These ser vices were pre vi ous ly paid by fee-for-ser-vice (FFS) meth od. Un der tar get pay ment meth od GP ser vice ac tiv i ties (ST) were com pared with those un der FFS meth od (SF) when oth er fac-tors that in flu ence ST and SF were con trolled.Hy pothe ses: ST will be in creased to tar get lev els; ST dis tri bu tion will be bi mo dal while SF nor mal; Oth er fac tors will have low er in flu ence on ST; ST will be in creased more promi nent ly for GPs who were pre vi ous ly with low er ser vice ac tiv i ty than those with high er one.Data/Meth ods: Data at na tion al and lo cal lev el (e.g. gen er al prac tice) were col lect ed to test the hy pothe ses by us ing time se ries, pan el data, and cross-sec tion al anal y ses.Re sults: ST has been in creased to tar get lev els; ST has not formed a bi mo dal dis tri bu tion; The in flu ence of oth er fac tors was not low er on ST; The ser vice ac tiv i ty has been in creased more promi nent ly for GPs who were pre vi ous ly with low er ser vice ac tiv i ty.

0612

Trans lat ing mea sure ment into a na tion al agen da; the fi rst Dutch health care re port, its im pact and what comes nextWest ert G. (Na tion al In sti tute for Health and the En vi ron ment (RIVM) and Tilburg Uni ver si ty, Bilthoven, Nether lands)

Ob jec tive/Aims: The aim of the pre sen ta tion is to re port on the de vel-op ment of a na tion al per for mance in di ca tor frame work for the Dutch

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health sys tem and to pres ent find ings from the first Dutch health care re port.Meth od: The Dutch Min istry of Health ini ti at ed a pro ject to as sess and re port the per for mance of health care qual i ty, ac ces si bil i ty and cost at the na tion al lev el in the Nether lands. RIVM pre pared the re port in two stag es: 1 defin ing a per for mance in di ca tor frame work, in col lab o ra tion with OECD; 2 find ing ap pro pri ate mea sures to re port about qual i ty, ac ces si bil i ty and cost. In ter na tion al and time com par isons were made were pos si ble. Re sult: In gen er al the Nether lands has a ac ces si ble health care sys tem in 2004. Health care ex pen di tures has risen sub stan tial ly be tween 2000 and 2004, but in line with the trend in the EU-15. Hol land ranks lit tle above av er age in cost de vel op ment in the EU-15 and OECD coun tries. Qual i ty of health care is for most in di ca tors above av er age, com pared to oth er OECD coun tries. Ca pac i ty to im prove is ob served for sub-in di-ca tors in the fol low ing in di ca tor do mains: ef fec tive ness of pre ven tion, cure and care, pa tient safe ty and con ti nu ity of care.Con clu sion/dis cus sion: The first Dutch health care re port has some strong and weak points. Strong is that the per for mance frame work used has a sol id in ter na tion al fun da ment (Arah et al, 2006). The set of in di-ca tors used is firm ly root ed in pres ent Dutch health pol i cy. Mea sures and in di ca tors not al ways match per fect ly. Time and space com par isons were lim it ed, be cause of (in ter na tion al) data avail abil i ty and com pa ra-bil i ty.The Dutch Min istry of Health will use the re port (af ter pub li ca tion in May 2006) to take the pulse of Dutch health care in 2004 and to steer it’s fu ture di rec tion. A quest for qual i ty is like ly to emerge fol low ing it’s pub li ca tion.

0333

Cost Eff ec tive ness Anal y sis (CEA) and the lo cal-lev el tech nol o gy cov er age de ci sions in Eng landWil liams I. (Health Ser vices Man age ment Cen tre, Uni ver si ty of Birm ing ham, UK)Stir ling B.

In a con text of rapid tech no log i cal ad vances in health care and in creas-ing de mand for ex pen sive treat ments, lo cal for mu lary com mit tees are a key play er in the man age ment of scarce re sources. How ev er lit tle is known about the in for ma tion and pro cess es these use when de cid ing on the in clu sion of new treat ments. We col lat ed and anal y sed new tech-nol o gy re quest forms’ in or der to gauge the types of in for ma tion rou-tine ly re quest ed by such com mit tees. We then con duct ed case stud ies of four com mit tees in volv ing ob ser va tion of meet ings and in ter views with com mit tee mem bers. In par tic u lar we sought to in ves ti gate the role and im pact of CEA on com mit tee de ter mi na tions. We found that only a small mi nor i ty of com mit tees rou tine ly re quest in for ma tion on the cost ef fec tive ness of a new tech nol o gy and the case study com mit-tees rarely ac cessed such stud ies. A range of bar ri ers to use of CEA were iden ti fied in clud ing lack of health eco nomics ex per tise with in the com-mit tee, doubts over the in de pen dence of anal y ses, and prob lems with im ple men ta tion of study rec om men da tions. There is a need to clar i fy the aims and func tions of lo cal lev el com mit tees, and to con sol i date their place with in the broad er po lit i cal and fi nan cial con text, if rou tine use of cost ef fec tive ness anal y sis is to be come a re al is tic aim.

0052

An es ti mate of the world wide costs of de men tia: re sults and method olog i cal as pectsWimo A. (Neu rotec, Har manger, Swe den)Jöns son L., Win blad B.

De men tia dis or ders are to day con sid ered to be a ma jor cost driv er in the health care and so cial sys tems not only in the ad vanced economies

but also in the de vel op ing coun tries. The main rea son is the ag ing pop-u la tion world wide and as a con se quence, the in creas ing num ber of peo-ple suf fer ing from de men tia, in con junc tion with the high lev el of care re quired by de ment ed el der ly.es ti mate of the world wide costs of de men-tia is based on world wide prev a lence fig ures of de men tia from dif fer ent re gions com bined with cost of ill ness stud ies of de men tia in key coun-tries. For coun tries with no avail able cost data, costs were mod elled based on the re la tion ship be tween cost of ill ness and the gross do mes-tic prod uct (GDP). Two ma jor cost com po nents need to be in clud ed in such a cost mod el a) for mal care costs in terms of di rect med i cal costs and di rect non med i cal costs and b) costs of in for mal care. the base op tion, the world wide di rect costs of de men tia are es ti mat ed at 156 bil-lion US$ and the costs of in for mal care to 92 bil lion US$, re sult ing in a to tal cost of 248 bil lion US$. of the as sump tions in clude both un cer-tain ties and also vari abil i ty. In a sen si tiv i ty anal y sis dif fer ent sce nar ios are in ves ti gat ed, re sult ing in a range of cost es ti mates. In com plete de mo-graph ic sta tis tics, dif fer ent ways to or ga nize care as well as its fi nanc ing, avail able re sources, and par tic u lar ly the way of mea sur ing and cost ing in for mal care are ex am ples of fac tors that con tribute to the un cer tain ty. This study demon strates that the world wide costs are sub stan tial, and par tic u lar ly the ex pect ed in crease of el der ly peo ple in the de vel op ing coun tries pres ent a great chal lenge for so cial and health care sys tems.

0183

Pay ing For Long-Term Care for Old er Peo ple in the Unit ed King domWit ten berg R. (Per son al So cial Ser vices Re search Unit, Lon don School of Eco nomics, Lon don, UK)Han cock R., Co mas-Her rera A., Pickard L., Juarez-Guar cia A., King D., Mal ley J.

The aim of this study is to make pro jec tions to 2050 of pub lic and pri-vate ex pen di ture on long term care ser vices, and its dis tri bu tion, un der a wide range of op tions for re form ing the sys tem for fund ing long term care for old er peo ple in the Unit ed King dom. study in volved link age be tween mac ro- and mi cro- sim u la tion mod els of long-term care fi nanc-ing. The for mer com pris es cell-based mod ules for mak ing pro jec tions of the num bers of ser vice re cip i ents and ex pen di tures. The lat ter sim u-lates the in comes and as sets of fu ture co horts of old er peo ple and their abil i ty to con tribute to ward care costs.re search team have ex pand ed their anal y ses of res i den tial care charg ing and added anal y ses of home care charg ing. They have ex am ined the im pact on cur rent and pro ject-ed fu ture pub lic ex pen di ture of a range of chang es to the fund ing sys-tem. They have in ves ti gat ed the im pact of the chang es, to geth er with the tax es need ed to fund them, on dif fer ent sec tions of the in come dis-tri bu tion. key find ing of this study is that re moval of the means test for per son al care would be cost ly and re gres sive. The same re sources could be used more pro gres sive ly by in creas ing the amount of in come ig nored in the means test.

0199

Un der stand ing the rea sons for the non re course to the French Sup ple men tal Pub lic Health Cov er age (called the CMU Com plé men taire or CMUC)Wit twer J. (LEGOSé Par is Dauphine, Par is, France)Du four-Kip pe len S., Le Pen C., Le gal A.

This ab stract fea tures an anal y sis of the rea sons for the non re course to the CMUC, a means-test ed French Pub lic Health Pro gram which pro-vides an en tire ly free health care cov er age. On the non re course to pub lic ser vices are still very few in Eu rope. In France, the non re course to the CMUC can be ap prox i mat ed to 25% by com par ing the 4,7 mil lion in di-vid u als ben e fit ing to day from CMUC, to the 6 mil lion po ten tial re cip-i ents ini tial ly en vi sionned when the 1999 law was vot ed.com ple men ta-

S102 | Eur J Health Econom Suppl 1 · 2006

ry meth ods al low ing to con front ob jec tive and sub jec tive data are used here. First, de ter mi nants of non re sort ing peo ple are anal y sed by sta tis ti-cal and econo met ric meth ods ex ploit ing the data from the Na tion al Sur-vey on Health and Na tion al Health In sur ance (ESPS) by the Re search and In for ma tion In sti tute for Health Eco nomics (IRD ES). Then, face to face in ter views of ex clud ed peo ple will be con duct ed in an or ga ni za tion de vot ed to wel fare., the dy nam ic as pects will be ap proached thanks to the pan el di men sion of the sur vey and its ret ro spec tive ques tions.

0146

So cio-Eco nom ic, De mo graph ic and Cog ni tive Risk In di ca tors of Den tal Car ies Amongst Adults in the Re pub lic of Ire landWoods N. (Uni ver si ty Col lege Cork, Ire land)

Ob jec tive: To iden ti fy the so cio-eco nom ic, de mo graph ic and cog ni tive in di ca tors of car ies risk amongst adults in the Re pub lic of Ire land. The data is based on a clin i cal ex am i na tion un der tak en in the Na tion al Sur-vey Adult Oral Health be tween Oc to ber 2000 and June 2002. Treat ment need was es ti mat ed for 2,937 adults ac cord ing to el i gi bil i ty for den tal ser-vices. The sam ple was weight ed by gen der, med i cal card sta tus, and age. Meth ods: A high-risk car ies pre dic tion mod el was es ti mat ed for 16–24s, 35–44’s and those age 65 and over by lo gis tic re gres sion when the de pen-dent vari able (DMFS) was di choto mous, or by or dered lo gis tic re gres-sion when the de pen dent vari able was mul ti choto mous. Good ness of fit was eval u at ed by es ti mat ing its sen si tiv i ty and spec i fic i ty. Fac tors such as age, low er so cio-eco nom ic sta tus, oral hy giene be hav iour, den-tal at ten dance, ed u ca tion al at tain ment, smok ing, and un em ploy ment were “high car ies risk” in dic tors. “High need” in dic tors can be used to de vel op a pop u la tion-based re source al lo ca tion for mu la. As some sub-groups al ready have rel a tive ly good oral health, their ca pac i ty to ben e-fit fur ther is lim it ed. A re source al lo ca tion for mu la could be de vel oped, based on al lo cat ing re sources ac cord ing to the size of the prob lem (oral health need weight ed in terms of the ‘ca pac i ty to ben e fit’ from care).

0126

De sign of Effi cient Health Care Sys temsWranik D. (Dal housie Uni ver si ty – SPA, Hal i fax, Can a da)

De sign of health care pol i cy re quires de ci sion mak ing with re spect to choice of health care sys tem char ac ter is tics, such as ar range ments be tween pa tients, pay ers, and providers, pub lic ver sus pri vate in sur ance, re mu ner a tion of health care providers, gate keep ing ar range ments, and sec toral re source al lo ca tion. These char ac ter is tics have been as sessed from the per spec tive of health care sys tem costs, but not from the per-spec tive of health care sys tem ef fi cien cy. Sto chas tic fron tier anal y sis is used to as sess the ef fects of health sys tem char ac ter is tics on sys tem ef fi-cien cy, where char ac ter is tics are treat ed as en vi ron men tal in flu ences, which are nei ther in puts, nor out puts of the sys tem. Re sults point to ward the de sir abil i ty of cap i ta tion or salary ar range ments over fee for ser vice ar range ments, to ward a shift of re sources from acute care to chron ic care sec tors, and to ward a greater share of pub lic health care ex pen di ture.

0275

Qual i ty as sess ment of health sys tems: the con nec tion be tween struc ture, pro cess and out comes of care with in Ger manyWue bker A. (WHL Grad u ate School of Busi ness and Eco nomics, Lahr, Ger many)

Qual i ty as sess ment of health sys tems: the con nec tion be tween struc-ture, pro cess and out comes of care with in Ger many

Re cent ly, there have been enor mous ef forts to mea sure the per for mance of dif fer ent health sys tems (i.e. OECD, WHO) in or der to get in for ma-tion about ways to im prove the qual i ty of a cer tain health sys tem. How-ev er this re search area is still in an ear ly stage of de vel op ment and there is much more re search to be done.Ob jec tives: The re search plan out lines a frame work to an a lyse the qual-i ty of a health sys tem on the ba sis of the three qual i ty di men sions in tro-duced by Don abe di an. It tries to de vel op a con sis tent line of ar gu ments to clar i fy the log ic of how struc ture and pro cess mea sures af fect out-come mea sures. To do so, it refers to se lect ed dis eases and tests the va lid-i ty of this (the o ret i cal) frame work with in an em pir i cal anal y sis.Meth ods: As work ing ba sis serves the def i ni tion of qual i ty de vel oped by the In sti tute of Med i cine (IOM) and the Don abe di an ap proach that dis tin guish es be tween struc ture, pro cess and out come qual i ty. In a first step the pa per pre sents a con sis tent line of ar gu ments to clar i fy the re la-tion be tween those qual i ty di men sions. The next step is to se lect a set of preva lent dis eases to test the hy poth e sis, that good out come in di ca tors are de pen dent on good struc ture and good pro cess in di ca tors. Be cause of in creas ing fi nan cial short ages with in health sys tems the study refers to the most cost ly med i cal con di tions (i.e. heart dis eases). This ap proach forms a link be tween med i cal and eco nom ic prob lems. Re fer ring to ev i-dence based med i cal knowl edge mea sur able in di ca tors are de vel oped for each dis ease and the hy poth e sis men tioned above is test ed. Re sults: Em pir i cal anal y sis comes up with two re sults: First, the anal-y sis con firms the pre dict ed con nec tion be tween the dif fer ent di men-sions of qual i ty of care for some “Bun deslän der”. Sec ond ly, how ev er, a good struc ture and a good pro cess qual i ty alone can not guar an tee a good out come qual i ty.Con clu sion: In ad di tion to the health sys tem, there are oth er de ter mi-nants (i.e. ed u ca tion, in come per cap i ta) that also af fect the out come qual i ty of health care. Fur ther em pir i cal in ves ti ga tion of the in flu ence of these fac tors on the out come di men sion could close the “ex pla na tion gap” and could de liv er ad di tion al in sights.

0500

Pro vid ing ac cess for all to qual i ty health and long-term care in a fi nan cial ly sus tain able man ner: the EU Open Meth od of Co or di na tion at workXavier A. (Eu ro pean Com mis sion DG Em ploy ment, Unit E4 So cial Pro tec tion, Pen sions and Health Care, Brus sels, Bel gium)

Par of the or gan ised ses sion by the Eu ro pean Com mis sion: Pol i cy choic-es for Eu rope- age ing and sus tain abil i ty: “In 2004 the Coun cil de cid-ed to ex tend the Open Meth od of Co or di na tion (OMC) to health and long-term care. The OMC is an EU pol i cy tool where by EU coun tries ex change in for ma tion and iden ti fy best prac tice while re main ing ful ly re spon si ble for the or ga ni sa tion of their ser vices. It is used in the fields of So cial In clu sion and Pen sions. Con se quent ly, in 2005, EU coun tries sub mit ted to the Com mis sion na tion al state ments re gard ing ac cess, qual-i ty and fi nan cial sus tain abil i ty in the fields of health and long-term care. The anal y sis of these state ments iden ti fied com mon chal lenges faced by EU Mem ber States in those fields, re viewed pol i cy plans by in di vid u al coun tries and list ed com mon key work ar eas where the OMC could be use ful. These key ar eas in clude: en sur ing ac cess to care and re duc ing health in equal i ties, de vel op ing the pro vi sion of long-term care, pro mot-ing pre ven tion, ac tive life-styles and heal thy age ing, pro mot ing qual i ty mech a nisms, in creas ing pa tients’ choice and in volve ment, se cur ing heal-thy fi nanc ing to the sys tem through ef fi cient func tion ing of in sti tu tions, strength en ing in cen tives to users and providers for ra tio nal re source use, and tack ling staff short ages by de vel op ing hu man re sources stra te-gies. In 2006, EU coun tries will agree on the com mon pol i cy ob jec tives in these fields based on this re port ing and anal y sis ex er cise.”

Eur J Health Econom Suppl 1 · 2006 | S103

0114

Mod elling the Cost Eff ec tive ness of EPO for Can cer Treat ment-in duced Anae mia Yao G.L. (Uni ver si ty of Birm ing ham, UK.)Raftery J., Min ers A., Hyde C., Wil son J.

Back ground: Anae mia is a com pli ca tion as so ci at ed with che mo ther a-py. Whilst the use of eryth ro poi e tin (EPO) for the treat ment of anae mia has been shown to de crease the risk of blood trans fu sion and in crease haemoglobin (HB), its cost-ef fec tive ness re mains un cer tain.Pur pose: To eval u ate the cost-ef fec tive ness of EPO for the treat ment of anae mia as so ci at ed with che mo ther a py com pared with best stan dard care from the NHS per spec tive.Meth ods: A sim u la tion mod el, in cor po rat ing sur vival, qual i ty ad just-ed life years (QALYs) and costs, was de vel oped. Pa tients were char ac-ter ized by their base line HB lev els. In put val ues were de rived from sys-tem at ic re views. The mod el has a 3-year time frame. The base case was 6 months che mo ther a py treat ment fol lowed by an off-che mo ther a py pe ri od. Re sults: The in cre men tal cost-ef fec tive ness ra tio (ICER) was £119,247 per QALY gained with no sur vival gain to EPO. The ICER de creased to £31,119 when the most favourable sur vival gain was as sumed. Re sults were sen si tive to the length of time frame and sur vival ben e fit of the treat ment.Con clu sions: EPO is ef fec tive in im prov ing red blood cell trans fu sion re quire ments. Its im pact on sur vival re mains high ly un cer tain. If there is no im pact on sur vival, it seems high ly un like ly that EPO is a cost ef fec-tive use of health care re sources.

0131

The Long-term Cost-Eff ec tive ness of Car di ac Resyn chro niza tion Ther a py with or with out an Im plantable Car dio vert er-De fi b ril la torYao G.L. (Uni ver si ty of Birm ing ham, UK)Free man tle N., Calvert M.J., Cle land J.G.F., Bryan S.

Back ground: Car di ac Resyn chro ni sa tion Ther a py (CRT-P) is an ef fec-tive treat ment for pa tients with heart fail ure and car di ac dyssyn chrony. Ad di tion of an im plantable-car dio vert er de fib ril la tor (ICD) func tion may fur ther re duce the risk of sud den death. We as sessed the cost-ef fec-tive ness of CRT-P and CRT-ICD com pared to med i cal ther a py (MT). Meth ods: A Markov mod el with Monte Car lo sim u la tion to as sess costs, life years and qual i ty ad just ed life years (QALYs) as so ci at ed with CRT (± ICD) and MT was de vel oped, based on a UK health care per spec tive. Mod el pa ram e ters were es ti mat ed from in di vid u al pa tient data from the CARE-HF tri al. The ad di tion al sur vival ben e fit of an ICD was based on re sults from SCD-HeFT. The base case anal y sis was based on 10,000 in di vid u al life-time sim u la tions as sum ing a bat tery life of 6 years.Re sult: The in cre men tal cost-ef fec tive ness of CRT-P com pared with med i cal ther a py £3,474 per QALY gained and £3,366 per life year gained. Data on the in cre men tal cost-ef fec tive ness of adding an ICD to CRT in pa tients at dif fer ent risks of sud den death will be pre sent ed. Con clu sions: Long-term treat ment with CRT-P ap pears cost-ef fec tive com pared to med i cal ther a py. Com pared to CRT-P, CRT-ICD was also cost-ef fec tive giv en a will ing ness to pay of £30000 per QALY.

0440

Set ting Pri or i ties for Man ag ing Re nal Fail ure in Ra mal lah Hos pi tal (Pales tine)Ziedan N. (Uni ver si ty Pales tini an Ter ri to ry, Ra mal lah, Pales tini an)Mataria A., Bate A., Don ald son C.

This pa per aims at de scrib ing a pi o neer ing at tempt to im ple ment the Pro gramme Bud get ing and Mar gin al Anal y sis ap proach to de ci sion-

mak ing vis-á-vis man ag ing re nal fail ure at a main re fer ral hos pi tal : Ra mal lah Hos pi tal : in the Oc cu pied Pales tini an Ter ri to ry. State-of-the-art stan dards in man ag ing re nal fail ure; e.g., kid ney trans plant, re nal/peri to ne al home/hos pi tal di al y sis, and med i ca tion-based dis ease man-age ment were re viewed. The op por tu ni ty costs as so ci at ed with the dif-fer ent op tions were es ti mat ed adopt ing a Min istry of Health and a so ci-etal per spec tives. Health out comes as so ci at ed with the dif fer ent treat-ment op tions were as sessed us ing the EQ-5D Qual i ty of Life in stru ment. Be side, pro grammes’ ben e fi cia ries were also ques tioned about their will-ing ness to pay val ues for ben e fit ing from one op tion and not the oth ers, us ing a mar gin al con tin gent val u a tion ap proach. Re sults form the cost-util i ty/ben e fit eval u a tions were then il lus trat ed in a fo cus group dis cus-sion with an ad vi so ry pan el com posed of de ci sion-mak ers and spe cial-ized health pro fes sion als. Dis cus sions were used to in form the ‘list of pri or i ties’ sus cep ti ble to en hance tech ni cal and al loca tive ef fi cien cies in man ag ing re nal fail ure, while ac count ing for ser vices growth and pos si-ble re duc tions. It was found that al though re nal di al y sis would ap pear the op tion of choice from the MoH per spec tive, should a so ci etal per-spec tive be adopt ed ben e fits from kid ney trans plan ta tion re veals to sur-pass trans plant-as so ci at ed costs.

S104 | Eur J Health Econom Suppl 1 · 2006

Poster presentations

0316

Pa tients’ per ceived in sur ance cov er age, a mis match with fac tu al den tal in sur ance cov er age Abra ham D. (pri vate per son; re search un der tak en dur ing em ploy ment at Katholieke Uni ver siteit Ni jmegen, Bantry, Ire land)

Pre lim i nary re sults have been pre sent ed in poster for mat at the con fer-ence of the in ter na tion al Health Eco nomics As so ci a tion (iHEA, San Fran cis co, 2003).Back ground: The ef fect of in sur ance on den tal uti li za tion is me di at ed by pa tients’ know ledge of cov er age but the pub lished lit er a ture does not ex plore this re la tion ship. Study ob jec tive: To study the lev el of in sur ance aware ness in reg u lar ly at ten ding adult den tal pa tients in the Nether lands. De sign: This study uses a pa tient ques tion naire and den tal uti li za tion data to mea sure knowl edge of re im burse ment for pe rio don to logy, resto-ra tions and crowns/bridg es. Re sults: Re im burse ment for pe ri odon tics, res to ra tions and crowns & bridg es is known cor rect ly to 27.2%, 38.5% and 21.1% re spec tive ly. Pub-licly in sured seem less aware of in sur ance cov er age for crowns & bridg es com pared to res to ra tions and pe ri odon tics. Pri vate den tal pa tients have equal aware ness for res to ra tions, pe ri odon tics and crowns & bridg es.Con clu sions: The Dutch have poor un der stand ing of their den tal in sur-ance ben e fits. There fore den tal uti li za tion re search must in clude both in sur ance sta tus and a mea sure of in sur ance aware ness to gain in sight in the re la tion ship be tween in sur ance cov er age and uti li za tion.

0570

Cost of Cer vix Can cer Treat ment in Hun garyÁcs N. (Ob stet ri cal and Gy ne co log i cal Clin ic of Sem mel weis Med i cal Uni ver si ty, Bu dapest, Hun gary)Brandt müller Á., Nagy L., Kovács F., Erdész D.

Dis cus sion/Re sults: In dis ease ar eas where sev er al dif fer ent dis ease stag-es and al ter na tive treat ment op tions ex its (i.e. can cers, CNS dis or ders) the cost ing is sue plays a piv otal role in any cost ef fec tive ness anal y sis. The ob jec tive of this pa per is to iden ti fy and quan ti fy the dif fer ent cost el e ments in the treat ment of cer vix can cer in CINI to CIS and in IA1, IA2,IB, IIA, IIB, III, IV FIGO stag es. The need to ac cess the cost ef fec-tive ness of the na tion al cer vix screen ing pro gram “Jo han Bela Na tion-al Pro gram of the Decade of Health” and the mar ket en try of new HPV vac cines in 2006 gives fur ther im por tance to the is sue. In our study cer-vix can cer treat ment cost were com pared from two sep a rate sources: i. data from So cial Se cu ri ty data base, ii. Del phi pan el con struct ed from 20 Hun gar i an key opin ion lead ers. From the So cial Se cu ri ty data base in ter ven tion costs (out pa tient, in pa tient care and drug cost) were col lect-ed based on BNO and anonym pa tient iden ti fi ca tion num ber on year ly ag gre gate lev el. As a lim i ta tion no stage spe cif ic costs are record ed in the database. In the Del phi pan el, with the use of Hy per Point 2003 vot ing sys tem, the dis tri bu tion of the dif fer ent in ter ven tions were as sessed, and con vert ed to cost us ing the ac tu al ONO and HBCS HUF equiv a lents.

0113

As sess ing self-as sessed health dataAhn N. (FEDEA, Madrid, Spain)

Dis cus sion/Re sults: Many stud ies have used self-as sessed health data to ex am ine the de ter mi nants of health sta tus and the ef fects of health sta tus on broad ar eas of hu man be hav ior. Giv en sub jec tiv i ty and pos si-ble mea sure ment er rors imbed ded in self-as sessed health data, we ex am-ine their va lid i ty and use ful ness us ing the data from Eu ro pean Com mu-ni ty House hold Pan el. Our anal y sis pro vides clear ev i dence against care-less use of self-as sessed health sta tus sur vey data. The strongest case is cross-coun try com par isons of self-as sessed health sta tus and dis abil i-ty rate. Age-spe cif ic health mea sures based on self-as sessed health sta-tus vary enor mous ly be tween coun tries and of ten coun try rank ings are hard to be lieve, thus sug gest ing the im por tance of lan guage, cul ture and so cial en vi ron ment in self-as sessed health data. When we com pare self-as sessed health sta tus across re gions with in a coun try (Spain), we find that re gion al dif fer ences are con sis tent with oth er mea sures of health al though the re gion al vari a tions are also larg er than one would ex pect. Self-as sessed health mea sures are also sen si tive to the in sti tu tion al set-tings such as pen sion sys tem. For ex am ple, in Spain some re tired peo-ple who re ceive dis abil i ty pen sion seem to de clare worse health sta tus than real to jus ti fy their pen sion el i gi bil i ty.

0446

In equal i ty in health care use among old er peo ple in the Unit ed King dom: ev i dence from the British House hold Pan el Sur vey Allin S. (Lon don School of Eco nomics Health and So cial Care, Lon don, UK)Masse ria C., Mossia los E.

Dis cus sion/Re sults: This study in ves ti gates in come-re lat ed in equal i-ties in GP, hos pi tal, spe cial ist and den tist care among over 65s in the UK be tween 1997 and 2003 us ing data from the BHPS. The prob a bil i ty of a vis it to the GP, spe cial ist, den tist or ad mis sion to hos pi tal was pre-dict ed us ing mul ti ple ran dom ef fects lo gis tic re gres sion mod els. Con-cen tra tion in dices were cal cu lat ed based on in di rect stan dard iza tion ap proach; a hor i zon tal in equity in dex equal to zero im plies that af ter con trol ling for dif fer ences in need across in come groups, in di vid u als have equal prob a bil i ty of ser vice use, re gard less of in come. The re sults in di cate that in di vid u als on low er in come are more like ly to vis it a GP, spe cial ist and hos pi tal than the bet ter-off, with the re verse for den tal vis-its. Af ter ad just ing for dif fer ences in need (health sta tus) with in come, a sig nif i cant pro-rich in equity is found for all ser vice ar eas, par tic u lar-ly spe cial ist and den tal care, even when pri vate sec tor care was ex clud-ed. While a re cent anal y sis among the gen er al British pop u la tion found health ser vice use to be large ly eq ui table (with the ex cep tion of den tal care), it ap pears that in equal i ties may in crease among the old er age groups. As the high est con sumers of health care, and with po ten tial-ly more bar ri ers to ac cess, more at ten tion should be paid to ex ist ing in equities among this age group.

0154

Risk of Own Death and the Death of Oth ersAn der s son H. (Swedish Na tion al Road & Trans port Re search In sti tute (VTI), Sol na, Swe den)Lund borg P.

Dis cus sion/Re sults: The pur pose of this study is to ex am ine dif fer ences be tween Swedish in di vid u als’ per cep tion of their own mor tal i ty risk and ob jec tive risk mea sures, to an a lyze the mag ni tude of any risk bias, and to ex am ine in di vid u als’ risk per cep tion for ma tion. Risk per cep tion for-ma tion is an a lyzed in the Bayesian learn ing frame work. Two dif fer ent

Eur J Health Econom 2006 · [Suppl 1] 7:105–138

DOI 10.1007/s10198-006-0369-7

© Springer Medizin Verlag 2005

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mor tal i ty risks are an a lyzed, road-traf fic and over all risk. Both risks are ex am ined since we as sume that in di vid u als re gard road-traf fic risk as con trol lable, where as over all risk is re gard ed as a mor tal i ty risk which to a large ex tend is out of the in di vid u al’s own con trol. We find a pat ter for road-traf fic mor tal i ty risk in line with the Bayesian learn ing mod el, but not for over all mor tal i ty risk. The re sults also im ply that: (i) men are more like ly to un der assess their mor tal i ty risk, (ii) wom en are more ac cu rate in their be liefs, and (iii) men per ceive the risks as low er than wom en. We also find re sults which im ply that in come lev el and health sta tus in flu ence the in di vid u als’ risk per cep tion.

0258

Health-re lat ed qual i ty-of-life mea sured by EQ-5D in de pressed pa tients in pri ma ry careAn dlin-Soboc ki P. (Stock holm Health Eco nomics, Stock holm, Swe denIn sti tutet, Stock holm, Swe den)Ek man M., Jöns son B.

Dis cus sion/Re sults: Back ground. De pres sion is a preva lent psy chi at ric dis or der as so ci at ed with im paired pa tient func tion ing and re duc tions in health-re lat ed qual i ty of life (HRQL). The pres ent study de scribes the im pact of de pres sion on pa tients_RQL and as sess es the im pact of an ti de-pres sant treat ment on HRQL. 447 pa tients were re cruit ed at 65 pri ma ry care cen tres to this nat u ral is tic lon gi tu di nal ob ser va tion al study. Pa tients over 18 years with de pres sive symp toms, and who ini ti at ed a new an ti-de pres sant ther a py were in clud ed in the study. Data on pa tients’ so cio-de mo graph ics, dai ly ac tiv i ty and qual i ty-of-life (EQ-5D) were col lect-ed us ing ques tion naires com plet ed dur ing out pa tient GP vis it for a fol-low-up pe ri od of ap prox i mate ly 6 months. Dis ease sever i ty was as sessed with the Clin i cal Glob al Im pres sion Sever i ty scale (CGI-S). Re gres sion anal y sis was em ployed to an a lyse the de ter mi nants of qual i ty-of-life in de pressed pa tients.. The mean EQ-5D util i ty score at base line was 0.47 (0.44–0.49). Milder cas es of de pres sion re port ed a health util i ty of 0.60, where as mod er ate ly and severe ly de pressed pa tients re port ed util i ty val-ues of 0.46 and 0.27 re spec tive ly (p<0.001). At the end of fol low-up the av er age util i ty in the sam ple was 0.69 (0.67–0.72), cor re spond ing to an in crease in util i ty by 0.23 (p<0.001). A re gres sion mod el showed that pa tients with a sta tus of sick-leave were as so ci at ed with low er util i ty by 9% (p<0.0001). There were no sta tis ti cal ly sig nif i cant dif fer ences in util i ties by de mo graph ic vari ables. More over, in creased dis ease sever i-ty (as sessed with CGI) was as so ci at ed de creased health-re lat ed qual i ty-of-life. By treat ing the pa tient to achieve clin i cal re mis sion is as so ci at ed with high er qual i ty-of-life and the pres ence of co-mor bid i ty is as so ci at-ed with de creased qual i ty-of-life.. De pres sion has a sub stan tial im pact on the health-re lat ed qual i ty-of-life of the pa tient and our re sults in di-cate that an tide pres sants have sig nif i cant im prove ment on EQ-5D in dex score over a course of 6 months. Self-re port ed pa tient val u a tions are im por tant out comes for cost-ef fec tive ness anal y sis of new an ti de pres-sant com pounds.words de pres sion, pri ma ry care, qual i ty-of-life.

0369

Ge o graph i cal Vari ance and Con ver gence of Med i cal Ser vices in JapanAne gawa T. (Keio Uni ver si ty, Grad u ate School of Busi ness Ad min is tra tion, Yoko hama, Japan)

Dis cus sion/Re sults: Us ing data of 47 “pre fec tures” be tween 1981 and 2000, this study in ves ti gates an em pir i cal ques tion what fac tors ac count for ge o graph i cal vari a tions and con ver gence in med i cal ser vice in Japan. I ex am ine de mand for “im pa tient ser vices”, “out pa tients ser vices”, and “den tal ser vices” for “non-aged” and “aged” groups. De mand for med i cal ser vices is re spon sive to own prices as well as prices of med i cal ser vices. This fact in di cates that de mand for a spe cif ic med i cal ser vice is in duced by sup pli ers to com pen sate the de crease of oth er ser vices. In the 1990s,

the num ber of physi cians, nurs es, and beds has come to play sig nif i cant roles on de mand for im pa tient ser vices. The ef fects, how ev er, are com-pli cat ed. For ex am ple, the num ber of phy si cian per pop u la tion has pos-i tive ef fects which sup ports “phy si cian in duced de mand.” At the same time, phy si cian per beds has neg a tive ef fects on pa tients-days. Gov ern-ment at tempts to con tain med i cal cost by low er ing prices and lim it ing the num ber of beds in re gions. Our re sults in di cate that the ef fects of con tain ing im pa tient ser vice might in duce de mand for out pa tient ser-vices. The gov ern ment should main tain ap pro pri ate ra tio of physi cians or nurs es with re spect to bed num ber.

0386

Health ser vices with out bor dersAn tai I. (Han ken school of Eco nomics and Busi ness Ad min is tra tion, Helsin ki, Fin land)

Dis cus sion/Re sults: Over twen ty years, health lit er a ture has de fined qual i ty in terms of struc ture, pro cess and out come. As op por tu ni ties for cross-bor der trade in health ser vices open up, what are the im pli ca-tions on the qual i ty of health in the EU15.of health qual i ty vary among pop u la tions, formed by in con sis ten cies be tween ex pec ta tions and ex pe-ri ences of care re ceived by the pa tient. With the Gen er al agree ment on trade and ser vices (GATS), the qual i ty of health care ex pe ri enced in the EU will like ly be af fect ed un der the in tend ed reg u la to ry frame-work of GATS.pa per in ves ti gates chang es to qual i ty of ser vice in health-care and con se quent ly on the val ue of such care ser vices re sult ing from the GATS agree ment.in tend ed phe nom e na are stud ied, first the chang-es that are like ly to oc cur when GATS is ful ly op er a tional ized. Sec ond, the con se quences for health ser vices in sti tu tions e.g. in sur ance com pa-nies, health care providers etc, and users of these health care ser vices.to lit er a ture by ex plor ing the lo cal ized na ture of qual i ty, show ing how qual-i ty could change as rapid ly as re gion al ten den cies change across re gions and what this could mean un der the GATS. Sec ond ly, it tries to show how EU25 mem ber ship would af fect the qual i ty of health in the re gion as it is present ly known.

0022

Ma lar ia, pro duc tion and in come of the pro duc ers of coff ee and co coaAu dib ert M. (CER DI – Uni ver sité d’Au vergne, Cler mont-Fer rand, France)Brun J-F., Math on nat J.

Top ic: Health in de vel op ing coun triesDis cus sion/Re sults: The sec tors of cof fee and co coa rep re sent ed in Côte d’Ivoire, be fore the po lit i cal cri sis, ap prox i mate ly 15% of the GDP and 40% of ex ports. First world co coa pro duc er, the Côte d’Ivoire then pro-vid ed 40% to 45% of the world pro duc tion (1.1 mil lion tons in 1996/97) while the pro duc tion of cof fee ac count ed for 7 to 8% of the world mar-ket for Ro bus ta and 3% of the mar ket for Ara bi ca. The zones of pro duc-tion of these two cul tures are in the for est area which is, in ad di tion, in fect ed with ma lar ia. The cul ture of these prod ucts is less con strain ing than that of the food crops such as rice or yam (one does not need to re plant each year for ex am ple). How ev er, the main te nance of the ground and the trees and, the plant health treat ment con tribute to ob tain ing good out puts. In ad di tion, in so far as the price to pro duc er does not fall, these prod ucts can al low to ob tain mon e tary in comes. How ev er, the out-put is not the only de ter mi nant of the lev el of the in comes: the pre coc-i ty and the speed of the gath er ing, which will make it pos si ble to sell be fore the oth ers, con tribute, with out put to ob tain high er in comes. At the side of these pe ren ni al cul tures, are pro duced rain or ir ri gat ed food crops such as rice. But, this area of pro duc tion is lo cat ed in a zone where ma lar ia is en dem ic. Stud ies un der tak en in the sa van nah zone of Côte d’Ivoire on cot ton pro duc ers showed that ma lar ia has a neg a tive ef fect on Ef fi cien cy and the pro duc tiv i ty of the own ers.

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The ob jec tive of this com mu ni ca tion is then to es ti mate the de ter mi-nants of the pro duc tion of cof fee and co coa and of the in comes re sult-ing from these two cul tures by mak ing a cer tain num ber of as sump tions: the re spect of the cul ti va tion meth ods, the se nior i ty of the seedlings, con-sti tute the whole of the tech ni cal de ter mi nants, the de mo graph ic com-po si tion of the house holds and the health of the mem bers in flu ence the re course or not to ex tra-fam i ly labour (days-work er, share crop pers). For the lat ter, the pro duc tiv i ty, the ef fort with work and the de ci sion-mak ing should be less ef fi cient than those of the own ers of the plan ta-tions. The ma lar ia, which af fects the house holds un equal ly, will also con-tribute to re duce the pro duc tiv i ty and the ef fort to the work. High er stan dard of liv ing and of in come al low the own ers and their fam-i ly to bet ter pro tect them selves against ma lar ia, the cul ture of rice, in par-tic u lar if it is ir ri gat ed (more labour in ten sive), can have a neg a tive ef fect on those of the cof fee and the co coa by di vert ing fam i ly labour from these ac tiv i ties, the in come re sult ing from the pe ren ni al cul tures does not de pend only on the out puts, but on the ca pac i ty to be col lect ed quick ly.Data and Econo met ric Meth od: The as sump tions are test ed on a sur-vey, car ried out in 1999 in the for est area of Danané (sec ond zone of pro-duc tion of Côte d’Ivoire for the cof fee and fourth for the co coa), com-posed of ap prox i mate ly 800 house holds. The house holds are di vid ed into three sys tems of cul ture, and thus of dif fer ent risk re gard ing ma lar-ia. The sur vey cov ers 21 vil lages.The es ti mate of the func tions of pro duc tion and of in come uses clus ter econo met rics. The func tions of pro duc tion of the cof fee and the co coa are es ti mat ed sep a rate ly while the in come func tion (in come is the re sult of the sell of co coa and cof fee), is con sid ered as a sin gle func tion. Ma-lar ia de ter mi nants are also as sessed us ing a pro bit mod el.Re sults show that ma lar ia does not have an ef fect on the pro duc tion of cof fee and co coa (and thus on the in comes drawn from these cul tures). The fam-i lies whose stan dard of liv ing (or well-be ing), mea sured by the val ue of the goods of com fort, is high, are less con cerned with ma lar ia than the oth ers, more par tic u lar ly for the cof fee planters. If the ge o graph i cal lo cal isa tion of the vil lages is a de ter mi nant of ma lar ia lev el, to cul ti vate rice in low lands does not have any ef fect on ma lar ia. Key words: Ma lar ia, co coa, cof fee, low lands, rice.

0513

Ag ing and tech nol o gy diff u sionBaranyi L. (Min istry of Health, Bu dapest, Hun gary)Bondár É., Lelkes I., Baranyi L.

Dis cus sion/Re sults: The ef fect of the tech no log i cal de vel op ment and the age ing so ci ety on the health care ex pen di tures has been dis cussed sev er al times. The tech no log i cal change has been con sid ered the main driv er of ris ing health care costs. In the case of age ing, there is no the o-ret i cal or em pir i cal con sen sus in the lit er a ture whether its ef fect on the cost is sub stan tial or not. It is not clear that how the dif fer ence be tween the life ex pect an cy and the heal thy life years will change in the fu ture. Our as sump tion is that in ves ti gat ing the fac tors men tioned above is not pos si ble sep a rate ly. The main fo cus of our study is the in ter ac tion be tween ag ing and tech nol o gy de vel op ment in the case of Hun gary. Our ex pec ta tion is that a new tech nol o gy and af fects the cost func tion of a gen er a tion sub stan tial ly, so the ef fect of age ing de pends on the adop tion and dif fu sion of dif fer ent treat ments.

0478

Eco nom ic eval u a tion of stra te gies for screen ing new borns for bi lat er al hear ing im pair mentBarre S. (Haute Au torite de Sante (HAS), Saint De nis La Plaine, France)Cor bil lon E.

Back ground: About 1 to 3 chil dren/1000 in France are born with at least mod er ate bi lat er al hear ing im pair ment which should be de tect ed

and treat ed ear ly for nor mal de vel op ment (speech, cog ni tive and so cial func tions). Ev i dence for uni ver sal screen ing is scarce be cause avail able tests have low pos i tive pre dic tive val ue, need fur ther de vel op ment, and costs and con se quences of screen ing are not ful ly known. Aim: To com pare the cost-ef fec tive ness of 3 screen ing stra te gies in France (birth co hort of 800,000 chil dren).Meth od: We en tered eco nom ic/clin i cal data and ex pert opin ion into a clin i cal de ci sion mod el in or der to com pare: 1.Tar get ed screen ing (TS) of chil dren with one or more risk fac tors for hear ing dis or ders 2.Uni ver-sal neo na tal hear ing screen ing (UNHS) by au to mat ed au di to ry brain-stem re sponse (AABR) 3.UNHS by otoa cous tic emis sion (OAE) test-ing.Re sults: 1.TS de tect ed few er than 15% of cas es of bi lat er al hear ing im pair ment. 2.AABR-based UNHS was the most ef fi cient but also cost-ly strat e gy. 3.OAE-based UNHS gave a high er num ber of false pos i tives than strat e gy 2 did. Re sults were sen si tive to prev a lence, lost-to-fol low-up rates, and costs.Dis cus sion: Our re sults for France con firm pub lished data for oth er coun tries and can help our de ci sion-mak ers pri or i tize screen ing stra te-gies. How ev er, lon ger term dy nam ic mod elling is need ed.

0247

A new mod el to as sess the cost-eff ec tive ness of screen ing for Chla myd ia tra choma tisBar ton P. (Health Eco nomics Fa cil i ty of Birm ing ham, UK)Rob erts T., Rob in son S.

Dis cus sion/Re sults: Chla myd ia tra choma tis is one of the most preva-lent sex u al ly trans mit ted in fec tions in de vel oped coun tries. The se que-lae as so ci at ed with the dis ease in clude re duced fer til i ty, in fer til i ty, ec top-ic preg nan cy and po ten tial dam age to chil dren born to in fect ed moth-ers. Our re view of pub lished eco nom ic eval u a tions of chla myd ia screen-ing found that the ma jor i ty used a mod el which does not re flect the re al i ty of the sit u a tion. Be cause of the in fec tious na ture of the con di-tion, and the high ly het ero ge ne ous pat tern of spread of the in fec tion, only a dy nam ic mod el that con sid ers a whole pop u la tion at in di vid u al lev el (of a type akin to dis crete event sim u la tion) can be guar an teed to give ad e quate es ti mates of the re sults of ap ply ing dif fer ent poli cies. The Chla myd ia Screen ing Stud ies (ClaSS) pro ject in the UK in ves ti gat ed ac tive pop u la tion screen ing us ing home-col lect ed spec i mens and gen-er at ed em pir i cal data about the cov er age and up take of screen ing, pop-u la tion chla myd ia prev a lence, the ef fec tive ness of part ner no ti fi ca tion, and the costs of screen ing. This pa per re ports on the de vel op ment of a new mod el based on the work of Kret zschmar et al (2000). This mod-el is both the first to use UK pri ma ry data to as sess the ef fect of pop u la-tion screen ing and the first to in cor po rate se que lae with in the dy nam-ic mod el struc ture.

0227

The con tri bu tion of so cial mar ket ing to solve so cial and health prob lemsBauer A. (Corv i nus Uni ver si ty of Bu dapest, Hun gary)Mitev A.

Dis cus sion/Re sults: For so cial and health prob lems, mar ket ing of fers the so lu tion of so cial mar ket ing, which ex ploits a mar ket ing tool in ven-to ry to achieve a type of be hav iour al ter ation. That might lead to an in crease of the wel fare of both the in di vid u al and so ci ety. aim is to in tro-duce what al co hol con sump tion means for to day’s uni ver si ty stu dents and what their re lat ed sto ries are like. We claim that the mo tives found in au then tic texts can be used in plan ning and im ple ment ing so cial mar ket ing ac tions. 146 al co hol con sump tion sto ries were an a lyzed, which en abled us to ob tain vivid, high ly var ied nar ra tives that are rich in ex pe ri ence.upon Propp’s idea, who iden ti fied the func tion of won der

Eur J Health Econom Suppl 1 · 2006 | S107

tales, we have iden ti fied the main stag es of uni ver si ty stu dents’ al co hol con sump tion, i.e. de par ture, ob tain ing al co hol, warm-up, quest, main ac tion at the place of the rit u al, re turn home, the day af ter. The sto ry-teller is free to de cide on what he high lights and what he omits. If it is about a good and suc cess ful par ty, then ex pe ri ences near the cli max are de ter mi nant and less is said about neg a tive con se quences. If the whole ex pe ri ence is neg a tive, then the dark side gets men tioned more (the day af ter)., we ap proach the whole phe nom e non from an in sti tu-tion al per spec tive.

0416

The im pact of print me dia ad ver tis ing on pub lic health in sur ance switch ing in Ger manyBeck er B. (Ifo In sti tute for Eco nom ic Re search at the Uni ver si ty of Mu nich, Ger many)Übelmess er S.

Dis cus sion/Re sults: Ex plo ra tion of a new dataset of print me dia ad ver-tis ing by Ger man pub lic health funds dur ing the pe ri od 1993–2004 sug-gests that health funds have at tempt ed to se lec tive ly re cruit en rolees since com pe ti tion in the pub lic health in sur ance mar ket was in tro duced in the mid-1990s. Whether this strat e gy has proven suc cess ful in the sense that health funds have man aged to af fect the risk port fo lio of their in sured is not straight for ward to as sess as switch ing of the in sured is bi ased to wards the young and heal thy due to switch ing costs. this pa per, we link in for ma-tion about health in sur ances’ ad ver tis ing in dif fer ent kinds of print me dia to data on switch ing be hav iour of the in sured from a large Ger man house-hold pan el. Us ing bi na ry choice tech niques and con sid er ing rel e vant con-trol vari ables iden ti fied in the lit er a ture, such as age and per son al health and in come sta tus of the in sured, we test whether health in sur ances’ ad ver-tis ing ac tiv i ties sig nif i cant ly af fect the prob a bil i ty of house holds’ pub lic health in sur ance switch ing. This anal y sis also en ables us to as sess any im pact the in clu sion of our ad ver tis ing vari able has on con clu sions drawn on the im pact from, for in stance, con tri bu tion rates.

0605

Im ple ment ing health risk man age ment prin ci ples to as sist the em ploy er in the re al i sa tion and rein vest ment of sunk en costs for em ploy ee and com mu ni ty health care sub sidi s a tionBeira B. (Lekana Em ploy ee Ben e fi t So lu tions, South Africa)

Aims: De scribe a new mod el for eval u at ing the so cioe co nom ic im pact of health re lat ed short term sick leave ab sence in terms of a stan dard-ized health risk in dex.Pres ent a stan dard ized frame work for as sess ing health risk in de pen dent of em ploy ment sec tor and size, ge o graph ic re gion and na ture of em ploy-er (pub lic or pri vate).Dis cuss po ten tial fis cal and pro duc tiv i ty sav ings gained by mov ing in ca-pac i ty, dis abil i ty and chron ic dis ease man age ment up stream to ward ear-ly rec og ni tion and pre ven tive care us ing ex ist ing be hav iour en gage ment tools cur rent ly de ployed by em ploy ers?Pro pose mech a nisms for rein vest ment of a per cent age of re alised sav-ings by Em ploy ers to as sist in pub lic health ini tia tives for de fined com-mu ni ties.Meth ods: Im ple men ta tion of Health Risk In dex in South Africa and par-tic i pat ing glob al Em ploy ersEval u a tion of risk trends in terms of three ar eas: im pact on pro duc tiv i-ty, du ra tion of ab sence and fre quen cy with in work force.Con sid er a tion and ex plo ra tion of re lat ed eco nom i cal fac tors re lat ing to in ci dence and prev a lence pat terns of ill ness lead ing to non at ten dance and in creased health riskAp pli ca tion of gen er al ized na tion al la bor costs to pre dict fi nan cial health risk

Com par a tive anal y sis of ab sence pro files in in di vid u als with and with-out pri vate health in sur anceEval u a tion on em ploy er will ing ness to adopt a new paradigm to em ploy-ee health cov erRe sults: Fi nanc ing pub lic health ser vices and meet ing health man age-ment ex pens es for low in come earn ers has proven to be a glob al chal-lenge. Or ga ni za tions have the mech a nism to man age sunk en health re lat-ed costs and gain pro duc tiv i ty ben e fits with min i mum in vest ments.This mod el rep re sents a new paradigm of pub lic / pri vate ini tia tives for fa cil i tat ing health man age ment stra te gies for the low earn er group who are of ten not able to af ford pri vate health in sur ance.A ve hi cle ex ists to re duce or gan i sa tion al group life risk. Per cent age of Em ploy ers who en gaged in the pi lot phase was 87%Con clu sion: A mod el has been con struct ed that cal cu lates Health Risk for or ga ni za tions and pro vides a stan dard ized mea sure with three in dices pro vid ing ar eas of par tic u lar risk. Ap pli ca tion of the mod el and en gage-ment with the work force has the po ten tial to re duce the in ci dence of In ca-pac i ty, Dis abil i ty and Chron ic dis ease health man age ment costs.

0072

Sense of co her ence and length of stay – im pli ca tions for cost con tain mentBerg J.E. (Psy chi a trist and Economist Lo visen berg, Di akon al Hos pi tal,De part ment of Acute Psy chi a try, Oslo, Nor way)

In tro duc tion: Sense of co her ence as mea sured by Antonovskys test has been shown to pre dict de fec tion from treat ment and mor tal i ty in drug ad dicts. In ten si fied treat ment and re ha bil i ta tion ef forts may im prove out come. The test has not been used to the same ex tent with pa tients in acute care for men tal dis or ders. The aim of the study is to in ves ti-gate whether a patho log i cal score on the test cor re lates pos i tive ly with length of stay. Ma te ri al: 150 con sec u tive pa tiens from an acute care clin ic will be test-ed by Antonovskys Sense of Co her ence scale and length of stay will be record ed to geth er with di ag noses and so ciode mo graph ic vari ables.

0318

Ge o graph i cal In for ma tion sys tem (GIS) anal y sis of small area in equal i ties in home care ex pen di tures in Hun garyBetle hem J. (Uni ver si ty of Pécs, In sti tute of Clin i cal Prac tice and Nurs ing Sci ence, Pécs, Hun gary)Oláh A., Bon cz I., Sebestyén A., Dózsa Cs.

Aim: To an a lyse the small are in equal i ties in uti li za tion of home care in Hun gary mea sured by the num ber of vis its and re im burse ment. Data and meth ods: Data de rives from the cen tral database of the Hun-gar i an Na tion al Health In sur ance Fund Ad min is tra tion cov er ing the years 1998-2002 and con tain ing all the home care fi nanc ing data from the South-Trans danu bian Re gion. For the anal y sis we used 3 dif fer ent kinds of meth od: crude uti li za tion data, age and gen der stan dard ized data and Bayesian ap proach. The sta tis ti cal anal y sis was car ried out with SPSS ver sion 12.01. Small ar eas re fer to the postal code (zip code) dis-tricts of Hun gary and the pa tients were as signed to small ar eas ac cord-ing to their per ma nent ad dress. The Ge o graph i cal In for ma tion Sys tem (GIS) anal y sis was car ried out by the Map In fo Pro fes sion al soft ware ver sion 7.5. Re sults: The uti li za tion of home care ser vices in creased in the whole re gion be tween 1998–2002. With each of the 3 meth ods (crude uti li za-tion, age and gen der stan dard iza tion and Bayesian ap proach) we found sig nif i cant small area in equal i ties both in the num ber of vis its and re im-burse ment. Fur ther re sults are pre sent ed on GIS maps. Con clu sions: The GIS anal y sis helps to iden ti fy the ge o graph i cal in equal i ties of home care fi nanc ing show ing the over and un der uti li-za tion.

S108 | Eur J Health Econom Suppl 1 · 2006

0239

Cost-eff ec tive ness of rise dronate for the treat ment of os teo po ro sis in Swiss post meno paus al wom enBischof M. (In stitue for Clin i cal Epi de mi ol o gy, Uni ver si ty Hos pi tal Basel, Switzer land)Kraen zlin M., Sen di P.

Ob jec tive: Os teo po ro sis is a ma jor pub lic health con cern in Switzer land and is as so ci at ed with an in creased rate of bone fac tures, health care costs, mor tal i ty and loss of qual i ty of life. Rise dronate has been shown to ef fec tive ly pre vent frac tures in pa tients with os teo po ro sis. We ex am-ined the cost-ef fec tive ness of rise dronate from the Swiss health care per-spec tive. Meth o dol o gy: A prob a bilis tic Markov mod el was de vel oped to ad dress this is sue. Data for treat ment ef fect was de rived from a meta-anal y sis and qual i ty of life es ti mates were ex tract ed from a sys tem at ic re view. Costs were iden ti fied by us ing Swiss sources and ex pressed in 2004 Swiss Francs (CHF). Re sults: Os teo po rot ic wom en, 70 years of age and treat ed over 5 con sec-u tive years, ex pe ri enced on av er age 0.024 ad di tion al QALYs (95% range –0.007; 0.061) com pared to un treat ed pa tients. Costs in the treat ment group were CHF 2’585 high er (95% range: 1’539; 3’771), yield ing an ex pect ed in cre men tal cost-ef fec tive ness ra tio (ICER) of CHF 110’982/QALY. For wom en of 75 years of age the ICER is sub stan tial ly low er (CHF 63’735/QALY). Con clu sion: Rise dronate for the treat ment of os teo po ro sis in el der ly wom en is cost-ef fec tive if ad min is tered at the age of 75 years, adopt ing the ar bi trary NICE thresh old of CHF 75’000/QALY. At younger ages rise dronate treat ment be comes less cost-ef fec tive.

0252

Does or gan i sa tion al fac tors in fl u ence on the pa tients’ ex pe ri ences with men tal health ser vices?Björn gaard J.H. (SIN TEF Health, Trond heim, Nor way)Ruud T.

Back ground: The ob jec tive of this study was to in ves ti gate how or ga ni-za tion al fac tors, such as care unit pro duc tiv i ty, in flu ence on treat ment qual i ty mea sured as the pa tients’ ex pe ri ences with a psy chi at ric out pa-tient set ting. Aim of the study: First we an a lyse to what ex tent pa tient ex pe ri ences sur veys are able to dis crim i nate be tween the qual i ty of care pro vid ed by care units at dif fer ent hi er ar chi cal lev els. The next step in the anal y-ses was to an a lyse whether the vari ance be tween care units in ter act with in di vid u al fac tors such as health sta tus, age and gen der. At last we test ed whether there was a re la tion ship be tween or gan i sa tion al vari ables and the pa tients’ ex pe ri ences.Data and Meth ods: Out-pa tient ex pe ri ences data (6,677 pa tients) were anal y sed nest ed with in 222 teams, with in 89 out-pa tient clin ics, with-in 33 hos pi tals. De pen dent vari able was an 11-item pa tient ex pe ri ence in dex. Mul ti level anal y ses were used to split up the vari ance be tween the dif fer ent or ga ni za tion al lev els. Re sults: Dif fer ences in the pa tients’ ex pe ri ences was pri mar i ly de ter-mined at the pa tient lev el. The vari a tion be tween out-pa tient clin ics and hos pi tals was not sig nif i cant. The vari ance be tween teams was sig-nif i cant, but at tribut ed to only 2.3% of the to tal vari a tion. The or gan i-sa tion al team lev el vari ables were only marginal ly as so ci at ed with the pa tient ex pe ri ences in dex.

0102

Defi cit of the Hun gar i an na tion al health in sur ance fund ad min is tra tion (OEP) be tween 1994-2005Bon cz I. (Na tion al Health In sur ance Fund Ad min is tra tion (OEP), Bu dapest, Hun gary)

Aim: The aim of the study to an a lyse the def i cit of the Hun gar i an Na tion-al Health In sur ance Fund Ad min is tra tion (OEP), the one and only health in sur ance fund in Hun gary. Data and meth ods: Data de rive from the fi nan cial database of the Hun-gar i an Na tion al Health In sur ance Fund Ad min is tra tion, cov er ing the pe ri od 1994-2005. We cal cu lat ed the def i cit of the Fund as dif fer ence be tween rev enues and ex pen di tures both in nom i nal and real val ues and as a per cent of ex pen di tures. Re sults: In each year be tween 1994–2005 we found a def i cit at the Fund. Be tween 1994–2002 the def i cit var ied be tween 3–11 % of ex pen di tures. Be tween 2003–2005 the def i cit in creased up to 22–23 % of ex pen di tures. In the last year with fi nan cial au dit (2004) there was 5,8 bil lion EUR (1448 bil lion HUF) rev enue, 4,5 bil lion EUR (1116 bil lion HUF) ex pen-di ture, thus the def i cit reached 1,3 bil lion EUR (332 bil lion HUF) which is 22,9 % of ex pen di tures. We found that since 2003 the ex pen di tures of the Fund in creased by far high er than the an nu al in fla tion rate while the in crease of rev enues did not fol low the in crease of ex pen di tures. Con clu sions: In or der to bal ance the health in sur ance bud get, one should close the widen ing gap be tween rev enues and ex pen di tures.

0103

Eq ui ty of health ex pen di tures: Lo renz con cen tra tion curves of health ex pen di tures on a na tion wide datasetBon cz I. (Na tion al Health In sur ance Fund Ad min is tra tion (OEP), Bu dapest, Hun gary)Sán tha K., Sza szkó D., Sebestyén A., Kóti T., Szigeti Sz., Nagy J.

Aim: The aim of the study to cal cu late the Lo renz con cen tra tion curves of health ex pen di tures in Hun gary. Data and meth ods: Data de rive from the fi nan cial database of the Hun-gar i an Na tion al Health In sur ance Fund Ad min is tra tion, cov er ing the pe ri od 2000-2004. The Hun gar i an health care fi nanc ing sys tem based on a reg u lar pa tient lev el data re port ing sys tem al lows us to cal cu late the cu mu la tive fre quen cy dis tri bu tions of health ex pen di tures. In each type of care we put the pa tients into 100 per cen tile group ranked by the health ex pen di tures. Re sults: The top quad rant (top 25 %) of the pa tients (with high est health ex pen di tures) re ceived dif fer ent por tion of health ex pen di tures (2004): 72,4 % in out-pa tient care, 64,1 % in in-pa tient care, 67,3 % in chron ic care, 56,3 % in CT/MRI ex am i na tions, 56,2 % in home care, 46,1 % in re nal di al y sis, 83,8 % in drug re im burse ment, 83,6 % in med i cal de vices re im burse ment. The vi su al Lo renz curves are pre sent ed for each type of care men tioned ear li er and for the 5 years be tween 2000-2004. There was not any sig nif i cant time trend with in the same type of care. Con clu sions: The bud gets of drug and med i cal de vices re im burse ment are high ly con cen trat ed while the dis tri bu tion of re nal di al y sis ex pen di-tures was the most lin ear.

0515

Im pact of pop u la tion age ing on the per cep tion of the role of health sec tor in the eco nom ic de vel op mentBon dar E. (Min istry of Health, Bu dapest, Hun gary)Mi hal icza P.

Dis cus sion/Re sults: A cru cial ar gu ment when pub licly al lo cat ing re sources for the main tainance and de vel op ment of health sec tor is that health ser vices play an im por tant role in the re pro duc tion of work-

Eur J Health Econom Suppl 1 · 2006 | S109

ing ca pac i ty. Pop u la tion ag ing means that the greater part of health ser-vices and ex pen di ture is spent on pop u la tion seg ments out of work ing age, con se quent ly their treat ment and care have no di rect im pact on the num ber of par tic i pants of pro duc tion. This shift un der mines the tra di-tion al ar gu ments used in the bud get de bates and gives room to ques tion the im por tance of health sec tor in eco nom ic de vel op ment. If we es tab-lish a sys tem where com mu ni ty pref er ences ex ist, the econ o my and the so cial field are in sep a ra bly in ter con nect ed, based on a def i ni tion of “eco nom ic de vel op ment” and a moral stance, fol lows that a dis tinc tion should be made be tween the eco nom ic im pact of qual i ta tive and quan-ti ta tive fea tures of man pow er, the di rect and in di rect eco nom ic im pact of the health sec tor. A broad er frame is pro vid ed to an a lyse el e ments of the above men tioned shift in the age pat tern of util i sa tion and ex pen-di ture. Some Hun gar i an ev i dence can il lus trate the role of health sec tor in gen er at ing em ploy ment (not only the di rect, but in di rect and in duced side as well) with spe cial at ten tion to ef fects on lo cal economies.

0080

Cost-eff ec tive ness of stan dard ized usu al care with and with out an tide pres sants in pri ma ry care pa tients with mild de pres sions: an eco nom ic eval u a tion along side a non-in fe ri or i ty tri alBosmans J.E. (EMGO-In sti tu ut, Ams ter dam, Nether lands)Her mens M.L.M., De Brui jne M.C., Van Hout H.P.J., Bouter L.M., Stal man W.A.B., Van Tul der M.W.

Ob jec tives: To eval u ate whether stan dard ized usu al care is non-in fe ri or to (i.e. at least as ef fec tive as and not more ex pen sive than) stan dard ized usu al care plus an ti de pres sant treat ment in mild ly de pressed pa tients.De sign: An eco nom ic eval u a tion along side a ran dom is ed con trolled non-in fe ri or i ty tri al from a so ci etal per spec tive with 52 weeks fol low up.Par tic i pants: Adult pri ma ry care pa tients with 3–6 out of 9 DSM-IV de pres sive symp toms.Main out come mea sures: Mont gom ery Ås berg De pres sion Rat ing Scale (MADRS) and the Eu ro Qol. Re source use was mea sured us ing cost di aries.Re sults: 181 pa tients were ran dom ly al lo cat ed to the stan dard ized usu al care group with (n=85) or with out an tide pres sants (n=96). For im prove-ment in MADRS score the stan dard ized usu al care group was non-in fe-ri or to the stan dard ized usu al care plus an ti de pres sant group at 6,13 and 52 weeks. For QALYs gained over 52 weeks non-in fe ri or i ty could not be shown. In the costs and cost-ef fec tive ness anal y ses non-in fe ri or-i ty could not be shown.Con clu sions: Al though non-in fe ri or i ty could not be shown in the costs and cost-ef fec tive ness anal y ses, costs in the two treat ment groups were very sim i lar. Con sid er ing the non-in fe ri or ef fects of stan dard ized usu al care alone and the dis ad van tages of an ti de pres sant use, we rec om mend gen er al prac ti tion ers in gen er al to re frain from pre scrib ing an tide pres-sants in pa tients with mild de pres sions.

0411

An eval u a tion of health care sys temsCa baller Tara zona M. (Po litec nic Uni ver si ty of Va len cia. Ciegs (Cen ter of re search in Man age ment and Health Econ o my), Va len cia, Spain)Vi vas D., Bar rachi na I.

In tro duc tion: The ma jor i ty of the coun tries in the world ded i cate a high per cent age of their bud get to their Health Care Sys tem. In ad di-tion, this per cent age grows year by year. For that rea son, the Health Care eval u a tion and its re per cus sion in the im prove ment of the pop u la-tion health are very im por tant.Ac cord ing to Com mu ni ty Health Anal y sis (Alan De v er 1980), state of health de pends on health care or ga ni za tion, life sryle, en vi ro ment and hu man bi ol o gy.

Ob jec tives: The aim of this pa per is de ter min ing which so cioe co nom-ic vari ables had a greater in flu ence on the state of the health for Latin Amer i can coun tries pop u la tion, mea sured by “Life ex pect an cy”. Meth o dol o gy: The study in clud ed 16 so cioe co nom ic and health care vari ables for 20 Latin Amer i can coun tries dur ing 2005 pe ri od.In for ma tion re gard ing the 16 vari ables is sum marised by means of a fac-to ri al anal y sis. Fur ther more, the mea sures that dif fer en ti at ed the La tian Amer i can coun tries are the most de ter mined. The ex tent to which the stud ied vari ables in flu enced the life ex pect an cy is de ter mined by means of a mul ti ple re gres sion anal y sis. Fol low ing with a clus ter anal y sis for clas sif ing the coun tries ac cord ing to the val ues of pre vi ous ly se lect ed vari ables.Re sults: A econométric mod el has been ob tained in which the life ex pect an cy is ex plained by vari ables more sig nif i cant. In oth er hand, clus ter anal isy has made a clas si fi ca tion of the coun tries in re la tion to the vari ables pre vi ous ly se lect ed.Con clu sion: In con clu sion, it have been ob tained the sig nif i cant vari-ables in re la tion to the “Life ex pect an cy”, for Lati nAmer i can coun tries. There fore, they are the vari ables, on which health pol i cy would have to act to im prove “Life ex pect an cy”.With the re sults of this study, and with the use ful guide that give us the rest of the analys of this pa per, there is enought in for ma tion to of fer an in ter est ing tool to de sign a health pol i cy.Nev er the less these re sults are not ex trap o lables to an oth er group of coun tries. For the re sults of coun tries of the Eu ro pean Union can be con sult ed a pre vi ous study.

0148

Post-re unifi caion health care re forms in Ger manyCar rera P. (Uni ver si ty of Hei del berg – Med i cal School, Hei del berg, Ger many)Bridg es J.

Dis cus sion/Re sults: Be tween the re uni fi ca tion of East and West Ger-many in 1990 and the gen er al elec tions of 2005, sev er al re form mea-sures have been adopt ed to ad dress the faults of and the chal lenges fac-ing the Ger man health care sys tem. Giv en the is sues oth er sys tems share with Ger many and the im por tance of learn ing from oth er’s ex pe ri ence, in ves ti ga tion into what Ger many did, how it was done and what came of it is es sen tial. The re forms have cov ered ev ery cor ner of the sys tem from fi nanc ing and re im burse ment, the or ga ni za tion of the health care sys tem and the de liv ery of health care. While the rash of mea sures points to the po lit i cal will of the gov ern ment in part such is the con se quence of re forms need ing re form. Thus, the re forms have not trans lat ed to far-reach ing chang es and sub stan tial im prove ment as promised and hoped-for. What the anal y sis of the post-re uni fi ca tion re forms tells us is that Ger mans are ready for re forms but not in a sin gle serv ing and with the prin ci ples un der pin ning their sys tem in tact; get ting mea sures off the leg isla tive mill solves only a part of the prob lem; mis sing a com po nent has se ri ous im pli ca tions on the im pact of re forms. Giv en the course of re forms, a big bang in the sys tem maybe in sight.

0451

A re view of the Ital ian phar ma coeco nom ic stud ies on an tipsy chotics for schizo phre nia.Cerzani M. (Mario Ne gri In sti tute, Mi lan, Italy) Bar bui C., Garat ti ni L.

Dis cus sion/Re sults: We re viewed the full phar ma coeco nom ic eco nom-ic eval u a tions (EEs) con duct ed in Italy on an tipsy chotics for schizo phre-nia by adopt ing com mon cri te ria of anal y sis to al low method olog i cal com par i son of the stud ies. The vari ables in ves ti gat ed can be grouped in three cat e gories: gen er al meth ods, costs, and con se quences. We se lect-ed all the orig i nal stud ies pub lished by Ital ian au thors in na tion al jour-

S110 | Eur J Health Econom Suppl 1 · 2006

nals from Jan uary 1994 to De cem ber 2004. We re viewed 5 ar ti cles and as sessed 7 EEs since some ar ti cles con tained mul ti ple anal y ses.All EEs un der anal y sis were per formed ac cord ing to the NHS view-point, 4 out of them were Cost Min imi sa tion Anal y ses (CMAs) while the re main ders were Cost Ef fec tive ness Anal y ses (CEAs). In al most all EEs, clin i cal ev i dence main ly stemmed from as sump tions. More-over, two stud ies based re source con sump tion on es ti mates made by au thors, while the re main ders de rived it from med i cal records of very small and lo cal sam ples. All EEs’ con clu sions were in favour of the spon-sor’s drug. Also these find ings on a se lect ed sam ple of spe cif ic stud ies con firm that re sults of phar ma coeco nom ic stud ies in Italy seem to be bi ased by flawed meth ods and spon sors’ in ter fer ence on re sults.

0073

Macroe co nom ic im pact of HIV/AIDS epi dem ic in UkraineSidorenko A. (Aus tri an Na tion al Uni ver si ty, Can ber ra, Aus tralia)(Át kel lene ten ni az “S” betűhöz.)

Dis cus sion/Re sults: Ukraine’s HIV/AIDS epi dem ic is among the fastest grow ing in Eu rope, with the of fi cial ly reg is tered new HIV cas es hav ing dou bled over 2000–2004. The of fi cial data sug gests that the HIV/AIDS epi dem ic in Ukraine may be en ter ing the gen er alised epi dem ic phase: by the end of 2004, the share of het ero sex u al mode of trans mis sion has in creased to al most a third of new cas es. The spread of HIV/AIDS is su per im posed on the ad verse de mo graph ic sit u a tion char ac ter ised by both de pop u la tion and de te ri o rat ing health sta tus. The pa per dis cuss-es macroe co nom ic ef fects of the epi dem ic in Ukraine based on the find-ing of the re cent study led by the au thor and fund ed by the World Bank. In ad e quate health pol i cy re sponse to HIV/AIDS may be come a threat to Ukraine’s eco nom ic de vel op ment and to the coun try’s am bi tions to join the Eu ro pean Union.

0543

Spon sored and not spon sored ed i ca tion in Greek Hos pi talsChristodoulou I. (2nd Sur gi cal De part ment, Pa paniko laou Hos pi tal,Thes sa loni ki,Greece)Pogo ni dis Chr., Xen o dox i do E.

Aim: The wide ly ac cept ed need for con tin u ing med i cal ed u ca tion (CME) is a grow ing re al i ty through out Eu rope. Fol low ing the in te gra-tion of Greece in the Eu ro pean Union(EU), na tion al train ing pro grams for health pro fes sion als have be come more nu mer ous than ever. Aim of the pres ent study is to record the avail able op por tu ni ties of con tin-u ing med i cal ed u ca tion in Greece and to cor re late them to the pro mo-tion of health. Ma te ri al and meth ods: We used in for ma tion de rived from the Greek Min istry of Health, the Na tion al Health Sys tem Leg is la tion, the EU sub-si dized na tion al train ing cours es for health pro fes sion als for 2005–2006, along with in for ma tion from the ed u ca tion al meet ings held by med i cal as so ci a tions and sci en tif ic med i cal so ci eties. Re sults: The con gress es for doc tors and nurs es held by the sci en tif ic so ci eties pro vide aside from knowl edge, a cer tifi cate of at ten dance, and a num ber of cred its for con tin u ing med i cal ed u ca tion (CME cred its), how ev er reg is tra tion re quires manda to ry pay ment. Dur ing 2005–2006, only 325 sub si dized na tion al sem i nars for health pro fes sion als were pro-grammed, giv ing the chance of free med i cal ed u ca tion to a small per-cent age of doc tors and nurs es. None of the above pro grams ac cepts un em ployed doc tors.Con clu sions: Con tin u ing med i cal ed u ca tion de pends main ly on per son-al mo ti va tion for each health pro fes sion al in Greece.

0544

Se cret costs of la paro scop ic sur geryChristodoulou I. (2nd Sur gi cal De part ment, Pa paniko laou Hos pi tal,Thes sa loni ki,Greece)Ba balis D., Pogo ni dis Chr., Xen o dox i dou E., Tso lakis M., Nakopou los I., Voskakis I., Gymnopou los D.

Aim of this study is to out line the so cial cost of health af ter la paro scop-ic sur gery in our Hos pi tal. We have start ed the study with the hy poth-e sis that ab sence from work is not re al ly short er af ter la paro scop ic sur-gery, in Greek Hos pi tals.Ma te ri al and meth ods: In to tal, 194 la paro scop ic chole cys tec tomies have been ex e cut ed in the Sur gi cal De part ment of Ko mo ti ni. We have col lect ed the data re fer ring to the time need ed for full re cov ery in cas es of open and la paro scop ic sur gery. The same num ber of open chole cys-tec tomies held in the past years was the com par i son group.Re sults: In la paro scop ic chole cys tec tomies the me di an pe ri od of stay-ing in Hos pi tal was 3 days. The me di an pe ri od need ed for the re turn to work was 7,5–20, 2 days. In cas es with open tech nique pa tients stayed in side hos pi tal 6 days and went back to home from 15 to 30 days. There were dif fer ences de pend ing on the pro fes sion of ev ery pa tient. Self oc cu-pied per sons went back to work ear li er (7–15 days), and the lon ger pe ri-od for re cov ery was need ed for peo ple work ing in pub lic ser vices (25–30 days).Con clu sions: We have not man aged yet to per suade pa tients to re turn ear li er to work, al though the gen er al im pres sion in in ter na tion al bib li-og ra phy is that la paro scop ic sur gery brings mon ey back via the short er pe ri od of in abil i ty for work.

0545

The cost of over ther a py in can cer pa tientsChristodoulou I. (2nd Sur gi cal De part ment, Pa paniko laou Hos pi tal,Thes sa loni ki,Greece)Pogo ni dis Chr., Xen o dox i dou E.

Back ground: Var i ous moral dilem mas are en coun tered in cas es of can-cer. Some of these re late to the pa tients, the bi o log i cal ba sis of their ill ness, to on col o gists and sur geons, their at ti tudes, skills and Knowl-edge.Ma te ri als and meth ods: In for ma tion was tak en from the Hel lenic An ti-cancer So ci ety, the Greek Bioeth ic Com mis sion, the Greek Min istry of Health, the Eu ro pean Or ga ni sa tion for Re search and Treat ment for Can-cer and the Pa tients As so ci a tion of UK. Med i cal greek and in ter na tion-al jour nals and sites ori ent ed to bioeth i cal is sues were a use ful ba sis for re sults and dis cus sion, too.Re sults: Ev i dence- based med i cine and sur vival stud ies have made over-ther a py less fre quent than ever. How ev er, pa tients with non-cur able dis-eases are vul ner a ble to mar ket ing of var i ous Med i cal Cen ters of Ex cel-lence. Aware ness of Sur gi cal So ci eties is need ed and the sur geon must be taught the sen si bil i ty to deal with these pa tients. The prop er pa tient in for ma tion and re spect to per son al au ton o my are re quired. More over, vari a tions in def i ni tion of pal lia tive sur gery as well as lim it ed sci en tif ic ev i dence in rare on co log i cal cas es make sur geons per form op er a tions even in fi nal stage can cer cas es.Dis cus sion: Both in clin i cal prac tice but also in ed u ca tion and re search moral sen si bil i ty is re quired in or der to pro mote pub lic health and main-ly in the field of sur gi cal on col o gy.

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0546

The cost of team work in Greek Hos pi talsChristodoulou I. (2nd Sur gi cal De part ment, Pa paniko laou Hos pi tal,Thes sa loni ki,Greece)Pogo ni dis Ch., Xen o dox i dou E., Maropoulou, Dri mala M., Michaeli dou D., Ba balis D., De spou di K.

Aims and ob jec tives: Our study writes down prob lems of team work among health pro fes sion als in Greek Hos pi tals.Meth ods: We used ques tion naires and in ter viewed health pro fes sion als of dif fer ent spe cial ties. We fo cused on prob lem at ic ar eas of team work such as Emer gen cies De part ments, In ten sive Care Units and Sur gi cal De part ments. We asked sur geons, pa thol o gists, an es the si ol o gists, car di-ol o gists, doc tors work ing in ICU units and nurs es of the rel a tive de part-ments. In to tal, 112 health pro fes sion als were asked.Re sults: Team work is thought to be prob lem at ic or ad e quate ly held, caus ing lim it ed team ef fec tive ness ac cord ing to the 56%. The co-or di na-tor of the med i cal team does not al ways have the ap proval of the team ac cord ing to the 85% of asked physi cians. In a case of sud den death or se vere com pli ca tion the team mem bers of ten do not have a com mon strat e gy (66%) and of ten have lim it ed knowl edge of med i cal leg is la tion (73%), while only 26% feel se cure and safe in side the Hos pi tal. The es tab-lish ment of team work sem i nars and ac tive psy cho mod u lat ing ex er cis es are ap proved by all asked physi cians and nurs es.Con clu sions: Man age ment of hu man re sources is rather un suc cess ful, lead ing to med i cal, le gal and man age ri al prob lems. Stress of health pro-fes sion als could be elim i nat ed by sem i nars teach ing be hav ior of work-ing in a team.

0450

A com par a tive anal y sis of prices on a se lect ed bas ket of in -patent drugs in 7 EU coun triesCor na go D. (Mario Ne gri In sti tute, Mi lan, Italy)Mot ter li ni N., Garat ti ni L.

Dis cus sion/Re sults: We com pared the prices of a se lect ed bas ket of twen ty in-patent drugs in sev en Eu ro pean coun tries (Bel gium, France, Ger many, Italy, the Nether lands, Spain, and the Unit ed King dom) fol-low ing a com mon meth o dol o gy. The av er age mar ket ex-fac to ry price and pub lic price were cal cu lat ed for each ac tive in each coun try. The sources of in for ma tion were the IMS data mar ket sur veys for each coun-try. This in clud ed the vol umes sold for each dif fer ent pack age and the cor re spond ing 2004 sales (ex-fac to ry prices). From these data we iden-ti fied the most sold pack age for each ac tive prin ci ple in all 7 coun tries and es ti mat ed its ex-fac to ry price in each coun try. The sec ond step was to add dis tri bu tion mar gins (tak ing into ac count manda to ry dis counts due to pub lic au thor i ties) and VAT, in or der to cal cu late the pub lic price of each “most sold” pack age in all 7 coun tries. On av er age, Italy had the low est ex-fac to ry prices, fol lowed by Spain and France, while Ger many and the UK had the high est ones. Mov ing to pub lic prices, the trend was dif fer ent and the UK had even low er pub lic av er age prices com pared to Italy. The rea sons of these dif fer ences stem from gen er al tax a tion and dis tri bu tion mar gins: in par tic u lar, coun tries like Italy and Spain, char ac ter ized by the mo nop o lis tic dis tri bu tion of phar ma cies (the so called “one phar ma cy one phar ma cist” rule), show the high est dis tri bu tion mar gins, while the UK, where his tor i cal ly this monopoly has nev er ex ist ed, has the low est mar gins.

0452

A re view of the phar ma coeco nom ic stud ies on glau co ma in the in ter na tion al lit er a tureCor na go D. (Mario Ne gri In sti tute, Mi lan, Italy)Seres A., Schi avone M., Garat ti ni L.

Dis cus sion/Re sults: We re viewed the full phar ma coeco nom ic eco nom-ic eval u a tions (EEs) con duct ed on glau co ma by adopt ing com mon cri te-ria of anal y sis to al low method olog i cal com par i son of the stud ies. The vari ables in ves ti gat ed can be grouped in three cat e gories: gen er al meth-ods, costs, and con se quences. We se lect ed all the orig i nal stud ies pub-lished in na tion al or in ter na tion al jour nals from Jan uary 1994 to June 2005. We se lect ed 5 ar ti cles and as sessed the 14 EEs per formed, find ing that 7 were Cost Ef fec tive ness Anal y ses, 6 were Cost Util i ty Anal y ses and the re main der was a Cost Min imi sa tion Anal y sis.The re sults of this re view showed that, de spite the use of re li able sources of clin i cal ev i dence in al most all stud ies (13 vs 14), 13 out of the 14 EEs un der anal y sis es ti mat ed re source con sump tion through as sump-tions made ei ther by au thors or ex pert pan els, while the re main ing EE showed the pre lim i nary re sults of a Markov mod el based on as sump-tions which has nev er been fol lowed by a fur ther pub li ca tion.This re view on the EEs on glau co ma con firms that a lot of stud ies are based on clin i cal tri als for clin i cal ev i dence and long-term mod elling for eco nom ic con se quences. We dis cuss if the “added val ue” of economists might be more ap pre ci at ed by health care pro fes sion als whether costs were based on ex per i men tal data rather than fore cast ing and as sump-tions only.

0050

To wards a labour sup ply mod el of wel fare chang esCoruge do I. (Uni ver si dad Com plutense, Pozue lo de Alar cón, Madrid, Spain)An tón E., Hi dal go Á.

Dis cus sion/Re sults: A mod el for mea sur ing wel fare chang es de ter-mined by health chang es will be ex plained here. This mod el fo cus es on the as pect of labour sup ply, dif fer ing from those mod els us ing will ing-ness to pay mea sures, fo cused on the as pect of de mand for goods.The main hy poth e sis of the mod el is that the ef fect of ill ness and its med i-cal treat ments on wages and wel fare are equiv a lent to those ef fects on wages de ter mined by chang es in per son al in come tax es. It means that the mod el makes equiv a lent, in terms of the ef fects and labour mar ket con se quences, a qual i ty of life in dex to a tax rate.new ap proach to eval-u ate the ben e fits of an in vest ment in health avoids the sub jec tive bi as es de ter mined by will ing ness to pay mea sures and once an iden ti fi ca tion of a qual i ty of life in dex to a cer tain ill ness or to a cer tain med i cal treat-ment ap plied to this ill ness is es tab lished, the mod el can get fast and pre cise con clu sions about the im pact of ill ness and its dif fer ent med i-cal treat ments on wel fare and labour mar ket ef fects (par tic i pa tion and chang es of work ing hours).

0403

Drug price reg u la tion mech a nisms in Por tu galCrisos to mo S. (Cen tre for Pgar ma coepi demi o log ic Re search, Por tu gal, Lis boa, Por tu gal)

In tro duc tion: Drugs prices in Por tu gal are heav i ly reg u lat ed with price and re im burse ment ap pli ca tions be ing two sep a rate pro ce dures, but with the pos si bil i ty of fix ing a low er price dur ing the re im burse ment pro ce dure, than the one ap proved ini tial ly.Ob jec tive: 1) To char ac ter ize the dif fer ent leg is la tions gov ern ing price and re im burse ment of drugs in Por tu gal and their di rect or in di rect

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ef fect on drugs prices. 2) To crit i cal ly as sess the com pli ance with the EU Trans paren cy di rec tive and the abil i ty of these leg is la tions in pur su-ing the goals of the gov ern men tal drugs pol i cy.Re sults: Cost-plus and prof it con trol mech a nisms are not im ple ment-ed in Por tu gal. All oth er com mon price reg u la tion mech a nisms are in place. Most rules that ap ply are clear ly de fined, how ev er some shad ow ar eas still ex ist where de ci sion cri te ria are not ex plic it ly made pub lic (e.g., when cost-ef fec tive ness stud ies are sub mit ted as part of the re im-burse ment pro ce dure or in those sit u a tions where di rect ne go ti a tion be tween com pa nies and the gov ern ment is al lowed by law). One of the most in ef fi cient mech a nisms is prob a bly the fix a tion of the ref er ence price at the price of the most ex pen sive ge ner ic. Con clu sion: Price reg u la tions seem to be in line with the gov ern ment pol i cy, but there is still some room to im prove their ef fi cien cy and trans-paren cy.

0342

To wards a com pre hen sive as sess ment of pre ven tion with in the na tion al health ac countsDe Bekker-Grob E.W. (De part ment of Pub lic Health, Rot ter dam, Nether lands)Meerd ing W.J.

In tro duc tion: The share of pre ven tion in the to tal health care bud get is con ven tion al ly es ti mat ed be tween 0.6-8.0%. How ev er, these es ti mates do not take into ac count many health-re lat ed pre ven tive ac tiv i ties in side and out side the health sec tor.Meth ods: We col lect ed in for ma tion on the ex pen di tures on pre ven-tive ac tiv i ties in side and out side the health sec tor in the Nether lands. We searched through rel e vant lit er a ture and pol i cy re ports, and con-sult ed ex perts in the field to iden ti fy pre ven tive ac tiv i ties that are part ly or en tire ly re lat ed to health. We used var i ous fi nan cial sta tis-tics to quan ti fy the year ly ex pen di tures on these ac tiv i ties. A so ci etal per spec tive was used. Costs were al lo cat ed to risk fac tors, dis eases, age groups and gen der us ing pop u la tion at tribu tive risks and ob vi-ous key vari ables.Re sults: The year ly ex pen di tures on pre ven tion are 2.5 bil lion eu ros in side the health sec tor (4.3 % of health care bud get) and 11.7 bil lion eu ros out-side the health sec tor. 3% was spent on health pro mo tion, 15% on dis ease pre ven tion (e.g. vac ci na tion, screen ing), and 82% on health pro tec tion. Con clu sions/Dis cus sion: The to tal ex pen di tures on pre ven tion are 6 times high er than nor mal ly re port ed. A com pre hen sive pic ture of pre-ven tion by risk fac tors and dis eases with in the na tion al health ac counts is es sen tial for health care plan ning and health pol i cy de vel op ment.

0374

Dis abil i ty and the labour force par tic i pa tion of old er work ersDe brand T. (IRD ES, Par is, France)Bar nay T.

Dis cus sion/Re sults: In this ar ti cle, we fo cus, with in a Eu ro pean frame-work, the im por tant role of health in the de ci sion of men from 50 to 64 about whether or not they will take part to the labour mar ket. We use a la tent vari able mod el (Bound (1991) and Cam poli eti (2002)) to es ti mate the ef fect of dis abil i ty sta tus on the labour force par tic i pa tion of old er men in Eu rope; with data from a new Eu ro pean database SHARE. force par tic i pa tion de pends on a group of so cio-de mo graph ic vari ables and un ob serv able la tent dis abil i ty. In a pre lim i nary step, we es ti mate an equa-tion of par tic i pa tion by di rect ly in tro duc ing the self-re port ed dis abil i ty, but the true’ dis abil i ty sta tus is un ob served. Thus in a sec ond step fol-low ing Bound meth o dol o gy, we use es ti ma tions of self-re port ed dis abil-i ty. In or der to take into ac count the self-re port ed bi as es, we in stru ment the ses mea sures with in for ma tion on health con di tions (health in di ca-

tors re lat ing to the dis eases, de fi cien cies, Body Mass In dex,...). Al though so cio-de mo graph ic vari ables, such as a high ed u ca tion lev el or liv ing as a cou ple, seem to keep se niors in ac tiv i ty, health in di ca tors are also rel-e vant. Our re sults sug gest that if we use the self-re port ed health mea-sure that leads to a down ward bias in the im pact of dis abil i ty sta tus on labour force par tic i pa tion.

0519

GPs’ strate gic be haviours to reach their tar get Desquins B. (IEMS, Lau sanne, Switzer land)Hol ly, Rochaix

Ob ject: In this pa per, we seek to de ter mine if the doc tors want to reach a tar get in come and if to reach this tar get, they adopt a com bi na tion of strate gic be haviours such as the de mand in duc tion, the re duc tion of the qual i ty of the care as sured to theirs pa tients (re duc tion of the du ra-tions of con sul ta tion, re duc tion of time vol ume af fect ed to the for ma-tion) or the ex er cise ac tiv i ties for sak en by their col leagues, like vis its, guards or ther a peu tic tests. Meth o dol o gy: We use a mul ti var i ate equa tions mod el to de ter mine the ar bi tra tion of GPs’ labour time be tween the dif fer ent ac tiv i ties of their med i cal prac tice. Data: Our sam ple con sists of 600 GPs ex ert ing in area PACA. Re sults: We ob serve that the doc tors, who favour the vis its with in their ac tiv i ties, tend to re strict the ac tiv i ties who im prove qual i ty of the care, like for ma tion, read ing of re views or guide lines. Con clu sion: This pa per high lights the var i ous strate gic be haviours adopt ed by the GPs’ to reach their tar get in come. We ob serve that the GPs pre fer to reach their tar get rather than to im prove qual i ty of the care ad min is tered to their pa tients (through the read ing of re views, guide lines, con tin u ous train ing, etc...).

0008

Why AIDS pre ven tion should be tar get ed to high-ac tive menDeuchert E. (De part ment of In tern. Eco nom ic Pol i cy, Freiburg, Ger many)

Dis cus sion/Re sults: The Pare to dis tri bu tion is wide ly used to de scribe the dis tri bu tion of in come, wealth, or stock mar ket re turns. Most re cent-ly, it has been found that com plex net works, such as the World Wide Web, can be de scribed by a Pare to dis tri bu tion (scale-free net works). It has been ar gued, that so cial net works based on sex u al con tacts may be also scale-free, since the em pir i cal dis tri bu tion of the num ber of sex u al part ner ships is typ i cal ly right-skewed with the ma jor i ty of peo ple hav-ing few part ners, while only some hav ing many part ners. The ex is tence of scale-free sex u al net works has im por tant im pli ca tions for the spread of sex u al ly trans mit ted dis eases. First, an epi dem ic is not thresh old con-strained and can spread into a pop u la tion even with low trans mis sion ef fi cien cy. This may ex plain how the rel a tive ly in ef fi cient HI vi rus could spread wide ly into some sub-Sa ha ran coun tries even though re port ed av er age sex u al be hav ior is sim i lar to oth er (less af fect ed) coun tries. Sec-ond, pub lic health in ter ven tions, which are not tar get ed to high-ac tive in di vid u als (hubs), are in ef fi cient, since scale-free net works dis play an ex cep tion al ro bust ness against ran dom be hav ior chang es.pres ent pa per de vel ops an epi demi o log i cal mod el with het ero ge ne ity in sex u al be hav-ior and het ero sex u al dis ease trans mis sion. It shows that the dis ease is not thresh old con straint if the num bers of part ner ships of at least one gen der are Pare to dis tribut ed with in fi nite vari ance. Us ing data pro-vid ed by the Tan za nia 2003 De mo graph ic Health Sur vey, this pa per em ploys the max i mum like li hood meth od to es ti mate the dis tri bu tion of the re port ed num ber of part ner ships. It is shown that the num ber of part ner ships of male re spon dents fol lows a Pare to dis tri bu tion with in fi nite vari ance, while vari ance of wom en’s part ner ships is fi nite.pa per con cludes that the HIV/AIDS epi dem ic in Tan za nia may be driv en by

Eur J Health Econom Suppl 1 · 2006 | S113

high-ac tive men. Hence, pub lic health in ter ven tions should be tar get ed to these hubs. The iden ti fi ca tion of hubs is es sen tial to ef fec tive ly de sign pub lic health in ter ven tions.

0302

Ap ply ing con cepts from mill and sen to the stan dard of liv ing for dis abled peo pleDoes sel D. (Queens land Cen tre for Men tal Health Re search (QCMHR)- School of Pop u la tion Health, The Uni ver si ty of Queens land, Bris bane, Aus tralia)White ford H.

Dis cus sion/Re sults: Im por tant pol i cy is sue re lates to how gov ern ments make ex pen di ture de ci sions (in come trans fers or in-kind goods or ser-vices) to as sist peo ple sub ject ed to var i ous lev els of dis abil i ty. This is an is sue of ten dis cussed by rel a tives/friends/car ers of peo ple with dis abil i-ty such dis cus sions are of ten char ac ter ised by anger at gov ern ment de ci-sions of one kind or an oth er. Al though this pol i cy is sue is of sub stan-tive eco nom ic im por tance, there is no the o ret i cal and/or em pir i cal lit-er a ture that ad dress es the prob lem. This pa per is con cerned with ap ply-ing some eco nom ic con cepts as so ci at ed with the nine teenth cen tu ry En glish philoso pher/economist, John Stu art Mill, and the 1998 No bel Lau re ate in Eco nomics, Amartya Sen. Mill’s gen er al con cep tion of how gov ern ment should be have in treat ing cit i zens (the gen er al no tion of equal i ty) has sub se quent ly been spelt out in de tail in the pub lic fi nance lit er a ture on prin ci ples of tax a tion, viz. fis cal eq ui ty. More specif i cal ly, the rel e vant con cepts are those of hor i zon tal eq ui ty and ver ti cal eq ui-ty, where the for mer val ue judge ment in volves “the equal treat ment of equals” and the lat ter “the un equal treat ment of un equals”. These prin-ci ples are com bined with Sen’s re cent dis cus sion of the is sue of “con ver-sion hand i cap”, in his gen er al frame work of ca pa bil i ties and/or func tion-ings as the cen tral con cepts to be con sid ered in any dis cus sion of the stan dard of liv ing. This pa per, while pro vid ing an im ma nent cri tique of ran dom and/or ar bi trary dis tri bu tion sys tems of as sis tance to hand i-capped peo ple, in di cates the key vari ables to which gov ern ments should di rect their at ten tion to achieve both hor i zon tal and ver ti cal eq ui ty in the pro vi sion of as sis tance to dis abled cit i zens.

0006

Past Un em ploy ment Ex pe ri ence and Health Sta tusEconomou A. (Uni ver si ty of Mace do nia, Eco nomics Dept., Thes sa loni ki, Greece)Niko laou A., Theo dos siou I.

Dis cus sion/Re sults: This pa per ex plores the re la tion ship be tween in di-vid u al past un em ploy ment ex pe ri ence and al ter na tive mea sures of in di-vid u al health state af ter con trol ling for a num ber of cur rent char ac ter is-tics and cur rent so cio-eco nom ic sta tus. Three al ter na tive in di ca tors of past un em ploy ment sta tus are used name ly; the num ber and the du ra-tion of past un em ploy ment spells. The study finds a cu mu la tive ef fect of pro longed past un em ploy ment ex pe ri ence on cur rent in di vid u al health sta tus. It also finds that those who are wealth i er are also health i er. Fi nal-ly the dif fer ent in sti tu tion al and cul tur al frame works pre vail ing across dif fer ent E.U coun tries ap pear to af fect the health – past un em ploy ment ex pe ri ence re la tion ship.

0606

De mand for Pri vate Health In sur ance in Ger manyEl he wai hi M. (Head of the De part ment for So cial Epi de mi ol o gy and Health Sys tems De sign, Biele feld, Ger many)Badu ra B., Grein er W.

Dis cus sion/Re sults: Un doubt ed ly, de mand for pri vate health in sur-ance (PHI) in Ger many is grow ing; alone in 2004 around 400.000 Ger-mans have cho sen one of the pri vate cov er age schemes. Be tween 2002 and 2003, about 300.000 of statu to ry in sured per sons have tak en out out pa tient sup ple men tary pri vate in sur ance, while in the same pe ri od; around 242.000 have tak en out op tion al hos pi tal ben e fits. We ar gue that per ceived qual i ty of pri vate and pub lic health care, in sur ance pre mi-ums and in come are among the de ter mi nants of this grow ing de mand. This study is the first in Ger many that moves from the o ret i cal to em pir-i cal frame work. It uses eco nom ic mod elling to an a lyze the ef fects of these de ter mi nants on the prob a bil i ty of pur chas ing (PHI). Eco nom-ic mod elling states that de mand for (PHI) is de mand for high er health care qual i ty. The mod el was de vel oped tak ing into con sid er a tion the un ob served en do gene ity and het ero ge ne ity. Sta tis ti cal an a lyt i cal tools of SPSS have been used to quan ti fy the ef fect of al most 13 vari ables on the in di vid u al’s pur chas ing be hav iour of (PHI). Among the ses vari ables are; Age as a main nu mer i cal vari able which then is di vid ed into four sub-dum my vari ables [Age (1) less than 30 years, Age (2) be tween 30 and 44, Age (3) be tween 45 and 64, Age (4) and 65 and over]. Ed u ca tion is also di vid ed into four sub-dum my vari ables [Ed u ca tion (1) for pri ma-ry ed u ca tion, Ed u ca tion (2) for sec ond ary ed u ca tion, Ed u ca tion (3) for ap pren tice ship and last ly Ed u ca tion (4) for uni ver si ty]. Health care uti-li za tion is also among the de ter mi nant of pur chas ing (PHI), it is mea-sured us ing two nu mer i cal vari ables of the num ber of vis its to gen er al prac ti tio ner and spe cial ist in the last six months. Fi nal ly per ceived qual-i ty has been quan ti fied us ing a scale from one for poor per ceived qual i-ty to 10 for ex cel lent per ceived qual i ty. Re sults sup port the hy poth e sis that the de mand for pri vate health in sur ance is driv en by the widen ing qual i ty gap be tween both in sur ance sec tors.

0457

Op ti mal In come Tax a tion and Pub lic Pro vi sion of Health Care.Em blem A.W. (Agder Uni ver si ty Col lege, Kris tiansand, Nor way)

Dis cus sion/Re sults: This study ex am ines how op ti mal non-lin ear in come tax a tion and dif fer en ti at ed pub lic pro vi sion of health care may form part of a scheme fa cil i tat ing in come re dis tri bu tion be tween dif-fer ent abil i ty types (high/low), and across dif fer ent health states (poor/good). In for ma tion about abil i ty and labour sup ply is pri vate. The gov-ern ment of fers con tracts in five di men sions pre- and post-tax in come if in good health, and pre- and post-tax in come, as well as med i cal treat-ment, if in poor health. The de rived in for ma tion con strained scheme fa cil i tates in come re dis tri bu tion to wards low-abil i ty in di vid u als. In ad di tion, it pro vides in sur ance against med i cal ex pen di tures and loss in in come due to dis abil i ty. The scheme is shown to en tail a down ward dis tor tion in low-abil i ty in di vid u als’ labour sup ply in both health states, and a down ward dis tor tion in their lev el of treat ment if in poor health.

0482

The Eu ro pean Bio tech nol o gy In dus try – As sess ment and Re search Per spec tivesFarag H. (Eu ro pean Busi ness School (ebs), Oestrich-Winkel, Ger many)

Dis cus sion/Re sults: While many stud ies – par tic u lar in the strate gic man age ment do main – have fo cussed on the bio tech nol o gy in dus try, some fun da men tal as pects of in dus try-spe cif ic re search have been

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large ly ne glect ed. Ad di tion al ly, these short com ings are much more pro-nounced for the Eu ro pean set ting than the U.S., where re searchers can read i ly rely on in dus try database ser vices and where cap i tal mar ket con-cerns are less preva lent. The pres ent re search aims to pro vide some in di ca tions re gard ing the study of Eu ro pean bio tech nol o gy firms. First, it em pir i cal ly com pares dif fer ent sources of in dus try clas si fi ca tions to ar rive a con vinc ing and par si mo nious iden ti fi ca tion of bio tech nol o gy firms. Sec ond, it uti lizes lon gi tu di nal econo met rics to dis tin guish fac-tors in flu enc ing the val ue of Eu ro pean bio tech nol o gy firms. Specif i cal-ly, it de com pos es val ue chang es into gen er al mar ket, coun try- and in dus-try-spe cif ic com po nents. The re search find ings sug gest that the Eu ro-pean bio tech nol o gy in dus try con sists of a rather broad core of firms. The val ue of these bio tech nol o gy firms is most close ly linked to each oth er. This ef fect clear ly dom i nates coun try-spe cif ic in flu ences as well as as so ci a tions with the gen er al health care and phar ma ceu ti cal in dus-tries. These find ings form an im por tant ba sis for fur ther re search con-duct ed in the Eu ro pean bio tech nol o gy in dus try.

0187

Fi nan cial in cen tives and the sup ply of lab o ra to ry tests in Gen er al Prac tice.Fauli S. (The Nor we gian Med i cal As so ci a tion, NOK LUS, HERO, Oslo, Nor way)

Dis cus sion/Re sults: The pay ment sys tem in Nor way for gen er al prac-ti tion ers (GPs) is a mix of cap i ta tion fee and fee-for-ser vice. Pre vi ous-ly pa tients paid a fee only when a lab o ra to ry test was anal y sed out side a GP’s of fice. Now, a fee is paid ev ery time a blood test is tak en in gen-er al prac tice. Si mul ta neous ly, the fees from the na tion al in sur ance for lab o ra to ry test have been re duced. For some lab o ra to ry tests the GP’s to tal in come from fees have in creased (“win ners”) and for oth ers not (“losers”). study to what ex tent GPs re spond to a change in the re mu-ner a tion per lab o ra to ry test, i.e. whether the “losers” are more like ly to be anal y sed out side GPs of fice com pared with the “win ners”. a mod el of a GP’s de ci sions we de rive whether it is op ti mal for lab o ra to ry tests to be anal y sed in gen er al prac tice or in an ex ter nal lab o ra to ry. em pir i-cal anal y sis em ploys data from the Na tion al In sur ance Ad min is tra tion and we use pan el data mod els.anal y ses shows that “losers” are more like-ly to be anal y sed out side GPs of fice.study con tributes to our un der stand-ing of the im pact of the com po si tion of fees on the ac tu al al lo ca tion of health care re sources.

0379

Cost-eff ec tive ness anal y sis of pneu mo coc cal vac ci na tion for el der ly in Lazio re gion (Italy)Mer i to M. (Pub lic Health Agen cy of Lazio Re gion, Rome, Italy)Rossi PG., Man to vani J., Bor gia P., Cur tale F., Fe deri ci A., Guas tic chi G.

Dis cus sion/Re sults: Pneu mo coc cal vac ci na tion among el der ly is cur-rent ly rec om mend ed in sev er al West ern coun tries. We try to es ti mate the cost-ef fec tive ness of a hy po thet i cal vac ci na tion cam paign among the 65+ gen er al pop u la tion in Lazio re gion (Italy). A co hort was fol-lowed dur ing a 5 years time frame. We es ti mat ed the in ci dence of in va-sive pneu mo coc cal dis ease based on sur veil lance and hos pi tal dis charge reg is try. The avoid ed deaths and cas es have been es ti mat ed ac cord ing to tri al re sults. Health ex pen di tures in clud ed: costs of vac cine pro gram, in pa tient and some out pa tient costs. Cost-ef fec tive ness was ex pressed as net health care costs per ep i sode avert ed and life-year gained (LYG) and was es ti mat ed at base line and in de ter min is tic and sto chas tic sen si-tiv i ty anal y ses. All pa ram e ters were age-spe cif ic (65-74, 75-84, 85+) and var ied ac cord ing lit er a ture data. At base line net costs per event avert ed and life year gained at 2001 prices were, re spec tive ly, €34,681 (95%CI: €28,699–€42,929) and 23,361 (95%CI: €16,419–€38,297). Bac ter aemic pneu mo nia in ci dence and vac cine ef fec tive ness in creased the net cost

per LYG (ICER) by 131% and 218% in the worst case. ICER was nev er be low €4,249, cor re spond ing to the best-case sce nario. Pneu mo coc cal vac ci na tion in the el der ly was not cost sav ing. Ma jor un cer tain ties con-cern the case def i ni tion of in va sive pneu mo coc cal dis ease and, con se-quent ly, vac cine ef fec tive ness in low in ci dence coun tries.

0049

Cost of Ro ta vi rus and Non ro tavirus Di ar rhea among young chil dren in BrazilFer raz M. (Sao Paulo Cen ter for Health Eco nomics, Sao Paulo, Brazil)De Soarez P.C., Ci conel li R.M., Kowal s ki C.C.G

Back ground: Ro ta vi rus is the lead ing cause of se vere acute gas tro en te-ri tis in chil dren < 5 years of age. Al though this dis ease is a sig nif i cant gen er a tor of costs, lit tle is known about the fi nan cial bur den of this dis-ease to the Brazil ian so ci ety.Ob jec tives: We sought to de ter mine the av er age cost per ep i sode of ro ta-vi rus di ar rhea and the av er age cost per ep i sode of non ro tavirus di ar rhea ac cord to the so ci ety per spec tive. Meth o dol o gy: This cost-of-ill ness study is based on data col lect ed along side a 1-year prospec tive, lab o ra to ry-con firmed epi demi o log ic study. The study pop u la tion com prised 2,652 chil dren < 5 years of age. Di rect costs in clud ed the costs of med i cal vis its, hos pi tal iza tion, med i ca-tions, lab o ra to ry tests, ex tra ex pens es, and trav el. In di rect costs in clud-ed fore gone earn ings of care giv er, and life time pro duc tiv i ty loss of a dy ing child. Re sults: The av er age cost per ep i sode of ro ta vi rus di ar rhea was $53. The av er age cost per ep i sode of non ro tavirus di ar rhea was $22.The es ti-mat ed to tal an nu al cost caused by ro ta vi rus di ar rhea to the state of São Paulo and Brazil is a whole were $1,082,721 and $4,657,362, re spec tive-ly. Re gard ing non ro tavirus di ar rhea the an nu al cost was es ti mat ed at $6,066,899 and $26,096,983, re spec tive ly.Con clu sions: This study demon strates the great im pact of ro ta vi rus and non ro tavirus di ar rhea, on health care costs in Brazil. Dis clo sure in for ma tion This re search was sup port ed by Glax o SmithK-line Bi o log i cals, Brazil.Key terms ro ta vi rus, di ar rhea, cost of ill ness, re source uti li za tion

0026

De vel op ing an in dex of ca pa bil i ty for health and so cial pol i cy eval u a tion for old er peo ple: the o ret i cal and method olog i cal chal lengesCoast J. (Health Eco nomics Fa cil i ty, Uni ver si ty of Birm ing ham, UK)Fly nn T., Gre w al I., Lew is J., Natara jan L., Spros ton K.(”C” betű !!!)

Dis cus sion/Re sults: Pre vi ous qual i ta tive work has de vel oped at tributes for a new mea sure fo cus ing on qual i ty of life (rather than health-re lat-ed qual i ty of life) for old er peo ple. Five at tributes were found: at tach-ment, en joy ment, se cu ri ty, con trol and role. Ca pa bil i ties, rather than util i ty, were the fo cus of old er per sons’ con cerns and the work con clud-ed that fur ther de vel op ment of this mea sure should be as an in dex of ca pa bil i ty. This pa per fo cus es on three method olog i cal chal lenges as so ci at ed with de vel op ing such an in dex: at tribute de vel op ment, val u a tion and an chor-ing. First, the con cep tu al at tributes de vel oped must be “re-writ ten” in lay lan guage and ex tend ed into lev els. Sec ond, valu ing these di men sions re quires the o ret i cal rec on cil i a tion be tween Sen’s view that pref er ences should not in form val ues, and con cern to base pol i cy on the views of those af fect ed. Is sues such as whose views are im por tant, and how many val ues any one in di vid u al can pro vide, are also ex am ined. Fi nal ly, con-cerns re lat ed to the an chor ing of an in dex of ca pa bil i ty are con sid ered, rang ing from “is an chor ing nec es sary and/or de sir able?” to the prac ti-cal i ties of such an chor ing.

Eur J Health Econom Suppl 1 · 2006 | S115

This pa per dis cuss es these chal lenges us ing qual i ta tive field work with 20 in for mants and a quan ti ta tive pi lot study with 32 re spon dents to il lu mi-nate the is sues and to in di cate how they have been re solved.

0034

Al co hol Con sump tion and Body WeightFrench M. (Uni ver si ty of Mi a mi, Coral Gables, Flori da, U.S.A.)Ma clean J.C., Nor ton E

Dis cus sion/Re sults: The num ber of Amer i cans who are clas si fied as obese or over weight has reached epi dem ic pro por tions in the last decade. Low er ing the prev a lence of obe si ty to less than 15% by 2010 is list ed as one of the na tion al health goals. Nu mer ous clin i cal stud ies have iden ti-fied as so ci a tions be tween el e vat ed body mass and a range of health prob-lems in clud ing hy per ten sion, di a be tes, cor o nary heart dis ease, stroke, sleep ap nea, and cer tain forms of can cer. The in creased con sump tion of cal o rie-dense con ve nience foods and a sed i men ta ry lifestyle has pro-duced an im bal ance be tween calo ries con sumed and calo ries ex pend ed. Health of fi cials, pol i cy mak ers, and gov ern ment agen cies are en cour ag-ing cit i zens to re duce por tion sizes and in crease phys i cal ac tiv i ty lev-els. Al co hol is a high-cal o rie bev er age and may play a con tribut ing role in the obe si ty/over weight pan dem ic fac ing the U.S. The pres ent study uses data from the Na tion al Epi demi o log ic Sur vey on Al co hol and Re lat-ed Con di tions (NE SARC), a large and re cent na tion al ly rep re sen ta tive sur vey, to in ves ti gate the ef fects of al co hol con sump tion on a va ri ety of body weight in di ca tors. Af ter con trol ling for the en do gene ity of al co-hol use in all spec i fi ca tions, we find ev i dence that var i ous mea sures of al co hol con sump tion are sig nif i cant ly re lat ed to be ing over weight and/or obese. These re sults have in ter est ing pol i cy and pub lic health im pli-ca tions re gard ing al co hol use and health sta tus.

0018

Na tion al health ac counts in Ser bia Gajic-Ste vanovic M. (Min istry of Health, Bel grade, Ser bia&Mon tene gro)

Dis cus sion/Re sults: Ser bia, like oth er parts of for mer Yu goslavia, has in her it ed a health sys tem fi nanced by com pul so ry so cial in sur ance con-tri bu tions. The sys tem was used to pro vide easy ac cess to com pre hen-sive health ser vices for all parts of the pop u la tion.Un for tu nate ly, po lit i cal prob lems and a re duced eco nom ic per for mance sub stan tial ly re duced the fi nan cial ba sis of Ser bia’s health care sys tem. Pub lic funds were in creas ing ly sub sti tut ed by pri vate spend ing, brought up by a pop u la tion vul ner a ble both ma te ri al ly and phys i cal ly. Ser bian Gov ern ment was thus con front ed with the need for bet ter plan ning and or ga ni za tion of health care pro vi sion.Im ple ment ing Na tion al Health Ac counts (NHA) be came part of the Ser bian Gov ern ment’s Health sec tor re form strat e gy to re gain fis cal sus-tain abil i ty as a means for bet ter mon i tor ing mon ey flows in health care. With NHA meth o dol o gy pol i cy mak ers ex pect to mon i tor and eval u-ate:1) Who pays how much for what? 2) Who pro vides which ser vices with those funds?3) Which providers and ser vices de pend on pri vate spend ing in par-

tic u lar?Rec om men da tions will be based on the in for ma tion re ceived and pro-cessed.NHA work start ed in Jan uary 2005. The ini tial phase is ded i cat ed to pro duc ing a first set of Health Ac counts. Pre lim i nary re sults and rec om-men da tions will be pre sent ed at the con fer ence.

0287

Re la tion ship be tween Men tal Health and For give nessGho bari Bonab B. (Uni ver si ty of Tehran, School of Psy chol o gy & Ed u ca tion, Tehran, Iran)Kho da yari fard M., Yek ta M.S.

Dis cus sion/Re sults: Main goal of this re search was to in ves ti gate the re la tion be tween de grees of for give ness and men tal health in young adults. To this end, 1320 col lege stu dents were se lect ed by clus ter sam-pling from Tehran Uni ver si ty and Med i cal sci ences Uni ver si ty of Tehran. “En right For give ness In ven to ry” (EFI), and “Symp tom Check List-90-Re vised” (SLR-90R) were used as in stru ments to get in for ma tion about stu dents’ de gree of for give ness and men tal health sta tus. Due to non-sy met ri cal i ty of for give ness dis tri bu tion MANO VA was used. By di vid-ing for give ness into two lev els of high (75%) and low (25%) and also cal-cu lat ing Hotelling’s T, and sub se quent anal y sis we found out that) There were no sig nif i cant gen der dif fer ences in terms of to tal score of for give-ness, how ev er, in cog ni tive do main fe males were found to be sig nif i cant-ly more prone to for give.) The in ten si ty of hurt had a neg a tive re la tion-ship with the de gree of for give ness.) Sub jects tend to for give peo ple who were close ly re lat ed to them more eas i ly than oth ers who were not keen.) High group in for give ness showed sig nif i cant ly low er Para noia, pho bic dis or ders, psy chot ic dis or ders, anx i ety, and de pres sion.) The more time pass es from the hurt, the more dif fi cult it is to for give.

0191

Pub lic and pri vate ini tal ian health careGi an i no M.M. (De part ment of Pub lic Health and Mi cro bi ol o gy, Uni ver si ty of Turin, Tori no, Italy)Rus so R., Icar di G.P., For a R., Ren ga G.

Dis cus sion/Re sults: This sur vey in tend ed to an a lyse the role of pub lic and pri vate pro duc ers in the cre ation of the vol umes of ser vices of hos-pi tal ad mit tances both in the or di nary set ting and in the dai ly form on the whole na tion al ter ri to ry in the pe ri od 2000–2002. In par tic u lar, we have de fined the trend of ad mit tances both in pub lic and pri vate sec-tors, we have iden ti fied the ar eas of DRG de fin able as be long ing to the pub lic and pri vate do main and the rel a tive mar ket ma jor i ty quo tas., we can af firm that there is a trend of the health care sys tem to ward the re al-lo ca tion of the vol umes of ser vices of or di nary ad mit tances in favour of the pri vate sec tor.the re al lo ca tion re gards the vol umes but not the ty pol o gy of the treat ed cas es since the mix of the DRG has an es sen tial-ly con stant trend in the three-year pe ri od as well as those DRG which ab sorb the 51% of pro duc tion are es sen tial ly con stantin this re al lo ca-tion trend the pri vate sec tor nev er has the mar ket ma jor i ty quo ta but it con trols mar ket nich es with mi nor i ty quo tas think it will be in ter est ing to mon i tor the years to come in or der to con firm or con fute the trends here de scribed.

0295

Age ing, life styles and chang es of the Ital ian NHS sup plyGior dani C. (Health Eco nomics and Man age ment Area, Fac ul ty of Eco nomics, Tor Ver ga ta Uni ver si ty of Rome, Italy)Ric ci R., Span donaro F.

Dis cus sion/Re sults: Most of the com pe ten cies in reg u late\on end de liv-ery of health care ser vices in Italy are de volved to the “Re gions”, ac cord-ing to the re cent ly ap proved re form.strong ly in flu ences the Ital ian NHS sup ply. The rais ing de mand of health care due to se nior i ty, it is ac tu al-ly di ver si fied on a re gion al ba sis, due to the dif fer ent de mo graph ic and eco nom ic con text. aim of this study is to cor re late sup ply of pub lic ser-vices, per ceived health sta tus and macrovari ables ac count ing for re gion-al set tings (re gion al health ser vice).means of a mul ti level ap proach an

S116 | Eur J Health Econom Suppl 1 · 2006

at tempt will be made to iden ti fy the ba sic mech a nisms through which a net work of re la tion ships amongst sin gle mi crovari ables (re flect ing the life style of se niors) can be re lat ed to re gion al macrovari ables (such as the so cial-health pub lic ser vice). Log lin ear and log it mod els will be em ployed.the con test of mul ti pur pose in ves ti ga tions, IS TAT is in charge of the study “Health con di tion and de mand of health ser vices”, from which it is pos si ble to fetch the in di vid u al data at a “re gion al” or “co mu-nal” lev el about health con di tions and life styles of the Ital ians.con clu-sion is that the chang es of the Ital ian NHS sup ply are not as fast as the chang es of the life styles of se niors.

0397

Car ing for el der ly suff er ing from men tal and be hav iour al dis or dersGra main A. (Cen tre d’Etude de l’Em ploi, Noisy le grand, France)Wit twer J.

Dis cus sion/Re sults: How to pro vide and fi nance long-term care for a grow ing num ber of the el der ly suf fer ing from dis abil i ty, is one of the chal-lenges that al most ev ery Eu ro pean coun try faces nowa days. Among dis-abled el der ly, those af fect ed by men tal or be hav iour al dis or ders due to de gen er a tive patholo gies (Alzheimers dis ease for ex am ple) live through a par tic u lar ly ad verse sit u a tion. What is the im pact of such dis or ders on pa tients and their rel a tives from an eco nom ic point of view? How do fam i lies re or gan ise them selves to pro vide and fi nance the need ed care? Which of the rel a tives is in volved in this sphere of fam i ly sol i dar i-ty (spouse, chil dren, chil dren-in-law, grand-chil dren’)? Does the bur den rely on a sin gle in for mal care-giv er or are mul ti ple car ers im plied? Does this con fig u ra tion and the care ar range ments re sult from the in de pen-dent de ci sion of in di vid u als or are they in re sponse to a form of col lec-tive ra tio nal i ty? A spe cif ic sur vey con duct ed in France on the rel a tives of 91 de ment ed el der ly, con sist ing of 260 ques tion naires cov er ing 483 rel a-tives, al lows us to ad dress these ques tions with new data con nect ing data col lect ed from sev er al house holds with in the same fam i ly, en abling us to an a lyse, with econo met rics tools, how col lec tive and in di vid u al al loca-tive de ci sions in ter fere with in for mal care be hav iour.

0569

Health-care uti li za tion and qual i ty of life among pa tients with her pes zos ter in Hun garyGyarmathy K. (MSD Hun gary Ltd., Bu dapest, Hun gary)Nagy P., Novoszath A., Nagy L.

Ob jec tive: To de scribe the bur den of her pes zos ter (HZ) among pa tients above 50 years of age in terms of health care use and im pact on abil i ty to con duct ev ery day ac tiv i ties. Meth ods: We con duct ed a ret ro spec tive sur vey of pa tients above age of 50 years with a re cent ep i sode of HZ. Pa tients were asked to re port their health care use and im pact of ev ery day life and work re lat ed to the ep i-sode of HZ. The SF-36 ques tion naire was used to mea sure the im pact of HZ on pa tients’ qual i ty of life. Re sults: The sur vey was com plet ed by 77 sub jects with a re cent ep i-sode of HZ. 75% of the pa tients re port ed hav ing a his to ry of va ri cel la in fec tion. The treat ment of HZ re quired fre quent med i cal con tact, on av er age 9 of fice vis its per ep i sode. Due to their ep i sode of HZ, pa tients were not able to man age their ev ery day life for an av er age of 10 days and missed on av er age 3 days of work. Re sults from the SF-36 ques tion-naire con firmed that HZ has a sig nif i cant im pact on the pa tients’ phys i-cal and men tal health-re lat ed qual i ty of life. Dis cus sion: This study con firms that HZ rep re sents a sig nif i cant bur-den to most pa tients aged 50 years or more. Pre vent ing HZ could re duce not only treat ment costs but also the im pact of the dis ease on pa tients’ health-re lat ed qual i ty of life and func tion ing, in clud ing their abil i ty to work.

0497

Oral health Pre ven tion plan of the Na tion al Health In sur ance Fund in Hun garyGyenes M. (Sem mel weis Uni ver si ty, Dept. of Pub lic Health, Bu dapest, Hun gary)Dózsa Cs., Balázs P.

Dis cus sion/Re sults: Based on the com pre hen sive Na tion al Pub lic Health Pro gramme, the NHIF in vit ed ap pli ca tions to health pro mo tion & pre ven tion ac tiv i ties at pri ma ry care lev el in den tist ry. To tal sum of fi nan cial sup port was 0.8 mil lion ¬ in the bud get year 2005. The call for ap pli ca tions has been pub lished in May, 2005. Ac cord ing to the spe-cif ic pre vent ing ac tiv i ties to be car ried out, there were set up two sub-pro grams. The first one com prised three main ar eas, and one of them was com pul so ry de pend ing on age-pat tern (un der age, mixed or adult care) of the prac tice. The three main ar eas to be tar get ed were: (1) pro-grams for pri ma ry and sec ond ary pre ven tion for un der age (un der 18 years) peo ple in pae di atric den tal prac tices (2) den tal care pro grams for ex pect ing moth ers in adult and/or mixed prac tices, and (3) pro grams for high-risk adults in prac tices pro vid ing pri ma ry, sec ond ary, and ter-tia ry care in den tal car ies, pe ri odon tal dis eases and oral can cer le sions. The sec ond sub pro gram aimed re duc ing of spe cial in equities. This way, it tar get ed a spe cif ic pre ven tion for men tal ly and/or phys i cal ly hand-i capped chil dren. Hav ing closed the eval u a tion, there were 206 prac-tices win ning the fi nan cial sup port (188 com plex, and 18 hand i capped pro grams). Ge o graph ic dis tri bu tion of prac tices show a favourable pat-tern re lat ed to the sev en Hun gar i an re gions: in low stan dard so cio-eco-nom ic re gions are more den tal prac tices among the win ners, than in the high GDP re gions.

0506

Mod elling re turn on in vest ment thresh olds of the Do nor Ac tion pro gramme – the Hun gar i an ad ap ta tionHer czeg B. (Sem mel weis Uni ver si ty, In sti tute of Phar ma cy Ad min is tra tion, Bu dapest, Hun gary)Bor ka P., Kaló Z.

Dis cus sion/Re sults: This eco nom ic eval u a tion com putes the re turn on in vest ment thresh olds for the im ple men ta tion of a qual i ty as sur ance pro-gramme (Do nor Ac tion: DA) to fa cil i tate or gan do na tion in Hun gar i an set tings. A Markov mod el was de vel oped to cal cu late the cost-sav ings and qual i ty ad just ed life years (QALYs) of ca dav er ic kid ney trans plan ta-tion ver sus di al y sis over a 20-year pe ri od. By em ploy ing this mod el to DA, cost-ben e fit and cost-sav ing thresh olds of the Hun gar i an im ple men-ta tion were cal cu lat ed as a func tion of the in cre men tal do na tion rate. In 2003 the ac tu al num ber of ca dav er do na tions was 161 out of 9770 deaths on in ten sive care units (ICU) which means that the Hun gar i an do na tion rate was 16,1 do nor / per mil lion pop u la tion (pmp). The di ag-nos tic tools of Do nor Ac tion pro gramme were ap plied in 11 pi lot hos pi-tals in Bu dapest, but not the 5 DA pro gramme moduls. These hos pi tals ref ferred 4,7 % of ICU deaths as po ten tial donors, and 46% of re ferred donors could be con vert ed into ac tu al donors. The ex trap o la tion of these ra tios for na tion al lev el would yield 21,2 pmp do na tion rate.If we as sume, that ac cord ing to in ter na tion al ref er ences of the DA the do na tion rate in creas es by 53%, im ple men ta tion of DA di ag nos tic tools plus its pro gramme moduls in cur rent hos pi tals with do na tion po ten tial would yield 8 more donors pmp or 14 ad di tion al ca dav er ic re nal trans-plan ta tions pmp in Hun gary. The pre lim i nary re sults of the Markov mod el sug gest that in Hun gary an ad di tion al re nal trans plan ta tion re sults in net 2,04 QALYs and 13,1 mil lion HUF cost sav ings over a 20 year pe ri od by ap ply ing 5% dis count rate for both QALYs and costs. Based upon con ser va tive es ti mates the cost-ef fec tive ness thresh old of ex tend ing DA to non-par tic i pat ing Hun gar i an hos pi tals is 330 mil lion HUF pmp.

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0220

Eval u a tion of In te grat ed Care Pro grammes in Ger manyHes sel F. (In sti tute for Health Care Man age ment, Uni ver si ty of Duis burg-Es sen, Ger many)

Back ground: By im ple ment ing strong fi nan cial in cen tives from the gov-ern ment since 2004 a rapid ly grow ing num ber of in te grat ed care pro-grammes were im ple ment ed in Ger many. Ob jec tive: To give an overview about the cur rent im ple men ta tion of in te grat ed care in Ger many and about eval u a tion con cepts for man age-ment de ci sions from a sick ness fund’s per spec tive. Re sults: Sick ness funds and care givers have a strong in ter est to eval u-ate the in te grat ed care pro grammes they are in volved in. Eval u a tion is seen as an on go ing sys tem at ic pro cess to con tin u ous ly con trol costs and im prove qual i ty by es tab lish ing a learn ing sys tem with reg u lar re ports and adap ta tions. In di ca tors of qual i ty are not only med i cal out come but also struc ture and pro cess pa ram e ter. For the se lec tion of a con trol group a con cept us ing a risk ad just ment-grouper showed a good prac ti-ca bil i ty and plau si ble re sults. Dis cus sion: To sup port a man age ment de ci sion of sick ness funds con-cern ing in te grat ed care pro grammes a ge ner ic eval u a tion con cept us ing a lim it ed num ber of out come pa ram e ter and a stan dard ized ap proach for dif fer ent in di ca tions is nec es sary. By us ing a stan dard grouper-based con cept and ex clu sive ly rou tine data a prag mat ic eval u a tion of costs and pa tient cen tred out comes could be re al ized.

0244

The costs of acute-on-chron ic liv er fail ure : A bot tom-up anal y sis based on in di vid u al pa tient dataHes sel F. (In sti tute for Health Care Man age ment, Uni ver si ty of Duis burg-Es sen, Es sen, Ger many)Mitzn er S., Wasem J.

Ra tio nale: Acute-on-chron ic liv er fail ure (ACLF) is a life-threat en ing acute de te ri o ra tion of a chron ic liv er dis ease. Ob jec tive of this pa per is to de ter mine the av er age cost of the treat ment of ACLF and iden ti fy the pre dic tive val ue of clin i cal vari ables. Meth o dol o gy: Based on the sam ple of all ACLF-pa tients of a large Ger-man uni ver si ty hos pi tal de tailed cost of ini tial hos pi tal stay and a three year fol low-up pe ri od were de ter mined. Rel e vant clin i cal and de mo-graph i cal vari ables were test ed in sin gle and mul ti ple re gres sion anal y-ses, as sum ing a gam ma dis tri bu tion. Con fi dence in ter vals were es ti mat-ed by Monte-Car lo sim u la tions.Re sults: From 1999 to 2002 103 pa tients could be iden ti fied. Mean costs per pa tient were 22,168 EUR; 11,956 EUR for the ini tial treat ment, 10.212EUR for fol low ing 3 years. The biggest in flu ence had use of ar ti-fi cial liv er sup port. Oth er sig nif i cant vari ables were re nal di al y sis and ae ti ol o gy. Con clu sion: Main cost fac tor of the treat ment of ACLF is the ini tial in pa tient treat ment. Us ing a bot tom-up ap proach and a re gres sion anal-y sis not only the di rect costs of ill ness but also the main pre dic tion fac tors for costs of ACLF could be de ter mined. The re sults un der line the ne ces si ty to dif fer en ti ate the re im burse ment sys tems for ad di tion al re nal fail ure, ar ti fi cial liv er sup port and the ae ti ol o gy of ACLF.

0041

Blood do na tion and char i tyHollingsworth B. (Monash Uni ver si ty, Mel bourne, Vic to ria, Aus tralia)Wild man J., Hollingsworth B.

Dis cus sion/Re sults: This pa per in ves ti gates char i ta ble be hav iour by mod elling the de ci sion to make blood do na tions. While the blood sup-ply is a pub lic good, with the as so ci at ed free rid er prob lems, there are

no is sues of gov ern ment in ter ven tion or crowd ing out. We can ex am ine a num ber of is sues us ing our unique blood do na tion data set of 130,000 donors. First ly, we can in ves ti gate the de ter mi nants of char i ta ble do na-tion, sec ond ly we can test for im per fect al tru ism and per fect al tru ism, fi nal ly we can in ves ti gate whether em bed ded ness in ones com mu ni ty af fects char i ta ble do na tions. We find that in di vid u als be have char i ta bly but that in di vid u als re spond to in cen tives, in terms of costs. We also find ev i dence for im per fect al tru ism and that in di vid u als who with few-er so cial ties are much less like ly to do nate.

0043

The eff ec tive trans la tion of health eco nomics re search into pol i cy and prac ticeHollingsworth B. (Monash Uni ver si ty, Mel bourne, Vic to ria, Aus tralia)Hauck K.

Dis cus sion/Re sults: Health in equal i ties are a fun da men tal pol i cy is sue. How ev er de spite many pol i cy ini tia tives in this area in equal i ty per sists, and in fact may be on the in crease. Ef fec tive pol i cy re quires an un der-stand ing of the caus es of in equal i ties. Health eco nomics has de vel oped tools which are use ful in mea sur ing and iden ti fy ing in equal i ties. This pa per will sum marise these meth ods, but will con cen trate on iden ti fy-ing meth ods that can be used to iden ti fy the ef fects of pol i cy chang es, es pe cial ly over time. aim to iden ti fy ar eas of pol i cy where the mea sure-ment of so cial in equal i ties would help ef fec tive tar get ing. For ex am ple, what are pol i cy mak ers look ing for in terms of use ful in for ma tion in this area, what do health economists think are the ar eas of in equal i ty where pol i cy can be most ef fec tive, and how do we know this? use the ex am-ple of obe si ty to ques tion what we, as health economists, should be con-cen trat ing on. Is it re fin ing mea sure ment tech niques, or should we be hon ing in on ar eas of in equal i ties re search which may have a real pol i cy im pact, if so how? This pa per asks as many ques tions as it an swers, aim-ing to set a frame work for a di a logue which will help trans late cut ting edge re search find ings into use able ev i dence for pol i cy mak ers.

0363

Cost-eff ec tive ness of treat ment re views for pri ma ry care pa tients with non-ul cer dys pep siaHolmes J. (PMSI Health care eco nomics & health pol i cy con sul tan cy, Lon don, UK)Evans N., Daw son S.

Dis cus sion/Re sults: NICE clin i cal guide lines em pha sise pa tient re views in non-ul cer dys pep sia and gas tro-oe sophageal re flux dis ease and rec-om mend step ping down from high to low dose pro ton pump in hib i-tor (PPI) treat ment af ter 1–2 months. How ev er, some pa tients ex pe ri-ence “acid re bound”, re quir ing use of a fast on set al gi nate. This study as sessed whether a low dose PPI/al gi nate com bi na tion pro vides sat is-fac to ry symp tom re lief at low er over all cost than a high dose PPI.au dit in nine Lon don GP prac tices re sult ed in 179 pa tients at tend ing a nurse-led clin ic. Data on symp tom fre quen cy and sever i ty, and pre scribed and OTC med i ca tion, were col lect ed at base line, then at 4–7 weeks, 9–15 weeks and 13–22 weeks. /179 (63%) had their treat ment stepped down. Dur ing the fol low ing 13–22 weeks, 7/112 pa tients (6%) re vert-ed to their pre vi ous PPI dose, with one study with draw al. For pa tients con tin u ing on the new treat ment (n=104), mean symp tom fre quen cy and sever i ty were not sig nif i cant ly dif fer ent from base line (p=0.84 and p=0.46 re spec tive ly) and sat is fac tion with the new treat ment was high. There was no in crease in use of OTC med i ca tion.med i ca tion chang es were cost sav ing. The av er age month ly cost per suc cess ful ly man aged pa tient was £14.52 com pared to £21.29 be fore base line (p<0.001), a re duc tion of 32%.

S118 | Eur J Health Econom Suppl 1 · 2006

0144

An Eff ec tive Men tal Health Pre ven tion and Pro mo tion for the 21st Cen tu ryIn darat na K. (Chu la longko rn Uni ver si ty, Bangkok, Thai land)

Dis cus sion/Re sults: Men tal health is a vi tal part of to tal health and qual-i ty of life. Sound men tal health en hances life and phys i cal health while men tal dis tress de te ri o rates them. The ris ing health and life threats since the be gin ning of the 21st cen tu ry have wors ened men tal health of the pop u la tion, es pe cial ly of in cur able and chron i cal ly ill pa tients, and their rel a tives. Ev i dent ly sui cide rates and drug ad dicts have risen world wide. In creas ing ly, men tal health prob lems man i fest in risky and un healthy life styles; crimes and vi o lence. The need of men tal health care usu al ly ex ceeds the ca pac i ty of health sys tem while men tal health pre ven tion/pro mo tion re mains vague and neg li gi ble. The bur den tends to be shoul-dered by the pa tients and rel a tive. An ef fec tive ap proach to pre vent/pro-mote men tal health could re duce the health and eco nomics bur den of the so ci ety. Its de sign must cul ti vate the mind into “mind in tel li gence” with which a per son is ca pa ble of mak ing right de ci sions, re duces risk fac-tors. It must de vel op pos i tive at ti tude and cre ative think ing to pro mote men tal ca pa bil i ty for non-harm ful and eth i cal be hav ior, for heal thy life styles. Pre cise ly “mind in tel li gence” in volves “hap pi ness” de vel op ment pro cess that strength ens an abil i ty to turn cri sis into op por tu ni ty. It is a means for valu ing life and im mu ni ty against de struc tive de ci sions.

0304

Im prov ing ge o graph ic ac cess to drugs in re mote ru ral ar eas of Kyr gyzs tan Jakab M. (WHO, Bishkek, Kyr gyz Re pub lic)Wan ing B., Ja farov A., Checheibaev E.

Dis cus sion/Re sults: In 2004, the Manda to ry Health In sur ance Fund of the Kyr gyz Re pub lic in tro duced an in no va tive pi lot to im prove ge o-graph ic ac cess to pre scrip tion drugs with fi nan cial sup port from the Swiss Red Cross. phar ma cies were opened in pri ma ry health care clin-ics and feld sch er posts in 13 vil lages staffed by nurs es work ing in these health care posts. For the pi lot, the Min istry of Health pro vid ed a sus-pen sion of the pro hi bi tion of drugs dis pens ing for med i cal staff and waved manda to ry staffing by a phar ma cist. A re volv ing drug fund was set up to pro vide the ini tial stock of medicines. The phar ma cies work with in the Ad di tion al Drug Pakcage (ADP) of the Manda to ry Health In sur ance Fund and are al lowed to fill ADP pre scrip tions. poster eval u-ates the suc cess of the pi lot in ex pand ing ac cess to pre scrip tion drugs. The main find ing is as fol lows De spite great ap pre ci a tion of the pi lot by the pop u la tion, we could not de tect a sig nif i cant im prove ment in ac cess to ADP pre scrip tion drugs di rect ly atr ributable to the pi lot. This is due to an ini tial un der es ti ma tion of true ac cess to drugs, and lim it ed over-all lev el of fund ing at tributable to the pro gram.

0014

Do Risk-tak ers Floss?Jami son J. (UC Berke ley, Oak land, CA, Unit ed States)

Dis cus sion/Re sults: Ex per i men tal eco nomics method olo gies pro vide a valu able and broad set of new tools with which to ap proach many is sues in pop u la tion health. The un der ly ing idea is to cre ate con trolled de ci-sion prob lems (ei ther strate gic games or sin gle-per son de ci sions) in a lab o ra to ry or field en vi ron ment, and to pay sub jects in cash in or der to in duce truth ful (i.e. in cen tive com pat i ble) re spons es. These prob lems can be used to mea sure a wide va ri ety of at tributes, in clud ing risk and time pref er ences, fair ness/gen eros i ty, trust, co op er a tion/co or di na tion, the o ry of mind, strate gic rea son ing, re ciproc i ty, and so on. We asked sub jects about their health be hav iors (smok ing, ex er cise, floss ing, etc.)

and cor re lat ed their an swers with the re spons es in the de ci sion prob-lems. This has been done so far with a sam ple of ap prox i mate ly 150 Berke ley MPH stu dents, af ter which we cre at ed an in dex of health be hav-iors (with high er scores cor re spond ing to more health-pro tec tive be hav-iors). In ter est ing ly, we find that this in dex is not cor re lat ed with time pref er ence (fi nan cial pa tience), but it is cor re lat ed with risk-avoid ance (in a fi nan cial gam ble over loss es). This sug gests that pol i cy in ter ven-tions based sole ly on in vest ment in the fu ture’ are un like ly to be ef fec-tive. We will be ex tend ing this work in the com ing months to sub ject pop u la tions in Africa and else where in or der to check the ro bust ness of the re sults in oth er rel e vant set tings.

0077

Im ple ment ing ac count abil i ty for rea son able ness – the case of phar ma ceu ti cal re im burse ment in Swe den.Jans son S. (The Swedish IHE, Lund, Swe den)

Ob jec tive: This pa per aims at de scrib ing the pri or i ty set ting pro ce dure of new orig i nal phar ma ceu ti cals at the Swedish Phar ma ceu ti cal Ben e-fits Board (LFN), an a lyse the out come of the pro ce dure in terms of de ci-sions and the rel a tive im por tance of eth i cal prin ci ples, and to ex am ine the re ac tions from stake hold ers. Meth ods: A case study of all “prin ci pal ly im por tant” de ci sions made by the LFN dur ing the first 33 months of op er a tion. The study is the o ret i-cal ly an chored in the the o ry of fair and le git i mate pri or i ty set ting pro-ce dures by Daniels & Sa bin, and based on pub lic doc u ments, ar ti cles in me dia and semi-struc tured in ter views.Re sults: Only nine cas es re sult ed in a re jec tion of sub sidy and 15 in lim it ed or con di tioned sub sidy. To tal re jec tions rather than lim i ta tions gave rise to ac tions from stake hold ers. Pri mar i ly the prin ci ple of cost-ef fec tive ness was claimed when lim it ing/con di tion ing or to tal ly re ject-ing sub sidy. Con clu sions: This study sug gests that im ple ment ing a pri or i ty set ting pro cess ful fill ing the con di tions of ac count abil i ty for rea son able ness, re sults in a pri or i ty set ting pro cess gen er al ly per ceived as fair and le git i-mate by the ma jor stake hold ers and in creas es the so cial learn ing of the ne ces si ty of pri or i ty set ting in health care. The prin ci ple of cost-ef fec-tive ness in creased in im por tance when the de mand for ope ness and trans paren cy in creased.

0153

The eco nom ic im pact of ad her ence in an ti de pres sant treat mentJär brink K. (Or ga non AB, Gothen burg, Swe den)Granst edt H.

Dis cus sion/Re sults: De pres sion caus es pro found suf fer ing to peo ple with the ill ness, and gen er ates high costs for health care sys tems and the wider so ci ety. The cost of an tide pres sants is of ten a small part of the to tal cost and ac counts for 2–11% in most stud ies de pend ing on what cost data are col lect ed. Nu mer ous stud ies have eval u at ed and com-pared the cost-ef fec tive ness of mod ern an ti de pres sant ther a pies. These stud ies have of ten ne glect ed the real ef fi cien cy of the drugs and there-by caused con fu sion among de ci sion-mak ers about how to ob tain an op ti mal use of the re sources. this study, we in ves ti gate the in flu ence of real life ad her ence on the cost-ef fec tive ness of mod ern an tide pres-sants from a so ci etal per spec tive. A mod el is built based on clin i cal out-comes data but with cost-in for ma tion ad just ed in or der to bet ter re flect the true cost-con se quences of de pres sion. By the use of sen si tiv i ty anal-y ses the re li abil i ty of the in cre men tal cost-ef fec tive ness ra tio (ICER) is ex am ined for com par isons be tween treat ment regimes were dif fer ences in ad her ence is ex pect ed in a real clin i cal set ting. The anal y sis in di cates that the im pact of ad her ence is huge and that com par isons that does not con sid er the in flu ence of at ti tudes, the for mu la tion and the drug

Eur J Health Econom Suppl 1 · 2006 | S119

sup port ing ma te ri al, can not dis tin guish the cost-ef fec tive ness be tween mod ern an tide pres sants.

0516

Re la tion ship be tween the fl ex i bil i ty of the in sti tu tions and the health care sys tem per for manceJob bagy J. (Valján Kft., De bre cen, Hun gary)

Ob jec tives: To re view some of the key de bates re lat ing to the role of the in sti tu tions and reg u la tion change in the health care sys tems and their in ter ac tion. Meth ods: A lit er a ture re view was con duct ed that cov ered both the o ret i-cal con tri bu tions and pub lished stud ies of the pro cess and out comes of in sti tu tion al and reg u la tion change.Re sults: There is lit tle con sen sus among schol ars over the ten den cy of the reg u la tion change. Three state ments can be ob served. First, there is con ver gence in the health mar ket be tween the rules of reg u la tion. Sec-ond, the suc cess stra te gies in coun tries di verge. Third, the flex i bil i ty of the in sti tu tions is a key fac tor to find an ef fi cient health care sys tem. The ex plana to ry pow er of the re gres sion mod els mea sur ing health out comes can be about 15% high er, if the flex i bil i ty of the in sti tu tions (mea sured with In dex of Eco nom ic Free dom) fac tor per forms in the mod el. In these mod els the flex i bil i ty of the in sti tu tions fac tor ex plains the chang-ing of the health out comes as much as the GDP per cap i ta fac tor. Con clu sion: There is a grow ing need to ex am ine the role of the in sti-tu tions and the change of the reg u la tion in or der to find out how they help to achieve a more ef fi cient health care sys tem.

0552

The role of the ESKI Offi ce of Health Tech nol o gy As sess ment Med i cal Group in the pro cess of med i cine sub sidy ap provalJóna G. (Na tion al In sti tute for Strate gic Health Re search, Bu dapest, Hun gary)Vit tay P., Pék li Novákné M.

Dis cus sion/Re sults: With re spect to the for mu la tion of the sec tor’s health pol i cy strat e gy and prep a ra tion for de ci sion-mak ing, the Na tion-al In sti tute for Strate gic Health Re search (ESKI) is ac tive in the fol low-ing ar eas:health in for mat ics; in for ma tion pol i cy; health eco nomics; health sci ences; tech nol o gy as sess ment; sub sidy pol i cy. ESKI is the par-ent or ga ni sa tion of the Of fice of Health Tech nol o gy As sess ment, which has the task of pro vid ing an or gan i sa tion al frame work for the tech nol-o gy as sess ment that forms the ba sis for the med i cine sub sidy ap proval pol i cy of the Na tion al Health In sur ance Fund, and per form ing the re lat-ed med i cal and eco nom ic as sess ment du ties. With in the Of fice, the du ties of the Med i cal Group are as fol lows:– check ing of the con tent of med i cal doc u men ta tion sub mit ted by

man u fac tur ers (the role and ef fect of the giv en med i cine in the treat-ment pro cess, the mon i tor ing of side ef fects, the re sults of piv otal clin i cal tri als, fac tors in favour of the pro ce dure)

– sum ma ry of the cred i ble Hun gar i an and in ter na tion al spe cial ist lit er-a ture per tain ing to the clin i cal ef fi ca cy and ef fec tive ness (EBM pro-to cols, meta-anal y ses, crit i cal anal y ses) of medicines,

– anal y sis of clin i cal tri als sub mit ted by ap pli cants for med i cine sub si-dies,

– prep a ra tion of sum ma ry med i cal opin ions, the pro vi sion of re li able and undis tort ed in for ma tion for judg ing the val ue of in di vid u al pro-ce dures

– in form ing de ci sion-mak ers of the re search find ings, with out ar tic u-lat ing spe cif ic sub sidy rec om men da tions

– an swer ing ques tions of a med i cal na ture that are raised at meet ings of the com mit tee mak ing pro pos als for the ap proval of med i cine · sub si dies by the Na tion al Health In sur ance Fund (OEP)

Be sides the above, the group also par tic i pates in the for mu la tion of health pol i cy and health eco nomics guide lines, li ais es with in ter na tion-al tech nol o gy as sess ment bod ies and in sti tutes, and fur ther de vel ops the skills of its em ploy ees through par tic i pa tion in in ter nal and ex ter-nal train ing cours es and con fer ences.

0184

Cost min i mal i sa tion anal y sis of capecitabine ver sus 5-fl u o ro ura cil-leu co vor in (5-FU/LV)Gá bor J. (Roche Hun gary Ltd., So pron, Hun gary)Gerenc sér Zs.

Ra tio nale of capecitabine: Per os capecitabine is equiv a lent as in tra ve-nous 5-FU/LV in the treat ment of meta stat ic col ore cal can cer in terms of ef fi ca cy. Pa tients pre fer oral che mo ther a py, if the per os ad min is tra-tion doesn’t com pro mise the ef fi ca cy. Back ground: Capecitabine is re im bursed in out pa tient care (based on pres rip tion), 5-FU/LV fi nanced as an in pa tient care pro to col (based on DRG sys tem).Ob jec tive: The goal was to demon strate cost sav ing, us ing per os capecitabine com par ing to 5-FU/LV. Meth od: The anal y sis in ves ti gat ed the the di rect med i cal costs of capecitabine and 5-FU/LV, in per spec tive of the Na tion al Health Fund Ad min is tra tion of Hun gary (OEP). Re sults: Costs of capecitabine were ac qui si tion al cost and lab o ra to ry ex am i na tions. The use of 5-FU/LV in clud ed the cost of drugs, hos pi tal-i sa tion and in tra ve nous ad min is tra tion. The DRG based costs of 5FU/LV were high er, than the cost of capecitabine, due to hos pi tal ly in tra ve-nous ad min is tra tion.Sav ing is 607.000 HUF (2380 Euro) per pa tient. Con clu sions: Use of capecitabine is cost sav ing. Al though the price of capecitabine is high er than drug cost of 5-FU/LV, the to tal cost of capecitabine is less by 53% than 5-FU/LV. Ap prox i mate ly 150 patient have been treat ed with capecitabine be tween Jan uary and Novem ber 2005, which re sult ed more than 91 Mil lion HUF (357 000 Euro) sav ing to OEP.

0121

Labour par tic i pa tion of pa tients liv ing with HIV/AIDSOli va J. (Univ Car los III. SESAM/De part ment of Eco nomics, Getafe (Ma-drid), Spain)Labea ga J.M.

Dis cus sion/Re sults: Con trol of HIV/AIDS is one of the pri or i ty tar gets of health pol i cy. Med i cal ad vances in re cent years have not achieved de fin i tive cure, al though they have al lowed im prove ments in the Qual-i ty of Life (QOL) of the pa tients, as well as a de lay in ar riv ing to the ter mi nal phase for a larg er share of the af fect ed pop u la tion. Most of the pa tients with HIV are work ing-age peo ple who, un til re cent ly, were forced to aban don the labour mar ket at time be cause of their health shock. The main aim of this study is to an a lyze the de ter mi nants of labour par tic i pa tion of HIV/AIDS pa tients in Spain. To this end, we con duct a sur vey on 241 pa tients who ac cept to pro vide the re quest ed in for ma tion in a ques tion naire dur ing an out pa tient vis it. We es ti mate an equa tion with typ i cal de ter mi nants of par tic i pa tion of neo clas si cal mod els. We iden ti fy as sig nif i cant vari ables gen der, ed u ca tion, QOL, lev el of im mune de fences (CD4 cells) and non-salary in come. De ter mi-nants of labour par tic i pa tion can be use ful for de ci sion mak ers in the de vel op ment of labour poli cies di rect ed to se ro pos i tive peo ple. Also, labour par tic i pa tion chang es can be of in ter est for eco nom ic eval u a tion mod elling and for the op ti mal al lo ca tion of re sources from a so ci etal point of view.

S120 | Eur J Health Econom Suppl 1 · 2006

0317

The cost eff ec tive ness of Meth a done and Bu pre nor phine main te nance treat ment of opi o id de pen denceJuarez-Gar cia A. (Health Ser vices Mange ment Cen tre, Uni ver si ty of Birm ing ham, UK)Jowett S., Rob erts T., Frew E.

Dis cus sion/Re sults: Opi o id de pen dence is a chron ic, re laps ing-re mit-ting con di tion with phys i cal, psy cho log i cal and so cial di men sions. The con se quences in clude in creased risk of in fec tious dis ease, high mor tal i-ty rates, men tal health, so cial prob lems and crim i nal ac tiv i ty. Thus, the costs to the pa tient, the NHS and so ci ety are sig nif i cant.study, com mis-sioned by the Na tion al In sti tute for Clin i cal Ex cel lence (NICE), ex am-ines the rel a tive cost-ef fec tive ness of Meth a done and Bu pre nor phine as main te nance ther a py for her o in de pen dence in Britain. Ev i dence from a sys tem at ic re view of the clin i cal ef fec tive ness of the treat ments pro vid ed pa ram e ter es ti mates for the eco nom ic eval u a tion. New data, on Health Re lat ed Qual i ty of Life (HRQoL) out comes, were es ti mat ed from a new util i ty pan el pi lot pro ject, re ferred to as the &#8216;Val ue of Health Pan el’, de signed to eval u ate the use of lay peo ple’s val ues in cost util i ty anal y sis. mod el is the first to in cor po rate the re duc tion in risk of con tract ing in fec tious dis eases into a cost util i ty anal y sis, in the eco nom ic eval u a tion of opi o id de pen dence in the UK. The base case per spec tive is that of the Na tion al Health Ser vice and Per son al So cial Ser vices. In sen si tiv i ty anal y sis, the per spec tive is widened to in clude costs and ben e fits rel e vant to a so ci etal per spec tive, in clud ing the costs as so ci at ed with crime.

0492

A bench mark ing mod el for spe cial ist careKaar boe O. (Dep. of Eco nomics, Health Eco nomics Bergen, Uni ver si ty of Bergen, Nor way)Ha gen T.P.

Dis cus sion/Re sults: The pur pose of this pa per is to dis cuss how health re gions (the prin ci pal) can al lo cate funds to health care providers (hos-pi tals) in a NHS. We pro pose a mod el that builds on two prin ci ples. The first is that each health care provider is al lot ted a catch ments area. The sec ond prin ci ple is that the health re gion should com pen sate the health care providers for dif fer ences in needs, dif fer ences is lo cal costs con di tions that the hos pi tal can not af fect, and for dif fer ences in teach-ing and re search ac tiv i ties. In ad di tion hos pi tals’ funds should be cor-rect ed for pa tient mo bil i ty across catch ment ar eas. The idea of the mod-el is that health care providers can be bench marked against each oth er us ing the DRG-sys tem as these dif fer ences are com pen sat ed. The pa per il lus trates, based on em pir i cal ly gen er at ed cost weights, how the mod-el can be im ple ment ed in the Nor we gian spe cial ized health care sec tor.

0525

In fl u ence of el der ly pa tients’ fi nan cial back ground on cac er screen ing in USAKa hana E. (De part ment of So ci ol o gy, Case West ern Re serve Uni ver si ty, Cleve land, Ohio, USA)Ka hana B.

Dis cus sion/Re sults: Di min ished ac cess of el der ly mi nori ties in the USA to can cer screen ing rec om men da tions has been ex ten sive ly doc u ment-ed,even in the pres ence of Medi care cov er age. This pa per con sid ers the rel a tive in flu ence of old er pa tient’s race,eco nom ic sta tus and source of med i cal care (HMO or Fee for Ser vice)as they in flu ence can cer screen-ing rec om men da tions they re port to have re ceived from their physi-cians.Data will be re port ed from a pan el study of 500 ur ban el ders and 400 re tire ment com mu ni ty dwelling aged.The rel a tive in flu ence of age

and co mor bid i ty will be con sid ered along with eco nom ic fac tors as they im pact on can cer screen ing in late life when can cer risk is high. Our pri-or re search on these pop u la tions has doc u ment ed greater pa tient sat is-fac tion with care among those re ceiv ing Fee for Ser vice care than HMO care re cip i ens.Nev er the less, those uti liz ing HMOs had bet ter cov er age for pre ven tive ser vices.(Ka hana et al.2003)Im pli ca tions of find ings for health care pol i cy will be dis cussed.

0176

De veop ment and ap pli ca tion of a hos pi tal bud get ing mod el to South Ko reaKo S. (Health In sur ance Re view Agen cy, Seoul, South Ko rea)Yang B.

Dis cus sion/Re sults: This study was con duct ed to find out and ap ply a hos pi tal bud get ing mod el to South Ko rea. hos pi tal bud get mod els rel e-vant to Ko rea were de vel oped based on the find ings from com pre hen-sive ly re view ing hos pi tal bud get sys tems of Eu ro pean coun tries. Va lidi-ties of each mod el were ex am ined by com par ing the pre dict ed ex pen-di tures and ac tu al ex pen di tures of all ter tia ry hos pi tals in Ko rea us ing the health in sur ance claims data for 36 months in clud ing in for ma tion on health care uti li za tion of al most all the pop u la tion.bud get mod els based on hos pi tal ac tiv i ties were ac cept ed as an ap pro pri ate mod el for Ko rea among sev er al mod els. Un der these mod els, bud get was de cid ed by mul ti ply ing ‘ex pect ed amount of ser vices’ by ‘pre vi ous ly fixed cost per ser vices’. The ‘ex pect ed amount of ser vices’ was es ti mat ed from his-tor i cal ser vice amount of each hos pi tal and the ‘fixed cost per ser vices’ was cal cu lat ed from av er age cost of all hos pi tals, with vary ing the def i-ni tion of ‘unit of ser vices’. The es ti mat ed ex pen di tures were very sim i lar to the real one, show ing most cor re la tion co ef fi cients were over 0.98. In the case of us ing the ‘dis ease-ad just ed dai ly cost’ as the ‘unit of ser vices’, the cor re la tion co ef fi cient was 0.99 and the ra tio of pre dict ed ex pen di-ture to ac tu al ex pen di ture was be tween 0.9 and 1.1.

0574

Cost-eff ec tive ness anal y sis of an ti hy per ten sive treat ments: a com pli ance mod el in the Hun gar i an health care set tingKósa J. (No var tis Hun gary Ltd, Bu dapest, Hun gary)

Ob jec tive: The aim of this study was to de ter mine the ef fec tive ness and cost-ef fec tive ness of an ti hy per ten sive med i ca tions over a life time treat-ment in the Hun gar i an health care set tings. Meth ods: A Markov mod el was de vel oped to mod el car dio vas cu lar risk pro tec tion of bet ter com pli ance and its costs over a pa tient’s life time. Three dif fer ent treat ments for hy per ten sion in a hy po thet i cal co horts with high blood pres sure over age 50 was mod eled as a Markov pro cess us ing DATA for Health care soft ware (ver sion 3.5). Briefly, a hy po thet i-cal co hort of pa tients was fol lowed over a num ber of time cy cles. At the end of each time cy cle, pa tients can move be tween a num ber of health states ac cord ing to prob a bil i ties de rived from stud ies done on large pop-u la tion data bases. Health states from which no move ment is pos si ble (in this case, death) are known as ‘ab sorb ing’ health states. The Fram ing-ham risk func tions were em ployed to es ti mate gains in life ex pect an cy at tributable to a sin gle risk fac tor such as con trolled blood pres sure. Main out come mea sures were life ex pect an cy, and in cre men tal costs of dif fer ent treat ment stra te gies. All costs are pre sent ed in 2005 prices and the anal y sis was per formed from a health ser vices per spec tive.Re sults: Treat ing hy per ten sion with val sar tan re sult ed in bet ter com pli-ance and high er num ber of days pa tients spent on ther a py when com-pared to am lodip ine and lisino pril. Pa tients on val sar tan, gained an ad di-tion al con trolled year on an ti hy per ten sive ther a py for an in cre men tal cost of 300–360 000 Ft. The Fram ing ham study showed that 27,68 years on ther a py re sults 4,31 life years gained, which is in our case trans lates

Eur J Health Econom Suppl 1 · 2006 | S121

into an in cre men tal cost ef fec tive ness ra tio of 1 900 000–2 300 000 Ft per life years gained. Con clu sions: Val sar tan treat ment for hy per ten sive pa tients proved to be cost-ef fec tive and re sult ed in bet ter com pli ance and ad di tion al life years gained at a rea son able cost.

0573

Cost-eff ec tive ness anal y sis of oma l izum ab as a treat ment for pa tients with se vere per sist ing asth ma in Hun garyKósa J. (No var tis Hun gary Ltd, Bu dapest, Hun gary)

Ob jec tive: To as sess the costs, con se quences and cost-ef fec tive ness of oma l izum ab (Xo lair) as treat ment for adults with se vere per sist ing asth-ma in Hun gary.Meth ods: A Markov mod el con struct ed for the UK based upon the IN NO VATE tri al was adopt ed to the Hun gar i an health care set tings. The IN NO VATE pop u la tion is com prised of in di vid u als with se vere per sis tent asth ma who are in ad e quate ly con trolled de spite GINA step 4 ther a py. The num ber of clin i cal ly sig nif i cant mild and se vere ex ac-er ba tions was col lect ed in the tri al as well as emer gen cy use (hos pi tal ad mis sions, un sched uled doc tor vis its and ER vis its) and qual i ty of life in terms of EQ5D, AQLQ and GETE scores. Com bin ing tri al data with lo cal Hun gar i an cost in for ma tion were used to con duct cost-ef fec tive-ness anal y ses and sen si tiv i ty anal y ses for the rel e vant pop u la tion. The Markov mod el com pare the costs and out comes from a pay er per-spec tive of high risk asth ma pa tients man aged with usu al med i cal care (high dose ICS + LABA) ver sus adding oma l izum ab to stan dard ther a-py. It mod els the events for a pe ri od of 3 years based upon clin i cal tri-al data up to 28 weeks, with a pos si ble long-term pay off af ter ad di tion-al 40 years (based on the av er age life ex pec ta tion of the IN NO VATE pa tient pop u la tion). The mod el es ti mates the num ber of pa tients who ex pe ri ence clin i cal-ly sig nif i cant mild ex ac er ba tions, clin i cal ly sig nif i cant se vere ex ac er ba-tions and death. Costs are con sid ered from a pay er per spec tive only. Costs and out comes for each Markov state are cal cu lat ed and dis count-ed at a 3%.Re sults: The per-pa tient costs for the base case anal y sis show that the av er age treat ment and ex ac er ba tion costs are 5 195 285 Ft for the stan-dard ther a py group and 11 002 870 Ft for the oma l izum ab add-on ther-a py treat ment group (a dif fer ence of 5 807 584 Ft). The anal y sis in di cates that dur ing the 3 years of oma l izum ab ther a py, oma l izum ab add-on ther a py plus usu al man age ment has avoid ed 173 ex ac er ba tions for ev ery 100 pa tients: 110 clin i cal ly sig nif i cant se vere ex ac er ba tions and 64 clin i cal ly sig nif i cant mild ex ac er ba tions. Also, 3,22 asth ma-re lat ed deaths have been avoid ed with oma l izum ab for ev ery 100 pa tients.These events trans late into qual i ty ad just ed years of life saved. In the stan-dard ther a py group, pa tients have a to tal of 10,775 dis count ed QALYs per pa tient, com pared to 11,592 dis count ed QALYs for the oma l izum-ab add-on ther a py group. This is a dif fer ence of 0,817 QALYs. Thus for ev ery 100 pa tients treat ed, there are an ad di tion al 81,7 QALYs. The in cre men tal cost ef fec tive ness ra tio (ICER), with costs and out-comes dis count ed at 3%, is 7 111 966 for each QALY gained. Con clu sions: Oma l izum ab ther a py pro vid ed sig nif i cant clin i cal ben e-fits for pa tients suf fer ing from se vere per sist ing asth ma at a rea son able in cre men tal cost per QALY ra tio.

0054

The struc ture, the prob lems and the per spec tives of the phar ma ceu ti cal in dus try in GreeceKousoulak ou H. (Foun da tion for Econom & In dus tr Re search, Athens, Greece)Fragoulakis V.

Ob jec tives: The study was based on a sur vey con duct ed in the field of phar ma ceu ti cal com pa nies in Greece. It aimed to col lect pri ma ry data on the com pa nies’ em ploy ment, in vest ments, de vel op ment stra te gies, prob lems and the im pact of the statu to ry frame work.Meth ods: An 8-page ques tion naire was de vel oped and sent to all phar-ma ceu ti cal com pa nies op er at ing in Greece. The re sponse rate was 36.3%, which rep re sent ed 67% of the ref er ence pop u la tion’s turn over.Re sults: The main prob lem that phar ma ceu ti cal com pa nies face is the de lay in the de ci sion mak ing pro cess of the com pe tent au thor i ties. The con tin u ous mod i fi ca tions of the phar ma ceu ti cal leg is la tion lead to an in creas ing ly vary ing and un sta ble busi ness en vi ron ment, which nei ther al lows long-term strate gic plan ning nor fa cil i tates the com pa ny’s de vel-op ment. More over, many of the pol i cy in ter ven tions, such as the new pric ing sys tem in tro duced in 1997, have neg a tive ly af fect ed the sec tor and led to phe nom e na, such as the par al lel ex ports and the shrink age of do mes tic pro duc tion.Con clu sion: The phar ma ceu ti cal sec tor in Greece ex hibits high po ten-tial and dy nam ics of de vel op ment, which arise from both the pro duc-tion and de vel op ment stra te gies and the in crease in sales and em ploy-ment. How ev er, the com pa nies’ rep re sen ta tives ex press a con ser va tive opin ion re gard ing the sec tor’s per spec tives, main ly due to the pre vail ing un cer tain ty in view of the new phar ma ceu ti cal pol i cy.

0204

Va lid i ty of the EQ-5D in pa tients with men tal dis or dersKönig H.H. (Health Eco nomics Re search Unit, Uni ver si ty of Leipzig, Ger many)Gün ther O., Roick C., Anger mey er M.C.

Pur pose: The EQ-5D is a ge ner ic ques tion naire gen er at ing a health pro-file and a sin gle in dex score for health-re lat ed qual i ty of life for cost-util i-ty anal y sis. The study aimed to an a lyze and com pare dis crim i na tive abil i-ty and va lid i ty of the EQ-5D in pa tients with var i ous men tal dis or ders. Meth ods: 172 pa tients with af fec tive, 166 with schizo phren ic and 160 with al co hol-re lat ed men tal dis or ders com plet ed the EQ-5D. Mea sures of qual i ty of life (WHO QOL-BREF), util i ty (TTO), sub jec tive (SCL-90R) and ob jec tive (CGI-S) psy cho pa thol o gy, and func tion ing (GAF, GARF, SO FAS, HoN OS) pro vid ed com par i son. Dis crim i na tive abil i-ty was an a lyzed by as sess ing fre quen cy dis tri bu tions of EQ-5D scores. Va lid i ty of the EQ-5D self-clas si fi er was an a lyzed by as sess ing dif fer-ences in re lat ed oth er scores grouped by re sponse lev els of EQ-5D items. Va lid i ty of the vi su al an a logue scale (EQ VAS) and the EQ-5D in dex (UK so cial tar iff) was an a lyzed by as sess ing their cor re la tion with all oth er scores. Re sults: Among pa tients with af fec tive/schizo phren ic/al co hol-re lat ed dis or ders, 88/79/75% re port ed prob lems in at least one of the EQ-5D di men sions; most fre quent were prob lems in the di men sion anx i ety/de pres sion (77/57/53%), fol lowed by usu al ac tiv i ties (63/45/31%) or pain/dis com fort (61/44/45%). The mean EQ VAS score was 53/66/59, the mean EQ-5D in dex 0.60/0.71/0.74. Sev en most fre quent ly re port ed EQ-5D health states cov ered 53/58/68% of all re spon dents. For al most all EQ-5D di men sions, dif fer ent re sponse lev els were as so ci at ed with sig nif i cant ly dif fer ent scores of mea sures used for com par i son. The EQ VAS score and EQ-5D in dex cor re lat ed high ly with oth er scores in pa tients with af fec tive and mod er ate in pa tients with schizo phren ic or al co hol-re lat ed dis or ders. Con clu sions: The EQ-5D showed a mod er ate ceil ing ef fect but seems to be rea son ably valid in pa tients with men tal dis or ders.

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0561

Es tab lish ing the life time costs of ce re bral pal syKruse M. (Na tion al In si tute of Pub lic Health, Copen hagen, Den mark)

Back ground: The pro ject aims to cast light over the cost of ce re bral pal sy over a life time per spec tive. This has not been anal y sed in a Eu ro-pean con text be fore. Only a few Amer i can stud ies ex ist on the top ic, dis play ing some method olog i cal dis crep an cy over pro duc tiv i ty costs as well as so cial costs. Meth o dol o gy: The pres ent pro ject ap plies a reg is ter-based per spec tive. From a pop u la tion-based reg is ter of ce re bral pal sy pa tients, health care costs and pro duc tiv i ty costs are es tab lished. Health care costs are com-put ed us ing at tributable cost ing as de tailed in for ma tion on a con trol group not suf fer ing from ce re bral pal sy ex ists. Re sults: pre lim i nary re sults will be pre sent ed at the con fer ence.

0228

Pub lic Owned Hos pi tals in Ger manyKuchinke B.A. (Il me nau Uni ver si ty of Tech nol o gy, Il me nau, Ger many)

Dis cus sion/Re sults: In Ger many there were three types of hos pi tal own-er ship. One can find pri vate and pub lic owned hos pi tals as well as hos pi-tals that are owned by non-prof it (char i ta ble) or ga ni za tions like the red cross. But only if the hos pi tal is pub lic owned a short fall is as sumed by the pub lic own er. That means in the case of a hos pi tal which is owned by a city or a dis trict a short fall is fi nanced by the pub lic hand, e.g. by tax rev-enues of the city or dis trict. In this mean ing pub lic owned hos pi tals get sub si dies. Oth ers do not. These sub si dies are ob served over a long pe ri od of time. They are some kind of a bar ri er to en try and cause a bias and in ef-fi cien cy on Ger man hos pi tal mar kets.this pa per the ex tent of the short-falls of pub lic owned hos pi tals in Ger many for the pe ri od be tween 1998 and 2003 is shown for the first time. The data shows that the ex ist ing sub-si dies have an over all vol ume for Ger many of more than 2.000.000.000 Eu ros per year. In the data the prob lem of sub si dies first is shown dif fer-en ti at ed and in a de scrip tive way. That in cludes a view on east and west Ger many and on ev ery sin gle state (Bun des land). Sec ond ly the caus es for the short falls are shown. The data is sup ple ment ed by facts about the num ber of hos pi tals in each state sub ject to es pe cial ly the statewide own-er ship struc ture, the ca pac i ty (num ber of beds) and the num ber of com-part ments. In ad di tion to that the vol ume of in pa tients, the form of or ga-ni za tion, the num ber of com peti tors in the rel e vant mar ket, the ben e fit of the oth er hos pi tals and the lev el of the ser vices are tak en into ac count. Con clud ing a mul ti var i ate cross sec tion anal y sis and al ter na tive em pir i-cal tests are used to find the caus es for the ex tent of the short falls.

0203

Cost-eff ec tive ness of in ter ven tions for de pres sion: coun try lev el use of who-choice in Es to niaLai T.(De part ment of Pub lic Health, Uni ver si ty of Tar tu, Es to nia)Reinap M., Habicht J., Chisholm D.

Dis cus sion/Re sults: Most of cost ef fec tive ness (CE) stud ies for men tal health area or i gin from de vel oped coun tries, but there is less avail able from east ern Eu rope. To fos ter the ev i dence base for de ci sions we have ap plied WHO-CHOICE mod el and adapt ed re gion al CE re sults to Es to-nia where tak ing ac count of lo cal costs, re sources and in ter ven tion ef fec-tive ness for de pres sion.A sim pli fied mod elling frame work was used to es ti mate the to tal costs and ef fects of in ter ven tions com pared to a sit u a tion in which no in ter-ven tions are im ple ment ed. Costs were pri mar i ly as sessed for 2004 and ef fects were ex pressed in DALYs avert ed.Sev en singe in ter ven tions were anal y sed – tri cy clic med i ca tion, use of se lec tive se ro to nin re up take in hibitors (SSRI), psy cho ther a py, proac tive

col lab o ra tive care and their com bi na tions were anal y sed. The tar get com-bi na tion was mod elled with in creased cov er age and high er role of in ter-ven tions in volv ing psy cho ther a py and proac tive col lab o ra tive care. The most ef fec tive sin gle in ter ven tion was treat ment with SSRI sup port-ed by psy cho ther a py and proac tive col lab o ra tive care with 4 214 DALYs avert ed an nu al ly. The most cost-ef fec tive in ter ven tion to re duce bur den of dis ease from de pres sion was the tar get com bi na tion of all sin gle in ter-ven tions which costs €2 756 per DALY avert ed. All in ter ven tions anal y sed were found to be cost-ef fec tive and con tex-tu alised re sults have bet ter CE ra tios com pared to pre vi ous WHO es ti-mates.More im por tant ly the dif fer ences be tween WHO es ti mates and ad just-ed re sults un der line the im por tance of con tex tu al is ing WHO-CHOICE re sults for small coun tries like Es to nia as more ac cu rate data on cost-ef fec tive ness of in ter ven tions al lows bet ter health pol i cy de ci sions on na tion al lev el.

0429

Sim u lat ing the Multi-year im pacts of Med i cal Sav ing Ac count un der a Uni ver sal Health In sur ance Sys temLai C.L. (In sti tute of Health Care Or ga ni za tions & Ad min is tra tion, Col lege of Pub lic Health, Na tion al Tai wan Uni ver si ty, Sin jhuang city, Taipei coun ty, Tai wan)Chang R.E.

Dis cus sion/Re sults: Med i cal sav ing ac count is one of the cost sav ing mech a nisms by mak ing pa tients more sen si tive to the costs of care. Al though the ex pe ri ences in some coun tries have dem on stra ted cer tain po ten tial for con tain ing ex pen di tures, de bates con tin ue re gard ing its ap pli ca bil i ty and ef fec tive ness. study in tend ed to de vel op a di ag nos tic in for ma tion risk ad just ment mod el, and eval u ate the ef fects of risk ad just-ment on MSAs and ex am ine the abil i ty of eval u ate the ef fect of multi-year out pa tient risk-ad just ed med i cal sav ing ac counts (RA-MSAs) on the in sur er’s fi nan cial sol ven cy with re spect to de ductible vari ants un der Tai wan’s uni ver sal health plan. sam ple con sist ed of 164,275 NHI’s ben-e fi cia ries con tin u ous ly en rolled from 2000 and 2002. re sults show that the pre dictabil i ty of the di ag nos tic in for ma tion mod el for out pa tient ser vices is 40.7%. In the first pre dict ing year, about 35% of all ac counts would have in suf fi cient bal ances. Three-fourths of the ac counts are with-in the dif fer ence of $US 171 per year. Us ing the cu mu lat ed RA-MSA_mech a nism, the NHI could save $US 357 mil lion in 2002.di ag nos tic risk ad jus tors, the amount in med i cal sav ings ac counts can more ap pro-pri ate ly re flect in di vid u al health ex pen di ture needs. The cu mu lat ed RA-MSAs could al le vi ate the fi nan cial pres sure on the NHI.

0135

In vest ing in health qual i ty when physi cians are de vot ed and ob jec tives asym met ricLev ag gi R. (Di par ti men to di Scien ze Eco nomiche, Bres cia, Italy)Moret to M., Reb ba V.

Ra tio nale: The cost and qual i ty trade-off is stud ied in a con text where qual i ty is a run ning cost. We ar gue that this ap proach does not con sid er that: 1)qual i ty is the re sult of: ef fort of the med i cal staff, in vest ment in tech nol o gy and ho tel-re lat ed ser vices 2) the med i cal staff de rives util i ty from the out put pro-duced (de vot ed work er).Meth o dol o gy: We adopt a more gen er al ap proach to mod el qual i ty and de vel op an in te grat ed ap proach to hos pi tal care con tract de sign. We de vel op an in tertem po ral mod el where in vest ment in health tech nol o-gy is com plete ly ir re vers ible while the ef fort of the med i cal staff is de ter-mined at the be gin ning of the first pe ri od; we use a real op tion ap proach as in Lev ag gi, Moret to, Reb ba (2005). We ex am ine qual i ty set ting in an en vi ron ment where it de pends on: the ef fort of the med i cal staff, in vest-ment in new tech nol o gy and char ac ter is tics of the pa tients.

Eur J Health Econom Suppl 1 · 2006 | S123

Re sults: We high light the trade-off that ex ists be tween med i cal ef fort and op ti mal in vest ment path in pro mot ing hos pi tal qual i ty. We also an a-lyse the ef fect of dif fer ent pric ing rules (cost re im burse ment vs prospec-tive pay ment sys tems) on the op ti mal con tract in a con text where the ac tors use asym met ric weights on the dif fer ent com po nents of qual i ty in their max imi sa tion pro cess.

0422

To bailout or not to bailout?Lev ag gi R. (Di par ti men to di Scien ze Eco nomiche – Uni ver si ta, Bres cia, Italy)Zanola R.

Dis cus sion/Re sults: Pur pose of soft bud get con straints, bailouts, and fi nan cial in sta bil i ty demon strate the dif fi cul ties of in sti tu tion al de sign in a fed er a tion. Bailouts are like ly to be high er when (i) there are ex ter-nal i ties (non res i dents con cerned about some lo cal pol i cy); (ii) res i dents are not harmed too much by pol i cy set ac cord ing to ex ter nal pref er-ences; (iii) non res i dents are pre pared to pay to main tain sig nif i cant amounts of pub lic ser vice in the ab sence of lo cal pro vi sion (Wildasin, 2004). The pur pose of this pa per is to em pir i cal ly in ves ti gate these im pli-ca tions, fo cus ing on the Ital ian health care sec tor. In Italy the Na tion-al Health Sys tem has a unique com bi na tion of soft bud get con straints, bailouts, and fi nan cial in sta bil i ty. Hence, it rep re sents a nat u ral frame-work to in ves ti gate the fea tures that drive lo cal gov ern ments into high-er bailouts da ta GMM meth o dol o gy ap plied to a sam ple of 20 Ital ian re gions over the pe ri od 1999–2004. pan el anal y sis al lows to in ves ti gate rich mod el spec i fi ca tion and to con trol for joint en do gene ity in or der to ob tain con sis tent es ti mates of the ef fect of ex plana to ry vari ables on bailout lev el sRe sult s anal y sis is in tend ed to con tribute to un der stand un der what con di tions lo cal gov ern ments lead to fi nan cial dis tress and un der what con di tions these out comes may be avoid ed.

0017

Treat ment Progress and Pa tient Com pli ance in Al co hol Ther a pyLu M. (Uni ver si ty of Cal gary, Can a da)Lien H.M., Lu M., Ma C.T.A., McGuire T.G.

Dis cus sion/Re sults: Im prov ing pa tient com pli ance – the ex tent to which pa tients fol low doc tors’ rec om mend ed ther a peu tic regimes – has long been an im por tant goal in med i cal prac tice. It is un clear why pa tients fre quent ly do not com ply. This pa per ex am ines the caus al re la tion ship be tween treat ment progress and pa tient com pli ance. We hy poth e size that, in de cid ing about com pli ance, pa tients bal ance ex pect ed costs and ben e fits dur ing a treat ment ep i sode. A pa tient is more like ly to fol low med i cal ad vice if do ing so re sults in an ex pect ed net gain in his wel-fare or health ben e fit. ex ploit a unique data set of al co hol abuse clients re ceiv ing out pa tient treat ment. Us ing treat ment records, we mea sure the client’s com pli ance by his at ten dance at sched uled ap point ments. We mea sure a client’s health progress by the cli ni cian’s com ments af ter each at tend ed vis it. We test the ef fect of bet ter progress on two mea sures of com pli ance drop ping out of treat ment and mis sing the next sched-uled vis it. Our re sults in di cate progress in a pre vi ous vis it re duces the chance of drop ping out of treat ment while a re lapse in creas es it. This is true even af ter con trol ling for un ob served het ero ge ne ity of pa tients. On the oth er hand, we do not find ev i dence that treat ment progress re duces the chance of mis sing the sched uled vis it.

0336

Es ti mat ing the im pact of smok ing re stric tions on bar sales.Lud brook A. (Health Eco nomics Re search Unit, Uni ver si ty of Ab erdeen, Scot land)

Dis cus sion/Re sults: Re stric tions on smok ing in pub lic places are ad vo-cat ed to pro tect non-smok ers from the ad verse health ef fects of en vi ron-men tal to bac co smoke. A num ber of coun ter ar gu ments are pro posed when ev er the in tro duc tion of such mea sures is de bat ed, in clud ing the po ten tial for ad verse eco nom ic ef fects on the hos pi tal i ty sec tor. De spite a num ber of stud ies which have found no sig nif i cant ef fect on turn over re lat ing to smok ing bans and re stric tions, this is sue con tin ues to be con-tro ver sial, par tic u lar ly with re spect to the bar sec tor.ma jor i ty of pre vi-ous stud ies have con sid ered the ef fects of lo cal re stric tions on ho tel and restau rant busi ness. Reg u la tions af fect ing bars are more re cent and have been sub ject to less study. The in tro duc tion of a com pre hen sive ban on smok ing in pub lic places in Ire land in 2004 pro vides an op por tu ni ty to con sid er the im pact of such reg u la tion on the bar trade. This pa per pre-sents re sults based on both the val ue and the vol ume of bar sales. Dif fer-ent an a lyt i cal ap proach es are com pared and the sen si tiv i ty of the re sults to the time pe ri od of the anal y sis, both pre and post ban, is con sid ered. The im pact of oth er con found ing fac tors, such as tax a tion and oth er reg-u la to ry chang es, is dis cussed.

0436

Mar ket Struc ture and Provider Pay ment Mech a nisms in Health CareMa ceira D. (Cen ter for the Study of State and So ci ety (CEDES), Buenos Aires, Ar genti na)Poblete C.

Dis cus sion/Re sults: The study doc u ments the in ter ac tion be tween chang es in provider pay ment mech a nisms in health care with the mar-ket struc ture in pro vid ing health ser vices and the in ter nal or ga ni za tion of the sup pli ers. It was per formed in three dis tricts of the province of Men doza, Ar genti na, which joint ly rep re sent ed 80,25% of the provin-cial pop u la tion of 1,57 mil lion for the pe ri od un der study (1989–1999). The re search fo cus es on the con tract rene go ti a tion per formed by PAMI (the so cial in sur ance in sti tu tion for the el der ly) in 1991 and fol lowed by oth er health care fi nanciers. The goal of the pa per is to show how chang es in mon e tary in cen tives af fect and are af fect ed by the size of the mar ket and the rel a tive bar gain ing pow er of the dif fer ent par tic i pant ac tors. The re search rests on in ter views with all sec ond ary and ter tia ry-lev el pub lic and pri vate health care providers, as well as rep re sen ta tives of in ter me di ate or ga ni za tions in the se lect ed dis tricts. The re sults sup-port the hy pothe ses re lat ed to rel a tive pow er of fi nanciers and providers, the in ter play be tween mar ket size and rel a tive pow er of physi cians and hos pi tal as so ci a tions, and its in flu ence on the trans fer of risk down the chain of ser vice pro vi sion. The doc u ment finds a pos i tive as so ci a tion be tween mar ket com pe ti tion, ver ti cal dein te gra tion and de gree of prod-uct dif fer en ti a tion.

0437

Pub lic Con tract ing of Non Gov ern ment Or ga ni za tions in El Sal vadorMa ceira D. (Cen ter for the Study of State and So ci ety (CEDES), Buenos Aires, Ar genti na)

Dis cus sion/Re sults: The pa per aims to an a lyse, based on the Pro gram of Health and Nu tri tion Es sen tial Ser vices (SESYN), the con tract ing by El Sal vador of four NGOs with funds from in ter na tion al loans. The aim sought by the ini tia tive is to pro vide pre ven tive and pri ma ry cov er age to

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low in come and ru ral groups. The pur pose is to an a lyze the char ac ter is-tics of the con tract and the the o ret i cal in cen tives it gen er at ed. The clas-si cal in cen tives of the cap i tat ed mech a nism sug gest the need for struc-tured sys tems of in for ma tion fol low-up, es pe cial ly where each pro mot er “mo nop o lizes” its in flu ence area. A house hold sur vey was im ple ment ed to com pare the ex pe ri ence ini ti at ed in 2003 with a con trol group the tra-di tion al pub lic pro mot ers de vel oped in oth er can tons than those in cor-po rat ed to the SESYN Pro gram. The re sults sug gest that the con tract-ing of NGOs achieved a good per for mance in most en coun ters re lat ed to pre ven tive and heal ing med i cine. The in ter ven tions pro vid ed with in the pri vate pro mot ers’ ge o graph i cal vary when the ini tia tive is con sid-ered as a whole, in cor po rat ing the per for mance of the Mo bile Health Care Teams or ga nized un der the NGO ini tia tive, who acts be yond the bor ders of the can tons. Fi nal ly, a con trol mech a nism that de ter mines the ef fec tive ness of the ini tia tive and of the eval u a tion mod el of the pro-gram is checked.

0003

Cost Ad van tage of Out sourc ing Health care for Ca reer Sol diersMag nezi R. (Med i cal Ser vice and Sup ply Cen ter, Med i cal Corps, Is rael De fense Forces)Dankn er R., Ke dem R., Reuveni H.

Back ground: The pur pose of this study was to an a lyze the ef fect of out-sourc ing health care uti li za tion by ca reer sol diers in the Is rael De fense Forces in dif fer ent set tings: mil i tary clin ics, am bu la to ry clin ics in a hos-pi tal, and health fund clin ics and to de vel op a mod el for pre dict ing per cap i ta med i cal costs for ca reer sol diers in each set ting. Meth ods: De mo graph ic in for ma tion (age, gen der, mil i tary rank, ed u ca-tion), and data on health care uti li za tion and costs were gath ered from three com put er ized billing database sys tems: The Med i cal Corps of the Is rael De fense Forces, a civil ian hos pi tal, and a health care fund, pro vid-ing ser vices to 3746, 3971, and 6400 ca reer sol diers, re spec tive ly. Vis its to pri ma ry care physi cians and spe cial ists, lab o ra to ry and im ag ing ex ams, num ber of sick days, and days of hos pi tal iza tion were to taled for men and wom en sep a rate ly for each type of clin ic. A uni form cost was as signed to each type of treat ment to cre ate an av er age an nu al per cap i ta cost for med i cal ser vices of ca reer sol diers for each type of clin ic. Re sults and Dis cus sion – In mil i tary clin ics, ca reer sol diers had the fewest vis its to pri ma ry physi cians and the most vis its (not by re fer ral of a pri ma ry phy si cian) to spe cial ist physi cians. Lab o ra to ry tests and emer-gen cy room vis its were high est when med i cal ser vices were pro vid ed by hos pi tal clin ics. Over all ex pens es were low est when ser vices were pro-vid ed by the health care fund clin ics.Con clu sions: Out sourc ing pri ma ry care to a health care fund spe cial-iz ing in pro vid ing pri ma ry care rep re sents a ma jor con cep tu al change that max i mizes the re sources of the Med i cal Corps of the Is rael De fense Forces. Costs of care are re lat ed to physi cians’ prac tices, sol diers’ habits, and co-pay ment pol i cy, but not to a fi nan cial agree ment lack ing in cen-tives to both physi cians and clients. Out sourc ing en ables the Med i cal Corps to re spond ad e quate ly to con tin u ous chang es in the health care are na. Thus, out sourc ing of med i cal care is ben e fi cial world wide.

0488

Health sys tem per for mance and eq ui ty in Italy: a dis ease based ap proachMasse ria C. (Lon don School of Eco nomics and Po lit i cal Sci ence, Health and So cial Care, Lon don, UK)Gi an noni M.

Dis cus sion/Re sults: Al though eq ui table ac cess to health care is a core ob jec tive of the Ital ian health care sys tem, there is mount ing ev i dence that not all in di vid u als in equal need are treat ed equal ly, with in equal-

i ties sys tem at i cal ly as so ci at ed with in come. The aim of this pa per is to pres ent new es ti mates of in come-re lat ed hor i zon tal in equity in the ac cess to health care (GP, spe cial ists and in pa tient care/elec tive) stan-dar d is ing not only for self-as sessed health sta tus, age and gen der but also for the pres ence of sev er al chron ic con di tions and dis abil i ties. The data are tak en from the Mul ti scopo sur vey, 1999–2000 sub se quent ly matched with the ECH PS (1999–2000) for Italy to ob tain in come in for-ma tion (mis sing in the for mer). The re sults show the bet ter-off have a sta tis ti cal ly sig nif i cant high er prob a bil i ty of ac cess ing spe cial ist and GP care. No in equity was found for in pa tient/elec tive care. Ce teris paribus peo ple with tu mour and heart dis eases seek more med i cal care than oth er in di vid u als. In come-re lat ed in equity in ac cess to health care was, more over, mea sured sep a rate ly for peo ple with tu mour, heart dis eases, ar thri tis, hy per ten sion and al ler gic dis eases. It ap pears that, for spe cial-ist care, there is sta tis ti cal ly sig nif i cant ly pro-rich in equity for four of the five chron ic dis eases for in pa tient care, in equity is sig nif i cant ly pro-poor only for peo ple with tu mour.

0341

Ra tio nal iz ing the use of med i ca tions in the con text of ex treme ly scarce re sources.Mataria A. (In sti tute of Com mu ni ty and Pub lic Health – Birzeit Uni ver si ty – Pales tini an Ter ri to ry, Ra mal lah)Rana K., Amal D., Niveen A.R.

Dis cus sion/Re sults: Health care sys tems ab sorb a sig nif i cant share of all coun tries’ scarce re sources, and ex pen di tures on phar ma ceu ti cals are usu-al ly ranked high on the list of bud getary items of most coun tries’ pub lic in sti tu tions. The Oc cu pied Pales tini an Ter ri to ry (OPT) is not an ex cep-tion. The po lit i cal chang es that took place in the OPT dur ing the past decade, ac com pa nied with the es tab lish ment of a Pales tini an Min istry of Health, have had crit i cal im pli ca tions on the fund ing avail able for a his-tor i cal ly promi nent sec tor of Pales tini an Non-Gov ern men tal Or ga ni za-tions (PN GOs). In or der for the lat ter to sur vive an ac cen tu at ed re source-starved en vi ron ment, sev er al at tempts were made to ra tio nal ize the use of med i ca tions and hence en hance an ef fi cient uti li za tion of lim it ed bud-gets. It is be lieved that the pro cess of ra tio nal iz ing the use of med i ca-tions should com prise an en hance ment of health pro fes sion als’ knowl-edge in the area of drug man age ment in clud ing: se lec tion, pro cure ment, dis tri bu tion and use; and an elab o ra tion of prop er in cen tive schemes. Fol low ing a se ries of train ing mod ules, health pro fes sion als in a se lect ed sam ple of PN GOs [n = 70] were in ten sive ly [n=20] and less-in ten sive ly [n=50] mon i tored to guar an tee un der stand ing and prop er im ple men ta-tion of con veyed con cepts and ex pe ri ences. The study demon strates the val ue added from an in ten sive par tic i pa to ry con text-spe cif ic train ing in en hanc ing knowl edge, re duc ing cost and chang ing prac tices.

0431

Qual i ty of life as so ci at ed with mod er ate to se vere pso ri a sisMa teus C. (Es co la Na cional de Saúde Públi ca, Uni ver si dade Nova de Lis boa)Pereira J.

Ob jec tives: To an a lyse the im pact of mod er ate to se vere pso ri a sis on Por tuguese pa tients’ qual i ty of life.Meth ods: Study con duct ed in 7 Por tuguese hos pi tals with a sam ple of 170 pa tients with mod er ate to se vere pso ri a sis. In for ma tion con cern ing sever i ty of dis ease mea sured through PASI, BSA and an itch ing scale. Qual i ty of life mea sured through SF-36, EQ-5D and two spe cif ic in stru-ments, DLQI and PDI. Ques tion naires were sent by mail and par tic i pa-tion was vol un tary and con fi den tial.Re sults: Sev en ty five per cent valid an swers were re ceived (n=127). Re spon dents were pre dom i nant ly male (61%) with av er age age 53 years.

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Av er age PASI lev el was 15.4 and av er age BSA af fect ed was 27%. Av er age DLQI was 6 and PDI 12. Qual i ty of life mea sured through EQ-5D was 0.73 (±0,021) with a large ma jor i ty of an swers be tween 0,5 and 1,0. The av er age val ue for SF-36 was 57. Dis cus sion: Dif fer ences in QoL re lat ed to gen der ex cept for PDI. Cor re la-tion be tween QoL in stru ments and sever i ty of dis ease found for PDI but not for oth er in stru ments. Cor re la tion be tween QoL in stru ments was found to be in ac cor dance with stud ies in oth er coun tries. QoL mea sured through SF-36 was con sis tent ly low er than the Por tuguese norm. Re sults of QoL in Por tuguese pa tients with mod er ate to se vere pso ri a sis found to be com pa ra ble to the scarce avail able ev i dence in oth er coun tries.

0382

Hu man cost of dis ease in ItalyMen ni ni F.S. (Cen tre for Health Eco nomics and Man age ment (CHEM), Fac ul ty of Eco nomics, Uni ver si ty of Rome Tor Ver ga ta, Rome, Italy)Palaz zo F., Minel li G., Soli m i ni R., Toc caceli V., Stir paro G., Con ti S.

In tro duc tion: With in the ac tu al Fed er al frame work of the Ital ian health sys tem, a mor tal i ty anal y sis at a re gion al lev el pro vides spe cif ic in for-ma tion which al lows for de tec tion of health pri or i ties and ob jec tives for each re gion.Metodol o gy: Of fi cial mor tal i ty data record ed and cod ed by IS TAT (Ital-ian Na tion al Sta tis tics In sti tute) in ac cor dance with ICD IX were an a-lyzed. The data refers to deaths oc curred in Italy dur ing the year 2001 (most re cent avail able year). Tak ing mor tal i ty data, as a start ing point, it is pos si ble to cal cu late a se ries of in di ca tors, such as: life ex pect an cy, stan dard ized mor tal i ty rates, Years of Po ten tial Life Lost (YPLL) and rates of YPLL, which al low us to com pare mor tal i ty through time and space. Me di an ages at death were also cal cu lat ed for both men and wom en and each cause of death. More over, oth er caus es of death were an a lyzed. In par tic u lar, Acute Myo-car dial In farc tion, Lung can cer, Breast can cer and Co lon-rec tum can cer, Road ac ci dents and Sui cide.Re sults: From a fed er al per spec tive, YPLL and me di an ages at death re sult to be ef fec tive in di ca tors of pos si ble lack of the Re gion al Health Ser vices. It is worth notic ing the vari abil i ty among Re gions of the me di-an age at death for Breast can cer; it is well known nowa days that mor-tal i ty from this cause can be re duced thanks to ear ly di ag no sis and treat-ment, con se quent ly re gion al val ues of the me di an ages low er than those at na tion al lev el could sug gest, apart from any pos si ble epi demi o log i-cal and clin i cal dif fer ence re gard ing wom en af fect ed by this pa thol o gy, also the lack of ef fec tive screen ing pro grammes as well as treat ments the Re gion al Health Ser vices are in charge of.

0470

The Evo lu tion and Im pact of Gener ics mar ket in ItalyMen ni ni F.S. (CEIS Cen tre for Health Eco nomics and Man age ment, Fac ul ty of Eco nomics, Uni ver si ty of Rome Tor Ver ga ta, Rome, Italy)Cap pel li S., Rat ti M.

Fore word: The cost con tain ment poli cies for phar ma ceu ti cals have suc-ced ed fre quent ly dur ing the last ten years in Italy.It seems that us ing gener ics and the Ref er ence Price (RP) sys tem, Ital ian reg u la to ry of fices want to in cen ti vate com pe ti tion based on the gener ics prod uct. Aim, meth o dol o gy and data col lec tion: The aim of the pres ent pa per is to demon strate that the ge ner ic is not only used in a mech a nism to lim it phar ma ceu ti cal ex pen di ture, but that is prefer able in com par i son with oth er phar ma ceu ti cal cost con tain ment mech a nisms. We study and an a lyse the his tor i cal vari ables, quan ti ty and prices, re lat ed to dif fer ent Ac tive Con stituents (AC). This anal y sis is very im por tant for price and quan ti ty es ti mates dur ing the pe ri od 2005–2010.Re sults: Look ing at our anal y sis it is pos si ble to ar gue that there could be a real and sig nif i cant re duc tion of both Pub lic and Pri vate phar ma-

ceu ti cal ex pen di ture us ing sta ble and ho mog e nous cost con tain ment pol i cy re ferred to gener ics. Ev i dent ly, the ma jor sav ings will be re al ized where gener ics pro duce the best ef fects of “Price Ero sion“. At the same time it is pos si ble to ar gue that the ge ner ic pol i cy in Italy is not well de vel oped, ex pe cial ly in com par i son with oth er EU coun tries. The prin-ci pal rea son is rep re sent ed by the per sist ing in flu ence of the Com ple-men ta ry Pro tec tion Cer tifi cate (CPC).

0533

A mac ro anal y sis of stra te gies and per for mances in the phar ma ceu ti cal Ital ian mar ket.Men ni ni F.S. (CEIS Cen tre for Health Eco nomics and Man age ment, Fac ul ty of Eco nomics, Uni ver si ty of Rome Tor Ver ga ta, Rome, Italy)Git to L., Rat ti M.

In tro duc tion: Vari a tions in the eco nom ic re sults of phar ma ceu ti cal firms may be due to the choice of an ap pro pri ate strat e gy, in or der to com pete in both na tion al and for eign mar ket. The strat e gy se lec tion pro-cess might de pend on some struc tur al “ex og e nous” fac tors, such as reg-u la to ry is sues, con cen tra tion in the mar ket, chang es in the in sti tu tion al frame work, etc., like ly to in flu ence firms’ per for mances. A com pet i tive ad van tage is es tab lished by those firms that de vel op in no va tive prod-ucts, be long ing to dif fer ent ther a peu tic class es. An in no va tive strat e gy re lies on merg ers and ac qui si tions too. The lat ter al low to im prove R&D pro duc tiv i ty, low er ing re search costs: the larg er the to tal R&D pro gram, in fact, the greater the num ber of in di vid u al pro jects that could ben e-fit from the new ca pa bil i ty. Merg ers, more over, widen op por tu ni ties for com pe ti tion, al low ing firms to com pete in more ther a peu tic class es. Aim of the pa per: The aim of the pa per is that of an a lys ing how the Ital-ian phar ma ceu ti cal mar ket has been evolv ing in the last decade, ver i fy-ing if chang es in firms’ stra te gies have in flu enced their eco nom ic re sults. The leg isla tive mea sures im ple ment ed af ter the third health care re form (1999/2000), in fact, have mod i fied the ini tial sce nario, lead ing phar ma-ceu ti cal firms to adapt their stra te gies to aris ing chal lenges.Meth ods and re sults: A sam ple of Ital ian phar ma ceu ti cal firms, that, across the pe ri od 1994/2004, have ob tained the 75% of to tal rev enues, has been ob served. Es ti ma tions have been car ried out through a OLS re gres sion, test ing for any struc tur al change oc curred in the years im me-di ate ly fol low ing the re form of 1999. Con cen tra tion in the mar ket and prod uct di ver si fi ca tion ap pear to be the key fac tors for firms in se lect-ing an ap pro pri ate strat e gy and im prov ing per for mances too. Re sults of this pa per are use ful to un der stand trends in phar ma ceu ti cal in dus try in Italy and may be used for in ter na tion al com par isons.

0377

Re gion al con cen tra tion or dis per sion of hos pi talsMoschet ti K. (Uni ver sitet del la Svizzera ital iana MecoP, Lugano, Switzer land)Rochaix L.

Dis cus sion/Re sults: In terms of hos pi tal ser vices’ plan ning the ques-tion of trade-offs be tween the size and num ber of hos pi tals of ten aris es. As sum ing that pa tients min i mize the trav eled dis tance to reach hos pi tal care, the al lo ca tion of many small hos pi tals over space in creas es the eq ui-ty of ac cess for pa tients uni form ly dis tribut ed over space and re duces the av er age dis tance trav eled. pa per aims at in ves ti gat ing how spa tial al lo ca tion de ci sions of hos pi tal re sources can be af fect ed by pa tients’ pref er ences for qual i ty. Agent Sys tem (MAS) al low us to con sid er a bi-di men sion al space and het ero ge ne ous pa tients who ac quire in for ma-tion on hos pi tal qual i ty through ex pe ri ence. We use two in di ca tors to de fine the so cial wel fare. The first in di ca tor uses the to tal num ber of de nied pa tients as a mea sure of the con ges tion ef fects. The sec ond cor-re sponds to the av er age dis tance trav eled by pa tients. re sults sug gest that a greater num ber of small hos pi tals in creas es the con ges tion ef fects

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which are in ten si fied by de mand elas tic i ty for qual i ty. A ge o graph ic dis-per sion of hos pi tals seems to lead to op po site re sults as those ex pect ed when pa tients’ pref er ences de pend on qual i ty. ser vices’ plan ning poli-cies need to pay at ten tion to the neg a tive ex ter nal i ties that de rive from both the al lo ca tion of more small hos pi tals and pa tients’ search be hav-ior for qual i ty.

0413

Ty pol o gy of the french psy chi at ric and men tal health sec tor or ga ni sa tionMousques J. (IRD ES (In sti tut de Recherche et Doc u men ta tion en Econo-mie de la San té), Par is, France)Le Fur P., Lu cas V., Per ronnin M.

Dis cus sion/Re sults: The French psy chi at ric and men tal health care sys-tem con tain un ques tion able strength but acute weak ness too. One of them was that even if psy chi at ric and men tal health care sup ply is con-sid er as very ex ten sive and or ga nized on an in no va tive way (psy chi at-ric and men tal health care sec tor or ga ni sa tion) there is a gap be tween the o ry and prac tice be cause of ge o graph i cal dis par i ties in fi nan cial re sources and hu man or equip ment ca pac i ty and struc tur al im bal ance be tween sec tor or ga ni sa tion. This study aim at in ves ti gate this dis par-i ties and was based on an ad min is tra tive sur vey of french psy chi at ric and men tal health care sec tor or ga ni sa tion. This study pre sents first two ty polo gies of the sup ply of the sec tors: the one re gard ing the hos pi tal pa tient en coun ters by year, the oth er re gard ing the pop u la tion cov ered in the ge o graph i cal area of the sec tor or ga ni sa tion. Based on the Mul ti-ple Cor re spon dence Anal y sis, both ty polo gies dif fer in their re sults but they both al low to clas si fy the sec tors ac cord ing to the dif fer ent sup ply lev els and to high light the « well-dot ed », the « mid dle (well and bad) en dowed » and the « un der-en dowed » sec tors. Fi nal ly, some re gres sion anal y sis in ves ti gate how the lev el of this sup ply can ex plain in pa tient, out pa tient and am bu la to ry care lev el of en coun ters.

0553

The role of the ESKI Health Eco nomics group in the pro cess of med i cine sub sidy ap provalNá dud vari N. (Na tion al In sti tute for Strate gic Health Re search, Bu dapest, Hun gary)Sinkovits B., Odhi ambo R., Koz ma P.

Dis cus sion/Re sults: As a method olog i cal re search in sti tute, with re spect to the for mu la tion of the sec tor’s health pol i cy strat e gy and prep a ra tion for de ci sion-mak ing, the Na tion al In sti tute for Strate gic Health Re search (ESKI) is ac tive in the fol low ing ar eas: health in for mat-ics; in for ma tion pol i cy; health eco nomics; health sci ences, tech nol o gy as sess ment and sub sidy pol i cy. The Of fice of Health Tech nol o gy As sess-ment pro vides an or gan i sa tion al frame work for the tech nol o gy as sess-ment that forms the ba sis for the med i cine sub sidy ap proval pol i cy of the Na tion al Health In sur ance Fund, and per forms the re lat ed med i cal and eco nom ic as sess ment du ties. The role of the health eco nomics sec-tion in this pro cess is as fol lows:– check ing the ve rac i ty of health eco nomics doc u men ta tion sub mit ted

by man u fac tur ers– sum maris ing the rel e vant Hun gar i an and in ter na tion al health eco-

nomics lit er a ture– prepar ing a crit i cal eval u a tion of the health eco nomics anal y ses sub-

mit ted by the ap pli cant, and com par ing them with in ter na tion al bench marks

– prepar ing a sum ma ry opin ion of the ap pli ca tion from a health eco-nomics point of view, pro vid ing re li able and undis tort ed in for ma tion for judg ing the val ue of the in di vid u al pro ce dures

– in form ing de ci sion-mak ers of the re search find ings, with out ar tic u-lat ing spe cif ic sub sidy rec om men da tions

Be sides the above, the sec tion pre pares oth er health eco nomics stud ies to fa cil i tate the ra tio nal us age of health re sources, and par tic i pates in the draft ing of med i cal pro to cols and statu to ry pro vi sions. The staff of the health eco nomics group con tin u ous ly de vel op their skills through par-tic i pa tion in Hun gar i an and in ter na tion al spe cial ist fo rums.

0496

Ap pro pri ate es ti ma tion of staffi ng costs in eco nom ic eval u a tions: Mea sure ment of pa tient de pen den cy and nurs ing timeNichol son T. (Pub lic Health Sci ences & Med i cal Sta tis tics, Southamp ton Gen er al Hos pi tal, UK)Ger ard K., Rod er ick P.

In eco nom ic eval u a tions, staff costs of ten form a large and hence im por-tant pro por tion of ex pen di ture. How ev er, sep a rat ing staff time need ed by dif fer ent types of pa tient be cause casemix or pa tient de pen den cies vary is not straight for ward and there is lit tle guid ance on the ap pro pri-ate meth ods to choose.Aim: To in ves ti gate and com pare the rel a tive costs and ben e fits of three meth ods to at tribute nurs ing re source use (i.e. time) and hence es ti mate costs of pa tient care for eco nom ic eval u a tions.Meth ods: The study in volves three data col lec tion meth ods: 1) Usu-al prac tice of mak ing as sump tions to ap por tion the rel a tive work load based on dis cus sions with key staff com pared with two ap proach es to mea sure nurs ing time: 2) Nurs es bar code scan ning to record pa tient-time, and 3) An ob serv er work sam pling the time nurs es spend on face-to-face pa tient-con tacts. The time es ti mates are used to cal cu late mean costs per pa tient by de pen den cy lev el. The main data col lec tion is for pa tients on chron ic haemodial y sis.Re sults will be pre sent ed: 1) Com par ing ap pro pri ate ness of the meth-ods (in terms of va lid i ty, re li abil i ty and prac ti cal i ty, in clud ing re search costs) to at tribute nurs ing time for dif fer ent casemix and/or pa tient de pen den cy groups. 2) To de ter mine whether ei ther al ter na tive nurs-ing time or cost es ti mates vary by pa tient de pen den cy.

0462

In ves ti ga tion and phar ma coeco nom ic eval u a tion of drug in ter ac tions ac cord ing to the anal y sis of 1.2 mil lion pre scrip tionsNya ka B. (De part ment of Phar ma cy, Med i cal School, Uni ver si ty of Pécs, Hun gary)So moskeöy S., Szücs F., Botz L.

Back ground: Re cent ly more and more con tro ver sial opin ions sur faced re gard ing the ef fec tive ness and cost-ef fec tive ness of phar ma co ther a-py. These crit ics like to re fer to the un ex pect ed side-ef fects, con sid er-able ad verse drug re ac tions and the in ad e quate ef fec tive ness of drugs. The pos si ble cause of these prob lems may be due to drug in ter ac tions. These prob lems lead to in creased med i cal ex pens es. Nu mer ous stud ies on drug-drug in ter ac tions and their se quel were car ried out out side Hun gary but only few ex per i ments were pub lished in our coun try. Aim: The aim of the cur rent study was to iden ti fy the most com mon drug-drug in ter ac tions of great clin i cal im por tance and to make phar ma-coeco nom ic cal cu la tions in ref er ence to med i cal costs of these pairs. Meth ods: We have ex am ined 1,227,851 pre scrip tions by a com put er pro-gram 8.611 doc tors par tic i pat ed in this study and 3.209 drugs were giv-en to 187.895 pa tients with in the anal y sed pe ri od. The data col lec tion took place be tween 29 June 2001 and 31 March 2004. The in ter ac tion anal y sis was based on three data sources: (1) the of fi cial drug pre scrip-tions, (2) the se lect ed pub lished lit er a ture and (3) the ef fect of the in ter-ac tions on the cy to chrome P450 en zyme sys tem. Re sults: By the help of our study we have re ceived many data about drug pre scrib ing prac tice, Rx num bers, drug and ac tive in gre di ent in ter-

Eur J Health Econom Suppl 1 · 2006 | S127

ac tion pairs, in ter ac tion num bers. For in stance, the num ber of in ter ac-tions be tween drugs which were pre scribed to geth er was 118.624 where-as ac cord ing to stud ies car ried out out side Hun gary this num ber was 43.340. Con clu sion: In our coun try the Rx num ber was 161 mil lion in 2003. Ac cord ing to both the in land and the for eign data po ten cial ly se ri ous drug in ter ac tions can oc cur in 3-4% of pa tients which can cause ap prox-i mate ly 10% in crease in med i cal costs. Our data can help and pro vide op por tu ni ties to make sev er al in land eco nom ic anal y ses.

0010

Pa tients' re ac tions to free choice of hos pi tal in Nor way, Den mark and Swe denO’ster gren K. (Nor we gian School of Eco nomics and Busines, Bergen, Nor way)Vrang bäligk K., Späng berg U.W., Birk H.O.

Dis cus sion/Re sults: This pa per de scribes a com par a tive study be tween free choice of hos pi tal in Nor way, Den mark and Swe den. The start ing point is the trend of free choice of hos pi tal in North ern Eu ro pean health sys tems. This rais es im por tant ques tions re gard ing the func tion al i ty of choice in pub lic in te grat ed sys tems and the con se quences for oth-er pol i cy goals such as eq ui ty, demo crat ic plan ning and ex pen di ture con trol. the pa per we pres ent an anal y sis of the ef fects of in tro duc ing free choice of hos pi tal in three coun tries. The anal y sis is ad dress ing two ques tions; What does the avail able ev i dence tell us about chang es in pa tients´ be hav iour af ter the in tro duc tion of choice in Scan di navia? Can pa tients´ be hav iour al re spons es to choice be ex plained by the in sti-tu tion al de sign in the three coun tries?re sults of the study show clear sim i lar i ties be tween the three coun tries. The re sults in di cate that few pa tients have ac tu al ly cho sen oth er fa cil i ties for care. A slow in crease over the years is no ticed though. It is few for mal, leg isla tive or eco nom ic bar ri ers that ex ist for the pa tients. In stead, pa tients´ lim it ed knowl edge about the re forms in com bi na tion with too lit tle sup port from GPs and lim it ed qual i ty in for ma tion can ex plain why few pa tients choose a hos-pi tal in oth er parts of the coun try.

0399

Costs As so ci at ed with Two Diff er ent Meth ods of Re cruit ing the Tar get Pop u la tion for Co lo rec tal Can cer Screen ingPalaz zo F. (IRPPS-CNR, Rome, Italy)Fe deri ci A., Bor gia P., Guas tic chi G., Ric cia r di A., Valle S., Pip pa G., Fer rara M.

Dis cus sion/Re sults: Two co lo rec tal can cer screen ing pro grammes with dif fer ent or ga ni za tion al ap proach es to pa tient re cruit ment were ex am-ined in the first pro gramme (study A) Com mu ni ty Phar ma cies dis tribut-ed the kit for fe cal oc cult blood test to per sons in vit ed by let ter; in the sec ond one (study B) Gen er al Prac ti tion ers (GP) in vit ed and dis tribut-ed the kits to pa tients and re ceived a fee of € 13.00 for each com pli ant pa tient. Com pli ance rates were 25.5% and 54.3 % re spec tive ly. Cen tre of Tech nol o gy As sess ment in Pub lic Health (CTAph) has cal cu lat ed the in vi ta tion costs for 1,000 screened pa tients in screen ing pro gram. Per-son nel, ma te ri al and equip ment costs were con sid ered; only costs dif fer-ing be tween the two stud ies have been in clud ed. The costs were about € 3,689 in study A, and € 13,097 in study B, for an av er age costs of € 3.69 and € 13.10 for each screened per son re spec tive ly. It fol lows that study A had a low er costs but poor er com pli ance than study B. Fi nal ly, an hy po-thet i cal com bined ap proach was con sid ered, send ing the first in vi ta tion from Com mu ni ty Phar ma cies and the sec ond in vi ta tion to peo ple had not yet parte ci pat ed through the GP. This ap proach en sures high com-pli ance with low er av er age costs than the B study.

0190

Eff ects of a glob al bud get on health care uti li za tionPark D. (Grad u ate School of Pub lic Health, Seoul Na tion al Uni ver si ty, Seoul, South Ko rea)Ko S., Yang B.

Dis cus sion/Re sults: This study was con duct ed to find out the ef fects of a glob al bud get on health care uti li za tion. Re cent Ko re an health care sys tem needs to im ple ment a cost con trol mech a nism since there has been enor mous in crease in health ex pen di tures af ter 2000. care uti li za-tion be fore and af ter in tro duc ing glob al bud get ing sys tem of five Eu ro-pean coun tries (the Nether lands, the Unit ed King dom, France, Ger many, Swe den) was com pared us ing re gres sion anal y sis with the OECD health data for 15 years. Pop u la tion size, GDP, and the ra tio of el der ly were used for con trol vari ables about in creas ing health ex pen di tures. Se ri al cor re la-tion was test ed us ing the D-val ue of Durbin-Wat son and au tore gres sive mod el was used to elim i nate au to cor re la tion. Dum my vari able for ‘glob-al bud get’, which ap plied to pe ri ods af ter in tro duc ing glob al bud get, was used to es ti mate the ef fect of glob al bud get. hav ing glob al bud get sys tem showed con sid er able de crease of health care ex pen di tures af ter im ple-ment ing glob al bud get sys tem. The in tro duc tion of glob al bud get act ed as the sta tis ti cal ly sig nif i cant rea son of re duc tion in health care ex pen di-tures while it did not sig nif i cant ly af fect on the in pa tient days and the num ber of beds. re sults of this study im pli cates that Ko rea could con trol health ex pen di tures through the change of pay ment mech a nism.

0526

Eco nom ic eval u a tion of cor o nary heart dis ease(CHD): ex pec ta tions and chal lenges in UK and IranParsa A.D. (Di vi sion of car dio vas cu lar med i cine, Uni ver si ty of Not ting ham, UK)Gray D.

In tro duc tion: Hearth dis ease is a ma jor world-wide health prob lem with high in ci dence and prev a lence in de vel oped coun tries and ris ing in ci dence in de vel op ing coun tries. Dur ing last ten years, al most 20% of all acute hos pi tal ad mis sions are car di ac-re lat ed [5]. More than 25,000 by pass pro ce dures and about 40,000 an gio plas ty and oth er cor o nary in ter ven tion pro ce dures are car ried out an nu al ly in the UK[4]. CHD bur dens the UK econ o my by £7.06 bil lion [13]. Meth ods: Eco nom ic eval u a tion in volves three ba sic steps of cost iden-ti fi ca tion, cost val u a tion and cost mea sure ment. Per spec tive: The most ac cept ed per spec tive[19] is so ci etal. Data col lec tion: Pa tient data are ex tract ed from the pa tient file record or pa tients’ ques tion naire or in ter view. Data anal y sis: Both quan ti ta tive and qual i ta tive anal y sis us ing SPSS and AN OVA are used. Dis cus sion: Man age ment is im por tant clin i cal ly and from the eco-nomics view point (e.g. in di vid u als and so ci ety) must also be con sid-ered [20]. CHD man age ment is be com ing in creas ing ly cost ly. Di rect& in di rect costs di vert scarce re sources (pa tient’s or fam i ly and so ci ety) to med i cal care [12]. Eco nom ic eval u a tion as sess es the val ue of heart man age ment in terms of their ex pect ed costs and ex pect ed ben e fits[21], pro vid ed that it in cludes an anal y sis of all di rect and in di rect cost and also all ben e fits for gone[19, 22]. In creas ing ly tech ni cal so lu tions are de ployed and con sid er a tion must be giv en to which would bet ter meet health sec tor ob jec tives[23]. Health care ex pec ta tions: The ba sic prin ci-ple is sim ple- com pre hen sive, high qual i ty med i cal care should be avail-able to all with out fi nan cial bar ri ers to ac cess. How ev er, in the face of in creas ing costs and ever more pa tients, this is un der threat. In ad di tion some times pop u la tions in great est need are those least like ly to re ceive it [24]. It is ex pect ed that eco nom ic eval u a tion aids to de fine choic es on how best to use re sources[25]. Chal lenges of Health Eco nomics& man age ment of CHD

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De mand: The cur rent dis tri bu tion of re sources leaves some high- pri or-i ty de mands un met. The chal lenge of meet ing the de mand for free pub-lic ser vices is in creas ing[27]. De mand for CHD treat ment is un doubt-ed ly ris ing[27]. Ra tioning and al lo ca tion choice: Re source al lo ca tion stra te gies are de signed to man age dif fer ent ar eas of NHS ef fec tive ly. There are sev er-al ap proach es to ra tioning how ev er there are moral con sid er a tions that ought to be re cog ni sed. Cur rent ly, ra tioning is ac cord ing to a range of cri te ria that seem chal leng ing. Ef fi cien cy: With scarce re sources, it is im por tant that ser vices be pro-vid ed ef fi cient ly. Ef fi cien cy with in the NHS in volved im prov ing both pro duc tive ef fi cien cy and al loca tive ef fi cien cy. Eq ui ty: Eq ui ty in and health care has be come a pri or i ty [30]. Will ing-ness to pay (WTP): By eval u at ing WTP, pa tients’ pref er ences can be tak-en into ac count though there are dif fi cul ties in com par ing user (pa tient) val ues with non-user (non-pa tient) val ues. Eth ics: There are also moral is sues re gard ing the use of only eco nomics data in de ci sion-mak ing [33]. More over there is need[35] and pref er ence con flict and re quires to be man aged ap pro pri ate ly. Con clu sion: CHD growth in both de vel oped and de vel op ing coun-tries put health sys tems faced on greater de mand to ap pro pri ate care. Thus the no tion of eco nom ic eval u a tion is to help health pro fes sion al to di vert re sources to achieve the best health out comes for in di vid u als. There is an ur gent need to de vel op pre ven tive stra te gies in de vel op ing coun tries. Pre ven tion and treat ment stra te gies in de vel oped coun tries should be mod i fied for de vel op ing coun tries. These stra te gies should in clude ap proach es to pre vent the de vel op ment of risk fac tors in the pop-u la tion as a whole by chang es in pub lic pol i cy as well as ap proach es that can be ap plied to high risk in di vid u als.

0551

Na tion al In sti tute for Strate gic Health Re search Offi ce of Health Tech nol o gy As sess ment Pék li Novákné M. (Na tion al In sti tute for Strate gic Health Re search, Bu dapest, Hun gary)Jóna G., Ná dud vari N., Soltész G.

Back ground: The Of fice of Health Tech nol o gy As sess ment of the Na tion al In sti tute for Strate gic Health Re search was formed in 2004 with the aim of es tab lish ing in Hun gary, sim i lar ly to oth er EU mem ber states, an in de pen dent in sti tu tion to sup port de ci sion-mak ers in their ra tio nal use of health care re sources, through the pro vi sion of anal y ses and rec om men da tions.Role and du ties of the Of fice of Health Tech nol o gy As sess ment: The Of fice, as a new ly es tab lished or gan i sa tion al unit of a high ly re gard ed and long-es tab lished in sti tute, pro vides an or gan i sa tion al frame work for the tech nol o gy as sess ment that forms the ba sis for the med i cine sub sidy ap proval pol i cy of the Na tion al Health In sur-ance Fund, and per forms the re lat ed med i cal and eco nom ic as sess-ment du ties.The Na tion al Health In sur ance Fund makes de ci sions re gard ing the grant ing of sub si dies for new medicines, based on the find ings pre sent-ed by the Na tion al In sti tute for Strate gic Health Re search. The Of fice of Health Tech nol o gy As sess ment – de ter mines the pro fes sion al guide lines for an a lys ing health tech nol-

o gy, co or di nates the as sess ment of new and ex ist ing tech nolo gies, and is sues in struc tions for the use of in di vid u al tech nolo gies. It also dis tributes the as sess ments at clin i cal and lo cal lev el, and com piles us age guide lines based on best clin i cal prac tice.

– based on a com bi na tion of clin i cal ev i dence, ef fi ca cy and cost-ef fec-tive ness fac tors, pro vides re li able and undis tort ed in for ma tion for the ap praisal of in di vid u al pro ce dures, com par ing them with al ter-na tive op por tu ni ties for the use of re sources.

– fa cil i tates the ap pro pri ate use of cost-ef fec tive health care tech nolo-gies, and pro vides sup port for de ci sion-mak ers.

– per forms anal y ses and pre pares rec om men da tions for the ra tio nal util i sa tion of health care re sources.

Re sults: The ma jor i ty of ap pli ca tions were re lat ed to anti-tu mour drugs and prod ucts de signed to treat dis eases of the car dio vas cu lar or cen tral ner vous sys tem.In ad di tion, the Of fice per forms prob lem-ori ent ed com par a tive ex am i-na tions, such as the com pre hen sive pol i cy study of Pos i tron Emis sion Tomo gra phy (PET) and Gam ma-knife Sur gery, be sides which a fur ther two large-scale spe cial ist stud ies are cur rent ly be ing car ried out in the key ar eas of car di ol o gy and on col o gy.The spe cial ist work car ried out at the Of fice are the re sult of ef fec tive team work by teams of med i cal and health eco nomics ex perts.Sum ma ry: In the ini tial pe ri od, staff at the Of fice of Health Tech nol o-gy As sess ment fo cused pri mar i ly on as sess ments of medicines to de ter-mine their el i gi bil i ty for so cial in sur ance fund ing, but as the new in sti-tu tion al struc ture be comes more firm ly es tab lished, it is in creas ing ly able to per form thor ough, com pre hen sive as sess ments of oth er health tech nolo gies.

0196

Mea sur ing healthPer ronnin M. (IRD ES (In sti tut de recherche et doc u men ta tion en econo-mie de la sante), Par is, France)Rochaix L., Tubeuf S.

Dis cus sion/Re sults: Al though a large set of in di ca tors is avail able to mea sure dif fer ent as pects of health, as sess ing health glob al ly is dif fi cult be cause of its mul ti di men sion al i ty. In deed, ac cord ing to Blax ter (1990), three di men sions com pose an in di vid u al health sta tus: sub jec tive, med-i cal and func tion al. The scope of this pa per is to de rive an in di ca tor that ag gre gates two of these three di men sions: sub jec tive and med i cal. The data comes from the 2002 IRD ES Health and Health In sur ance Sur vey, which is rep re sen ta tive of French house holds and cov ers about 20,000 in di vid u als in 7,338 house holds. We first clas si fy dis eases ac cord ing to the vi tal risk and dis abil i ty lev el that they in duce; we then con struct a semi con tin u ous in dex of sever i ty based on the num ber of dis eases in each class that in di vid u als de clare. Fi nal ly, we regress this semi con tin-u ous in dex and a set of con trol vari ables on self as sessed health us ing an or dered log it mod el with ran dom ef fects to ac count for un ob served house holds char ac ter is tics. We also ex plore po ten tial re port ing bi as es by shift ing thresh olds. Fi nal ly, we use the co ef fi cients as so ci at ed to the sever i ty in dex to at tribute each dis ease a weight and we then gen er ate the ag gre gate in di ca tor as a weight ed sum of dis eases. This in di ca tor can then be used in com par ing health dis tri bu tion across pop u la tions and of fer promis ing util i sa tion in oth er health eco nomics anal y ses.

0393

A Na tion al Sur vey on Co lo nos co py Costs Items Anal y sisPip pa G. (Os pedale S. Eu ge nio, Rome, Italy)Di Giulio E., Fer rara M., Rossi A., Du rante G., Valle S., Guas tic chi G., Men ni ni F.S.

Dis cus sion/Re sults: To car ry out a Cost-Ef fec tive ness Anal y sis (CEA) among dif fer ent co lo rec tal can cer (CRC) screen ing stra te gies, Ital ian So ci ety for Di ges tive En dos co py (SIED) joint ly with the Cen tre of Tech-nol o gy As sess ment in Pub lic Health (CTAph), a Re search Unit of the Agen cy for Pub lic Health of Lazio Re gion (ASP), sent a ques tion naire by In ter net to all SIED mem bers to as sess hu man (per son nel) and ma te-ri al re sources (drug and oth er con sump tion, equip ment) em ployed by co lo nos co py that is the most ex pen sive CRC screen ing pro ce dure. three En dos co py Units, from dif fer ent re gions across Italy, re turned the ques-tion naire. A to tal of 37,249 CSs (86% com plete and 14% par tial) was per formed in 2004, 60% in con scious se da tion and 4% in deep se da tion. Com pli ca tions in ci dence was 1,4%. Mean time spent by a gas tro en ter ol-

Eur J Health Econom Suppl 1 · 2006 | S129

o gist for a stan dard di ag nos tic CS is 27 min utes, for a CS with bi op sy is 30 and for a CS with polipec to my is 37. In stead a nurse spends re spec-tive ly 36, 39 and 39 min utes. Mean time spends by an aes the tist is 36 min-utes. A mean of 324 CSs/co lo no scope was per formed. Mon e tary eval u-a tion of re sources em ploied will be cal cu lat ed in di rect ly through an in-de pht study. Data from the sur vey will be utilised for a CS cost anal y sis and fi nal ly for a CRC screen ing CEA.

0285

Ex pen di ture on health and eco nom ic growth in Rus sian Fed er a tion: com par isons, anal y sis, mod elling and fore cast ingPle shanov A. (RMA-Pharm, Odintso vo, Moscow Sub urb, Rus sian Fed er a tion)Simp son D.

Dis cus sion/Re sults: In our un der stand ing, one hun dred per cent age in creas ing GDP of Rus sian Fed er a tion dur ing 10 years pe ri od that was iden ti fied by Rus sia Pres i dent as key na tion al tar get means that Rus sian Fed er a tion will soon need a new up-to-date health ex pen di ture strat e-gy based on ex pe ri ence of most de vel oped (high in come) coun tries. That is why, the au thors start ed study ing pos si ble ways of in creas ing of health care spend ing in Rus sia dur ing next mid dle-term and long-term pe ri ods, in clud ing the choice for Rus sia avail able mod els of de vel op-ment of in dex of health ex pen di ture share of GDP dur ing long last pe ri-od of eco nom ic growth. Com par a tive sta tis ti cal anal y sis of cur rent sta-tus and dy nam ic of de vel op ment of in dices of ex pen di ture on health as share of GDP, size of GDP and evo lu tion of GDP was made. Growth in health spend ing and GDP were cal cu lat ed based on 1995 GDP con stant prices lev el. The main trends in coun tries of four dif fer ent groups (the world lead ers, Bis marck and Bev eridge mod els and Rus sian Fed er a tion) were iden ti fied, us ing meth ods of data anal y sis and mod el ing, that were rec om mend ed by the UN Sta tis ti cal Com mis sion and Eco nom ic Com-mis sion for Eu rope, and econo met ric eval u a tion. The main ideas and ap proach es of this re search were pro duced by the au thors with in the EC Tacis Re form of Health Care Fi nanc ing Pro ject, AP 1998. The au thors used the mod el ing of to tal, pub lic and pri vate health ex pen di ture data based on re gres sion, cor re la tion and time se ries anal y sis. More than 500 econo met ric mod els were made and in ves ti gat ed. Most of them were eval u at ed as ad e quate mod els to be used for fur ther pro cess of pre dict-ing health ex pen di ture val ues. In par tic u lar, the cri te ria of good choice were as fol low ings: the val ue of co ef fi cient of de ter mi na tion (R2 ≥ 0.8) and the re sid u al anal y sis re sults ac cept able. The re search con cept in clud-ed econo met ric mod els cre at ed for to tal, pub lic and pri vate health spend-ing. The con cept also de scribed three stag es of health ex pen di ture in dex change dur ing long-term pe ri od of eco nom ic de vel op ment that best fit ted by lin ear re gres sion (first stage), poly no mi al re gres sion (sec ond stage) and lim its (third stage). Fi nal ly, the au thors of fered the smoothed mod els of health spend ing for mid dle-term and long-term pe ri ods, and the set of spe cial ma tri ces of pre dict ed health ex pen di ture val ues, that could be seen as ori en tat ing for fur ther de vel op ment of more de tailed pre dic tion mod els in frame of new health ex pen di ture strat e gy for Rus-sian Fed er a tion. Con clu sion: the ap proach rec om mend ed by Rus sian Med i cal As so ci a tion for im ple men ta tion in prac tice.

0372

Dis en tan gling the Age, Pe ri od, and Co hort eff ects us ing a mod el ing ap proachPor trait F. (Vri je Uni ver siteit, Ams ter dam, Nether lands)Deeg D., Alessie R.

Dis cus sion/Re sults: Dis en tan gling age, pe ri od, and co hort ef fects in ex plain ing health is cru cial to as sess fu ture prev a lence of health dis or ders.iden ti fi ca tion prob lem – year of birth plus age is cal en dar – is tack led by

mod el ing co hort and pe ri od ef fects us ing macro-in di ca tors. The meth-od also re veals mech a nism sco hort and pe ri od ef fects. Spe cif ic at ten tion is paidthe im pact of omit ted rel e vant vari ables, un ob servedand to se lec-tive at tri tion. We ap ply the graph i cal,fac tors, and mod el ing ap proach es on trends in self-re ports on lim i ta tions and com pare re sults. We ar gue that theap proach is high ly ap pro pri ate. The prev a lence oflim i ta tions is found to in crease in thenineties due to ad verse pe ri od ef fects.

0491

Is home-based che mo ther a py re al ly cost sav ing and for whom ?Preaubert-Hayes N. (HAS/ Haute au torité de san té (French Na tion al Health Au thor i ty), Saint-De nis la Plaine Cedex, France)Hirt zlin I.

Pur pose: Con sid er ing che mo ther a py, the HAS had com pared costs of home-care with hos pi tal-care and had iden ti fied the main pa ram e ters in ter ven ing in the cost cal cu la tion.Meth ods: Com par i son of costs was based on a crit i cal lit er a ture re view and ad di tion al in for ma tion from the French DRG costs database and a French home-based hos pi tal costs study.Re sults: Con sid er ing av er age di rect costs, 9 out of 13 in ter na tion al stud-ies showed that home-based che mo ther a py was less ex pen sive. Only one French study was avail able. Its con clu sion was dif fer ent when con-sid er ing av er age or mar gin al costs. Us ing French data we showed that, on a one day care, che mo ther a py costs less at home than in hos pi tal (?.2 ver sus ?). Nev er the less, be cause pa tients at home re ceive care dur ing a lon ger pe ri od (7.78 days on av er age), home-based che mo ther a py is fi nal-ly cost ing more. As sev er al dif fer ences had been iden ti fied be tween the two al ter na tives, our study em pha sised the ques tion of the com pa ra bil i-ty of the two ser vices pro duced. Con clu sions: In or der to de vel op home-based hos pi tal, French pol i-cy mak ers had re cent ly pro posed a new re im burse ment scheme. Our study con clud ed that these mea sures would not be suf fi cient: an eco-nom ic anal y sis in clud ing in tan gi ble ben e fits (pa tient com fort) should be done be fore for each can cer types and for the most com mon treat-ment pro to cols.

0358

De ter mi nants of med i cal prac tice among el der ly breast can cer pa tientsPro tiere C. (IN SERM U379, Mar seilles, France)Rousseau F., Viens P., Moat ti J.P.

Dis cus sion/Re sults: Care of the el der ly has be come an im por tant field in med i cine. Ad vanc ing age is as so ci at ed with co mor bidi ties and chrono log ic age doesn’t al ways pre dict phys i o log ic age. El der ly pa tients are of ten ex clud ed from clin i cal tri als and treat ed with some po ten tial-ly sub-op ti mal treat ments. In this con text, ques tion of eq ui ty in ac cess to health care arise.spe cif ic ques tion naire was de signed and send to French spe cial ists from pri vate and pub lic sec tors in or der to 1/ as sess fac tors in flu enc ing de ci sion; 2/ de ter mine eval u a tion tools and com ple-men ta ry ad vice used be fore med i cal de ci sion mak ing, and 3/ elic it med-i cal prac tice us ing four clin i cal cas es.the 494 spe cial ists, very few used spe cif ic ge ri at ric tools where as lit er a ture showed the ne ces si ty of such an eval u a tion. 65% of spe cial ists would ad min is trat ed the same treat-ment to el der ly pa tients than for their younger coun ter parts. How ev er, sig nif i cant dif fer ence in choice of treat ment was found with the only vari a tion of pa tient’s age. Like li hood of re ceiv ing che mo ther a py de pend of the spe cial ty and sex of phy si cian, kind of struc ture, de ci sion tak en with a cor re spon dent or in a mul ti dis ci plinary com mit tee, phy si cian’s per cep tion of age of an el der ly pa tient.some cas es po ten tial ben e fit was omit ted for old er pa tients. Know ing the multi-di men sion al as pect of the pro cess of care to ward this spe cif ic pop u la tion, with typ i cal ly multi

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risk con text, pa tients’ pref er ences should be in cor po rat ed and then have to be elicit ed.

0210

In cor po rat ing a PTO for mat pre vi ous to DCEQueve do Gar cia J.L. (De part ment of Ap plied Eco nom ic Anal y sis of Las Pal mas de Gran Ca naria, Spain)León C., Araña J.

Dis cus sion/Re sults: In the con text of the eval u a tion of a screen ing pro-gramme for cer vi cal can cer in Gran Ca naria, we have de signed a DCE sur vey where we have in clud ed a set of PTO-for mat choic es. Pre vi ous stud ies have shown that wom en’s knowl edge about cer vi cal can cer and screen ing is quite lim it ed. We make the hy poth e sis that the in clu sion of the PTO choic es helps the wom en to fa mil iar ize with the eval u a tion ex er cise. In this work we use the re sults of the ex per i ment to deal with the prob lem of in ter nal iz ing the un cer tain ty as so ci at ed with the in di-vid u al val u a tion.un fa mil iar i ty is pres ent in re la tion to the good to be eval u at ed, the ques tion naire holds an ad di tion al con tri bu tion it leads the in ter vie wee to im prove her lev el of in for ma tion about the good and ad di tion al ly to learn about her own val u a tion pro cess. The data we use in this pa per come from home in ter views to wom en ran dom ly se lect ed from the Ca nari an Health Ser vice ID card. We study the eval u a tion of the ben e fits aris ing from the in tro duc tion of a cer vix can cer screen ing pro gramme us ing the DCE tech nique. We are in the pro cess of col lect-ing and com put ing the data. The con clu sion we are ex pect ing to test is that the in clu sion of the PTO ex er cise de creas es the in di vid u al im pre ci-sion as so ci at ed with the pref er ence es ti ma tion.

0610

Does Binge ing Aff ect Earn ings? Ev i dence from Aus traliaRam ful P. (Dept. of Econo met rics and Busi ness Sta tis tics, Monash Uni ver si ty, Clay ton, Vic to ria, Aus tralia)

Key words: Binge drink ing, earn ings, se lec tiv i ty bias, multi no mi al se lec-tion.Ab stract: While ex ces sive drink ing is as so ci at ed with low er earn ings through ad verse health ef fects, ab sen teeism and low pro duc tiv i ty, mod-er ate al co hol con sump tion seems to gen er ate pos i tive wage ef fects. These pos i tive wage pre mi ums are ex pect ed to arise from the “net work-ing” ef fect of drink ing and the ben e fi cial health ef fects of drink ing in mod er a tion. Us ing unit-record data from the Na tion al Drug Strat e gy House hold Sur veys, this pa per ex am ines the im pact of drink ing and binge ing on in di vid u als’ earn ings, con trol ling for se lec tiv i ty bias and the en dog e nous re la tion ship be tween drink ing sta tus and earn ings us ing a Multi no mi al Log it Se lec tiv i ty mod el. Some im por tant dif fer en-tial ef fects are found across the four drink ing groups and sig nif i cant se lec tion bias is ob served for mod er ate drinkers and fre quent bingers. In line with pre vi ous stud ies, it is found that ex ces sive drink ing is as so-ci at ed with re duced earn ings whilst mod er ate drinkers and oc ca sion al bingers earn a pos i tive pre mi um over ab stain ers.

0321

Com par ing cost-util i ty of six com mon sur gi cal pro ce duresRäsä nen P. (Helsin ki and Uusi maa Hos pi tal Group, Group Ad min is tra tion and Finnish Offi ce for Health Tech nol o gy As sess ment, Helsin ki, Fin land)Sin to nen H., Ryynä nen O.P., Blom M., Roine R.

Ob jec tive: To com pare the cost-util i ty of six com mon sur gi cal pro ce-dures in a real-world set ting. Meth ods 763 pa tients (219 cat a ract, 96 hip ar thro plas ty, 103 knee ar thro plas ty, 169 cer vi cal spine, 101 lum bar spine, 75 cor o nary by pass) en ter ing the Helsin ki Uni ver si ty Hos pi tal for

rou tine op er a tive treat ment filled in the 15D HRQoL sur vey be fore and 3–12 months af ter op er a tion. QALYs were cal cu lat ed us ing the ob tained util i ty data and the ex pect ed re main ing life years of the pa tients. Cost-util i ty was cal cu lat ed as the re la tion of QALY gained to costs of pro-vid ing sur gery. Mean dis count ed (5%) QALY gain was largest for lum-bar spine sur gery (0.943) fol lowed by pri ma ry hip ar thro plas ty (0.708), cer vi cal spine sur gery (0.577), cor o nary by pass sur gery (0.473), pri-ma ry knee ar thro plas ty (0.359), and cat a ract sur gery (0.113). The dis-count ed cost per QALY gained was low est for lum bar spine sur gery (€3704) fol lowed by cer vi cal spine sur gery (€5816), pri ma ry hip ar thro-plas ty (€12340), cat a ract sur gery (€14501), pri ma ry knee ar thro plas ty (€ 22415), and cor o nary by pass sur gery (€28074).Dis cus sion: There is great vari a tion in the cost-util i ty of sur gi cal in ter-ven tions per formed in a real-world set ting even when only com mon, wide ly ac cept ed in ter ven tions are con sid ered. This calls four con tin u ous mon i tor ing of cost-util i ty of var i ous in ter ven tions to op ti mize health care spend ing.

0593

Diff u sion of com plex health in no va tions – im ple men ta tion of pri ma ry care re forms in Bosnia & Herze gov inaRi fat A. (Im pe ri al Col lege Lon don, UK)Kyrat sis I., Jel ic G., Mal icbe gov ic D.R., Ur gan ci I.G.

Back ground: WHO and oth er mul ti lat er al agen cies such as the World Bank (WB) have iden ti fied pri ma ry health care (PHC) as the ve hi cle to en hance health sys tems per for mance. Scal ing up re form ini tia tives based on the prin ci ples of PHC is a key pri or i ty es pe cial ly for the Tran si-tion Coun tries. Our study is the first which ex am ines in de tail the in tro-duc tion of PHC re forms in Bosnia and Herze gov ina (BiH). In spite of a chal leng ing post-war con text, with in a few years, Bosnia has man aged to scale up mul ti faceted re forms to cov er over 25% of the coun try.Meth ods: We em ploy a nov el method olog i cal ap proach, us ing an in no va-tion lens, to ex am ine the PHC re forms. The study in volved both qual i ta-tive and quan ti ta tive meth ods of in quiry. In this study, we re port the find-ings of the qual i ta tive re search. Multi-lev el, multi-stake hold er pur po sive (the o ret i cal) sam pling was used over three stag es for the data col lec tion phase, in clud ing pi lot ing of the re search in stru ment. Data anal y sis was done in duc tive ly us ing a frame work ap proach and in volved in de pen dent anal y sis by the par tic i pat ing re searchers to al low tri an gu la tion.Re sults: We demon strate, qual i ta tive ly, the crit i cal suc cess fac tors which cre-at ed an en abling en vi ron ment for these mul ti faceted re forms to progress but also high light the bar ri ers which must be ad dressed if the re forms are to be ful ly scaled up. Anal y sis in di cates a com plex set ting and a set of in ter-ac tions be tween the at tributes of in no va tion, adopter char ac ter is tics and con tex tu al fac tors, which all in flu enced the dif fu sion pro cess.Con clu sions: Our find ings are in line with ear li er work on dif fu sion of in no va tions, but have also iden ti fied a num ber of fac tors spe cif ic to BiH. The find ings are rel e vant to Tran si tion Coun tries in Balka ns, Cen-tral and East ern Eu rope and Cen tral Asia as well as the fund ing agen-cies (i.e. WHO, WB, EU) – which have in vest ed very large sums to de vel-op PHC in these coun tries.

0455

Is sues in the eco nom ic eval u a tion of gene tech nol o gy in health careRo gows ki W. (GSF – Na tion al Re search Cen ter for En vi ron ment and Health; In sti tute of Health Eco nomics and Health Care Man age ment, Neuher berg, Ger many)

Ob jec tives: It has been claimed that gene tech nol o gy will rev o lu tion ar-i ly change health care. This study in ves ti gates to what ex tent health eco-nom ic ev i dence can guide these chang es.

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Meth ods: A three di men sion al frame work was de vel oped to map dif-fer ent uses of gene tech nol o gy in health care which have been eco nom i-cal ly eval u at ed. Method olog i cal is sues and the cur rent state of eco nom-ic ev i dence con cern ing hu man DNA tech nol o gy were ex tract ed from pu bli ca tions with in these groups of eval u a tions.Re sults: Eco nom ic eval u a tions of “health care con sist ing of gene tech-nol o gy” were iden ti fied only for DNA test ing. Cur rent eval u a tions cov-er screen ing, di ag nos tic and treat ment tech nolo gies in in ves ti ga tion al, new and es tab lished stag es. Con clu sive ev i dence of favourable cost-ef fec-tive ness ra tios is avail able only for few con di tions. “Health care en abled by gene tech nol o gy” is far more en com pass ing and in cludes e.g. bio-tech nol o gy drugs for which var i ous health eco nom ic eval u a tions can be found. Yet here, the im pact of gene tech nol o gy in ter twines with the im pact of oth er tech nolo gies and is thus hard ly sus cep ti ble to health eco nom ic eval u a tion. Con clu sion: Health care con sist ing of gene tech nol o gy can and has par tial ly been in ves ti gat ed by health eco nom ic eval u a tion. Cur rent ev i-dence does not sup port widespread pre dic tive test ing. The im pact of gene tech nol o gy as an en abling tech nol o gy can hard ly be eval u at ed as its con tri bu tion cur rent ly can not be quan ti fied.

0417

The health ex pen di ture gap in Bel gium Ruz Tor res R. (DUL BEA (De part ment of Ap plied Eco nomics, Uni ver sité li bre de Brux elles), Bel gium)

Dis cus sion/Re sults: This pa per de com pos es ob served health ex pen di-ture vari a tions (“health ex pen di ture gap”) in Bel gium us ing the Oax a-ca-Bind er de com po si tion. This de com po si tion sep a rates dif fer ences in mean wages into a com po nent ex plained by dif fer ences in char ac ter is-tics and a com po nent ex plained by dif fer ences in co ef fi cients.fo cus on the ob served health ex pen di ture gap be tween a giv en sick ness fund or re gion and the Bel gian pop u la tion. This gap is de com posed in or der to iso late vari a tions in ex pen di tures that re sult from dif fer ences in de mo-graph ic, so cio-eco nom ic, in di rect mor bid i ty vari ables, and lo cal char ac-ter is tics vari ables, from what is due to dif fer ences in the co ef fi cients of these vari ables be tween groups. Dif fer ences in co ef fi cients re flect vari-a tions in health care util i sa tion rather than the ef fects of dis crim i na-tion.em pir i cal anal y sis re lies on a sam ple of 500,000 in di vid u als from all Bel gian sick ness funds for 1998. The spec i fi ca tion used for the risk ad just ment scheme is es ti mat ed for ev ery group in or der to com pute dif fer ences in co ef fi cients. in di cate that the ob served health ex pen di-ture gap is main ly due to dif fer ences in ob serv able char ac ter is tics? Dif-fer ences in the co ef fi cients only play a mar gin al role (less than 3% of the ob served health ex pen di ture gap). Un ex plained vari a tions in con-sumer be hav iour be tween re gions, provinces or be tween sick ness funds are not sig nif i cant.

0138

The re la tion ship be tween BMI and health re lat ed qual i ty of lifeSach T. (Uni ver si ty of Not ting ham, UK)Bar ton GR., Do her ty M., Jenk in son C., Av ery T., Muir K.

Ob jec tive: To ex am ine the re la tion ship be tween BMI and HRQL ac cord-ing to the EQ-5D, Eu ro Qol vi su al an a logue scale (EQ-VAS) and SF-6D. Meth ods: Pa tients aged ≥45 years at one UK gen er al prac tice were asked to com plete the EQ-5D, EQ-VAS, SF-36 ques tion naire (used to de rive the SF-6D), and in for ma tion on their char ac ter is tics and co-mor bid i ty. BMI was cat e gorised ac cord ing to WHO rec om men da tions. Re gres sion anal y sis was used to com pare the HRQL of nor mal BMI pa tients to the HRQL of pa tients in oth er BMI cat e gories, whilst con trol ling for pa tient char ac ter is tics and co-mor bid i ty.

Re sults: 1865 pa tients re spond ed (67%), mean BMI 26.0 kg/m2, 16% obese (BMI≥30). Af ter con trol ling for oth er fac tors, com pared to nor-mal BMI pa tients, obese pa tients had a low er HRQL ac cord ing to the EQ-5D (p<0.01), EQ-VAS (p<0.001), and SF-6D (p<0.001). Pre-obese pa tients were not es ti mat ed to have a sig nif i cant ly low er HRQL, and un der weight pa tients were only es ti mat ed to have a sig nif i cant ly low er HRQL ac cord ing to the SF-6D (p<0.05). Con clu sion: The EQ-5D, EQ-VAS, and SF-6D were in agree ment that, rel a tive to a nor mal BMI, obe si ty is as so ci at ed with a low er HRQL, even af ter con trol ling for pa tient char ac ter is tics and co-mor bid i ty. These three mea sures are there by sen si tive to the HRQL ef fects of obe si ty.

0222

The Ger man strat e gy for qual i ty as sur ance and im prove ment in health careSauer land D. (WHL Grad u ate School of Busi ness and Eco nomics, Lahr, Ger many)

In 2001, the strat e gy for en sur ing and im prov ing the qual i ty of med i cal care fi nanced by the statu to ry health in sur ance scheme in Ger many was char ac ter ized by state reg u la tions and could be de scribed as “in need of im prove ment”. Since then, a se ries of health care re forms have been passed; these have also af fect ed the qual i ty as sur ance strat e gy.Ob jec tives: This pa per ex am ines these chang es, many of which have been brought about by the SHI Mod ern iza tion Act [Gesetz zur Mod-ernisierung der geset zlichen Kranken ver sicherung], which came into force in 2004. The anal y sis shows im prove ments in the area of reg u la-tion. Fur ther more, there are now rec og niz able ap proach es to ward the more widespread use of qual i ty-based com pe ti tion be tween providers of med i cal ser vices in Ger many. Meth ods: The pros and cons of reg u la tion and com pe ti tion as in stru-ments to en sure qual i ty of care are dis cussed. Based on a nor ma tive ref er ence point, the Ger man Sta tus quo is an a lyzed, which is ba si cal ly framed by the le gal rules fixed in the So cial Code Book V.Re sults: The anal y sis shows im prove ments in the area of reg u la tion. Fur ther more, there are now rec og niz able ap proach es to ward the more widespread use of qual i ty-based com pe ti tion be tween providers of med-i cal ser vices in Ger many.

0224

Eco nom ic prin ci ples as guide lines for the de sign of a Health Sys temSauer land D. (WHL Grad u ate School of Busi ness and Eco nomics, Lahr, Ger many)

Not only the for mer ly so cial ist coun tries in Mid dle and East ern Eu rope have to re-de sign their health sys tems to meet the needs of their cit i zens and to de vel op a sys tem that is com pat i ble with a free so ci ety and a mar-ket based econ o my.Ob jec tives: This pa per out lines le git i mate aims for health pol i cy. It also de vel ops cri te ria for the se lec tion of ad e quate in stru ments to reach these aims.Meth ods: The the o ret i cal ap proach of a con sen sus – reached be hind a veil of un cer tain ty (or ig no rance) – is used to find le git i mate aims for a gov ern ment with in a health sys tem. In a sec ond step, the con sen sus ap proach is tak en to find “the rules of the game”, i.e. the cri te ria, that should be ap plied in in stru ment se lec tion.Re sults: Two le git i mate aims are found, that cit i zens can agree on: First, to en sure ac cess to med i cal treat ment for all, and sec ond, to en sure a pre ferred pro vi sion of med i cal goods and ser vices. Se lect ing the ad e-quate in stru ments to reach these aims, the prin ci ples of sub sidiar i ty, of fis cal equiv a lence, of equal i ty, and of ef fi cien cy should serve as guide-lines. On this ba sis, a con tri bu tion-based sys tem with a statu to ry health in sur ance is a good in stru ment to reach the first aim. For peo ple who

S132 | Eur J Health Econom Suppl 1 · 2006

can not af ford the in sur ance pre mi um, tax fi nanced trans fers should be paid. With re gards to the sec ond aim, qual i ty com pe ti tion of in sur ance com pa nies and med i cal providers is cho sen. Con clu sion: Tak ing into ac count le git i mate aims and try ing to reach them ap ply ing ad e quate in stru ments can help to en sure broad sup port of cit i zens for their health sys tem and for nec es sary re forms.

0182

Mod elling the net pres ent val ue of dis ease man age ment pro grammes in com pet i tive so cial health in sur ance mar ketsSchreyögg J. (Ber lin Uni ver si ty of Tech nol o gy, Ber lin, Ger many)Schlöss er R.

Ob jec tives: Since 2003 health in sur ance funds in Ger many have the op tion to of fer Dis ease Man age ment Pro grammes (DMP) for the chron-i cal ly ill. These pro grammes en able health in sur ance funds to re duce costs and at tract new clients. As an ad di tion al in cen tive for health in sur-ance funds to of fer DMP, the in sured reg is tered in a DMP are re im-bursed sep a rate ly in the Risk Struc ture Com pen sa tion Scheme. The ob jec tive is to quan ti fy the net pres ent val ue of a DMP for health in sur-ance funds which can be used as a de ci sion cri te ri on for in vest ment.Meth ods: An an a lyt i cal mod el is de vel oped based on the net pres ent val-ue ap proach con sid er ing all in- and out flows for DMP. Data from the Ger man Fed er al In sur ance Of fice for the DMP Di a be tes Mel li tus Type II is used to cal cu late the mod el de ter min is ti cal ly as well as stochas ti cal-ly by us ing Monte-Car lo Sim u la tion. Re sults: A DMP should only be ini ti at ed if a long term re duc tion of costs seems re al is tic. The mere ini ti a tion of a DMP only leads to a mar-gin al in crease of a health in sur ance fund’s fi nan cial re sources. How ev er, for a Ger man health in sur ance fund of av er age size there is a 99% prob a-bil i ty that the net pres ent val ue ex ceeds an amount of €0.75 Mio.Con clu sion: In com pet i tive so cial health in sur ance mar kets, health in sur ance funds will re ceive in creas ing ly more in stru ments to com pete. The con struct ed mod el can be used to as sess dif fer ent in stru ments, which are linked to the risk struc ture com pen sa tion scheme, en sur ing ef fi cient al lo ca tion of re sources.

0435

Phar ma coeco nom ic eval u a tions as fourth hur dle re quire ment in Hun garySchüler R. (Scher ing AG, Ber lin, Ger many)Lo vas K., Gu lac si L.

Ra tio nale: Hun gary is one of the first coun tries in Cen tral East ern Eu rope (CEE) mak ing use of phar ma coeco nomics in the re im burse-ment pro cess. Due to sim i lar prob lems in CEE (e.g. low er pop u la tion health, low er af ford abil i ty) oth er coun tries may fol low the Hun gar i an ex am ple. Thus, it is es sen tial for the phar ma ceu ti cal in dus try to un der-stand the new sit u a tion.Meth ods: The pre sent ed in for ma tion was gained by lit er a ture re search, by in ter views and by a com par i son of ex ist ing phar ma coeco nom ic guide lines.Re sults: Phar ma coeco nom ic data is need ed dur ing the re im burse ment pro cess of drugs con tain ing new ac tive in gre di ents or for pre mi um price ap pli ca tions. Trans paren cy is in creased due to clear time lines in the de ci sion-mak ing pro cess. Un like many West ern HTA agen cies, the HTA of fice (ESKI) con ducts only desk top re search. Af ford abil i ty and bud get im pact are the main de ci sion cri te ria. The Hun gar i an guide lines cor re spond to oth er guide lines but the re al i sa tion is com plex due to lim-it ed data on epi de mi ol o gy, costs and re source use.Dis cus sion: Be cause of lack of lo cal stud ies and in suf fi cient data there may arise ex pec ta tions to spon sor lo cal health eco nom ic stud ies by phar-ma ceu ti cal com pa nies. Align ment with sim i lar ini tia tives in CEE is

prob a ble and would in crease the pres sure on the phar ma ceu ti cal in dus-try. Fur ther stud ies are need ed to eval u ate the real-life im pact on the re im burse ment pro ceed ings.

0094

At ti tudes and choic es: Are diff er ences a mat ter of task or der?Schwap pach D.L.B. (Uni ver si ty Wit ten-Herdecke, Wit ten, Ger many)Strasmann T.J.

Ob jec tive: We in ves ti gat ed dif fer ences be tween self-ex pli cat ed at tribute im por tance rat ings and at tribute weights de rived post-hoc from a dis-crete choice ex per i ment in a sur vey that as sessed pref er ences to wards sur gi cal care pro vi sion. Meth ods: In a ran dom ized ex per i men tal de sign, 1,273 sub jects pro vid-ed at tribute im por tance rat ings be fore and af ter, or only af ter the ex pe-ri ence of a dis crete choice ex per i ment. We as sessed chang es in at ti tudes in duced by pref er ence mea sure ment and the lev el of agree ment in the at ti tude and pref er ence com po nents be tween the ex per i men tal groups. Re sults: Re spon dents ad just ed their ini tial eval u a tion of at tributes af ter be ing ex posed to the choice task. Three di men sions of ad just ment were ob served: a change in the rel a tive im por tance as signed to at tributes; a de creased over all lev el of at tribute im por tance; and an in creased dis per-sion of at tribute im por tance scores. Rat ings pro vid ed af ter the ex pe ri-ence of trade-off showed bet ter agree ment with the data ob tained in the dis crete choice ex per i ment than ini tial rat ings. Pref er ences ex hib it ed in the choice task were un af fect ed by pri or at tribute rat ings. Con clu sions: The sub stan tial shift in at tribute judg ments we ob served be fore and af ter the choice ex pe ri ence rais es se ri ous doubts about the use of self-ex pli cat ed im por tance weights in the eval u a tion of un com-mon ser vices. At ti tude and choice-based val u a tions might yield data pro-vid ed at ‚dif fer ent states of minds’.

0300

Com par i son of the acute in-pa tient care cost of diff er ent sur gi cal meth ods on a two years fol low up af ter me di al fe mur neck frac turesSebestyén A. (Na tion al Health In sur ance Fund Ad min is tra tion (OEP), Coun ty Baranya Health In sur ance Fund, Pécs, Hun gary)Boncz I., Betle hem J., Nyárády J.

Aim: To an a lyse the acute in-pa tient care cost of dif fer ent sur gi cal meth-ods af ter me di al fe mur neck frac tures on two years fol low up. Data and meth ods: Data de rive from the database of the Hun gar i an Na tion al Health In sur ance Fund Ad min is tra tion. Pa tients un der the age of 60 had me di al fe mur neck frac ture and pri ma ry treat ment in 2000 de fined by the In ter na tion al Clas si fi ca tion of Dis ease (ICD) as “S7200”. Pa tients with poly trau mat ic events and ma jor co mor bidi ties were ex clud-ed from the study. Pa tients were clas si fied into 2 groups: with only pri-ma ry treat ment and with com pli ca tions af ter pri ma ry treat ment. Re sults: Al to geth er 518 pa tients were in clud ed into the study. The dis tri-bu tion of pri ma ry sur gi cal in ter ven tion was: ar thro plas ty 9,3 %, screw fix a tion 79,7 %, dy nam ic hip screw (DHS) 6,6 %, fem o ral neck nail ing 3,4 %, oth ers 1 %. The av er age cost of treat ment was: ar thro plas ty €1357, screw fix a tion €1033, dy nam ic hip screw (DHS) €925, fem o ral neck nail-ing €1094, oth ers €1337. The cost of pa tients with com pli ca tions was sig-nif i cant ly high er ac cord ing to each sur gi cal meth od. Con clu sions: Pa tients with com pli ca tions had a high er acute care cost on a 2 years run. The cost dif fer ence be tween pa tients with and with-out com pli ca tions is the high est in screw fix a tion and fem o ral neck nail-ing.

Eur J Health Econom Suppl 1 · 2006 | S133

0301

Cor re la tion be tween the acute in pa tient cost of me di al fe mur neck frac ture and Gar den clas si fi ca tionSebestyén A. (Na tion al Health In sur ance Fund Ad min is tra tion (OEP), Coun ty Baranya Health In sur ance Fund, Pécs, Hun gary)Boncz I., Betle hem J., Nyárády J.

Aim: To an a lyse the acute in-pa tient care cost of pa tients ac cord ing to Gar den clas si fi ca tion af ter me di al fe mur neck frac tures on two years fol low up. Data and meth ods: Data de rive from the database of the Hun gar i an Na tion al Health In sur ance Fund Ad min is tra tion. Pa tients un der the age of 60 had me di al fe mur neck frac ture and pri ma ry treat ment in 2000 de fined by the In ter na tion al Clas si fi ca tion of Dis ease (ICD) as “S7200”. Pa tients with poly trau mat ic events or co mor bidi ties were ex clud ed from the study. Pa tients were clas si fied into 2 groups: with only pri ma ry treat-ment and with com pli ca tions af ter pri ma ry treat ment. Re sults: Al to geth er 518 pa tients were in clud ed into the study. The dis-tri bu tion of pa tients ac cord ing to Gar den clas si fi ca tion was: Gar den-I: 5,26%; Gar den-II: 20%; Gar den-III:18,98 %; Gar den-IV: 23,29%. The av er age cost of treat ment per pa tient on 2 years run: Gar den-I: €865; Gar den-II: €1043; Gar den-III: €1072; Gar den-IV: €1249. The cost of pa tients with com pli ca tions was sig nif i cant ly high er ac cord ing in each Gar den grade. Con clu sions: There is a strong cor re la tion be tween the med i cal sta tus and treat ment cost of pa tients. Pa tients with high er Gar den grade (more se ri ous cas es) had high er acute in-pa tient care cost on 2 years run. Cost dif fer ence be tween pa tients with and with out com pli ca tions was the high est in pa tients Gar den-IV.

0438

A Com par i son of To tal Di rect Costs of Es c i talo pram vs. Parox e tine in Gen er al ized Anx i ety Dis or derShar ma D. (For est Lab o ra to ries, Inc., Jer sey City, USA)Erder H., Shar ma D., Saikali K.

Back ground: While all SS RIs are now con sid ered first-line treat ment for gen er al ized anx i ety dis or der (GAD), their ad verse event pro files dif-fer sig nif i cant ly and may im pact re source use and over all costs.Ob jec tive: Based on a prospec tive, flex i ble-dose, 24-week clin i cal tri al, this anal y sis com pares the to tal di rect costs of es c i talo pram (n=61) and parox e tine (n=62) as first-line ther a pies for GAD.Meth ods: A to tal of 123 pa tients re ceived dou ble-blind study med i-ca tion. A cost min i miza tion mod el from a man aged care per spec tive was de vel oped con sist ing of 3 re sources: 1) Drug costs were mod eled based on com ple tion and with draw al rates. 2) The costs of ad verse event (as sum ing only 25% of pa tients with ad verse events re ceived treat ment). 3) The costs for switch ing to an oth er ther a py. Ro bust ness of the find ings was test ed with sen si tiv i ty anal y sis.Re sults: Es c i talo pram of fered sig nif i cant sav ings over parox e tine on all re sources used. Due to high er com ple tion rates (es c i talo pram=64%, parox e tine=53%) and low er dos age (es c i talo pram=14.4mg, parox e-tine=29.9mg) es c i talo pram had low er over all drug costs than ge ner-ic parox e tine. Due to a low er in ci dence of ad verse events (es c i talo-pram=77%, parox e tine=89%), es c i talo pram had low er costs for treat-ment. Fi nal ly, due to low er with draw al rates (es c i talo pram=22%, parox-e tine=29%), es c i talo pram had low er costs due to switch ing and fol low-up treat ment.Con clu sion: With high er com ple tion rates and a low er in ci dence of ad verse events, es c i talo pram of fers sig nif i cant cost sav ings com pared with ge ner ic parox e tine or parox e tine.

0229

Can the Phy si cian Sat is fac tion Lit er a ture Pre dict Provi-der Re sponse to a Change in Pri ma ry Care Pol i cy? A Cana di an Case Study Shortt S. (Queen Uni ver si ty Cen tre for Health Ser vices and Pol i cy Re search, Kingston, Can a da)Green M., Hogg W., Shortt S., Gray D., Ross er W., Vin er G., Koller M., Sar ma S., Schultz J.

Dis cus sion/Re sults: This pro ject ex am ined the abil i ty of the lit er a-ture on phy si cian work sat is fac tion to pre dict phy si cian re ac tions to a change in pri ma ry care or ga ni za tion in On tario, Can a da. The gov ern-ment, rec og niz ing the need to re cruit and re tain fam i ly physi cians and to make prac tices more com pre hen sive, cre at ed a pro gram called Fam-i ly Health Net works [FHN]. Key el e ments in clud ed pa tient ros ter ing; blend ed pay ment of cap i ta tion, fee-for-ser vice and bonus es; mul ti dis ci-plinary teams; and en hanced in for ma tion tech nol o gy. Physi cians were told they would find the pay ment for mat yield ed greater in come and that they would find en hanced job sat is fac tion. Our pro ject used sur-vey re spons es and in come tax data to as sess whether the pro gram was cor rect ly de signed to achieve ei ther of these ob jec tives. We found that FHN physi cians were more sat is fied than non-par tic i pants on al most all mea sured di men sions, in clud ing bur den of work, in come-pres tige, per son al re wards, pro fes sion al re la tions and qual i ty of pa tient care, and ap pear to have gen er al ly in creased their in comes. We con clude that the pro gram struc ture is well aligned to com po nents of phy si cian fi nan cial and job sat is fac tion doc u ment ed in the lit er a ture.

0362

Per for mance in di ca tors for qual i ty in health care when abil i ty is pri vate in for ma tionSi cil iani L. (De part ment of Eco nomics, Uni ver si ty of York, UK)Khun M., Si cil iani L.

Dis cus sion/Re sults: Per for mance in di ca tors are in creas ing ly used to reg u late qual i ty in the health care sec tor. Prospec tive pay ment sys-tems clear ly in duce an in crease in cost-con tain ment ef fort, but this may come at the cost of a re duc tion in qual i ty. For ex am ple, if there is ex cess de mand or if de mand does not re spond to qual i ty, and the provider is prof it max imiser, then un der a pure ly prospec tive pay ment sys tem, qual i ty will suf fer (Chak ley and Mal com son, 1998, Eco nom ic Jour nal and 1998, Jour nal of Health Eco nomics). One pos si bil i ty is to in tro duce cost shar ing. A sec ond pos si bil i ty, which pol i cy mak ers seem to have pre ferred, is the de vel op ment of per for mance in di ca tors. We de vel op an ad verse se lec tion mod el, which de rives the op ti mal pay ment scheme, when the abil i ty of the provider is pri vate in for ma tion. We show that there are at least three rea sons for hav ing low-pow ered in cen-tive schemes in health care: a) high er abil i ty in creas es qual i ty di rect ly (and not only through a low er mar gin al cost of qual i ty – in di rect ly); b) in equal i ty aver sion; c) mis re port ing.

0221

Aus tri an stu dents and smok ingSom mersguter-Reich mann M. (Graz Uni ver si ty of In dus tri al Man age ment, Graz, Aus tria)Reich mann G.

Dis cus sion/Re sults: In Aus tria, as in many oth er coun tries, the im pact of smok ing on health has in creas ing ly be come a sub ject of pub lic de bate. As a con se quence, a num ber of mea sures has been tak en, such as a ban on smok ing in pub lic build ings and work places, an in crease in cig a rette prices and warn ing hints on cig a rette pack ets. Fur ther pol i cy mea sures, such as risk pre mi ums in so cial health in sur ance for smok ers have been

S134 | Eur J Health Econom Suppl 1 · 2006

ad dressed from time to time. Over all, there are only few data on the smok ing be hav iour in Aus tria and vir tu al ly noth ing on the ef fect and ap proval of these mea sures. The aim of the pre vail ing study is to an a-lyse in-depth the smok ing be hav iour of col lege and uni ver si ty stu dents in one Aus tri an province (Styr ia), the ef fect of im ple ment ed mea sures on these stu dents’ smok ing be hav iour as well as their at ti tude to wards in tend ed pol i cy mea sures. For that pur pose we gen er ate a strat i fied sam ple of ap prox i mate ly 2% of the pop u la tion of around 40.000 Styr i-an stu dents, the strat i fi ca tion cri te ria be ing uni ver si ty/col lege mem ber-ship, smok ing be hav iour and gen der. The sur vey will be car ried out in spring 2006 and pro cessed us ing a stan dard ised ques tion naire. The cen-tral ques tion is to in ves ti gate whether or not the pol i cy mea sures are ac cept ed as a health ed u ca tion mea sure and there fore have some im pact on smok ing be hav iour among Styr i an stu dents.

0617

Path ways of care and di rect costs as so ci at ed with hip frac ture in state-run health-care sys tems (UK ver sus Hun gary): Con sid er a tions for the ad ap ta tion of the ScHARR os teo po ro sis mod el to a Hun gar i an set tingSoron cz-Sz abó T. (MSD Hun gary Ltd.)

Back ground: Hip frac tures (HFx) make a sub stan tial con tri bu tion to the de nom i na tor of cost-ef fec tive ness mea sures of os teo po ro sis ther a-pies, re gard less of the health-care sys tem in ques tion. Path ways of HFx care and the as so ci at ed di rect cost items, how ev er, show a large de gree of vari a tion in ter na tion al ly, which may cause an eco nom ic mod el work well in cer tain coun tries and pro duce in valid re sults in oth ers. Ob jec tive: To com pare the usu al man age ment path ways and di rect cost items as so ci at ed with HFx in Hun gary and the UK, and ac cord ing ly adapt the os teo po ro sis mod el de vel oped at the School of Health and Re lat ed Re search, Uni ver si ty of Sheffield (ScHARR). Meth ods: An in-depth lit er a ture search was un der tak en on the epi demi-o log ic, eco nom ic and clin i cal data about HFx man age ment in Hun gary and the UK. Se nior man age ment each of a health-care provider and a so cial-care provider in sti tu tion was con tact ed for the ex plo ra tion of hid-den or ig nored di rect costs in Hun gary. Re sults: Cur rent es ti mates of di rect costs of HFx in Hun gary ad dress nei ther the most rel e vant (post meno paus al fe male) pop u la tion, nor the most cost ly cas es (pa tients with co mor bidi ties or com pli ca tions, and those im mo bile af ter pri ma ry sur gery). Some rel e vant ser vices fund ed by the Na tion al Health In sur ance Fund (NHIF) as well as costs cov ered by non-health re lat ed gov ern men tal bud gets or by the pa tient’s fam i-ly are ig nored. Sev er al dif fer ences be tween the two coun tries are to be con sid ered for the ad ap ta tion of the ScHARR mod el: frac ture prev a-lence and in ci dence, out comes of pri ma ry HFx sur gery, hos pi tal stay, and trans fer to long-term care fa cil i ties. In a Hun gar i an set ting, the eco-nom i cal ly im por tant health state of “nurs ing home fol low ing a HFx” in the ScHARR mod el should be re placed with “home care of im mo bile pa tients fol low ing a HFx”, which is much less cost ly (al though not so if fam i ly ex pen di tures and in di rect costs are also con sid ered). Fur ther anal y ses are need ed to show the po ten tial im prove ments in es ti mates when oth er costs are in clud ed, whether cov ered (phys io ther a py, bal ne o-ther a py, pro fes sion al home care, or the ses and oth er de vices, spe cial ist’s vis its, pa tient trav el, com pli ca tions [e.g., in fec tion, bed sore], sec ond ary sur gery [e.g., to tal hip re place ment]) or not cov ered (“so cial homes”, dis-abil i ty al lowance, car pur chase sup port) by the Hun gar i an NHIF. Con clu sion: More rig or ous cost es ti mates and mod elling pa ram e ters of HFx man age ment in the Hun gar i an post meno paus al fe male pop u la tion are nec es sary to en sure the va lid i ty of eco nom ic eval u a tions of os teo po-ro sis ther a pies. One sug gest ed ap proach is the ad ap ta tion of in ter na tion-al ly es tab lished eco nom ic mod els (like that of ScHARR), con sid er ing the ob vi ous dif fer ences in the path ways of care and di rect costs as so ci at-ed with HFx in the UK ver sus Hun gary.

0205

Does on set or qual i ty of pre na tal care mat ter more for in fant health?Sosa-Rubi S.G. (Cen tre for Health Eco nomics. Uni ver si ty of York, UK)

Dis cus sion/Re sults: We in ves ti gate the im pact of the on set of pre na tal care and the qual i ty of health ser vices on the health of the new born. Our spec i fi ca tion is non lin ear and si mul ta ne ous and uses la tent fac tors to al low for un ob served in flu ences on on set and qual i ty of pre na tal care to af fect in fant-health. We ap ply max i mum sim u lat ed like li hood (MLS) tech niques to es ti mate the pa ram e ters of our mod els. We find a pos i tive and sig nif i cant as so ci a tion be tween the qual i ty of care and the health of new borns. The ac cess to pre ven tive health in ter ven tions by preg nant wom en dur ing the pre na tal pe ri od con tributes to the ad e quate de vel op-ment of the preg nan cy and, in con se quence, pos i tive ly in flu ences the health of the new born. On the con trary, we find a small and non sig-nif i cant ef fect of the time ly use of pre na tal care on the weight of the in fant.

0230

Age ing, im pov er ish ment and health care in the Ital ian sys temSpan donaro F. (Uni ver si ty of Rome Tor Ver ga ta, Rome, Italy)Doglia M.

Dis cus sion/Re sults: Fore word of the ital ian pop u la tion is a mat ter of fact; this not only im plies high er ex pens es for the Na tion al Health Ser-vice but also a big ger bur den on house holds for those ex pen di tures not paid for by the pub lic sys tem.and method ol o gy our ar ti cle we will use the ap proach of the WHO that sug gests that the eq ui tative im pact of health care sys tems should be stud ied by ex plic it ly tak ing into ac count ex pen di tures in curred by the house holds and their im pact on the house-hold bal ances. WHO ap proach will be used to show how pop u la tion’s age ing has in flu enced the im pov er ish ment due to health re lat ed ex pens-es of the Ital ian house holds be tween 1997 and 2004.anal y sis is based on IS TAT sur vey on house hold con sump tion.and con clu sion swill be shown how the im pov er ish ment due to health care re lates to the age of the house holds’ ref er ence per son, to the pres ence of at least an el der in the house hold and to the num ber of el ders in the house hold. More over the evo lu tion of these re la tions over the years will be out lined.

0249

Com par i son of diff er ent sources for the costs of In fl am ma to ry Bow el Dis ease in Ger manyStark R. (In sti tute of Health Eco nomics and Health Care Man age ment the GSF – Na tion al Re search Cen ter for En vi ron ment and Health, Neuher berg, Ger many)König H.H., Lei dl R.

Dis cus sion/Re sults: De ter mi na tion of dis ease costs im proves al lo ca-tion de ci sions by pro vid ing fun da men tal in for ma tion to pol i cy mak-ers. How ev er, dis ease costs may dif fer de pend ing on cost source. This study’s aim was to com pare costs of in flam ma to ry bow el dis ease (IBD) in Ger many de ter mined from dif fer ent sources.Med i cal costs of IBD cal cu lat ed from cost-di aries were com pared be tween mem bers of the Ger man IBD as so ci a tion (GIA-mem bers) (n=483) and uni ver si ty out pa tients (U-pa tients) (n=92). Spe cif ic vis-it costs were com pared to cal cu la tions us ing a gen er al-prac ti tio ner database (GP-Data) (n=191). Mean costs, cal cu lat ed us ing the cost-di ary, were sim i lar for GIA-mem-bers and U-pa tients. For ex am ple, mean 4-week di rect med i cal costs of GIA-mem bers were only 27€ high er (95%CI: -141, 194) than of U-pa tients (p=0.8) and mean 4-week costs of gen er al-prac tice vis its of GIA-

Eur J Health Econom Suppl 1 · 2006 | S135

mem bers were only 0.48€ low er (95%CI: –3.9, 2.9) than of U-pa tients (p=0.8). How ev er, mean cost-di ary vis it costs dif fered sig nif i cant ly from database vis it costs. For in stance, mean gen er al-prac tice vis it costs of GIA mem bers were 11€ low er (95%CI: –12, –10) than costs cal cu lat-ed from GP-Data.Thus, mean dis ease costs eval u at ed us ing di aries pro vide con sis tent re sults in var i ous pop u la tions. How ev er, mean med i cal vis it costs de ter-mined by di aries may un der es ti mate true costs as de ter mined from data-bases. De creased cost vari ance would be achieved if cost sources were com bined.

0289

While Moth ers work do chil dren shirk? Tele vi sion view ing and oth er de ter mi nants of youth obe si tyStew art J. (School of Pub lic Pol i cy, Car le ton Uni ver si ty, Ot tawa, Can a da)Chowhan J.

Dis cus sion/Re sults: This re search ex am ines the re la tion ship be tween child obe si ty and ma ter nal em ploy ment by ex am in ing the po ten tial caus al path ways, such as, tele vi sion view ing and ad o les cent dis pos able in come. We use a Cana di an sur vey, the Na tion al Lon gi tu di nal Sur vey of Chil dren and Youth (NLSCY), to study this re la tion ship. We ex tend the knowl edge about the re la tion ship be tween ma ter nal em ploy ment and child obe si ty by ap ply ing anal y sis sim i lar to An der son et al. [2003] for ado les cents be tween the ages 12 and 17 in 2000. We deal with the is sue of po ten tial se lec tion bias into em ploy ment by us ing three meth-ods. First, de tailed data from NLSCY about the moth er is in clud ed in the anal y sis to con trol for any ob served dif fer ences. Sec ond, fixed ef fects mod els are used. These mod els com pare chang es over time of the moth er’s em ploy ment and the child out comes thus con trol ling for un ob served char ac ter is tics that are con stant over time. Third, we use an in stru men tal vari able ap proach to mea sure ex og e nous chang es in ma ter nal em ploy ment. Stud ies have found that weight sta tus as an ad o-les cent is a good pre dic tor of weight sta tus as an adult (Kvaavik et al. [2003]), there fore, these find ings may have pol i cy im pli ca tions in the short-run for labour pol i cy and par ent ing prac tices, and in the long-run for pub lic health.

0501

Are there ‚Spe cial ties’ of Health Eco nomics Pol i cy Ad vice? A Case Study of Ger man Health Pol i cy De ci sion Mak ersSund mach er T. (Uni ver sität Duis burg-Es sen, Cam pus Duis burg, Fach bere ich Be trieb swirtschaft slehre, Lehrge bi et Mikroökonomik, Duis burg, Ger many)Sauer land D.

Dis cus sion/Re sults: Sci en tif ic pol i cy ad vice is faced with the prob lem to have to op er ate in ‚two worlds’ Health economists have it on the one hand eas i er and on the oth er hand hard er. They have it hard er, be cause as sci en tists they must en ter more of ten into ‘oth er worlds’ of oth er re lat-ed sci ences – this dif fers in ex am ple com par ing to ‚clas si cal‘ eco nom ic con sul ta tion. This in ter dis ci plinary ‘dou ble’ some times be cause es pe-cial ly the med i cal sci ence shows far reach ing me thod i cal dif fer ences. How ev er, with a look at pol i cy con sul ta tion health economists have it eas i er just be cause of this sit u a tion in the ‘sci ence sys tem’. This leads to the fact that health economists know much bet ter that there are a lot of oth er per cep tions on a sub ject. This ef fec tive ness of health eco nom ic con sul ta tion will be ex am ined in 100 in ter views. The ques tion ing is a part of a big ger pro ject in which the ef fects of health eco nom ic ex pert’s ad vices on eco nom ic de ci sion mak ers are ex am ined. In the in ter views it is asked first ly for the pro cess qual i ty of the con sul tan cy ser vice (in ex am ple: do sci en tif ic ad vi sors know some thing about the po lit i cal pro-cess and about dif fer ent con sul ta tion func tions?). Sec ond ly, the qual i-

ties of re sults are picked out as a cen tral theme (in ex am ple: witch in flu-ences do they have in re form pro cess es?). In sti tu tion al ar range ment pro-pos als will arise from the ques tion ing re sults. Es pe cial ly the ar range-ment of the in ter face be tween sci ence and con sul ta tion is a source of ef fi cien cy-im prov ing

0502

Ag ing and Health Care Ex pens es. In sti tu tion al In fl u ences on the Causal i tiesSund mach er T. (Uni ver sität Duis burg-Es sen, Cam pus Duis burg, Fach bere ich Be trieb swirtschaft slehre, Lehrge bi et Mikroökonomik, Duis burg, Ger many)Postler A.

Dis cus sion/Re sults: The con nec tion be tween ag ing and health ex pens-es is re mark able at first sight. On the sec ond look the causal i ty sup po si-tion starts to be come blurred. And on the third look in sides into al ter-na tive ex pla na tion con cepts aris es (like the time to death). Em pir i cal re sults too shows very dif fer ent re sults which seem to be driv en also by data and not only by meth o dol o gy. From health-pol i cy view the dis cus-sion is ex treme ly im por tant, be cause very dif fer ent mea sures have to be cho sen. If cost ex plo sion it just an in evitable ef fect of de mog ra phy, fi nanc ing-sid ed mea sures (as for ex am ple a cap i tal cov er) at tain a strong weight. If the time to death plays a de ter min ing roll, in stru ments on the per for mance side (like a re sult-re lat ed re im burse ment) have more im por tance. This pa per fol lows the ques tion which in sti tu tion al set tings in flu ence the con nec tion be tween ag ing and health ex pens es. These set-tings are dis cussed sys tem at i cal ly and their in flu ences are ex am ined with the help of a pro jec tion of the ex pen di tures of the Ger man GKV un til 2040. It is shown that the in sti tu tion al in flu ence is im mense and, hence, very wide ly ‘formable’. For this rea son it is clear that the ef fect of age ing on health ex pens es will dif fer very much in dif fer ent health care sys tems.

0463

Phar ma co ge net ic ap proach of the phar ma coeco nom ic op ti miza tion of an ti de pres sant drug treat mentSzücs F. (De part ment of Phar ma cy, Med i cal School, Uni ver si ty of Pécs, Hun gary)Háber Á, Nya ka B, Fekete S., Botz L.

Back ground: Ma jor de pres sive dis or der is among the most im por-tant caus es of death and dis abil i ty world wide. The eco nom ic bur den of de pres sion reach es $44 bil lion in the US and $346 mil lion a year in Hun gary and these costs are con stant ly in creas ing.Aim: The aim of the cur rent study was to de vel op a sys tem for the phar-ma coeco nom i cal op ti miza tion of an ti de pres sant drug treat ment with the tools of phar ma co ge net ics.Pa tients and meth ods: Un re lat ed in di vid u als with re cur rent de pres sion were screened for med i ca tion his to ry, phar ma coeco nom ic prop er ties and the prev a lence of the most com mon cau casian al lel ic vari ants of CYP 2D6 and 2C19 en zymes.Re sults: The du ra tion of treat ment was av er age ly 64 months. The mean of chang es in an ti de pres sant ther a py was 2,26. Two-third of ther a py chang es were due to in ef fec tive ness. The cost of one change in an ti de-pres sant treat ment means $1200 al to geth er. The DDD based dai ly phar-ma co ther a py cost for out pa tients was $0,76 in av er age.Con clu sion: Us ing the tools of phar ma co ge net ics for pa tients with al tered drug metabolis ing en zymes we could re duce the num ber of ther-a py chang es and in ef fec tive cas es by 10-15%. That means the eco nom-ic gain for di rect costs in 1 patent would be ap prox $24 per year, and it only rep re sents about 45% of all eco nom ic im pact of de pres sion. In con-trary the cost of phar ma co ge net ic screen ing not ex ceeds $500.

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0181

To bac co and Al co holTauch mann H. (RWI Es sen, Ger many)Göhlmann S.

Dis cus sion/Re sults: The ques tion of whether two drugs: name ly al co-hol and to bac co: are used as com ple ments or sub sti tutes is of cru cial in ter est if side-ef fects of anti-drug poli cies are con sid ered. Nu mer ous pa pers have em pir i cal ly ad dressed this is sue by es ti mat ing de mand sys-tems for al co hol and to bac co and sub se quent ly cal cu lat ing cross-price ef fects. How ev er, this tra di tion al ap proach of ten is se ri ous ly ham pered by in suf fi cient price-vari a tion ob served in sur vey data. We, there fore, sug gest an al ter na tive in stru men tal vari ables ap proach that sta tis ti cal ly mim ics an ex per i men tal study and does not rely on prices as ex plana to-ry vari ables. This ap proach is ap plied to Ger man sur vey data. Our es ti-ma tion re sults sug gest that a re duc tion in to bac co con sump tion re sults in a re duc tion in al co hol con sump tion, too. We, there fore, con clude that suc cess ful anti-smok ing poli cies will not re sult in the un in tend ed side-ef fect of an in creased (ab)use of al co hol.

0149

Mea sur ing the Effi cien cy of In for ma tion and Com mu ni ca tion Tech nol o gy In vest ment in health careTesti A. (Uni ver si ty of Gen o va, De part ment of Eco nomics and Quan ti ta tive Meth ods, Gen o va, Italy)Tan fani E., Ival di E.

Dis cus sion/Re sults: Over the last decade health care or ga ni za tions have been in creas ing ly in vest ing in In for ma tion and Com mu ni ca tion Tech-nol o gy (ICT)., lit er a ture fo cus es on the iden ti fi ca tion of the ap pro pri ate meth o dol o gy to eval u ate the ef fi cien cy of ICT in vest ment in health care de liv ery. In fact, the ICT in vest ment in non prof it or ga ni za tions should not be car ried out us ing tra di tion al in stru ments based on eco nom ic and fi nan cial meth ods. Start ing by the o ret i cal in sights from health eco-nomics and op er a tional re search lit er a ture, this pa per de vel ops a frame-work for mea sur ing ef fi cien cy of ICT pro jects us ing Data En vel op ment Anal y sis (DEA). While DEA ap proach es usu al ly take into ac count only one spe cif ic stage of the pro cess (e.g. tech ni cal im ple men ta tion phase), here a non- lin ear pro gram ming mod el is used to eval u ate the im pact of ICT in vest ment on the mul ti ple stag es of the wider pro cess, or chain, of care de liv ery.par tic u lar the ini tial in put mea sure (IT in vest ment) is split on the suc ces sive stag es of the pro cess and the out put mea sures of the first stage (em ploy ees and hard ware as sets) are used as in puts of the sec ond step and so on. A case study about 12 ICT pro jects car ried out in an Ital ian Re gion al Health Sys tem is anal y sed. Com pu ta tion al re sults are pre sent ed to geth er with some in sights and crit ics.

0250

Screen ing to pre vent pre-term birthTsoura pas A. (Health Eco nomics Fa cil i ty Ser vices Man age ment, Cen tre of Birm ing ham, UK)Rob erts T., Jowett S., Bar ton P.

Dis cus sion/Re sults: Pre-term de liv ery, par tic u lar ly be fore 34 weeks’ ges-ta tion, ac counts for three-quar ters of neo na tal mor tal i ty and one-half of long term neu ro log i cal im pair ment in chil dren. In cor rect or de layed di ag no sis can put moth er and baby at risk of an ad verse out come and im pose sig nif i cant costs. In con trast, the cor rect pre dic tion al lows an op por tu ni ty to in sti tute ef fec tive ther a peu tic in ter ven tions. Ob ste tri-cians rou tine ly in cor po rate many test re sults into their de ci sion mak-ing pro cess for man ag ing wom en at risk of pre-term birth, but stud ies to ex am ine the ways in which even a small num ber of these tests al ter the ben e fit and harm of treat ments are rare. The ev i dence from sys tem-

at ic re views of ac cu ra cy and ef fec tive ness stud ies will pro vide the pa ram-e ters re quired for the eco nom ic eval u a tion. These data will be syn the-sised in a de ci sion tree mod el fa cil i tat ing com par isons for the var i ous stra te gies for di ag no sis or pre dic tion of pre-term labour, with var i ous pre ven ta tive in ter ven tions, in terms of ef fec tive ness and costs. The dis tri-bu tions as so ci ate with the pa ram e ters will be used to per form prob a bilis-tic sen si tiv i ty anal y sis with in a Bayesian frame work. This study, com mis-sioned by the UK’s Na tion al Co-or di nat ing Cen tre for Health Tech nol-o gy As sess ment (NC CH TA) on be half of the Na tion al Screen ing Com-mit tee (NSC), is re quired to re port to the NSC in July 2006.

0292

The pros and cons of wait ing for careVan Exel J. (Eras mus MC, In sti tute for Med i cal Tech nol o gy As sess ment (iMTA) & De part ment of Health Pol i cy and Man age ment (iBMG), Rot ter dam, Nether lands)Brouw er W.B.F.

Dis cus sion/Re sults: Wait ing for care is com mon and in sur mount able in many pub licly fund ed health care sys tems. Gen er al ly, wait ing lists are seen as a fair ra tioning mech a nism when re sources are scarce, as pri or-i ty for treat ment is based on wait ing time and ur gen cy. Lengthy wait-ing times have how ev er been a pub lic and po lit i cal con cern, as wait ing may come with costs to the pa tient and the pa tient’s fam i ly and em ploy-er. These ef fects have pri mar i ly been in ves ti gat ed for peo ple wait ing for hos pi tal care. con duct ed in ter views with 193 peo ple wait ing for nurs ing home, res i den tial and home care. Per ceived wait ing times were slight ly high er than ac tu al val ues. 80% was in need of as sis tance, of whom 75% re port ed suf fi cient in ter mit tent care. About half in di cat ed their health had de te ri o rat ed while wait ing, 20% re port ed ad di tion al costs as so ci-at ed with wait ing. 45% of in for mal care givers was rea son ably to over-strained. Most peo ple in di cat ed hap pi ness would in crease in case they would re ceive the care they had been wait ing for im me di ate ly or would be giv en a wait ing time guar an tee, ex cept for im me di ate ad mis sion to nurs ing home or res i den tial care fa cil i ty. Al though al most half found their wait ing time un ac cept able, will ing ness to pay to re ceive care im me-di ate ly of ten was nil, oth er wise mod er ate.

0294

In for mal Care givers Val u a tion of Their Time In puts – with a Lit tle Help from an An chorVan Exel J. (Eras mus MC, In sti tute for Med i cal Tech nol o gy As sess ment (iMTA) & De part ment of Health Pol i cy and Man age ment (iBMG), Rot ter dam, Nether lands)Brouw er W.B.F., Koop man schap M.A.

Dis cus sion/Re sults: Many peo ple pro vide sup port to dis eased fam i ly mem-bers or friends. The time spent on care giv ing ac tiv i ties may be sub stan-tial, and of ten the per ceived bur den goes be yond the care giv er´s sup port-ing ca pac i ty. Sub stan tial bur den is as so ci at ed with health, psy cho log i cal, so cial and fi nan cial prob lems., in many coun tries, health care bud gets are un der pres sure and the sys tem in creas ing ly re lies on in for mal care givers to fill the re sult ing gaps at the front and back doors of health care. In part this is be cause in for mal care most ly is val ued too low or not at all in eco-nom ic eval u a tions, mak ing it a rel a tive ly cheap sub sti tute for pro fes sion al care. con duct ed a study to iden ti fy, mea sure and val ue in for mal care givers time in puts for use in health eco nom ic eval u a tions. One of the meth ods used to val ue time was con tin gent val u a tion, us ing both open-end ed and dis crete-choice with fol low-up elic i ta tion for mats. We pres ent the re sults from three con sec u tive con tin gent val u a tion ex per i ments and ev i dence of an chor ing in the dis crete-choice elic i ta tion for mat. We dis cuss the ef fect of sub jec tive bur den on time val u a tion, pos si ble an chors peo ple used in their val u a tion, and the main pros and cons of the mea sure ment meth od as com-pared to oth er meth ods we used to val ue in for mal care giv er time.

Eur J Health Econom Suppl 1 · 2006 | S137

0356

Clin i cal effi ca cy and eco nom ic ben e fi ts of psy cho so cial on col o gy careVárady E. (Na tion al Inst.of On col o gy, Bu dapest, Hun gary)

Dis cus sion/Re sults: Clin i cal ef fi ca cy and eco nom ic ben e fits of psy cho-so cial on col o gy care health care costs con tin ue to rise, de ci sion mak ers must al lo cate their in creas ing ly scare re sources to ward ther a pies which of fer the most ben e fit per unit of cost. To be con sid ered by these de ci-sion mak ers, ef fi ca cy of psy cho so cial in ter ven tions in can cer pa tients and their out comes must be known. Psy cho so cial dis tress is a sig nif i cant prob lem for one-third to one-half of all can cer pa tients. How ev er, few-er than 10 % of pa tients are ac tu al ly iden ti fied and re ferred for psy cho-so cial help. Unat tend ed dis tress can con tribute to poor treat ment com-pli ance, in creased hos pi tal stays, and pos si bly mor tal i ty. Psy cho log i cal in ter ven tions of fered as an ad junct to the med i cal care of re cent ly di ag-nosed can cer pa tients aim to pre vent dis tress and en hance cop ing styles. As some ran dom is ed stud ies have found that pa tients who have re ceived psy cho so cial in ter ven tion show not only im proved qual i ty of life scores but tend to live lon ger. Psy cho so cial in ter ven tions saves mon ey by re duc-ing un nec es sary of fice vis its, med i cal pro ce dures, and hos pi tal ad mit-tance. The es ti mat ed ben e fit of psy cho so cial care is much greater than the cost of the psy cho log i cal ser vice. Au thors want to con vince de ci sion mak ers that psy cho so cial in ter ven tions have proven ef fi ca cious for help-ing can cer pa tients and not only ef fec tive, but also eco nom i cal.

0238

Com par ing the cost eff ec tive ness of smok ing pre ven tion with smok ing ces sa tionVi j gen S. (Na tion al In sti tute for Pub lic Health and the En vi ron ment, Cen tre for Pre ven tion and Health Ser vices Re search, Bilthoven, Nether lands)

Dis cus sion/Re sults: Most peo ple start smok ing for the first time when they are young. There fore to bac co con trol pol i cy in ado les cents is po ten-tial ly very re ward ing. In this study health ef fects and cost ef fec tive ness of two dif fer ent school pro grams were com pared one that re duces smok-ing ini ti a tion among ado les cents, and one that in creas es quit rates. trans-late ef fects on quit and ini ti a tion rates into health gains the RIVM Chron-ic Dis ease Mod el (a dy nam ic pop u la tion mod el) was used. This mod el al lows es ti mat ing ef fects of smok ing in ter ven tions on smok ing re lat ed dis eases, gains in (qual i ty ad just ed) life years and ef fects on health care costs. the in ter ven tion costs of the smok ing pre ven tion pro gram were high est, cu mu la tive QALYs gained were high est as well. The costs per QALY, if dif fer ences in health care costs were tak en into ac count, did not dif fer sig nif i cant ly from each oth er and were about € 20,000 per QALY gained. ef fec tive ness of the dif fer ent school pro grams do not dif-fer much. More health gains can be ex pect ed from smok ing pre ven tion pro grams, since there is much un cer tain ty about the ef fec tive ness of the school in ter ven tions with re spect to dai ly smok ing. There fore these re sults should be in ter pret ed with cau tion.

0464

Eco nom i cal Im pact of Sub cu ta ne ous Am i fos tine in the Kaiser Per ma nente Health Care Sys temWang R. (South ern Cal i for nia Kaiser Per ma nente, Los An ge les, USA)Hast ings J., Ka gan R., Tome M.

Back ground: We have pre vi ous ly re port ed that Sub cu ta ne ous am i fos-tine (SQ A) was safe and ef fec tive in de creas ing the ear ly and late com-pli ca tions of pa tients (PTS) treat ed with ra dio ther a py (RT) or chemora-dio ther a py (CRT) for head and neck can cer (HNC). We have fur ther ob served that the QOL is bet ter for many PTS treat ed with SQ A com-

pared with his tor i cal con trols (HC). Al though we be lieve we can not put a price on QOL, we hy poth e sized that the use of SQ A could re sult in cost sav ings to our in sti tu tion be cause of the ob served de crease in treat-ment-re lat ed com pli ca tions. Meth ods: From May 2001 to Oc to ber 2004, we treat ed 52 con sec u tive HNC PTS with RT or CRT and dai ly SQ A. PTS treat ed in our SQ A pro-to col re ceived 500 mg of SQ A at least 30 min utes pri or to dai ly RT. In or der to be in clud ed in our pres ent study, SQ A PTS had to have com-plet ed at least 80% of the pre scribed SQ A dose. These PTS were then matched with HC based on age, sex, stage, pri ma ry site, smok ing sta-tus, co-mor bidi ites, and treat ment (RT or CRT). Four teen PTS treat ed with SQ A (SQ A Group) were suc cess ful ly matched with HC (Con trol Group). The en tire costs of these 28 PTS to our in sti tu tion (in clud ing the cost of SQ A) was ob tained us ing our Man age ment Ac count ing and Anal y sis database. Cost data was ob tained at 6 months and 12 months af ter the com ple tion of treat ment. The me di an fol low-up is 18 months (range 12-31). The eco nom i cal im pact of SQ A on xe ros to mia and den-tal care were not ad dressed in this study. Re sults: Ten PTS re ceived RT and 18 re ceived CRT. At 6 months of fol low-up, the to tal cost for the Con trol Group was $196,789 ver sus $211,711 for the SQ A Group (p= 0.59). At 12 months, the to tal cost in the Con trol Group and SQ A Group were $287,594 and $275,654 re spec tive ly (p=0.51). With in the SQ A Group, the cost was low est in PTS who had nev er smoked or had a re mote (>5 years) smok ing his to-ry (p<0.01). Con clu sions: This study pri mar i ly ad dress es one of SQ A’s cy to pro tec-tive prop er ties, mu co si tis. Our anal y sis sug gests that we were able to off set the cost of SQ A in most PTS be cause of few er com pli ca tions ob served in this group. The cost ben e fit of SQ A ap pears to be greater at 12 months vs. 6 months af ter treat ment, sug gest ing con tin ued cy to-pro tec tion.. QOL is bet ter in the SQ A Group. We plan to con tin ue to fol-low these PTS and ac crue new ones in a prospec tive fash ion.

S138 | Eur J Health Econom Suppl 1 · 2006

A

Aal to nen, J. #0345 Aas, E. #0161 Aa vik soo, A. #0355 Abe gun de, D. #0061, #0151 Abel lan, J.M. #0579 Abra ham, D. #0316 Ach dut, L. #0370 Ács, N. #0570 Adda, J. #0045 Ad or ján, R. #0549 Adri an na, C. #0085 Ahn, N. #0113, #0261 Akan de, T.M. #0061 Ak ka zie va, B. #0074 Ala ry, D. #0375 Al ber to, C. #0291 Ales sie, R. #0372 Al-Jana bi, H. #0083 Al lin, S. #0167, #0200, #0446 Amal, D. #0341 Ama ya-Ama ya, M. #0213,

#0388 Ame lung, V.E. #0201 An der sen, G. #0098 An ders son, H. #0154, #0165 And lin-So bocki, P. #0256,

#0257, #0258 An drew, S. #0087, #0596 An e ga wa, T. #0367, #0369 An ell, A. #0226 An ger mey er, M.C. #0204,

#0206, #0343 Ania, A. B. #0211 An ker, G. #0263 Anna, Ko vács, A. #0498 An tai, I. #0386 Antón, E. #0050 An tonio, P.L. #0118 Ap p le by, J. #0209 Araña, J. #0210 Aris te, R. #0364 Arm strong, J. #0040, #0212 Arntz, M. #0253 As kild sen, J. E. #0476 At til la, V. #0370 Atun, R.A. #0591 Au, F. #0107 Au di bert, M. #0022 Au er bach, H. #0166 Au gurz ky, B. #0323 Ave ry, AJ. #0091 Ave ry, T. #0138

B

Baal, P. #0373 Ba ba lis, D. #0544, #0546 Ba du ra, B. #0606 Bae, EY. #0303

Bae za, C. #0587 Ba ker, R. #0328, #0346, #0487 Balázs, P. #0011, #0068, #0497,

#00667 Ba lia, S. #0410 Bal san, D. #0394 Bal tus sen, R. #0243 Ba ner jee, R. #0178 Ba ra nyi, L. #0511, #0513, #0514 Bar ber, P. #0357 Bar bie ri, E. #0433, #0484Bar bui, C. #0451, #0484Bar dey, D. #0468, #0469 Bar nay, T. #0374Bar ra chi na, I. #0411Bar re, S. #0478Bar rel la, A. #0128Bar ros, P.P. #0084, #0092,

#0157, #0296, #0311, #0454, #0484

Bar ton, G.R. #0090, #0091, #0138Bar ton, P. #0246, #0247, #0250,

#0351 Bar ton, PM. #0262 Bar tozs, P. #0499 Bas si, L. #0448 Bas ti da, J.L. #0272 Basu, K. #0389 Bate, A. #0337, #0440, #0615 Ba teman, I. #0487 Bau er, A. #0227 Bech, M. #0098, #0140 Beck, K. #0063, #0088, #0119,

#0137 Be cker, B. #0129, #0416 Be cker, K. #0024 Beek man, A. #0079 Beh rend, C. #0063 Bei ra, B. #0605 Béjean, S. #0402 Be la za, J. #0109 Be licza, E. #0611 Bell, D. #0189 Be mel mans, W. #0373 Be ne dict, A. #0528, #0529 Berg, J.E. #0072 Berg gren, F. #0207 Ber nal-Del ga do, E. #0396 Ber nar di, B. #0370 Ber nats ky, S. #0479 Ber net, P. #0023 Ber ni ce Ober man, M.A. #0331 Bet le hem, J. #0300, #0301,

#0313, #0318 Bien, F. #0375 Bigi, R. #0218, #0325 Bird, S. #0338 Birk, H.O. #0010 Bi schof, M. #0239, #0248 Bjos lashrk, S. #0076 Björn gaard, J.H. #0252, #0360

Blais, R. #0111 Blai se, D. #0343 Bleich rodt, H. #0579 Blom, M. #0321 Bo dro gi, J. #0483 Bo hi gas, L. #0380 Bo lin, K. #0350 Bo luar te, T. #0095 Bom mier, A. #0468 Bon cz, I. #0102, #0103, #0125,

#0260, #0300, #0301, #0313, #0318, #0489, #0498, #0548, #0555, #0556, #0611

Bon dar, E. #0513, #0514, #0515 Bo net, M.J. #0332 Boom, G. #0171 Boo nen, L. #0036Borc sek, B. #0489, #0498, #0555 Bor gia, P. #0352, #0379, #0381,

#0399Bor ka, P. #0506 Bos hui zen, H. #0158 Bo sko vic, T. #0081 Bos mans, J.E. #0079, #0080 Botz, L. #0462, #0463 Bou reil le, B. #0016 Bour gueil, Y. #0395 Bou ter, L.M. #0079, #0080 Bou vard, L. #0145Bou w mans, C.A.M. #0447Brandt mul ler, A. #0074, #0556,

#0570, #0577Brek ke, K.R. #0314, #0344 Bré mond, A. #0390 Brey er, F. #0125 Bridges, J. #0074, #0148, #0173 Bridges, J.F.P. #0179 Briggs, A. #0385 Brodsz ky, V. #0562, #0601,

#0607 Bro sa, F. #0380, #0421 Brou wer, W.B.F. #0243, #0245,

#0292, #0294, #0312, #0445 Brown, T. #0142, #0143 Brui jn, D. #0099 Brui j ne, M. #0079 Brun, J-F. #0022 Brüg gen jür gen, B. #0365 Bry an, S. #0131, #0246, #0262,

#0274, #0348, #0349, #0351 Buch mu el ler, T. #0032 Burls, A. #0246 Bus se, R. #0174, #0465 Bux ton, M. #0434 By wa ter, T. #0152

C

Ca bal ler Ta ra zo na, M. #0411 Ca ba nas, M. #0120 Cae ser, M. #0162 Cairns, J. #0225 Cal vert, M.J. #0131 Ca mos so-Ste fi no vic, J. #0328 Cap pel li, S. #0470 Car ra ge ta, M. #0159 Car ra re, MO. #0390

Car re ra, P. #0148, #0173 Car re re, M.O. #0096, #0507,

#0608 Car rie, C. #0608 Car ter, R. #0308, #0309 Cas tel li, A. #0359 Ca va lie ri, M. #0409 Cer co ne, J. #0020 Cer za ni, M. #0451 Céu, M. #0541 Chae, S. #0139 Chai, P.Y. #0518 Cha kra b or ty, S. #0081 Chal kley, M. #0388 Chang, R.E. #0428, #0429 Chechei baev, E. #0304 Che vrou-Sé ver ac, H. #0421 Chis holm, D. #0203, #0520 Chowhan, J. #0289 Chris tian sen, T. #0076 Chri sto dou lou, I. #0543,

#0544, #0545, #0546, #0547 Chung, W. #0070 Cic chi tel li, F. #0169 Ci co nel li, R.M. #0048, #0049 Clar ke, A. #0479 Clau sen, LB. #0098 Cla ve ro, A. #0412 Clean thous, P. #0001 Cle land, J.G.F. #0131 Cle men te, J. #0004 Clí ma co, M.I. #0311, #0098 Clo son, M.C. #0538 Coast, J. #0026, #0033, #0083,

#0133 Co hen, Y. #0002 Col lett, B. #0385 Co mas-Her re ra, A. #0183 Com pa dri, P. #0449 Cond lif fe, S. #0251 Con ti, S. #0382 Coo mer, N. #0439 Cor bil lon, E. #0478 Cor nag lia, F. #0045 Cor na go, D. #0448, #0449,

#0450, #0452 Cor ne lis, B. #0171 Co ro na, A. #0264 Coru ge do, I. #0050 Costa, Font, J. #0405, #0406 Cour ba ge, C. #0039 Cri so sto mo, S. #0123, #0403 Crom well, J. #0241 Cur rais, L. #0134 Cur ta le, F. #0379 Czir ják, L. #0601

D

Dankner, R. #0003 Dan tas, A. #0591 Dario, G. #0325 Daub ner, M. #0498 Dávid, T. #0577 Da vid son, T. #0383 Daw son, D. #0085 Daw son, S. #0363

Eur J Health Econom 2006 · [Suppl 1] 7:139–143

DOI 10.1007/s10198-006-0370-1

© Springer Medizin Verlag 2005

Eur J Health Econom Suppl 1 · 2006 | S139

Index

De Bek ker-Grob, E.W. #0342 De Brui j ne, M.C. #0080 De Gae ta no, A. #0117 De la Puen te, ML, #0380 De Soa rez, P.C. #0049 De Wit, G.A. #0233, #0276 Dea les, A. #0169 De brand, T. #0374, #0378, #0407 De col lo gny, A. #0330 Deeg, D. #0372 Del ga do, J. #0280 Déméo this, C. #0334 Dench, H.C. #0235 De si de ri, A. #0218, #0325 Despou di, K. #0546 Des quins, B. #0330, #0519 Deu chert, E. #0008 De vaux, Y. #0507 Dev lin, N. #0209 De za teux, D. #0335 Di, Gi u lio, E. #0393 Di jk graaf, E. #0028 Di ma k ou, S. #0209 Does sel, D. #302 Do g lia, M. #0230, #0352 Do her ty, M. #0091, #0138 Domín guez Ugá, M.A. #0038 Do nald son, C. #0337, #0346,

#0440, #0487, #0615 Do nia So fio, A. #0117 Don ker, M.C.H. #0447 Dor, A. #0127, #0269 Dor mont, B. #0371 Dos tie, B. #0164 Dour gnon, P. #0368 Dóz sa, Cs. #0162, #0260,

#0313, #0318, #0489, #0497, #0498, #0555

Dri ma la, M. #0546, #0547 Drum mond, M. #0334,

#0495 Duffy, C. #0479 Du four-Kip pe len, S. #0199 Du ran te, G. #0393 Dwor kin, R. #0385 Dzi worski, W. #0550

E

Ea gan, L. #0405 Ea ton, K. #0068 Eco no mou, A. #0006, #0007 Ede balk, P.G. #0069 Ed wards, RT. #0152 Eh lers, L. #0098 Ei sen, R. #0267, #0283 Eke, E. #0554 Ek man, M. #0256, #0257, #0258 El he wai hi, M. #0606 El liott, R. #0189 El liott, R.F. #0320 Em blem, A.W. #0457 Em neus, M. #0076 En ci no sa, W. #0127 End veld, M. #0370 Ene mark, U. #0319 Er der, H. #0438

Erdész, D. #0568, #0570 Esch bach, MA. #0392 Et ner, J. #0453 Eugs ter, P. #0089 Evans, N. #0363 Exel, NJA. #0243, #0245

F

Fa lu si, Zs. #0260, #0548 Fa rag, H. #0481, #0482 Farr ar, S. #0388, #0401 Fau cher, C. #0343 Fau li, S. #0071, #0187 Fa varo, D. #0510 Fe de ri ci, A. #0379, #0381,

#0399, #0532 Feen stra, T. #0158, #0373 Fe ke te, S. #0463 Fel der, S. #0255 Feld man, D. #0479 Fer ran dob, A. #0218 Fer ra ra, M. #0393, #0399 Fer raz, M.B. #0048, #0049 Fer rei ra, L.N. #0293 Fer rei ra, P.L. #0293, #0310,

#0454 Fil ip pi ni, M. #0282 Fitz mau ri ce, D. #0274 Flynn, T. #0026, #0033, #0083,

#0133 Fold spang, A. #0319 For, a, R. #0191 Fors berg, B. #0509 Fra gou la kis, V. #0054 Frank, R.G. #0232 Fran zet ti, F. #0264 Freed man, L.S. #0219 Free man, T. #0348, #0349 Free mant le, N. #0131 French, M. #0034, #0035 Frew, E. #0271, #0317

G

Gaal, P. #0542 Gá bor, J. #0184 Ga jic-Ste va no vic, M. #0018 Gal de a no, A.S. #0484 Ga me ren, E. #0009, #0208 Gan der, P. #0599 Gan non, B. #0047, #0051 Ga rat ti ni, L. #0450, #0451,

#0452, #0472, #0448, #0449 Gar cía, E. #0475 Gar cía, Gó mez, P. #0268 Gar cia-Goni, M. #0062 Gar gett, S. #0141 Ga ruz, R. #0194 Gar vey, E. #0415 Gash, V. #0030 Gem mill, M. #0059 Gen ti, Gy. #0601 Geof fard, P-Y. #0371 Ge rard, K. #0496 Ge ren csér, Zs. #0184 Ger fin, M. #0398

Ger ma na, H.R. #0046 Ghis lan di, S. #0472, #0473 Gho ba ri, Bo n ab, B. #0287 Giam ma ri le, F. #0608 Gia ni no, M.M. #0191 Gi an no ni, M. #0488 Gib bon, M. #0479 Gior da ni, C. #0295 Gi ral des, M.R. #0005 Gi ralt, X.M. #0092 Gis bert, R. #0380 Git to, L. #0533 Glus sich, A. #0364 God dard, M. #0065 González, L.M. #0585 Gon za lez Lo pez-Val car cel, B.

#0357González, M.C. #0585 González-Al va rez, #0412 Goo de, A. #0213 Gor do, L.R. #0030 Gorp, B. #0245 Go the, H. #0162 Gou veia Pin to, C. #0159 Göhlmann, S. #0181, #0323 Grab ka, M. #0465 Gra ham, B. #0235 Gramain, A. #0397 Gran s tedt, H. #0153 Gras dal, A. #0476 Grä ßel, E. #0106 Gra vel le, H. #0085, #0320, #0339 Gray, A. #0326, #0335 Gray, D. #0229, #0526,

#0571 Green, A. #0076 Green, M. #0229 Gre go ri, D. #0325 Gre go rie, D. #0218 Grei ner, W. #0606 Greß, S. #0063, #0088, #0223,

#0323 Gre wal, I. #0026 Grie ve, R. #0086 Gri gnon, M. #0032, #0368 Gron din, D. #0592 Groot, M. #0171 Groß feld-Schmitz, M. #0106 Gu a stic chi, G. #0379, #0381,

#0393, #0399 Guc cio, C. #0240, #0409 Gu lac si, L. #0074, #0313,

#0435, #0548, #0556, #0562, #0577, #0601, #0607

Gupta, A. #0389 Gupta, N.D. #0082 Gu rol-Ur gan ci, I. #0591 Gün ther, O. #0204, #0206 Gyar ma thy, K. #0569 Gye nes, M. #0497 Gym no pou los, D. #0544

H

Há ber, Á. #0463 Ha bicht, J. #0203, #0520 Haby, M. #0309

Ha gen, T.P. #0299, #0492 Ha gist, C. #0013 Hais ken-De New, J. #0242 Hak kaart, L. #0447 Häk ki nen, U. #0180, #0237, #0597 Hal li day, M. #0535 Han cock, R. #0183 Han sen, K.S. #0319 Har ding, A. #0589 Hart mann, L. #0522 Has tings, J. #0464 Hauck, K. #0043 Häuss ler, B. #0162 He hen kamp, B. #0100 Her c zeg, B. #0506 Her mens, M.L.M. #0080 Her na e lig;s, K. #0471 Her nan dez-V, J.A. #0460 Hes h mat, S. #0044 Hes sel, F. #0220, #0244, #0263,

#0265 Hi dal go, Á. #0050 Hirtz lin, I. #0491 Hjelm gren, J. #0226 Hogg, W. #0229 Hole, A.R. #0320 Hol le, R. #0106 Hol lings worth, B. #0041,

#0042, #0043, #0461 Hol lo, I. #0215 Hol mas, T.H. #0185 Hol mes, J. #0363 Hol ly, A. #0330, #0519 Hon ka lam pi, T. #0426 Hoo gen veen, R. #0158, #0373 Hop, J.P. #0195 Hop kins, S. #0019 Hor váth, K. #0529 Hou gaard, J.L. #0101 Hout, H. #0079 Hsieh, M.F. #0428 Hsu an, F. #0023 Hu bicki, L. #0400 Hu gue nin, J. #0421 Hulst, M. #0392 Hut chings, J. #0152 Hut ton, J. #0578 Hyde, C. #0114

I

Ibe rn, P. #0062 Icar di, G.P. #0191 Iken wi lo, D. #0189, #0388 Il gin, Y. #0267, #0283 Ilku, L. #0498 In darat na, K. #0144 Ito, M. #0122 Ivády, V. #0523 Ival di, E. #0149, #0150 Ivan cocs ky, M. #0219 Iver sen, T. #0175, #0188

J

Jaa na, M. #0327 Ja cobs, R. #0065, #0066, #0085

Index

S140 | Eur J Health Econom Suppl 1 · 2006

Ja farov, A. #0304 Ja kab, M. #0304, #0305 Ja mi son, J. #0014 Jans son, S. #0077 Ja nus, K. #0201 Jara, M. #0460 Jär brink, K. #0153 Jär viö, M.L. #0345 Jas mi na, J.I. #0171 Je le va, M. #0453 Je lic, G. #0593 Jen kin son, C. #0091, #0138 Jes se, M. #0355 Jo ban pu tra, P. #0246 Job bagy, J. #0516 Jo hans son, P. #0118 John ston, D. #0107 Jóna, G. #0551, #0552 Jones, A.M. #0163 Jor gen sen, N. #0120 Jo wett, S. #0250, #0274, #0317 Jöns son, B. #0256, #0257, #0258 Jöns son, L. #0052 Juan, O. #0272 Jua rez-Gar cia, A. #0183, #0317,

#0328 Jul li en, B. #0468 Jun jan, V. #0537 Ju noy, J.P. #0472 Ju sot, F. #0032, #0368, #0378

K

Kaamb wa, B. #0262 Kaar boe, O. #0100, #0185,

#0492 Ka gan, R. #0464 Ka ha na, B. #0524, #0525 Ka ha na, E. #0524, #0525 Kal las te, E. #0355 Kalo, Z. #0483, #0506 Ka na vos, P. #0405, #0406 Kan gas har ju, A. #0288 Kar pa ti, K. #0556, #0577 Kär vin ge, C. #0207 Ke dem, R. #0003 Kel ley, E. #0613 Ken kel, D. #0387 Ken nel ly, B. #0536, #0415 Kerr, R. #0326 Kho da ya ri fard, M. #0287 Khun, M. #0362 Kidd, M. #0019 Ki li an, R. #0534 Kim, C. #0139 Kim, W. #0001 Kind, P. #0170 King, D. #0183, #0423 Kit tel sen, S.A.C. #0471, #0597 Kjae se rud, G. #0505 Kjos las hl by, M. #0098 Klaauw, B. #0315 Kla zin ga, N. #0594,#0604 Kleo phas, W. #0566 Kliemt, H. #0125 Klok, R. #0392 Knapp, M. #0423, #0485, #0535

Knu ut ti la, M. #0237 Ko, S. #0139, #0176, #0190 Ko belt, G. #0562, #0601 Ko ciel, P. #0400 Ko i nu ma, N. #0122 Kok, L. #0195, #0208 Kol ler, M. #0229 Kon nop ka, A. #0202 Kon to di mo pou los, N. #0110 Ko op man schap, M.A. #0294,

#0466 Kósa, J. #0572, #0573, #0574 Kos ki nen, H. #0327 Kóti, T. #0103, #0260 Kot li koff, L.J. #0013 Ko to mä ki, T. #0426 Kou sou la k ou, H. #0054 Ko vacs, A. #0498 Ko vacs, E. #0424 Ko vács, F. #0568, #0570 Ko wals ka, K. #0177 Ko wal ski, C.C.G, #0049 Koz ma, P. #0553 Kö nig, H.H. #0202, #0204,

#0206, #0249 Kö nig bau er, I. #0259, #0314 Kövi, R. #0555 Kraenz lin, M. #0239 Kra jew ski-Si u da, K. #0400 Kretz schmar, M. #0233, #0276 Kre vers, B. #0383 Kru se, M. #0561 Ku chin ke, B.A. #0228, #0234 Kus zew ski, K. #0517 Kut zin, J. #0136, #0305 Ky rat sis, I. #0593

L

La be a ga, J.M. #0121 Lai, C.L. #0428, #0429 Lai, T. #0203, #0520 Lam bo, E.S. #0061 La mei re, N. #0567 Lamers, L.M. #0056, #0447 La mi raud, K. #0232, #0371 Lan ge, R. #0116 Lan gen brun ner, J. #0307,

#0587 Lari, N. #0278 Lar sen, M. #0082 Las ke-Al ders hof, T. #266 Lau rid sen, J. #0140 Le Cor rol ler So ria no, AG.

#0343 Le Fur, P. #0413 Le Pen, C. #0199 Leal, J. #0335 Lee, P. #0419 Le gal, A. #0199 Lé ger, P.T. #0164 Leidl, R. #0249, #0557 Lel kes, I. #0511, #0513 Len ga gne, P. #0407 Len gyel, G. #0531, #0577 León, C. #0210 Lessard, C. #0037

Le vag gi, R. #0135, #0217, #0422Le vin, L.Å. #0383 Le wis, J. #0026 Le wis, M. #0527 Lien, H.M. #0017 Li gnel li, B. #0433 Lil lard, D. #0387 Lin de boom, M. #0315, #0366 Lind gren, B. #0350 Link, C. #0251 Lin na, M. #0597 Lin nos maa, I. #0288 Lip pi, Bru ni, M. #0192 Lle na-No zal, A. #0315 Lobo, F. #0120 Loo mes, G. #0487 Lo pes, S. #0430 Ló pez, F. #0140 Loth, K. #0494 Lou ka no va, S, #0179 Lou renço, Ó. #0311, #0454 Lou vie re, JJ. #0133 Lo vas, K. #0435 Low, N. #0351 Lu, M. #0017 Lu cas, V. #0413 Lud brook, A. #0213, #0336,

#0338 Luf kin, T. #0421 Luke, C. #0306 Lund borg, P. #0154, #0350 Luño, J. #0565 Luo ma, K. #0345, #0347 Lu raas, H. #0188 Luz, M. #0412

M

Ma, A. #0320 Ma, C.T.A. #0017 Ma cei ra, D. #0433, #0436,

#0437 Macha do, M. #0484 Ma cken bach, JP. #0361 Ma cken zie, M. #0535 Maclean, J.C. #0034 Ma gne zi, R. #0002, #0003 Ma gnus, A. #0309 Ma gnus sen, J. #0360, #0471,

#0597 Májer, I. #0562, #0601, #0607 Ma lic be go vic, D.R. #0593 Mal ja nen, T. #0327 Mal le son, P. #0479 Mal ley, J. #0183 Man ga lo re, R. #0485 Man gen, M.J. #0233, #0276 Mank, J. #0162 Man to va ni, J. #0379 Ma pel li, V. #0354 Ma ra nin chi, D. #0343 Ma rañón, G. #0565 Mar ci ni ak, A. #0385 Mar co bel li, A. #0169 Mar cuel lo, C. #0004 Mar ghe ri ta, G. #0414 Ma ri ni, G. #0066

Mark wick, A. #0309 Ma ro pou lou, #0546 Mar ques, R.M. #0582 Mar quez, P. #0590 Mar quis, P. #0558 Marsh, K. #0575 Mar ti kai nen, P. #0180 Mar tin, S. #0085 Mar ti nez-Gi ralt, X. #0084 Mar tins, M. #0111 Mar wi jk, H. #0079 Ma sel la, C. #0286 Ma sie ro, G. #0282 Ma son, H. #0346 Mas se ria, C. #0167, #0200,

#0214, #0414, #0446, #0488 Ma ta ria, A. #0341, #0440 Ma teus, C. #0157, #0431 Ma thi vet, B. #0093 Ma thon nat, J. #0022 Max well, M. #0535 May nard, A. #0279 Mc Bri de, D. #0365 Mc Ca hon, D. #0274 Mc Col lam, A. #0535 Mc Cor mick, B. #0456 McDaid, D. #0535 Mc Gre gor, P. #0193, #0329 Mc Gui re, A. #0059, #0284,

#0332 Mc Gui re, T.G. #0017 McIn to sh, E. #0385 McKee, M. #0486, #0508 McKee, P. #0329 McLean, J. #0535 Me din, E. #0509, #0597 Me er ding, W.J. #0342, #0361 Men des, Á. #0582 Men ni ni, F.S. #0381, #0382,

#0393, #0470, #0532, #0533, #0602

Me ri to, M. #0379 Mer tens, A. #0030 Me stad, O. #0493 Mey er, E. #0391 Mi chae li dou, D. #0546 Mi chae lis, J. #0253 Mic lu tia, I. #0537 Mi guel, L.S. #0159 Mihae re, K. #0599 Mi ha licza, P. #0511, #0515 Mil cent, C. #0075 Mi nel li, G. #0382 Mi ners, A. #0114 Mi sie go, A. #0194 Mis kie wicz, P. #0517 Mit ev, A. #0227 Mitz ner, S. #0244 Moat ti, J.P. #0358, #0343 Mo gyo ro sy, Zs. #0444 Mo ly neux, A. #0326 Mon stad, K. #0521 Mon tañes, A. #0004 Moo die, M. #0309 Mo rel le, M. #0507, #0608 Mo ret to, M. #0135, #0217 Mor gan, D. #0384

Eur J Health Econom Suppl 1 · 2006 | S141

Mor ris, S. #0320 Mo schet ti, K. #0282, #0377,

#0394 Mos sia los, E. #0446 Moss man, J. #0530 Mot ter li ni, N. #0450 Moumjid, N. #0390 Mous ques, J. #0395, #0413 Muir, K. #0138 Muir, KR. #0091 Mu kesh, C. #0586 Mu nis wa my, S. #0434 Mur ray, E. #0274 Mur ray, R. #0124 Mur tagh, M. #0337 Mu sig ra ve, F. #0264 Musz bek, N. #0483, #0529

N

Ná dud va ri, N. #0551, #0553 Nagy, B. #0260, #0548 Nagy, J. #0103, #0489, #0555 Nagy, L. #0568, #0569,

#0570 Nagy, N. #0498 Nagy, P. #0569 Na ko pou los, I. #0544 Na ta ra jan, L. #0026 Neill, C. #0329 Net ten, A. #0581 Neu bau er, S. #0106 Nguy en, F. #0390 Nguy en, L. #0237 Nia kas, D. #0110 Ni chol son, T. #0496, #0564 Ni colás, A.L. #0268 Ni gen da, G. #0585 Nih ti lä, E. #0180 Ni ko la j sen, J. #0597 Ni ko laou, A. #0006, #0007 Ni veen, A.R. #0341 Ni xon, J. #0155, #0334 Ni xon, R. #0086 No bi lio, L. #0192 No lan, A. #0193 No lan, B. #0193 Nord ling, S. #0226 Nor heim, O.F. #0493 Nor mand, M. #0016 Noro, A. #0180 Nor ton, E, #0034 No vos zath, A. #0569 Nya ka, B. #0462, #0463 Nyárády, J. #0300, #0301

O

Ó’Céil le achair, A. #0152 O’Ma hony, M. #0085 O’Shea, A. #0536 O’ster gren, K. #0010 Ober man, B. #0219 Od hiam bo, R. #0553 Oea, E. #0415 Oer ton, J. #0335 Oes ter le, A. #0280

Oill, C. #0193 Oláh, A. #0313, #0318 Oli va, J. #0120, #0121 Or, Z. #0297 Oritz-Ava rez, O. #0479 Orosz, E. #0384 Or te ga, M. #0194 Ossa, D.F. #0385 Øs ter dal, L.P. #0012 Os ter kamp, R. #0324 Osuna, R. #0120, #0272 Over gaard, C. #0101

P

Pa ga no, E. #0218, #0325 Pa laz zo, F. #0381, #0382,

#0399, #0532 Pa nait, D. #0364 Pao luc ci, F. #0088 Par do, C.M.L. #0584 Pa rent, O. #0016 Park, D. #0190 Par kin, D. #0209 Par sa, A.D. #0526, #0571 Pau ly, M. #0269 Pe a cock, S. #0615 Peiró-Mo re no, S. #0396 Pék li, No vákné M. #0551,

#0552 Pe leg, K. #0219 Pel to la, M. #0180 Pen tek, M. #0074, #0562,

#0601, #0607 Per, T. #0118 Perei ra, J. #0430, #0431 Pérez, J.E.M. #0580 Per piñan, J.M.A. #0580 Per ron nin, M. #0032, #0196,

#0413 Pe ters, TJ. #0133 Pe trin co, M. #0218, #0325 Phi lips, P. #0335 Pia cen za, M. #0277, #0291 Pickard, L. #0183 Pi gna ta ro, G. #0240, #0290 Pi lyavs ky, A. #0160 Pin to, J.L. #0487 Pip pa, G. #0393, #0399 Pi rai no, N. #0286 Platt, S. #0535 Ples ha nov, A. #0285 Po ble te, C. #0436 Po go ni dis, Chr. #0543, #0544,

#0545#, 0546, #0547 Po lac sek, A. #0128 Pol der, J. #0158, #0604 Pol gár, A. #0601 Po lis te na, B. #0115, #0130 Po li ti, C. #0169 Pom mer, E. #0009 Poór, Gy. #0601 Po pes cu, C.A. #0537 Por to, S. #0216 Por trait, F. #0366, #0372 Por trait, M. #0366 Post ler, A. #0502

Post ma, M.J. #0171, #0392 Pou vour ville, de, G. #0334 Pra des, J.L.P. #0580 Préau bert-Hayes, N. #0490,

#0491 Pre ker, A. #0588 Prinsze, F.J. #0099 Proi te, A. #0015 Pro tie re, C. #0358 Pro to po pes cu, C. #0330 Puen te, C. #0583

Q

Que ve do, C.H. #0163 Que ve do, Gar cia, J.L. #0210 Quin tal, C. #0454

R

Raf te ry, J. #0114 Rai k ou, M. #0284 Rai mon di, F. #0264 Ram ful, P. #0610 Rana, K. #0341 Rä sä nen, P. #0321 Rat ti, M. #0115, #0130, #0381,

#0470, #0533, #0600 Räty, T. #0345, #0347 Reb ba, V. #0135 Re de kop, K. #0245, #0376 Reed, M. #0142 Rehn berg, C. #0509, #0597 Rei chel, H. #0566 Reich mann, G. #0221 Rein ap, M. #0203, #0520 Rein hard, B. #0441 Re mon nay, R. #0507, #0608 Ren ga, G. #0191 Res ze gi, Cs. #0548 Reu ve ni, H. #0003 Ric ci, R. #0128, #0295 Ric ciar di, A. #0381, #0399 Rice, N. #0163 Rice, S. #0334 Ri chard, H. #0563 Ri dao-Ló pez, M. #0396 Ri fat, A. #0593 Ri ve ra, B. #0134 Ri ve ro-Ari as, O. #0326 Riz zo, I. #0240 Ro berts, E. #0189 Ro berts, T. #0247, #0250,

#0317, #0351 Ro bin son, A. #0346, #0487 Ro bin son, S. #0247, #0348,

#0349, #0351 Roc co, L. #0508 Ro chaix, L. #0145, #0196,

#0330, #0377, #0394, #0519, #0522

Ro chet, JC. #0469 Ro de rick, P. #0496, #0564 Ro d ri gues, J.M. #0539 Ro ehn, O. #0324 Ro gow ski, W. #0455 Roick, C. #0204, #0206

Ro i ne, R. #0321 Ro j ko vich, B. #0601 Ro ma niuk, P. #0400 Ro meu, Gor do, L. #0030 Ro sen thal, V.D. #0264 Ros ser, W. #0229 Ros si, A. #0393 Ros si, PG. #0379 Ro th gang, H. #0432 Rous seau, F. #0358 Rudd, A. #0332 Rug ge ri, M. #0108 Run go, P. #0134 Rup nik, E. #0498 Rus sell, I.T. #0235 Rus so, R. #0191 Ruta, D. #0337 Rut ten, FFH. #0243 Ruud, T. #0252 Ruz, Tor res, R. #0417, #0418 Ryan, M. #0487 Ryynä nen, O.P. #0321

S

Sach, T. #0090, #0091, #0138, #0309, #0518

Sa di raj, K. #0208 Sa ik a li, K. #0438 Sail lour-Glé nis son, F. #0490 Saka, O. #0332 Sam paio, de, Sou sa, M.C.

#0015 Sán chez, M.M. #0140 Sán t ha, K. #0103 Sar ma, S. #0229 Sas si, F. #0420 Sau er land, D. #0198, #0222,

#0224, #0501 Scheff ler, R.M. #0142, #0143 Schell horn, M. #0398 Schia vo ne, M. #0452 Schie ber, G. #0307 Schlös ser, R. #0182 Schok kaert, E. #0063, #0156 Schreyögg, J. #0112, #0166,

#0174, #0182, #0442, #04665

Schultz, J. #0229 Schut, E. #0029, #0088 Schut, F.T. #0036, #0099 Schu ur man, A.R. #0576 Schü ler, R. #0435 Schw ap pach, D.L.B. #0094, v, Scott, A. #0189 Scott, G. #0598, #0599 Scott, H. #0598, #0599 Scri vens, E. #0603 Scuff ham, P.A. #0572 Se bes ty én, A. #0103, #0260,

#0300, #0301, #0318, #0313, #0555

Seid litz, C. #0162 Sen di, P. #0239, #0248 Se res, A. #0452 Ser met, C. #0378 Ser ra no, P. #0272

Index

S142 | Eur J Health Econom Suppl 1 · 2006

Ser ra-Sas tre, V. #0053 Ser ri er, H. #0334 Shack ley, P. #0346, #0487 Shah, N. #0178 Shar ma, D. #0438 Shaw, E. #0328 Shi ell, A. #0107 Shmu e li, A. #0002, #0063,

#0219, #0331, #0370 Shortt, S. #0229 Shur ke, M. #0590 Sib bald, B. #0320 Si ci lia ni, L. #0339, #0340,

#0362 Sid dall, C. #0505 Si do ren ko, A. #0073 Sim kins, A. #0614 Simp son, D. #0285 Sinkó E. #0020, #0523 Sin ko vits, B. #0553 Sin to nen, H. #0426, #0427,

#0321 Siv, S. #0118 Ska tun, D. #0189, #0320 Slap pen del, R. #0392 Smith, P.C. #0065, #0444 Smith, R. #0346, #0487 Soa rez, P.C. #0048 Sø berg Roed, A. #0597 So li mi ni, R. #0382 Sol tész, G. #0551 Som mers gu ter-Reich mann, M.

#0221 So mos ke öy, S. #0462 So ron cz-Sz abó T. #0617 Sosa-Rubi, S.G. #0205, #0322 Span do naro, F. #0115, #0128,

#0130, #0230, #0295, #0600, #0602

Späng berg, U.W. #0010 Späth, H.M. #0096 Sper mann, A. #0253 Spinks, J. #0042 Spro ston, K. #0026 St. Pierre, Y. #0479 Staat, M. #0160 Stal man, W. #0079 Stal man, W. A. B. #0080 Stan cio le, A. E. #0151 Sta nis lao, F. #0169 Star gardt, T. #0112 Stark, R. #0249 Stein mann, L. #0058 Ste vens, J. #0009, #0208 Ste vens, P. #0085 Ste wart, J. #0289 Stir ling, B. #0333 Stir paro, G. #0382 Sto kes, L. #0085 Sto kes, T. #0328 Stoy ko va, B. #0434 Stras mann, T.J. #0094 Stra ten, A. #0447 Strau me, O. R. #0314, #0344 Street, A. #0085 Sug den, B. #0487 Suhr cke, M. #0508, #0510

Su kyong, S. #0142 Sund ma cher, T. #0501, #0502,

#0503, #0504 Sus sex, J. #0401 Sut ton, M. #0320, #0388 Svens son, M. #0069, #0165 Swin burn, B. #0309 Sz abó T. #0020 Sz asz kó D. #0103 Száz, K. #0020 Sze kan ecz, Z. #0601 Szi ge ti, Sz. #0103 Szilárd, I. #0458 Szocs ka, M. #0020 Szu le, B. #0424 Szücs, F. #0462, #0463

T

Ta bou let, F. #0096 Taïeb, H.S. #0402 Takács, E. #0611 Ta keyos hi, H. #0122 Tamm, M. #0025 Tan fa ni, E. #0149, #0150 Tar ri co ne, R. #0264 Tauch mann, H. #0181 Ta va res, A.I. #0132 Tay-T.K. #0309 Te de schi, P. #0540 Tel ser, H. #0058 Tes ti, A. #0149, #0150 Theo dos siou, I. #0006, #0007 Thomp son, C. #0486 Thomp son, M. #0328 Thom son, C.E. #0235 Thue, G. #0071 Tip per, A. #0033 Tis saar at chy, P. #0105 Tjer bo, T. #0299 Toc ca ce li, V. #0382 Tol ley, K. #0168, #0559 Tome, M. #0464 Tor bi ca, A. #0264 Tough, S. #0107 Tow se, A. #0616 Tran noy, A. #0145 Trom bert-Pa vi ot, B. #0016 Tso la kis, M. #0544 Tsoura pas, A. #0250, #0271 Tu beuf, S. #0145, #0196 Tul der, M. #0079 Tu ra ti, G. #0277, #0291 Tur ra, E. #0046

U

Ue bel mes ser, S. #0129 Ugo li ni, C. #0192 Ul mann, P. #0155, #0334, #0522 Ur gan ci, I.G. #0593 Übel mes ser, S. #0416

V

Val le, S. #0393, #0399 Val to nen, H. #0288

Van, Baal, P. #0158 Van, Bie sen, W. #0567 Van de Ven, W. #0099 Van de Voor de, C. #0156 Van der Geest, S. #0028 Van der Pol, M. #0107, #0108 Van Exel, J. #0292, #0294,

#0312, #0467 Van Ga me ren, E. #0078 Van Hout, H.P.J. #0080 Van Kleef, R. #0137 Van Tul der, M.W. #0080 Van hol der, R. #0567 Van no ni, D. #0277, #0291 Vára dy, E. #0356 Var ke vis ser, M. #0028, #0029 Va z quez-Polo, FJ. #0357 Ven, W. P.M.M. #0137 Vi cen te, A. #0194 Vi ei ra, M. #0296 Viens, P. #0358 Vi j gen, S. #0238, #0373 Vi ner, G. #0229 Vit tay, P. #0552 Vi vas, D. #0411 Vliet, R. #0063 Vliet, R. C.J.A. #0137 Voor de, C. #0063, #0088 Vos, T. #0308 Vo s ka kis, I. #0544 Vo til derk, A. #0355 Vrang bä ligk, K. #0010 Vuil leu mier, M. #0057

W

Wa lend zik, A. #0223

Wang, Q. #0279 Wang, R. #0464 Wa ning, B. #0304 Wa sem, J. #0063, #0223, #0244,

#0263, #0323, Wea le, M. #0085 Weg ner, C. #0263 Weiss, Y. #0002 Wer blow, A. #0255 Wes tert, G. #0612 Whi te ford, H. #302 Why nes, D.K. #0518 Wild man, J. #0041 Wil liams, I. #0333 Wil lich, S.N. #0365 Wil son, J. #0114 Wimo, A. #0052 Winblad, B. #0052 Wit ten berg, R. #0183 Wit think, D.R. #0001 Witt wer, J. #0199, #0397 Wofe, C. #0332 Woit tiez, I. #0009, #0208 Wol s ten hol me, J. #0326 Won der ling, D. #0086 Wood hou se, A. #0535 Woods, N. #0146 Words worth, S. #0335 Wra nik, D. #0126

Wueb ker, A. #0275

X

Xa vier, A. #0500 Xe no doxi dou, E. #0543, #0544,

#0545, #0546, #0547 Xi ri nachs, Y. #0460

Y

Yang, B. #0176, #0190 Yao, G.L. #0114, #0131 Yek ta, M.S. #0287 Yuen, P. #0388

Z

Za no la, R. #0422 Zie dan, N. #0440 Zil da, M. #0123 Zmo ra, I. #0088, #0331 Zwei fel, P. #0024, #0058, #0089

Eur J Health Econom Suppl 1 · 2006 | S143

S144 | Eur J Health Econom Suppl 1 · 2006