Experience: the most critical factor in choosing after-hours medical care.

INTRODUCTION: In many countries, a reassessment of after-hours primary care has become necessary. In particular, centralised general practitioner deputizing services (GPDS) have emerged. In this study, consumers' preferences for after-hours medical care were obtained and the use of the new GPDS was predicted. METHOD: On the basis of the Theory of Reasoned Action, a survey was developed that was used at the Free Newborn and Child health care services in Antwerp. Consumers were asked about their knowledge, experience and perceptions concerning the performance of different medical services. RESULTS: 350 questionnaires were used for analysis. 98.6% of the respondents knew about the existence of the emergency department, whereas the GPDS was known by 81.7% of the respondents. The main reasons for preferring emergency department over the other services were an easy access, good explanation by the doctor and a late due time of the payment. Respondents preferred the GPDS mainly because of an expected shorter waiting time. Experience had a strong positive influence on choosing a particular after-hours medical service. CONCLUSION: In our study, the consumers' preferences concerning after-hours medical care were assessed. The following items are crucial for choosing after-hours care: experience with the services, easy access to the service, explanation by the doctor about the illness and the treatment and waiting time.

Belgian Schizophrenia Outcome Survey - results of a 2-year naturalistic study in patients stabilised on monotherapy with olanzapine, risperidone or haloperidol.

OBJECTIVES: This Schizophrenia Outcome Survey compared medical costs, psychopathology and adverse events in outpatients for 2 years following hospitalisation for an acute schizophrenic episode. METHODS: Adults stabilised with haloperidol, olanzapine or risperidone entered this observational study or=1 EPS; 69% (p<0.013), 40 and 44%, respectively, had >or=1 sexual problem (NS). Mean weight gain was 0.4 (NS), 2.6 (p<0.05) and 2.6 kg (p<0.05), respectively. CONCLUSIONS: In this naturalistic study, treatment allocation might have introduced a bias in the interpretation of efficiency results, but olanzapine and risperidone caused less EPS than haloperidol during 2 years of outpatient follow-up.

Social research as an intervention tool in tuberculosis control.

Our multidisciplinary project on TB control in the Free State, South Africa, is targeting two dimensions for intervention: firstly, patients, to facilitate compliance and improve quality of care; secondly, the health care system, to identify weaknesses that require remedying and best practices to promote better TB control. This communication illustrates how social scientists can contribute towards the implementation of interventions related to their research, thus influencing TB policy, programme planning and practice more directly.

[Economic evaluation in oral care. Methods and examples in restorative dentistry]. / Economische evaluatie in de mondzorg. Methodologie en toepassingen in de restauratieve tandheelkunde.

This article briefly outlines the principles of economic evaluation in dentistry. It discusses the different types of analyses, such as cost-effectiveness analysis, cost-benefit analysis and cost-utility analysis. Furthermore, it makes clear when these analyses are most appropriate for use. Having a basic understanding of the most common analyses can be helpful to make choices between different interventions. Increasing demand for dental interventions and limited budgets necessitate the allocation of scarce resources efficiently. By identifying, measuring, valuing and comparing costs and outcome of interventions, economic evaluation can also help patients and carers in choosing between interventions. The article gives some examples in restorative dentistry to explain the relevance of economic evaluation.

Financial situation of people living with HIV in Europe.

The objective was to investigate the financial situation of people living with HIV in Europe. Two surveys using an anonymous questionnaire were organized in Europe among people living with HIV, the first in 1996-97 and the second in 1998-99. One thousand one hundred and sixty-one people from the 1996-97 survey and 899 from the 1998-99 survey were included. Four hundred and fifty-seven (42%) of the 1996-97 participants reported that their income had decreased since HIV diagnosis. The latter participants reported significantly more often difficulties in paying for housing (27% vs 20%), food (18% vs 12%) and transport (17% vs 12%) compared to 1998-99 participants. In multiple regression analysis, severity of HIV disease, not being on highly active antiretroviral therapy (HAART), younger age, lower education level and living in the South of Europe were associated with having financial difficulties. We concluded that since the introduction of HAART, the financial situation of persons living with HIV in Europe has improved, but a relatively large percentage of them still have financial difficulties.

Direct costs of health care for HIV/AIDS patients in Belgium.

The cost of HIV/AIDS care was measured in Belgium in 1996. This paper is concerned with direct costs (formal and informal care). This is a prospective study, stratified by CDC-disease stage. A societal point of view was chosen. Eighty-two sequential patients agreed to join the study during outpatient visits. Data on service use and costs were obtained through a care-cost diary kept over three months. Half of the patients (41) returned a completed diary, which reduced the sample size considerably. Additional billing data were obtained from different sources and by calculating the time spent for certain services. In stage A (asymptomatic HIV), the mean (+/- SD) annual total direct costs are US$2,373 (2,079), rising to US$8,401 (7,520) in stage B (symptomatic HIV) and ending up at US$27,373 (22,087) in stage C (full blown AIDS). A difference in balance of costs at different stages of disease was observed. The principal cost of outpatient pharmaca in HIV patients is overtaken by the cost of hospitalization in AIDS patients. The cost of informal care is considerable (40% of the total cost) from stage B onwards. Health care use and costs increase with severity of illness.

[Cost effectiveness of vaccination against pneumococcal bacteremia in the elderly: the results in Belgium]. / Kosteneffectiviteit van vaccinatie tegen pneumokokkenbacteriëmie bij bejaarden: resultaten voor België.

BACKGROUND: Several studies have shown that pneumococcal vaccination of older persons would be cost-effective in preventing pneumococcal pneumonia, but evidence of clinical protection for this condition is uncertain. Given much better evidence of vaccination effectiveness against invasive disease, studies showing that vaccination is cost-effective in preventing invasive disease alone could provide strong support for public policies to vaccinate older persons. METHODS: We examined the cost-effectiveness of preventing invasive pneumococcal infection by vaccination with the 23-valent pneumococcal polysaccharide vaccine of persons > or = 65 years in age in Belgium. The direct medical costs expressed per quality adjusted life year (QALYs) of a cohort of vaccinated persons was compared with the costs per QALY in a cohort of persons who are not vaccinated. RESULTS: Preventing invasive pneumococcal infections by vaccinating elderly persons clearly benefits people's health. By vaccinating 10,000 persons over 65 years of age, approximately eight QALYs can be gained compared with no vaccination. Achieving these health benefits however requires additional costs,: 30,000 ECU per QALY gained. The cost-effectiveness ratio is slightly better (i.e. 25,000 ECU per QALY) for the age group 65-75 years, and slightly worse (i.e. 35,000 ECU per QALY) for the age group 75-84 years. It increases sharply to 77,000 ECU per QALY for the persons over 85 years of age. An extensive one-dimensional sensitivity analysis did not greatly affect these results. If vaccination is also clinically effective in preventing pneumococcal pneumonia, vaccinating all elderly persons is cost saving. CONCLUSION: Using empirical epidemiological data, pneumococcal vaccination to prevent invasive pneumococcal disease is acceptably to moderately cost-effective in Belgium. On the basis of our findings, we believe public health authorities should consider policies for encouraging pneumococcal vaccination for all persons > or = 65 years in age.

Cost-effectiveness of pneumococcal vaccination of older people: a study in 5 western European countries.

Pneumococcal vaccination of older persons is thought to be cost-effective in preventing pneumococcal pneumonia, but evidence of clinical protection is uncertain. Because there is better evidence of vaccination effectiveness against invasive pneumococcal disease, we determined the cost-effectiveness of pneumococcal vaccination of persons aged > or =65 years in preventing hospital admission for both invasive pneumococcal disease and pneumococcal pneumonia in 5 western European countries. In the base case analyses, the cost-effectiveness ratios for preventing invasive disease varied from approximately 11,000 to approximately 33,000 European currency units (ecu) per quality-adjusted life year (QALY). Assuming a common incidence (50 cases per 100,000) and mortality rate (20%-40%) for invasive disease, the cost-effectiveness ratios were <12,000 ecu per QALY in all 5 countries. For preventing pneumococcal pneumonia, vaccinating all elderly persons would be highly cost-effective to cost saving. Public health authorities should consider policies for encouraging pneumococcal vaccination for all persons aged > or =65 years.

Cost-effectiveness analysis of pneumococcal vaccination of adults and elderly persons in Belgium.

OBJECTIVE: To analyse the direct medical costs and effectiveness of vaccinating adults aged between 18 and 64 years and elderly persons > or = 65 years of age with the 23-valent pneumococcal polysaccharide vaccine. DESIGN AND SETTING: This was a decision-analytic modelling study from the societal perspective in Belgium. The analysis compared 'vaccination' with 'no vaccination and treatment'. METHODS: Calculations were based on the assumption that vaccination is as effective against all pneumococcal infections as it is against invasive pneumococcal disease. Data on the incidence of pneumococcal pneumonia and meningitis, frequency of hospitalisation, mortality rates and vaccine effectiveness were derived from the international literature. Costs were derived from analysis of historical data for cases of pneumococcal infection in Belgium. RESULTS: Vaccinating 1000 adults between the ages of 18 and 64 years gains approximately 2 life-years in comparison with the no vaccination option. However, to realise these additional health benefits requires additional costs of 11,800 European Currency Units (ECU; 1995 values) per life-year saved. Vaccinating 1000 elderly people (> or = 65 years) leads to > 9 life-years gained as well as a small monetary benefit of ECU1250. An extensive sensitivity analysis did not greatly affect the results for the elderly population: vaccination in this age group always remained favourable, and thus it is clearly indicated from an economic point of view. A crucial assumption for both age groups is that the effectiveness of the vaccine holds for all pneumococcal pneumonia. It is clear that the results will become less favourable if this assumption is dropped. CONCLUSIONS: Preventing pneumococcal infections by vaccination clearly benefits people's health. Reimbursement can be recommended for the elderly group; however, more accurate epidemiological data are still needed to make decisions concerning routine pneumococcal vaccination in adults < 65 years of age. Unfortunately, the issue of whether the effectiveness of the vaccine holds for all pneumococcal pneumonia is as yet unresolved in the medical literature.

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.

Patient classification and cost analysis of AIDS and HIV: the case of Belgium.

The study calculates inpatient costs generated at the University Hospital in Antwerp (Belgium) and outpatient costs generated at the Institute of Tropical Medicine or at the University Hospital of 213 seropositive patients without AIDS and of 48 AIDS patients, for the year 1991. Outpatient drug use other than Zidovudine was excluded. An HIV + patient has an average annual total billing cost of 2062 ECU, 43% of which is spent in hospital, 29% on Zidovudine and 28% for follow-up at the Institute of Tropical Medicine. The average cost of care for an AIDS patient is 5.5 times higher and amounts to 11,277 ECU--hospitalisation costs (8349 ECU) and costs of Zidovudine (2031 ECU) are much higher. Costs vary with the severity of illness. In comparison to 1987, costs decreased due to lower drug prices and reduced hospitalisations. Life time costs of a seropositive patient are estimated at about 35,000 ECU, based on cost calculations per CD4-class for a follow-up period from 1991 to 1993.

Pharmacoeconomic studies. Pitfalls and problems.

The literature on economic evaluation of pharmaceuticals is growing rapidly. Although there have been substantial methodologic advances, there remain serious problems and pitfalls. This presentation focuses on three aspects, i.e., use (and abuse) of evaluation studies, methodologic problems, and the quality of published studies.

Pharmacoeconomics of immunisation: a review.

The effects of immunisation programmes that have existed for several decades in developed countries are demonstrated by the decrease and even eradication of smallpox, poliomyelitis, measles, mumps and hepatitis B. Cost, health policy and spontaneous evolution in the incidence of communicable diseases have a decisive influence on the use of a vaccine. Investment in vaccination policy has to be encouraged to maintain this progress made in the control of infectious diseases and to meet new challenges. Studies re-evaluating ongoing immunisation programmes are scarce. Nevertheless, it can be concluded that for vaccination against hepatitis B in professionally exposed at-risk populations, arguments for positive returns are consistent. The same holds for vaccination against S. pneumoniae and for influenza virus in the elderly. The results of the economic evaluation of revaccination against measles, when insufficient coverage exists, are inconclusive. Universal vaccination of children against Haemophilus influenzae type b (Hib) and of children of hepatitis B-positive mothers against hepatitis may require costs to be paid in order to gain extra health benefits.