Theoretical arguments for the discounting of health consequences: where do we go from here?

Discounting money and health effects from communicable and noncommunicable diseases in Thailand

The purpose of this study was to determine the discount rates for money and health outcomes in the Thai context, including the discount rates for communicable and non-communicable diseases. Moreover, this study aimed to explore the socio-demographic characteristics that influence discounting. The computer-based experimental design was used to obtain time preferences for money and health in a total of 1202 Chiang Mai province population, aged 25-50, individually interviewed by trained interviewers. Money-related questions were carried out in all subjects. For health-related questions, all subjects were randomly assigned in a 1:1 ratio for response to questions about Coronavirus Disease 2019 (COVID-19) (N = 602) and air pollution (N = 600). A choice-based elicitation procedure was performed in the experiment to obtain the indifference values from subjects' time preferences. The cumulative weighting functions were generated using the indifference values to indicate the degree of discounting. The discount factors were computed from the cumulative weighting functions. The discount rates were estimated using a continuous approximation based on the relationship between the discount factors and the parameters governing the discounting model. The Tobit model was applied to investigate the relationships between discounting and socio-demographic characteristics. Discounting for money was greater than discounting for health. Money and health had annual discount rates of 6.2% and 1.3%, respectively. Furthermore, in the COVID -19 situation, the annual discount rate for health was higher than that in the air pollution situation (2.4% vs. 0.7%). Generation X subjects (aged 42 years and above), children under the age of 15 in the household, and underlying diseases were positively related to discounting, while household income was negatively related to discounting. Health should be discounted at a lower rate than money. Moreover, different discount rates should be considered for different types of diseases.

Understanding Health Economics in Joint Replacement Surgery

The number of arthroplasty procedures has been rising at a significant rate, contributing to a notable portion of the nation's health care spending. This growth has contributed to an increase in the number of health care economic studies in the field of adult reconstruction surgery. Although these articles are filled with important information, they can be difficult to understand without a background in business or economics. The goal of this review is to define the common terminology used in health care economic studies, assess their value and benefit in the context of total joint arthroplasty, and highlight shortcomings in the current literature. [Orthopedics. 2022;45(4):e174-e182.].

Determinants of Lifestyle Choices Among South Korean College Students: An Experimental Analysis

Purpose

Based on theoretical predictions from human capital theory, the aim of this exploratory study is to analyze the relationship between experimentally elicited, incentivized economic preference parameters, Big Five and Grit personality traits, cognitive ability, and the Alameda Seven lifestyles: smoking, drinking excessively, being overweight or obese, experiencing stress, following a healthy diet, exercising, and sleeping enough. In addition, self-reported general physical and mental health are analyzed.

Materials and Methods

Data collection took place in an incentivized paper-and-pencil experiment. Undergraduate students were recruited as subjects, with the requirement that they be freshmen, but no restrictions based on gender, major, or age. A pre-test and three experimental sessions were conducted in March and in April 2018, with a total of 178 subjects participating. After deleting observations with missing values, a total of n = 138 subjects remained. Regression analysis (multivariate probit models, resulting marginal effects and changes in predicted probabilities of adopting a lifestyle for “ideal types”) was used to analyze and compare the determinants of the Alameda Seven health behaviors.

Results

Findings suggest that preference parameters, a measure of cognitive ability, and Big Five personality traits are statistically significantly estimated in regressions for the determinants of adopting Alameda Seven health behaviors, but the Grit score is only statistically significantly estimated in a regression for the determinants of reported better general mental health.

Conclusion

The findings regarding preference parameters partly lend support to predictions from human capital theory and partly confirm previous findings in health psychology. Those results might be explained by the relatively small sample size and the inclusion of a measure of cognitive ability in addition to personality traits and preferences.

Loss Aversion and Health Behaviors: Results from Two Incentivized Economic Experiments

Experimental research in health economics has analyzed the effects of economic preference parameters such as risk attitude and time preference on the probability of adopting risky health behaviors. However, the existing evidence is mixed and previous research often fails to include controls for other determinants of health behaviors such as personality traits. The aim of this research is to analyze the relationships between an incentivized measure of loss aversion and three health behaviors: smoking, binge drinking, and engaging in physical activity. Loss aversion is a preference measure that has been derived from prospect theory as an alternative approach to analyze decision-making under risk, such as the decision to invest in health capital, and has never been used in an analysis of the determinants of health behaviors before. Using two experimental samples of college students in the Republic of Korea and the United States of America, and controlling for Big Five personality traits and a host of individual-level control variables, there are no statistically significant relationships between loss aversion and the three aforementioned health behaviors, but relationships for Big Five conscientiousness, extraversion, agreeableness, and neuroticism. A candidate explanation might be lack of domain independence for loss aversion. Differences between the Korean and the US samples indicate the possibility of intercultural differences.

Differential discounting in the economic evaluation of healthcare programs

Background

The question of appropriate discount rates in health economic evaluations has been a point of continuous scientific debate. Today, it is widely accepted that, under certain conditions regarding the social objective of the healthcare decision maker and the fixity of the budget for healthcare, a lower discount rate for health gains than for costs is justified if the consumption value of health is increasing over time. To date, however, there is neither empirical evidence nor a strong theoretical a priori supporting this assumption. Given this lack of evidence, we offer an additional approach to check the appropriateness of differential discounting.

Methods

Our approach is based on a two-goods extension of Ramsey's optimal growth model which allows accounting for changing relative values of goods explicitly. Assuming a constant elasticity of substitution (CES) utility function, the growth rate of the consumption value of health depends on three variables: the growth rate of consumption, the growth rate of health, and the income elasticity of the willingness to pay for health. Based on a review of the empirical literature on the monetary value of health, we apply the approach to obtain an empirical value of the growth rate of the consumption value of health in Germany.

Results

The empirical literature suggests that the income elasticity of the willingness to pay for health is probably not larger but rather smaller than 1 and probably not smaller but rather larger than 0.2. Combining this finding with reasonable values of the annual growth rates in consumption (1.5-1.6%) and health (0.1%) suggests, for Germany, an annual growth rate of the consumption value of health between 0.3 and 1.5%.

Conclusion

In the light of a two-goods extension of Ramsey's optimal growth model, the available empirical evidence makes the case for a growing consumption value of health. Therefore, the current German practice of applying the same discount rate to costs and health gains introduces a systematic bias against healthcare technologies with upfront costs and long-term health effects. Differential discounting with a lower rate for health effects appears to be a more appropriate discounting model.

Preferences, personality and health behaviors: results from an explorative economic experiment

This research note analyzes the relationship between experimentally elicited, incentivized economic preference parameters, personality traits, and three health behaviors: smoking, drinking, and physical activity. While there is a strand of economic research that uses proxy measures of risk and time preference that are not derived from an incentivized experiment and personality traits at the same time, and a considerably smaller one that uses experimentally elicited measures of risk and time preference only, the innovation of my work is to use experimentally elicited, incentivized preference measures and personality traits at the same time to explain a range of health behaviors. Findings presented in this paper suggest that personality traits seem to be more important determinants of health behaviors than economic preference parameters, and that Big Five personality traits, especially Agreeableness, seem to be more important determinants than the Grit score developed by Duckworth et al. (J Pers Soc Psychol 92(6):1087, 2007). When also controlling for a host of personality traits, risk preference is not related to the analyzed behaviors, but time preference is negatively related to smoking. When controlling for economic preferences and Big Five personality traits, the Grit score is unrelated to the analyzed health behaviors. Big Five openness is negatively related to the probability of engaging in physical activity, while Big Five agreeableness is negatively related to the probability of both drinking and binge drinking, but also to the probability of engaging in physical activity. Big Five neuroticism is negatively related to the probability of binge drinking.

Bidirectional relationship between time preference and adolescent smoking and alcohol use: Evidence from longitudinal data

INTRODUCTION

Scholarly interest in time preference as a potential predictor of risky health behaviors in adolescents has increased in recent years. However, most of the existing literature is limited due to the exclusive reliance on cross-sectional data, precluding the possibility of establishing the direction of causality. Using longitudinal data from the Korea Youth Panel Survey (2003-7), which followed up a nationally representative sample of 3449 adolescents aged 14years for five years, this study examines a bidirectional relationship between time preference and smoking and drinking behaviors among adolescents.

METHODS

We used discrete time hazard models of smoking and drinking initiation as a function of time preference measured at the baseline and fixed-effects ordered logit model of time preference, respectively. Our measure of time preference was derived from the survey question on a hypothetical choice between immediate enjoyment today and likely higher scores on an exam tomorrow.

RESULTS

The overall results provide evidence on the bidirectional relationship; that is, higher time discounting (i.e., greater relative preference for present utility over future utility) results in an increased risk of engaging in smoking and drinking, and conversely, adopting such behaviors leads to a higher discount rate.

CONCLUSIONS

The bidirectional relationship may function as a mechanism for adolescents to engage in increased smoking and drinking or additional negative health behaviors via gateway effects, strengthening the case for preventing the initiation of risky health behaviors among adolescents.

Temporal discounting rates and their relation to exercise behavior in older adults

As our nation's population ages, the rates of chronic illness and disability are expected to increase significantly. Despite the knowledge that exercise may prevent chronic disease and promote health among older adults, many still are inactive. Factors related to exercise behaviors have been explored in recent years. However, temporal discounting is a motivational concept that has not been explored in regard to exercise in older adults. Temporal discounting is a decision making process by which an individual chooses a smaller more immediate reward over a larger delayed reward. The aim of this study was to determine if temporal discounting rates vary between exercising and non-exercising older adults.

DESIGN

This study used cross-sectional survey of 137 older adults living in the community. Older adults were recruited from 11 rural Arkansas churches. The Kirby delay-discounting Monetary Choice Questionnaire was used to collect discounting rates and then bivariate analysis was performed to compare temporal discounting rate between the exercisers and non-exercisers. Finally, multivariate analysis was used to compare discounting rate controlling for other covariates.

RESULTS

The results indicated that exercising older adults display lower temporal discounting rates than non-exercising older adults. After controlling for education, exercisers still have lower temporal discounting rates than non-exercisers (p<0.001).

CONCLUSIONS AND IMPLICATIONS

These findings are important as several chronic health conditions relate to lack of exercise especially in older adults. This research suggests that if we can find appropriate incentives for discounting individuals, some type of immediate reward, then potentially we can design programs to engage and retain older adults in exercise.

Research priorities for economic analyses of prevention: current issues and future directions

In response to growing interest in economic analyses of prevention efforts, a diverse group of prevention researchers, economists, and policy analysts convened a scientific panel, on "Research Priorities in Economic Analysis of Prevention" at the 19th annual conference of the Society for Prevention Research. The panel articulated four priorities that, if followed in future research, would make economic analyses of prevention efforts easier to compare and more relevant to policymakers and community stakeholders. These priorities are: (1) increased standardization of evaluation methods, (2) improved economic valuation of common prevention outcomes, (3) expanded efforts to maximize evaluation generalizability and impact as well as (4) enhanced transparency and communicability of economic evaluations. In this paper, we define three types of economic analyses in prevention, provide context and rationale for these four priorities as well as related sub-priorities, and discuss the challenges inherent in meeting them.

How effective and cost-effective was the national mass media smoking cessation campaign 'Stoptober'?

BACKGROUND

A national smoking cessation campaign based on behaviour change theory and operating through both traditional and new media was launched across England during late 2012 ('Stoptober'). In addition to attempting to start a movement in which smokers would quit at the same time in response to a positive mass quitting trigger, the campaign set smokers the goal of being smoke-free for October and embodied other psychological principles in a range of tools and communications.

METHODS

Data on quit attempts were obtained from 31,566 past-year smokers during nationally representative household surveys conducted monthly between 2007 and 2012. The effectiveness of the campaign was assessed by the increase in national quit attempt rate in October relative to other months in 2012 vs. 2007-2011.

RESULTS

Relative to other months in the year, more people tried to quit in October in 2012 compared with 2007-2011 (OR=1.79, 95%CI=1.20-2.68). In 2012 there was an approximately 50% increase in quitting during October compared with other months of the same year (9.6% vs. 6.6%; OR=1.50, 95%CI=1.05-2.15), whereas in 2007-2011 the rate in October was non-significantly less than in other months of the same period (6.4% vs. 7.5%; OR=0.84, 95%CI=0.70-1.00). Stoptober is estimated to have generated an additional 350,000 quit attempts and saved 10,400 discounted life years (DLY) at less than £415 per DLY in the modal age group.

CONCLUSIONS

Designing a national public health campaign with a clear behavioural target (making a serious quit attempt) using key psychological principles can yield substantial behaviour change and public health impact.

Cost-utility of metal-on-metal hip resurfacing compared to conventional total hip replacement in young active patients with osteoarthritis

BACKGROUND

Metal-on-metal hip resurfacing arthroplasty (MoM HRA) has emerged as an alternative to total hip arthroplasty (THA) for younger active patients with osteoarthritis (OA). Birmingham hip resurfacing is the most common MoM HRA in Alberta, and is therefore compared with conventional THA.

OBJECTIVE

The objective of this study was to estimate the expected cost-utility of MoM HRA versus THA, in younger patients with OA, using a decision analytic model with a 15-year time horizon.

METHODS

A probabilistic Markov decision analytic model was constructed to estimate the expected cost per quality-adjusted life-year (QALY) of MoM HRA versus THA from a health care payer perspective. The base case considered patients with OA aged 50 years; men comprised 65.9% of the cohort. Sensitivity analyses evaluated cohort age, utility values, failure probabilities, and treatment costs. Data were derived from the Hip Improvement Project and the Hip and Knee Replacement Pilot databases in Alberta, the 2010 National Joint Replacement Registry of the Australian Orthopaedic Association, and the literature.

RESULTS

In the base case, THA was dominated by MoM HRA (incremental mean costs of -$583 and incremental mean QALYs of 0.079). In subgroup analyses, THA remained dominated when cohort age was 40 years instead of 50 years or when only men were assessed. THA dominated when the cohort age was 60 years or when only women were assessed. Results were sensitive to utilities, surgery costs, and MoM HRA revision and conversion probabilities. At a willingness-to-pay of Can $50,000/QALY, there was a 58% probability that MoM HRA is cost-effective.

CONCLUSIONS

The results show that, on average, MoM HRA was preferred to THA for younger and male patients, but THA is still a reasonable option if the patient or clinician prefers given the small absolute differences between the options and the confidence ellipses around the cost-effectiveness estimates.

Pneumococcal conjugate vaccine: review of cost-effectiveness studies in Australia, North America and Europe

The pneumococcal conjugate vaccine (PCV) is the first vaccine proven to be effective in reducing the incidence of invasive pneumococcal disease, pneumonia and acute otitis media in children, and has been recommended for universal use in children in a number of high-income countries. The high cost of the vaccine relative to previous vaccines has generated interest in assessing its cost-effectiveness and numerous cost-effectiveness analyses of PCV have been performed in Australia, North America and Europe. The primary objectives of this review are to enhance the ability to make direct comparisons between these analyses, to aid in the identification and interpretation of methodological differences and to summarize the findings. Although these studies varied greatly in terms of methodology and assumptions, if and when indirect effects and quality-of-life improvements are taken into account, the cost-effectiveness ratios of PCV in these countries are likely to be within the ranges generally considered favorable vis-à-vis other health interventions.

On discounting of health gains from human papillomavirus vaccination: effects of different approaches

OBJECTIVES

Discounting has long been a matter of controversy in the field of health economic evaluations. How to weigh future health effects has resulted in ongoing discussions. These discussions are imminently relevant for health care interventions with current costs but future benefits. Different approaches to discount health effects have been proposed. In this study, we estimated the impact of different approaches for discounting health benefits of human papillomavirus (HPV) vaccination.

METHODS

An HPV model was used to estimate the impact of different discounting approaches on the present value of health effects. For the constant discount approaches, we varied the discount rate for health effects ranging from 0% to 4%. Next, the impact of relevant alternative discounting approaches was estimated, including hyperbolic, proportional, stepwise, and time-shifted discounting.

RESULTS

The present value of health effects gained through HPV vaccination varied strongly when varying discount rates and approaches. The application of the current Dutch guidelines resulted in a present value of health effects that was eight or two times higher than that produced when using the proportional discounting approach or when using the internationally more common 4% discount rate for health effects, respectively. Obviously, such differences translate into large variations in corresponding incremental cost-effectiveness ratios.

CONCLUSION

The exact discount rate and approach chosen in an economic evaluation importantly impact the projected value of health benefits of HPV vaccination. Investigating alternative discounting approaches in health-economic analysis is important, especially for vaccination programs yielding health effects far into the future. Our study underlines the relevance of ongoing discussions on how and at what rates to discount.

Cost-effectiveness analysis of the bone-anchored hearing device

OBJECTIVE

To establish the cost-effectiveness of a bone-anchored hearing device (BAHD). To date, there has not been any formal economic analysis of this treatment.

STUDY DESIGN

A prospective cohort case-control analysis.

SETTING

Tertiary referral center, university hospital.

PATIENTS

Between April 2007 and June 2008, all adult patients undergoing their first BAHD were contacted and invited to take part in this study. Data of 70 patients were completed during the study period and were analyzed.

INTERVENTIONS

A health utility measure was made before and after the insertion of a BAHD to estimate the utility gain associated with this intervention.

MAIN OUTCOME MEASURES

The cost and quality-adjusted life year (QALY) gain for each patient was established, and an incremental cost-effectiveness ratio (ICER) was calculated.

RESULTS

The results of our analysis are that, compared with current standard care, the BAHD has an ICER of £17,610 (US $26,415) per QALY gained. The National Institute for Health and Clinical Excellence will endorse a health intervention as cost-effective if the ICER is below £20,000 to £30,000 per QALY (US $30,000-45,000).

CONCLUSION

This technology is likely to be cost-effective at the current thresholds used by National Institute for Health and Clinical Excellence. Therefore, this study suggests the BAHD may be a cost-effective method of auditory rehabilitation.

Methods for assessing the cost-effectiveness of public health interventions: key challenges and recommendations

RATIONALE

Increasing attention is being given to the evaluation of public health interventions. Methods for the economic evaluation of clinical interventions are well established. In contrast, the economic evaluation of public health interventions raises additional methodological challenges. The paper identifies these challenges and provides suggestions for overcoming them.

METHODS

To identify the methodological challenges, five reviews that explored the economics of public health were consulted. From these, four main methodological challenges for the economic evaluation of public health interventions were identified. A review of empirical studies was conducted to explore how the methodological challenges had been approached in practice and an expert workshop convened to discuss how they could be tackled in the future.

RESULTS

The empirical review confirmed that the four methodological challenges were important. In all, 154 empirical studies were identified, covering areas as diverse as alcohol, drug use, obesity and physical activity, and smoking. However, the four methodological challenges were handled badly, or ignored in most of the studies reviewed.

DISCUSSION

The empirical review offered few insights into ways of addressing the methodological challenges. The expert workshop suggested a number of ways forward for overcoming the methodological challenges.

CONCLUSION

Although the existing empirical literature offers few insights on how to respond to these challenges, expert opinion suggests a number of ways forward. Much of what is suggested here has not yet been applied in practice, and there is an urgent need both for pilot studies and more methodological research.

The economic burden of end-stage renal disease in Canada

End-stage renal disease (ESRD) is a serious illness with significant health consequences and high-cost treatment options. This study estimates direct and indirect cost associated with ESRD from a societal perspective. A prevalence-based approach was used to estimate direct health-care costs and productivity losses from short- and long-term disability. An incident-based human capital approach was used to estimate mortality costs as the sum of the discounted present value of current and future productivity losses from premature deaths. Less than 0.1% of Canadians have ESRD; however, the disease generated direct health-care costs of $1.3 billion in the year 2000. The amount of direct spending per person with ESRD is much more than the average spending per person for all health-care conditions. Adding indirect morbidity and mortality cost brings the total burden associated with ESRD to $1.9 billion. This economic impact is higher than that for skin or infectious diseases, about the same as for genitourinary or endocrine diseases, but lower than that for conditions such as cancer or stroke. This economic weight is borne by a relatively small number of individuals. With the rapid increase in the incidence of ESRD, these findings may be useful in setting priorities for research, prevention programs, and in the planning of treatments. A better understanding of the scope and magnitude of the total economic burden of ESRD would help to inform those making policy decisions.

The economics of primary prevention of cardiovascular disease - a systematic review of economic evaluations

BACKGROUND

In the quest for public and private resources, prevention continues to face a difficult challenge in obtaining tangible public and political support. This may be partly because the economic evidence in favour of prevention is often said to be largely missing. The overall aim of this paper is to examine whether economic evidence in favour of prevention does exist, and if so, what its main characteristics, weaknesses and strengths are. We concentrate on the evidence regarding primary prevention that targets cardiovascular disease event or risk reduction.

METHODS

We conducted a systematic literature review of journal articles published during the period 1995-2005, based on a comprehensive key-word based search in generic and specialized electronic databases, accompanied by manual searches of expert databases. The search strategy consisted of combinations of freetext and keywords related to economic evaluation, cardiovascular diseases, and primary preventive interventions of risk assessment or modification.

RESULTS

A total of 195 studies fulfilled all of the relevant inclusion criteria. Overall, a significant amount of relevant economic evidence in favour of prevention does exist, despite important remaining gaps. The majority of studies were cost-effectiveness-analyses, expressing benefits as "life years gained", were conducted in a US or UK setting, assessed clinical prevention, mainly drugs targeted at lowering lipid levels, and referred to subjects aged 35-64 years old with at least one risk factor.

CONCLUSION

First, this review has demonstrated the obvious lack of economic evaluations of broader health promotion interventions, when compared to clinical prevention. Second, the clear role for government to engage more actively in the economic evaluation of prevention has become very obvious, namely, to fill the gap left by private industry in terms of the evaluation of broader public health interventions and regarding clinical prevention, in light of the documented relationship between study funding and reporting of favourable results. Third, the value of greater adherence to established guidelines on economic evaluation cannot be emphasised enough. Finally, there appear to be certain methodological features in the practice of economic evaluations that might bias the choice between prevention and cure in favour of the latter.

Adherence of Pharmacoeconomic Studies to National Guidelines in the Netherlands

OBJECTIVE

This study examines the adherence of Dutch pharmacoeconomic studies to the national guidelines of conducting a pharmacoeconomic evaluation.

METHODS

Dutch guidelines for pharmacoeconomic research were issued in 1999. All Dutch pharmacoeconomic studies that were published in English during 2000-2002 were selected for our review. Two reviewers examined each study for relevance and compared each study with the nine methodological guidelines selected.

RESULTS

It was found that 29 studies satisfied the inclusion criteria. The societal perspective was taken in 13 out of the 29 studies (45%), an adequate time period of analysis was chosen in 21 (72%), effectiveness was explicitly differentiated from efficacy in 17 (59%), an incremental analysis was performed in 23 (79%), costs, benefits and health gains were discounted in 24 (83%), effectiveness was expressed in LYGs or QALYs in 16 (55%), reference prices were used in 8 (28%), subgroup analysis was presented in 13 (45%) and sensitivity analysis was included in 26 (90%).

CONCLUSIONS

In this review we found that the adherence of studies to some of the Dutch guidelines for pharmacoeconomic studies is fair. However, major improvements are required with respect to the adoption of the societal perspective, presentation of adequate subgroup analyses and application of reference prices.

Evaluation and review of pharmacoeconomic models

Difficult decisions as to whether to provide or withhold drug therapy to patients are needed to be made on a daily basis. These decisions should be based on carefully designed and constructed pharmacoeconomic models, with explicit and justifiable parameter values, validated by publication in peer-reviewed literature. This review describes and evaluates the common types of pharmacoeconomic models, modelling approaches and methods. It also discusses model quality, validity and usefulness.

Discounting health effects in pharmacoeconomic evaluations: current controversies

Currently, much debate still surrounds the discounting of health effects. Most general consensus statements have argued for the same discount rate for health and money; however, this practice has been questioned by several authors. The choice of discount rate can have varying effects on interventions, depending on the disease area. In this paper, we review two major current controversies around discounting: the use of similar or differential discount rates for health and money; and the validity of the underlying discounting model (time preference, constant discounting and the use of aggregated utilities for health effects). Various arguments justify a different rate of discounting for health effects than for money. Empirical evidence questions the validity of the constant discounting model, pointing out that time preference is not constant and should not be applied as such. Also, the validity of the aggregated utility model for health might be questioned, implying that a life cannot simply be cut into life years as single entities that are discounted back to the net present value. Such debates have led to varying methodologies being employed in economic evaluations, causing difficulties in their interpretation. Although there is sufficient evidence to question the use of similar discount rates for health and money, currently there is not enough information on the nature of the different processes that constitute discounting to reach a solid conclusion on the use of a different method. The lack of consensus on one of the most important topics in pharmacoeconomics makes the case for a more restricted use of cost-effectiveness or cost-utility ratios than as the most important singular outcome of pharmacoeconomic studies. Instead, results should be presented in a non-aggregated manner that enables policy makers to value health gains according to timing and to which subpopulation they are accrued in.

Ethical principles for collective immunisation programmes

Ethical issues arise in discussion of both the content and implementation of collective immunisation programmes. In this paper we propose and discuss seven principles that may guide reflection and debate in this controversial area. Whilst this paper is not intended to be a final and complete account of the relevant principles for collective immunisation programmes we hope that it can help stimulate more active discussion of these issues. Debate about these principles may help to make moral conflicts more explicit and open up the possibility of resolution. We argue that analysis and discussion of the ethical issues should be part of any justification of collective vaccination programmes.

Cost effectiveness of pneumococcal vaccination for infants and children with the conjugate vaccine PnC-7 in Germany

BACKGROUND

The introduction of the conjugate vaccine PnC-7 implies that a pneumococcal vaccine is available, for the first time, which also gives children under the age of 2 years reliable protection against invasive pneumococcal infections and offers some protection against non-invasive pneumococcal infections. OBJECTIVE AND PERSPECTIVE: In the context of a multiple-period Markov model, a cost-effectiveness analysis of a recommendation for general pneumococcal vaccination in Germany for infants and children under the age of 2 years was performed from the healthcare payer, public authority and societal perspectives.

DESIGN

Various published data on age-specific incidence rates, mortality rates, efficacy of the conjugate vaccine PnC-7 and treatment costs of pneumococcal infections were incorporated into a Markov model to quantify the consequences of vaccinating versus not vaccinating.

RESULTS

From a German healthcare payers' perspective, general vaccination with the conjugate vaccine would redeem 51.1% of the vaccination costs due to avoidable treatment costs, whereas, from a broader point of view, the benefits, expressed in monetary terms, would exceed the cost of vaccination. The conjugate vaccine would require an investment of euro72 866 per life-year saved (discounted, healthcare payers' viewpoint). Besides this benchmark, there are further outcome measures which cannot be ignored by those deciding on a general vaccination recommendation: 450 000 preventable episodes of illness and 134 cases of sequelae which can be prevented.

CONCLUSIONS

The vaccination with the conjugate vaccine PnC-7 is cost saving from a broader perspective and the results should not be ignored by policy makers in regard to a general vaccination recommendation.