A randomized trial of in-home visits for disability prevention in community-dwelling older people at low and high risk for nursing home admission.

BACKGROUND: In-home preventive visits with multidimensional geriatric assessments can delay the onset of disabilities in older people. METHODS: This was a stratified randomized trial. There were 791 participants, community-dwelling people in Bern, Switzerland, older than 75 years. The participants' risk status was based on 6 baseline predictors of functional deterioration. The intervention consisted of annual multidimensional assessments and quarterly follow-up in-home visits by 3 public health nurses (nurses A, B, and C), who, in collaboration with geriatricians, evaluated problems, gave recommendations, facilitated adherence with recommendations, and provided health education. Each nurse was responsible for conducting the home visits in 1 ZIP code area. RESULTS: After 3 years, surviving participants at low baseline risk in the intervention group were less dependent in instrumental activities of daily living (ADL) compared with controls (odds ratio, 0.6; 95% confidence interval, 0.3-1.0; P = .04). Among subjects at high baseline risk, there were no favorable intervention effects on ADL and an unfavorable increase in nursing home admissions (P= .02). Despite the similar health status of subjects, nurse C identified fewer problems in the subjects who were visited compared with those assessed by nurses A and B. Subgroup analysis revealed that among low-risk subjects visited by nurses A and B, the intervention had favorable effects on instrumental ADL (P = .005) and basic ADL (P = .009), reduced nursing home admissions (P = .004), and resulted in net cost savings in the third year (US $1403 per person per year). Among low-risk subjects visited by nurse C, the intervention had no favorable effects. CONCLUSIONS: These data suggest that this intervention can reduce disabilities among elderly people at low risk but not among those at high risk for functional impairment, and that these effects are likely related to the home visitor's performance in conducting the visits.

Equity in the delivery of health care in Europe and the US.

This paper presents a comparison of horizontal equity in health care utilization in 10 European countries and the US. It does not only extend previous work by using more recent data from a larger set of countries, but also uses new methods and presents disaggregated results by various types of care. In all countries, the lower-income groups are more intensive users of the health care system. But after indirect standardization for need differences, there is little or no evidence of significant inequity in the delivery of health care overall, though in half of the countries, significant pro-rich inequity emerges for physician contacts. This seems to be due mainly to a higher use of medical specialist services by higher-income groups and a higher use of GP care among lower-income groups. These findings appear to be fairly general and emerge in countries with very diverse characteristics regarding access and provider incentives.

Income-related inequalities in health: some international comparisons.

This paper presents evidence on income-related inequalities in self-assessed health in nine industrialized countries. Health interview survey data were used to construct concentration curves of self-assessed health, measured as a latent variable. Inequalities in health favoured the higher income groups and were statistically significant in all countries. Inequalities were particularly high in the United States and the United Kingdom. Amongst other European countries, Sweden, Finland and the former East Germany had the lowest inequality. Across countries, a strong association was found between inequalities in health and inequalities in income.

Life quality assessment of breast cancer patients receiving adjuvant therapy using incomplete data.

Previous research on the effects of adjuvant treatment for women with operable breast cancer focused exclusively on disease-free and overall survival. In this study we evaluate life quality of premenopausal node-positive breast cancer patients receiving adjuvant chemotherapy for at least three months. For the first time, a modified latent variable model is used to assess treatment outcome in a prospective clinical trial. This poses a number of econometric problems which did not occur in the preceding studies. One of them is how to deal with patients whose records are incomplete. The data are provided by the International Breast Cancer Study Group (study VI). The results indicate that the lowest dose treatment improves life quality faster than the remaining three alternatives. At the end of the 24 months observation period no significant differences between the four treatment options remain. Although the lowest dose treatment is also the least costly no definite conclusion regarding cost-effectiveness can be drawn at this stage since survival data is not yet available.

Equity in the delivery of health care: some international comparisons.

This paper presents the results of an eight-country comparative study of equity in the delivery of health care. Equity is taken to mean that persons in equal need of health care should be treated the same, irrespective of their income. Two methods are used to investigate inequity: an index of inequity based on standardized expenditure shares, and a regression-based test. The results suggest that inequity exists in most of the eight countries, but there is no simple one-to-one correspondence between a country's delivery system and the degree to which persons in equal need are treated the same.

Equity in the finance of health care: some international comparisons.

This paper presents the results of a ten-country comparative study of health care financing systems and their progressivity characteristics. It distinguishes between the tax-financed systems of Denmark, Portugal and the U.K., the social insurance systems of France, the Netherlands and Spain, and the predominantly private systems of Switzerland and the U.S. It concludes that tax-financed systems tend to be proportional or mildly progressive, that social insurance systems are regressive and that private systems are even more regressive. Out-of-pocket payments are in most countries an especially regressive means of raising health care revenues.

The validity of the MIMIC (Multiple Indicators/MultIple Causes) health index--some empirical evidence.

This study evaluates the potential of econometric models with latent (unobservable) variables for measuring health or health impairment due to a specific disease. A MIMIC disability index is estimated for a sample of 145 adults with chronic bronchitis, expressing their self-reported disability caused by the disease on a one-dimensional scale. The index is determined up to a linear transformation. Disability is thus measured on an interval scale. The data were collected by interviews. The questionnaire used for this purpose is based on a number of in-depth interviews with selected bronchitis patients conducted beforehand. The study therefore focuses directly on the patients' perceptions of their disease. The validity of the index is evaluated in three different ways. First, construct validity is assessed performing groupwise analysis and testing for differences in the index values by subgroup. To a large extent, the index is consistent with a priori expectations. Therefore, we conclude that it has high construct validity. Second, validity of the index is assessed by comparing its results to a direct rating scale produced by 21 physicians with various medical backgrounds. The MIMIC index turns out to be related in a systematic, but nonlinear way to this direct rating scale. This can be interpreted in two different ways. If one accepts the preferences of health providers as the ultimate yardstick when it comes to ranking health or chronic states the result suggests that the MIMIC index estimated in this way is not a valid measure of treatment success. By contrast, if patients' preferences are considered to be decisive, it suggests that physician-based ratings should be substituted for or at least complemented with patient-based indices (such as the MIMIC disability index estimated here) when evaluating medical services in terms of cost-effectiveness. Third we explore the extent to which the MIMIC index reflects utility associated with different states of disability, using a modified Torrance Standard Gamble approach. The above-mentioned physicians are used as experts in this procedure. The results indicate that the MIMIC index as estimated here is related in a systematic, but nonlinear way to the Standard Gamble risk index as well. The fact that this relationship is nonlinear indicates that the MIMIC index does not measure utility as derived from the experts' preferences directly. How this index would fare compared to a Standard Gamble risk index provided by patients (bronchitis subjects) is a question which remains open.(ABSTRACT TRUNCATED AT 400 WORDS)

[Socioeconomic significance of alcohol]. / Betrachtungen zur volkswirtschaftlichen Bedeutung des Alkohols.

This paper evaluates production and consumption of alcohol from an economic point of view. The economic rationale for public policies towards alcohol in a market system is discussed at the outset. Economic costs and benefits of alcohol consumption are then assessed. Three alternatives for taxing alcohol with a special excise tax are presented. The main results of a cost-benefit study of the treatment of chronic alcoholics in Switzerland are reported. Finally, some conclusions are drawn regarding public policy in this field.

Economic evaluation of new drug therapies in terms of improved life quality.

Assessment of the benefits is one of the major and largely unresolved problems in the economic evaluation of new drugs, particularly so when major benefits concern patients' well-being, joy of life or life quality rather than increased longevity or improved earnings capacity. In this study, a method for assessing the benefits of new drug therapies in terms of improved life quality is proposed. The approach is illustrated for psoriasis, one of the most common and disabling skin diseases. A MIMIC-structural-equation-model for psoriasis-related medical care demand is developed and estimated, treating the psycho-social disability associated with the disease as a latent (unobservable) variable which is characterized fully by its causes and indicators. The model allows computation of a MIMIC-DISABILITY-index, a one-dimensional measure of the overall psoriasis-related impairment in life-quality, for each patient or by selected patient characteristics. Contrary to traditional methods, the MIMIC-index incorporates a large number of disease aspects (indicators) without using arbitrary weights. Application of this approach to the evaluation of new drugs is straightforward. However, it requires a prospective study design, i.e. patients have to be interviewed at least twice, along with a control group, once before and at least once after onset of the new therapy. The MIMIC-index can then be computed for successive stages of the new therapy, expressing the therapy's effectiveness in improving patients' well-being. The index can be used as a physical output measure in cost-effectiveness analysis. Finally, it can be transformed into monetary units allowing performance of formal cost-benefit analysis of new treatment alternatives.

The Swiss Health Survey Project (SOMIPOPS): an example of a data collection effort from various sources.

In 1981/82 the first representative health survey (SOMIPOPS "Socio-medical indicators for the population of Switzerland") was conducted 1) to gain representative data on health status (perceived morbidity), use of health services, 2) to analyse the demand for health care, and 3) to develop reliable health and use indicators. In order to validate questionnaire and interview data (primary data sources), two additional (secondary sources) were used: income and wealth data for the whole of the original SOMIPOPS sample (N = 5,860), and health insurance records for 80% consenting members of the interviewed sample. The integration of different data sources on an individual level greatly enhances the analytic potential of health survey.

[External costs of energy illustrated by the example of mortality and morbidity]. / Externe Kosten der Energie am Beispiel von Mortalitat und Morbiditat

"The social costs of energy production and consumption in terms of increased mortality and morbidity are estimated for Switzerland using recent empirical studies on air pollution and health in the United States. These costs were between 100 and 300 million Swiss francs 1980 and occurred mainly as externalities. The paper illustrates how these externalities could be corrected via a Pigou tax. However, there is uncertainty about the epidemiological basis and the imputed values for health and mortality reductions making the imposition of such a tax infeasible until better cost estimates are available." (summary in ENG, FRE)

Anti-smoking publicity, taxation, and the demand for cigarettes.

This study demonstrates that anti-smoking publicity in the mass media in Switzerland has had a substantial permanent impact on cigarette consumption. Extended publicity, following the 1964 U.S. Surgeon General's Report, accompanying various tax increases, and preceding a public vote on an advertising ban for tobacco products, decreased consumption permanently by 11%. In addition, publicity had important indirect effects which are reflected in smokers' strong reactions to nominal cigarette price increases. Estimated nominal cigarette price elasticity is -1.0; by contrast, real cigarette prices failed to be significant. Thus, publicity in the mass media provides a powerful tool for deterring cigarette consumption.

Economic aspects of smoking.

Smoking has become a major issue for public health policy in recent years. This paper deals with the economic aspects of smoking. First, we outline the basic concepts of welfare economics which subsequently are used as the normative framework of the analysis. In particular, we stress the role of efficiency as a criterion for economic policy evaluation. Second, we demonstrate that smoking is associated with several market failures, notably externalities and dependency/addiction (non-rational behavior). Third, costs and benefits of smoking are considered. We argue that the benefits of smoking are the satisfaction (utility) which the consumers derive from it rather than the employment effect of producing tobacco products or the revenues of the excise tax on these products. A general model for estimating the costs of smoking is developed and various cost concepts are discussed. Empirical cost estimates are presented for Switzerland. In 1976, estimated social (economic) costs of smoking were between 560 and 800 million Swiss francs while the external costs were between 140 and 260 million francs. Contrary to a widely held belief, smoking hardly influenced health care costs because the higher medical care costs of smokers during their lifetime are offset by their reduced life expectancy. The last section deals with intervention strategies to reduce smoking: anti-smoking publicity, advertising restrictions, and taxation. We discuss these three instruments on a conceptual level and summarize previous empirical studies. The main results are: (1) Both publicity and taxation offer a considerable potential as deterrents of cigarette demand. (2) The results for Switzerland imply that publicity campaigns are likely to be efficient in the sense that expected campaign benefits outweigh its costs.

Does smoking increase medical care expenditure?

The impact of smoking on medical care expenditure is analyzed, challenging the widespread belief that smoking imposes a large cost burden on health services systems. The results imply that lifetime expenditure is higher for nonsmokers than for smokers because smokers' higher annual utilization rates are overcompensated for by nonsmokers' higher life expectancy. Population simulation, taking into account the effects of past smoking on present population size and composition, suggests that 1976 expenditure would have been the same if no male born since 1876 had ever smoked. The male population would have been larger, particularly at older ages, increasing medical care expenditure, but this increase would have been offset by lower annual medical care utilization rates. Thus the results imply that smoking does not increase medical care expenditure and, therefore, reducing smoking is unlikely to decrease it.

[The effect of smoking on mortality and life expectancy of the Swiss population]. / Der Einfluss des Rauchens auf die Mortalität und die Lebenserwartung der Schweizer Wohnbevölkerung.

The quantitative impact of smoking on mortality and longevity in Switzerland is investigated. The calculations are based on mortality ratios between smokers and nonsmokers reported in prospective epidemiologic studies, the prevalence of smoking in Switzerland, cause-specific mortality rates and the lifetable. The results imply that in 1976 roughly 3800 premature deaths were attributable to smoking, more than 90% involving males. Thus, smoking appears to be the leading preventable cause of death in Switzerland. The results of lifetable methods used to estimate the impact of smoking on longevity imply that smoking reduces male life expectancy by 12 to 16 months, and that eradication of smoking would increase life expectancy accordingly. Combining the above results suggests that, in 1976, between 52 000 and 54 000 life years were lost as a consequence of the smokers' premature mortality.