How do patients value features of biological medicine in rheumatoid arthritis? A discrete choice experiment.

BACKGROUND: The aim of this study was to quantify the preference of the patients regarding biological DMARDs. RESEARCH DESIGN AND METHODS: Patients' preferences were assessed using a discrete choice experiment. Eighteen different surveys describing eight attributes were designed using experimental design methods. Each survey presented eight choice tasks with two options for patients to choose one. A conditional logit model was used to calculate relative importance and willingness to pay. Subgroup analysis was conducted to evaluate the effect of the patients' characteristic on their preferences. RESULTS: A total of 306 patients were included in the study. All attributes had significant effects on the patients' choices. The most important feature was the ability to preserve physical function. The least important feature was the route of administration. Surprisingly, the out-of-pocket cost was one of the last priorities for respondents. According to the relative importance calculations, 80% of the patients' preferences can be obtained by clinical attributes. Based on subgroup analysis, the most important patient characteristic that affected their choices was the monthly out-of-pocket history. CONCLUSIONS: Different features of treatment had different effects on the patients' preferences. Quantification of the impact of each attribute not only revealed their relative importance but also determined the trade-off rate among them.

Main drivers of diabetes pharmaceuticals expenditures: evidence from OECD countries and Iran.

Purpose: This study aimed to identify the impact of prominent drivers on drug expenditure for diabetes. Method: Following the examination of previous studies, this study identified possible factors contributing to diabetes pharmaceutical expenditures. The explanatory variables for the study were the median population age, access to innovative drugs, GDP per capita, prevalence, price, and consumption of diabetes drugs. Then, to estimate the per capita expenditure among diabetic patients, this study developed the panel data model and two time-series regression models for OECD countries and Iran, respectively. Results: In the panel data regression model, R2 was 0.43. The influence of the age, prevalence, consumption volume and GDP per capita coefficients were + 1.79, + 0.704, + 3.86057, + 0.00054, respectively. Also, the probability level of all variables was less than 0.05. In Iran's comparative time-series regression model, R2 was 0.9, and the only significant influence coefficient was the age (ß=+0.91). In the another model for Iran, R2 was 0.99, the influence coefficient of age was + 0.249, the prevalence was + 0.131, innovation was + 0.029, and the price was + 0.00054; all the probability levels were less than 0.05. Conclusion: Pharmaceutical per capita expenditure is affected by several factors. These factors are not the same in various counties. Passing a judgment on drug utilization only based on pharmaceutical per capita expenditure cannot be perfect. Also, judging whether the per capita drug expenditure in one country is desirable without attention to the affecting factors and only relying on the value of utilized medicines is defective.

A comprehensive review of official discount rates in guidelines of health economic evaluations over time: the trends and roots.

BACKGROUND: The question of discounting in health economics is anything but settled, so much so that a section of the Health Technology Assessment (HTA) guidelines is devoted to it. OBJECTIVE: This study aimed to review the trend of the value of the official discount rates (DRs) of costs and health outcomes and their roots worldwide. METHODS: Four methods were combined to identify official DRs over time globally. These methods included a systematic review of the HTA/pharmacoeconomic/health economic evaluation guidelines, a review of methodological documents or guidelines accessible on the websites of HTA organizations, and two separated reviews of the websites of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the Guide to Health Economic Analysis and Research (GEAR). RESULTS: Our systematic search eventually yielded 339 documents from the literature, 35 links from the website of the HTA organizations, 51 documents from the website of the ISPOR, and 29 documents from the website of the GEAR. These documents referred to 48 countries over 30 years and 43 transnational guidelines over 43 years. DRs of 3% and 5% had the most frequent value. Among them, 38 countries always used an equal DR of costs and health outcomes. We categorized the rationales for selecting DRs into eight groups for the national documents and six groups for the transnational documents. CONCLUSION: The comparability approach was the most frequent rationale for choosing the DR in national and transnational guidelines. The value of DR of costs and health outcomes ranged from zero to 10% over the years, but the most common values were 3% and 5%, mainly arising from the comparability approach chosen. Several transnational guidelines have suggested a specific DR without taking into account countries' economic conditions. It is useful to establish a specific guideline for calculating and updating the DR of the health sector in each country.

Avoidable hospitalization after family physician and rural health insurance: interrupted time series and regression analyses, Tehran province, Iran.

BACKGROUND: Studying the effect of primary health care development when simultaneously implemented with health insurance schemes assesses effectiveness and use of health care services and gives us insight on how to develop such interventions in different countries. AIM: To analyze the impact of health insurance and the family physician program on total hospitalizations, and the relation between avoidable hospitalizations and access to family physicians among the rural population in Iran. METHODS: We conducted an interrupted time series (ITS) analysis of monthly hospitalization rates between the years of 2003 and 2014 to assess the immediate and gradual effects of these reforms on total hospitalization rates in the rural areas of Tehran province. In addition, we used a sample of 22 570 hospitalizations between 2006 and 2013 to develop a logistic regression model to measure the association between access to a family physician and avoidable hospitalizations. FINDINGS: ITS analysis showed that there was an immediate increase of about 1.96 hospitalizations per 1000 inhabitants (P<0.0001, CI=1.58, 2.34) hospitalization rates after the reforms. This was followed by a significant increase of about 0.089 per 1000 inhabitants (P<0.0001, CI=0.07, 0.1). Hospitalization increase continued up to four years after the policy implementation. Following that, hospitalization rates decreased among the rural population (a decrease of 0.066 per 1000, P<0.0001, CI=-0.084, -0.048). Studying the hospitalizations that occurred between 2006 and 2013 showed that there were 4106 avoidable hospitalizations from among a sample of 22 570 hospitalizations. Results of logistic regression models including gender, age and access to family physician variables showed that there was no statistical relation between access to a family physician and avoidable hospitalizations. CONCLUSION: Reforms had access effect and caused increased hospital services uses in people with unmet needs. Also the reforms did not decrease avoidable hospitalizations, and therefore had no efficiency effect.

Investigation the determinants of pharmaceutical expenditure share of GDP in Iran and selected OECD countries.

AIM: This study estimated the GDP share of pharmaceuticals in Iran based on the drivers of pharmaceutical expenditure and compared it with that of 31 members of the Organisation for Economic Cooperation and Development (OECD). SUBJECT AND METHODS: The factors contributing to pharmaceutical expenditure were identified through literature review and studied by 8 experts to classify the factors. Then, using the panel data method, a model was built to estimate the GDP share of pharmaceutical expenditure based on the extracted factors of the selected countries in Iran's model. To explain the observed differences, several regression analyses were performed based on cross-sectional data. The analyses were performed using EVIEWS software, version 10. RESULTS: The explanatory variables for the selected countries in the panel model (R2 = 0.98) were specified. Government health expenditure (ß = 0.1432), the share of generic drugs (ß = - 0.0143), gross domestic product (GDP) per capita (ß = - 0.0058) and the rate of disability-adjusted life-years (DALY) (ß = 0.0028) contributed most to pharmaceutical expenditure. In comparison, in the Iranian estimation model (R2 = 0.84), government health expenditure (ß = 0.0536) and the share of generic drugs (ß = 0.0369) had a significant impact on pharmaceutical expenditure. In the estimation model with more estimators for Iran (R2 = 0.99), government health expenditure (ß = 0.1694), disease prevalence (ß = 0.0537), the share of generic drugs (ß = 0.0102), the DALY rate (ß = 0.0039), GDP per capita (ß = - 0.0033), and the drug price index (ß = 0.0007) contribute most to pharmaceutical expenditure. CONCLUSION: In the models of the study, factors related to the structure of the healthcare system and the pharmaceutical system contributed most to pharmaceutical expenditure as a share of GDP. Moreover, disease profiles show its predictive role in the second model for Iran.

A Systematic Review of Discrete Choice Experiment Studies in Rheumatoid Arthritis Biological Medicines.

OBJECTIVE: Rheumatoid arthritis is a chronic disease with various clinical characteristics. The introduction of biological drugs has enhanced the efficacy and increased diversity of treatment options. Considering the patients' preferences in decision-making about treatment can improve their adherence. A discrete choice experiment is a type of conjoint method that can elicit preferences in more realistic scenarios. This article reviewed discrete choice experiment (DCE) studies to extract which attributes and levels were included in surveys. In addition, we focused on the process of designing surveys and the method that they used. Method: PubMed, EMBASE, Web of Science, Scopus, Ovid (Medline) and ProQuest were systematically searched in order to find studies that evaluated rheumatoid arthritis patients' preferences about biological medicines. Studies published in peer-reviewed journals between 1/1/1990 and 12/31/2019 were included. The included studies were analyzed using a narrative synthesis method and descriptive statistics. RESULTS: A total of 7124 studies were initially found. After deleting irrelevant and duplicate studies, 15 studies were included. The most common attributes that were used in surveys were efficacy, adverse effect, route of administration, frequency of administration, and cost. Most studies used a literature review for developing attributes and levels. The median number of included attributes and levels were seven and three, respectively. Eight studies explained their experimental design while seven studies did not. Conditional logit and mixed logit were the most common methods for modeling reciprocally. CONCLUSION: Several aspects of DCE studies investigating biological drugs in RA were assessed. Explaining the sample size, experimental design, and qualitative work for developing attributes can improve this type of study.

The impact of rural health insurance and the family physician program on hospitalizations, a beforeafter study at the county level conducted in Tehran province, Iran.

Background: The health insurance and family physician reform in Iran were implemented in 2005. This study was conducted to assess the effect of these reforms on avoidable hospitalizations among the rural population of Eslam-shahr County, Iran. Methods: We conducted a before-after study in Eslam-shahr County's single existing hospital. This county is a part of the Tehran Province of Iran. The demographic characteristics and diagnostic codes of the rural population that were hospitalized during the 2 years leading to, and after the reforms were extracted from the hospital's electronic information system. A list of 61 three-character and 131 four-character AHs codes were developed based on the literature review. We estimated a logistic regression model which included gender and age as independent variables to assess changes in the probability of avoidable hospitalizations following reform implementation. Analyses were carried out using STATA version 13. Results: We recorded 817 rural hospitalizations before and 967 hospitalizations after reform implementation, suggesting that hospitalization growth after the reforms was almost 18.4%. The logistic regression results show that the probability of avoidable hospitalizations after the interventions had decreased compared to before the interventions were put into place (OR: 0.46; 95% CI: 0.24-0.88). Also, the probability of AHs among the 60< year-old age group was considerably higher compared to other age groups. No statistical relationship was found between avoidable hospitalizations and gender. Conclusion: The reforms may have had a mixed effect on hospitalization. They may result in increased hospitalizations due to responding to the unmet needs of the population, and simultaneously they may lead to a decrease in avoidable hospitalizations and eliminate the costs imposed by them upon the health system.

Impact of economic sanctions on access to noncommunicable diseases medicines in the Islamic Republic of Iran.

BACKGROUND: It has been argued that economic sanctions and the economic crisis have adversely affected access to drugs. AIM: To assess the impact of economic sanctions on the Iranian banking system in 2011 and Central Bank in 2012 on access to and use of drugs for noncommunicable diseases (NCDs). METHODS: An interrupted time series study assessed the effects of sanctions on drugs for diabetes (5 drug groups), asthma (5 drug groups), cancer (14 drugs) and multiple sclerosis (2 drugs). We extracted data from national reference databases on the list of drugs on the Iranian pharmaceutical market before 2011 for each selected NCD and their monthly sales. For cancer drugs, we used stratified random sampling by volume and value of sales, and source of supply (domestic or imported). Data were analysed monthly from 2008 to 2013. RESULTS: Market availability of 13 of 26 drugs was significantly reduced. Ten other drugs showed nonsignificant reductions in their market availability. Interferon α2b usage reduced from 0.014 defined daily doses per 1000 inhabitants per day (DID) in 2010 to 0.008 in 2013; and cytarabine from 1.40 mg per 1000 population per day in 2010 to 0.96 in 2013. Selective ß2-adrenoreceptor agonists usage reduced from 8.4 to 6.8 DID in the same time period. CONCLUSION: There is strong evidence that sanctions have had a negative effect on access to drugs, particularly those that depended on the import of their raw material or finished products.

Evaluation of productivity in Iranian pharmaceutical companies: A DEA-based Malmquist approach and panel data analysis.

OBJECTIVE: In this study, we aimed to assess comparative productivity of 21 pharmaceutical companies in Iran during 2000-2013. METHODS: To evaluate the productivity trend of pharmaceutical companies in Iran, we used data envelopment analysis-based Malmquist index. "Total assets" and "capital stock" as inputs and "net sales" and "net profit" as outputs extracted from Tehran stock exchange, were selected to be included in the analysis. This method provides the possibility for analyzing the performance of each company in term of productivity changes over time. We also used an estimation generalized least square panel data model to identify the factors that might affect productivity of pharmaceutical companies in Iran using EViews 7 and Deep 2.1 software. FINDINGS: The mean total productivity during all years of the study was 0.9829, which indicates the improvement in their overall productivity. The results, over the 13-year period, indicated that the range of productivity changes in pharmaceutical companies, that were included in this study, was between 0.884 and 1.098. Panel data model indicated that age of company could positively (t = 4.765978, P < 0.001) and being located in cities other than Tehran (the capital) could negatively (t = -5.369549, P < 0.001) affect the productivity of pharmaceutical companies. The analysis showed the new policy (brand-generic scheme) and also the type of ownership did not have a significant effect on the productivity of pharmaceutical companies. CONCLUSION: In this study, pharmaceutical productivity trends were fluctuated that could be due to the sub-optimal attention of policy makers and managers of pharmaceutical companies toward long-term strategic planning, focusing on productivity improvement.