Societal Willingness Research Articles

Cutting back on low-value health care practices supports sustainable kidney care

July 2023 marked the hottest month on record, underscoring the urgent need for action on climate change. The imperative to reduce carbon emissions extends to all sectors including healthcare, with it being responsible for 5.5% of global emissions. In decarbonising healthcare, while much attention has focused on greening healthcare infrastructure and procurement, less attention has focused on reducing emissions through demand-side management. An important key element of this is reducing low-value care, given that approximately 20% of global healthcare expenditure is considered low-value.“Value” in healthcare, however, is subjective and dependent on how health outcomes are regarded. This review therefore examines the three main value perspectives specific to healthcare. Clinical effectiveness defines low-value care as interventions that offer little to no benefit, or have a risk of harm exceeding benefits. Cost-effectiveness compares health outcomes versus costs compared to an alternative treatment. In this case, low-value care is care greater than a societal willingness to pay for an additional unit of health (QALY). Lastly, community perspectives emphasize the value of shared decision-making and patient-centered care.These values sit within broader societal values of ethics and equity. Any reduction in low-value care should therefore also consider patient autonomy, societal value perspectives and opportunity costs, and equity. De-implementing entrenched low-value care practices without unnecessarily compromising ethics and equity will require tailored strategies, education, and transparency.

Assessment of the Environmental Public Goods of the Organic Farming System: A Lithuanian Case Study

Organic farming is a farming system that combines environmental farming practices, a high degree of biodiversity, and the protection of natural resources. All these environmental services are used in society as public goods, contributing to societal welfare. Understanding the opinions of residents on these environmental public goods is essential because they are both consumers and financial contributors to the common agricultural policy. Therefore, it is imperative to further existing scientific knowledge in the field of consumer behaviour. Using Lithuania as a case study, the present study focuses on analysing societal opinion and willingness to pay (WTP) with respect to the environmental public goods (reflected in three components: the reduction in water, soil, and air pollution) of organic farming. This study uses the contingent valuation (CV) method to obtain the WTP for public goods. The median WTP was calculated for multiple environmental public goods from organic agriculture, excluding the protest zero. This study revealed that the residents of Lithuania understood the contribution of organic farming in creating environmental public goods and were concerned about environmental issues. It was crucial for them to have a clean environment with, for example, better drinking water quality, lower air pollution and soil erosion. The application of the CV method showed a median WTP of EUR 24.58 annually per family for environmental public goods. The preference towards environmental public goods differs depending on the socioeconomic characteristics and knowledge about organic farming. These findings provide quantitative information regarding the demand for the environmental effects of organic farming, which could be useful for policy-makers. Such research could also prove useful in setting the future direction of the common agricultural policy. The example of Lithuania was used to present a universal research problem that concerns European countries, especially those in the European Union.

Socioeconomic per-case costs of stroke, myocardial infarction, and preterm birth attributable to air pollution in Sweden.

Incident cases of stroke, myocardial infarction, and preterm birth have established exposure-response functions associated with air pollution. However, there are no studies reporting detailed costs per case for these health outcomes that are adapted to the cost-benefit tools that guide the regulation of air pollution. The primary objective was to establish non-fatal per-case monetary estimates for stroke, myocardial infarction, and preterm birth attributable to air pollution in Sweden, and the secondary objective was to ease the economic evaluation process of air pollution morbidity effects and their inclusion in cost-benefit assessments. Based on recommendations from the literature, the case-cost analysis considered direct and indirect medical costs, as well as production losses and informal costs relevant for the calculation of the net present value. A literature search was conducted to estimate the costs of each category for each incident case in Sweden. Informal costs were estimated using the quality-adjusted life-years approach and the corresponding willingness-to-pay in the Swedish population. The total average per-case cost was estimated based on specific health outcome durations and severity and was discounted by 3.5% per year. Sensitivity analysis included varying discount rates, severity of health outcome, and the range of societal willingness to pay for quality-adjusted life years. The average net present value cost estimate was €2016 460k (185k-1M) for non-fatal stroke, €2016 24k (16k-38k) for myocardial infarction, and €2016 34k (19k-57k) for late preterm birth. The main drivers of the per-case total cost estimates were health outcome severity and societal willingness to pay for risk reduction. Varying the discount rate had the largest effect on preterm birth, with costs changing by ±30% for the discount rates analysed. Because stroke, myocardial infarction, and preterm birth have established exposure-response functions linking these to air pollution, cost-benefit analyses should include the costs for these health outcomes in order to adequately guide future air pollution and climate change policies.

Awareness and willingness to pay for green roofs in Mediterranean areas

Green roofs have been extensively investigated in recent years, showing that their implementation in urban areas provides multiple benefits (e.g., pluvial flood mitigation, urban heat island reduction, energy saving, increase of biodiversity, CO2 sequestration) and supports sustainable urban development. Although green roof benefits have been widely recognized, the perception that the community has of these nature-based solutions and the willingness to pay for their installation in urban areas is still not clear nor quantified. Societal perception and willingness to pay for green roofs are fundamental for urban planners and decision makers, since they represent the community participation in the sustainable development of urban areas. In this work, we aim to analyze how citizens perceive green roofs and how willing they are to pay for the installation and maintenance of these nature-based solutions. We used an online survey to investigate the perception and the knowledge of green roofs as a potential solution to common environmental issues (i.e., urban flood, increase of temperature, energy consumption, air pollution and lack of green spaces), and the interest and willingness to pay for green roof installation on both public and private roofs. Based on the answers of 389 respondents living in Sardinia (Italy), our analysis revealed that most citizens are aware of what green roofs are, and they are aware that, although these nature-based solutions can not completely solve environmental issues, they can greatly contribute to the mitigation of these phenomena. Results also show a higher interest in the installation of green roofs on public buildings than on private ones, due to the high installation costs. Moreover, for private roofs, the possibility to install photovoltaic panels instead of GRs is generally preferred. Most of the respondents are willing to spend less than 100 € per year for the maintenance of green roofs on public buildings and to invest less than 5000 € for the installation on their own house.

Cost-effectiveness analyses of population-based multi-gene testing for the prevention of breast and ovarian cancer in the United States.

10596 Background: The current method of testing for BRCA gene mutations, which is based on family history, often fails to identify many carriers. With the advancement of next-generation sequencing technologies, which have significantly lowered the cost of genetic testing and sequencing, population-based testing has been proposed. We evaluated the cost-effectiveness of population-based multi-gene testing as a means of preventing breast and ovarian cancer. Methods: We developed a microsimulation model to assess the cost-effectiveness of multi-gene testing (BRCA1/BRCA2/PALB2) for all women aged 30-35 years compared to the current standard of care that is family history-based. We selected these genes for analyses as they are most prevalent high penetrance genes. We assumed a test uptake rate of 70%. Carriers of pathogenic variants who were not affected by cancer were offered interventions, such as MRI/mammography, chemoprevention, or risk-reducing mastectomy and risk-reducing salpingo-ophorectomy (RRSO), to reduce the risk of breast and ovarian cancer. We incorporated excess coronary heart disease (CHD) deaths from premenopausal RRSO. Our main outcome measure was the incremental cost-effectiveness ratio (ICER)(i.e., cost per-quality-adjusted life year (QALY) gained), with the commonly used societal willingness to pay of $100,000/QALY in the US as the C-E threshold. We ran 500 simulations on 1,000,000 women, employing a lifetime time horizon and payer perspective, and adjusted the cost to 2022 US dollar. We also used probabilistic sensitivity analyses to evaluate model uncertainty. Results: In the base case, population-based multi-gene testing is more cost-effective compared to family-history based testing, with an ICER of $41,306/QALY (95%CI $35,630-$48,441/QALY). This new testing method is able to prevent an additional 1,369 cases of breast cancer and 807 cases of ovarian cancer, but it will also result in 8 excess heart-disease deaths per million women. The probabilistic sensitivity analyses show that the probability that population-based multi-gene testing is cost-effective is 100% for all the simulations. When the cost of the test exceeds $1,100 population-based multi-gene testing becomes economically inefficient (ICER $10,0886/QALY). Conclusions: Population-based multi-gene testing is a more cost-effective option for the prevention of breast cancer and ovarian cancer when compared to current family-history-based testing methods.

The value of a QALY towards the end of life and its determinants: Experimental evidence

ObjectivesIndividual and societal willingness to pay (WTP) for end-of-life medical interventions continue to be subject to considerable uncertainty. This study aims at deriving both types of WTP estimates for an extension of survival time and an improvement of quality of life amounting to a QALY. MethodsA discrete choice experiment (DCE) involving a hypothetical novel drug for the treatment of terminal cancer involving 1529 Swiss residents was performed in 2014. In its individual setting, respondents choose between the status quo and a hypothetical drug with varying characteristics and out-of-pocket payments, adopting the perspective of a terminal cancer patient. In the societal setting, participants are asked to choose between the status quo and a social health insurance contract with and without coverage of the novel drug and a varying insurance contribution. ResultsIn the individual setting, respondents put a higher value on their quality of life than on their survival time whereas in the societal setting, they put a higher value on extra survival time. The combination of the two extensions results in a mean individual WTP per QALY of CHF 96,150 (1 CHF = 1 USD as of 2014). Mean societal WTP for a QALY even amounts to CHF 213,500 in favor of an adult patient, CHF 255,600 for a child, and CHF 153,600 for a person aged over 70 years, respectively. While estimated societal values consistently exceed their individual counterparts, they vary considerably with respondents’ socioeconomic characteristics in both settings. ConclusionsThis research finds that individual WTP for an extension of survival time to one year is dominated by WTP for health-related quality of life whereas for societal WTP, it is the other way round. Both individual and societal WTP values exhibit a great deal of heterogeneity, with the latter depending on the type of beneficiary.

Local People Standings on Existing Farm Animal Welfare Legislation in the BRIC Countries and the USA. Comparison with Western European Legislation

ABSTRACT This study explored the demand for improved farm animal welfare (FAW) legislation in the BRIC countries and the USA. Results are discussed in comparison to Europe. Interviewees ranked their willingness to support or oppose introduction of more FAW-friendly laws in their country. A multinomial logistic regression was fit to the data (p < 0.001), with the parameters “country × gender” (p < 0.001) and “country × age” (p < 0.001) found significant. Americans, Russian women, and older Brazilian men are very supportive. The age effect is also felt in India, where older people are more supportive. Chinese, American men, and younger Indians are less supportive. Russian males are the group that oppose the most, followed by younger Brazilians and Indians. The law and its application vary a lot between countries. Nevertheless, the societal willingness to improve FAW legislation is high in all countries. The willingness is higher in Europe. The different cultural backgrounds, the socio-economic factors, and the social, economic, and environmental sustainability are enough reasons to create barriers to policy harmonization in the global trade of farm animal products.

Early Total Hip Arthroplasty is a Cost-Effective Treatment for Severe Radiographic Slipped Capital Femoral Epiphysis Over an Individual's Lifetime

BackgroundSlipped capital femoral epiphysis (SCFE) causes degenerative changes warranting total hip arthroplasty (THA) in approximately 50% of patients by age 60 years. For severe SCFE, a reorienting intertrochanteric osteotomy (ITO) following in situ pinning (ISP) can decrease impingement with hip flexion, but by altering proximal femoral geometry, complicates subsequent conversion THA. We hypothesized that increasing implant survivorship would affect the most cost-effective treatment strategy (ISP followed by ITO [ISP + ITO] with later THA versus ISP alone [ISPa] with earlier THA) over a patient’s lifetime. MethodsA state-transition Markov model was constructed to analyze the cost-effectiveness of either ISPa or ISP + ITO over a 60-year time horizon for children who have severe, stable SCFE. Transition probabilities associated with implant and native hip survivorship, state utilities, and costs were derived from the literature. Sensitivity analyses assessed the model robustness. Incremental cost-effectiveness ratios (ICERs) were compared to a societal willingness to pay (WTP) of $100,000 per quality-adjusted life year (QALY). ResultsOver a 60-year horizon, ISPa was costlier ($291,836) than ISP + ITO ($75,227) but achieved overall better outcomes (51.4 QALYs ISPa versus 48.7 QALYs ISP + ITO), rendering ISPa cost-effective with an ICER of $80,980/QALY. Implant survivorship and time horizon were sensitive variables. ConclusionBased upon current implant performance, ISPa with subsequent earlier THA is cost-effective when considering an individual’s life expectancy and thereby deserves consideration in patients who have severe SCFE. Without clear level 1 clinical data, our economic model considers a difficult problem, while providing families and clinicians with a framework for understanding treatment options. Level of EvidenceEconomic and decision analysis, Level III.

Access to effective but expensive treatments: An analysis of the solidarity argument in discussions on funding of medical treatments.

The development of new effective but expensive medical treatments leads to discussions about whether and how such treatments should be funded in solidarity-based healthcare systems. Solidarity is often seen as an elusive concept; it appears to be used to refer to different sets of concerns, and its interrelations with the concept of justice are not well understood. This paper provides a conceptual analysis of the concept of solidarity as it is used in discussions on the allocation of healthcare resources and the funding of expensive treatments. It contributes to the clarification of the concept of solidarity by identifying in the literature and discussing four uses of the concept: (1) assisting patients in need, (2) upholding the solidarity-based healthcare system, (3) willingness to contributeand (4) promoting equality. It distinguishes normative and descriptive uses of the conceptand outlines the overlap and differences between solidarity and justice. Our analysis shows that the various uses of the concept of solidarity point to different, even conflicting, ethical stances on whether and how access to effective, expensive treatments should be provided. We conclude that the concept of solidarity has a role to play in discussions on the accessibility and funding of newly approved medical treatments. It requires, for instance, that healthcare policies promote and maintain both societal willingness to contribute to the care of others and the value of providing care to vulnerable patients through public funding.

Cost-effectiveness of management strategies for patients with recurrent ovarian cancer and inoperable malignant bowel obstruction

ObjectivesPatients with recurrent platinum-resistant ovarian cancer often present with inoperable malignant bowel obstruction (MBO) from a large burden of abdominal disease. Interventions such as total parenteral nutrition (TPN) and chemotherapy may be used in this setting. We aim to describe the relative cost-effectiveness of these interventions to inform clinical decision making. MethodsFour strategies for management of platinum-resistant recurrent ovarian cancer with inoperable MBO were compared from a societal perspective using a Monte Carlo simulation: (1) hospice, (2) TPN, (3) chemotherapy, and (4) TPN + chemotherapy. Survival, hospitalization rates, end-of-life (EOL) setting, and MBO-related utilities were obtained from literature review: hospice (survival 38 days, 6% hospitalization), chemotherapy (42 days, 29%), TPN (55 days, 25%), TPN + chemotherapy (74 days, 47%). Outcomes were the average cost per strategy and incremental cost-effectiveness ratios (ICERs) in US dollars per quality-adjusted life year (QALY) gained. ResultsIn the base case scenario, TPN + chemotherapy was the most costly strategy (mean; 95% CI) ($49,741; $49,329–$50,162) and provided the highest QALYs (0.089; 0.089–0.090). The lowest cost strategy was hospice ($14,591; $14,527–$14,654). The TPN alone and chemotherapy alone strategies were dominated by a combination of hospice and TPN + chemotherapy. The ICER of TPN + chemotherapy was $918,538/QALY compared to hospice. With a societal willingness to pay threshold of $150,000/QALY, hospice was the strategy of choice in 71.6% of cases, chemotherapy alone in 28.4%, and TPN-containing strategies in 0%. ConclusionsTPN with or without chemotherapy is not cost-effective in management of inoperable malignant bowel obstruction and platinum-resistant ovarian cancer.

Estimating loss in capability wellbeing in the first year of the COVID-19 pandemic: a cross-sectional study of the general adult population in the UK, Australia and the Netherlands

ObjectivesTo estimate capability wellbeing lost from the general adult populations in the UK, Australia and the Netherlands in the first year of the COVID-19 pandemic and the associated social restrictions, including lockdowns.DesignCross-sectional with recalled timepoints.SettingOnline panels in the UK, Australia and the Netherlands conducted in February 2021 (data collected 26 January–2 March 2021).ParticipantsRepresentative general adult (≥ 18 years old) population samples in the UK (n = 1,017), Australia (n = 1,011) and the Netherlands (n = 1,017)Main outcome measureParticipants completed the ICECAP-A capability wellbeing measure in February 2021, and for two recalled timepoints during the initial lockdowns in April 2020 and in February 2020 (prior to COVID-19 restrictions in all three countries). ICECAP-A scores on a 0–1 no capability–full capability scale were calculated for each timepoint. Societal willingness to pay estimates for a year of full capability (YFC) was used to place a monetary value associated with change in capability per person and per country. Paired t tests were used to compare changes in ICECAP-A and YFC from pre- to post-COVID-19-related restrictions in each country.ResultsMean (standard deviation) loss of capability wellbeing during the initial lockdown was 0.100 (0.17) in the UK, 0.074 (0.17) in Australia and 0.049 (0.12) in the Netherlands. In February 2021, losses compared to pre-lockdown were 0.043 (0.14) in the UK, 0.022 (0.13) in Australia and 0.006 (0.11) in the Netherlands. In monetary terms, these losses were equivalent to £14.8 billion, AUD$8.6 billion and €2.1 billion lost per month in April 2020 and £6.4 billion, A$2.6 billion and €260 million per month in February 2021 for the UK, Australia and the Netherlands, respectively.ConclusionsThere were substantial losses in capability wellbeing in the first year of the COVID-19 pandemic. Future research is required to understand the specific impact of particular COVID-19 restrictions on people’s capabilities.

Fracture liaison service utilising an emergency department information system to identify patients effectively reduce re-fracture rate is cost-effective and cost saving in Western Australia.

ObjectivesTo assess the benefits of the Emergency Department Information System (EDIS)‐linked fracture liaison service (FLS).MethodsPatients identified through EDIS were invited to attend an FLS at the intervention hospital, the Sir Charles Gairdner Hospital (SCGS‐FLS). The intervention group was compared to usual care. Retrospective control (RC) at this hospital determined historical fracture risk (SCGH‐RC). Prospective control (PC) was from a comparator, Fremantle Hospital (FH‐PC). The main outcome measures were cost‐effectiveness from a health system perspective and quality of life by EuroQOL (EQ‐5D). Bottom‐up cost of medical care, against the cost of managing recurrent fracture (weighted basket), was determined from the literature and 2013/14 Australian Refined Diagnosis Related Groups (AR‐DRG) prices. Mean incremental cost‐effectiveness ratios were simulated from 5000 bootstrap iterations. Cost‐effectiveness acceptability curves were generated.ResultsThe SCGH‐FLS program reduced absolute re‐fracture rates versus control cohorts (9.2–10.2%), producing an estimated cost saving of AUD$750,168–AUD$810,400 per 1000 patient‐years in the first year. Between‐groups QALYs differed with worse outcomes in both control groups (p < 0.001).The SCGH‐FLS compared with SCGH‐RC and FH‐PC had a mean incremental cost of $8721 (95% CI −$1218, $35,044) and $8974 (95% CI −$26,701, $69,929), respectively, per 1% reduction in 12‐month recurrent fracture risk. The SCGH‐FLS compared with SCGH‐RC and FH‐PC had a mean incremental cost of $292 (95% CI −$3588, $3380) and −$261 (95% CI −$1521, $471) per EQ‐5D QALY gained at 12 months respectively. With societal willingness to pay of $16,000, recurrent fracture is reduced by 1% in >80% of patients.ConclusionsThis simple and easy model of identification and intervention demonstrated efficacy in reducing rates of recurrent fracture and was cost‐effective and potentially cost saving.

Dealing with impact of COVID-19 on transportation in a developing country: Insights and policy recommendations

While developed nations have established policy frameworks for dealing with various macroeconomic shocks, developing countries respond to the influx of COVID-19 on heterogeneous scales, borne out of varying institutional bottlenecks. These inadequate transport facilities are not diversified enough to deal with an impending public health crisis. With the growing divergence in public transport management procedures and societal responses and willingness to adjust to a "new normal" transport procedures in time of COVID-19 and post-pandemic, it becomes expedient to learn evidence-based policy responses to transport service delivery. Qualitative data from semi-structured interviews with commuters and operators were thematically analysed to understand the impact of COVID-19 on transportation in Lagos Nigeria. The analysis revealed that increased cost of transportation, financial sustainability, changes in travel needs and loss of revenue were the significant impacts of the pandemic. This study contributes such that transport stakeholders can better understand how to navigate their transportation needs at this time of global uncertainty. The understanding of these impacts advances policy recommendations that are most inclined to the development objectives of developing nations in the time of COVID-19 and beyond. The limitations and suggestions for further research were discussed.

Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up.

The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years. Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Cost-Utility Analysis of Drug Treatments in Patients with Polypoidal Choroidal Vasculopathy in Thailand.

PurposeThe aim of this study was to estimate the cost-utility and budget impact of pharmacological treatments for the eye with polypoidal choroidal vasculopathy (PCV) in Thailand.MethodsA Markov model-based cost-utility analysis (CUA) and budget impact analysis were conducted. The lifetime cost and outcomes of PCV treatments were estimated. We discounted costs and outcomes at 3% per annum. Parameters were estimated using data from published literatures, local cost and utility data, and epidemiology data among Thai patients. Univariate and probabilistic sensitivity analyses were performed to account for parameter uncertainty.ResultsIntravitreal bevacizumab (IVB) resulted in the lowest lifetime cost, followed by IVB plus verteporfin photodynamic therapy (IVB+vPDT) and intravitreal aflibercept (IVA). The combination of IVB or intravitreal ranibizumab (IVR) and verteporfin photodynamic therapy (IVB+vPDT or IVR+vPDT) yielded the highest quality-adjusted life-years (QALY). When compared with IVB from a societal perspective, the incremental cost-effectiveness ratio for patients with PCV receiving IVB+vPDT, IVR+vPDT, IVA were 10,304; 54,135; and 82,738 the United States dollar (USD) per QALY gained, respectively. At the Thai societal willingness to pay threshold of 4884 USD, IVB had the highest probability of being cost-effective (99%) followed by IVB+vPDT (1%). IVB+vPDT could be a cost-effective strategy and required a budget of 12.61 million USD over five fiscal years when the price of verteporfin reduced by approximately 45%.ConclusionNone of the drug treatments for PCV was cost-effective in the Thai context. The decreased price of verteporfin is required to support the inclusion of IVB+vPDT in the Thai National List of Essential Medicines for the treatment of PCV.

Conceptualising 'Benefits Beyond Health' in the Context of the Quality-Adjusted Life-Year: A Critical Interpretive Synthesis.

There is growing interest in extending the evaluative space of the quality-adjusted life-year framework beyond health. Using a critical interpretive synthesis approach, the objective was to review peer-reviewed literature that has discussed non-health outcomes within the context of quality-adjusted life-years and synthesise information into a thematic framework. Papers were identified through searches conducted in Web of Science, using forward citation searching. A critical interpretive synthesis allows for the development of interpretations (synthetic constructs) that go beyond those offered in the original sources. The final output of a critical interpretive synthesis is the synthesising argument, which integrates evidence from across studies into a coherent thematic framework. A concept map was developed to show the relationships between different types of non-health benefits. The critical interpretive synthesis was based on 99 papers. The thematic framework was constructed around four themes: (1) benefits affecting well-being (subjective well-being, psychological well-being, capability and empowerment); (2) benefits derived from the process of healthcare delivery; (3) benefits beyond the recipient of care (spillover effects, externalities, option value and distributional benefits); and (4) benefits beyond the healthcare sector. There is a wealth of research concerning non-health benefits and the evaluative space of the quality-adjusted life-year. Further dialogue and debate are necessary to address conceptual and normative challenges, to explore the societal willingness to sacrifice health for benefits beyond health and to consider the equity implications of different courses of action.

Health economics modeling of antiretroviral interventions amongst HIV serodiscordant couples

Antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP) for HIV-serodiscordant couples, effectively reduce mortality, transmission events and influence quality of life at the expense of increased costs. We aimed to evaluate health economics of antiretroviral-based strategies for HIV-serodiscordant couples in the China context. A deterministic model of HIV evolution and transmission within a cohort of serodiscordant couples was parameterized using the real-world database of Zhoukou city and published literature. We evaluated the mid-ART (a historical strategy, initiating ART with CD4 < 500 cells/mm3), early-ART (the current strategy, offering ART regardless of CD4 cell counts) and a hypothetical strategy (early-ART combined short-term daily PrEP) versus the late-ART (the baseline strategy, initiating ART with CD4 < 350 cells/mm3) offered by 2008 national guidelines. We estimated the incremental cost-effectiveness ratios (ICER) and incremental cost-utility ratios (ICUR) from a societal perspective, derived by clinical benefits and HIV-caused life quality respectively, and portrayed their changes over a 0–30 year’s timeframe. The model projections indicated that the antiretroviral-based interventions were more likely to obtain clinical benefits but difficult to improve quality of life, and cumulative ICER and ICUR were generally decreasing without achieving cost-saving. Scale-up access to ART for the HIV-positive among serodiscordant couples was easily fallen within the range of paying for incremental life-years and quality adjusted life years by the societal willingness. The hypothetical strategy had the potential to prevent most seroconversion events within marriages but required enormous upfront costs, thus it took a long time to reach established thresholds. The current strategy of early-ART is the most cost-effective. Clarifying the obstacles of high cost of PrEP and improving life quality for HIV-serodiscordant couples have emerged as an urgent requisition.

Is there a social justice to dentistry's social contract?

How should the dental profession of the 21st century frame its interactions with the society it is tasked to care for? What has this relationship looked like in the past, and what does it look like today? In this article, we examine these and other issues through the framework of the social contract, with a focus on exploring how social justice fits within the transaction of duties between the dental profession and society. We begin by describing the social contract and how this is uniquely defined within the context of dentistry; specifically, how the context of dentistry as, in part, an aesthetically driven discipline, impacts the social contract. We then consider how the nature of the profession's relationship with society, and the orientation by which it provides its services (which is sometimes critically unclear in its definitional terms), impacts the profession's contribution to ensuring social justice in oral health and oral healthcare. Through examining the nature of how the social contract has shifted (for example, by the attenuation of professional monopolies), we also ask whether this is evidence of a loss of confidence in the dental profession as an altruistic institution. We end by suggesting that the dental profession must engage with the tenets of social justice within the social contract. Failure to do so is likely to lead to erosion of dentistry as a high-status profession and societal willingness to seek solutions to oral health needs from other professional and non-professional sources.

A health economic assessment of air pollution effects under climate neutral vehicle fleet scenarios in Stockholm, Sweden

IntroductionElectric vehicles (EVs) are heavily promoted as beneficial for climate and health. In most studies, it is assumed that EVs contribution to urban air pollution is zero due to no tailpipe emissions, ignoring the contribution of non-exhaust particles (brake, tire and road wear), which are unregulated in EU. This study of Stockholm, Sweden, aims to 1) assess how a future vehicle fleet impacts concentrations of particles of size less than 2.5 μm (PM2.5) and evaluate the expected health outcomes economically and 2) compare this with CO2 savings. MethodsSource specific dispersion models of exhaust and non-exhaust PM2.5 was used to estimate the population weighted concentrations. Thereafter exposure differences within a business as usual (BAU2035) and a fossil free fuel (FFF2035) scenario were used to assess expected health and economic impacts. The assessment considered both exhaust and non-exhaust emissions, considering the vehicle weight and the proportion of vehicles using studded winter tires. Health economic costs were retrieved from the literature and societal willingness to pay was used to value quality-adjusted life-years lost due to morbidity and mortality. ResultsThe mean population weighted exhaust PM2.5 concentration decreased 0.012 μg/m3 (39%) in FFF2035 as compared to BAU2035. Assuming 50% higher road and tire wear PM2.5 emission because of higher weight among EVs and 30% less brake wear emissions, the estimated decrease in wear particle exposures were 0.152 (22%) and 0.014 μg/m3 (1.9%) for 0 and 30% use on studded winter tires, respectively. The resulting health economic costs were estimated to €217M and €32M, respectively. An increase by 0.079 μg/m3 (11%) was however estimated for 50% use of studded winter tires, corresponding to an €89M increase in health costs. ConclusionConsidering both exhaust and wear generated particles, it is not straight forward that an increase of EVs will decrease the negative health impacts.

Measuring the Value Healthy Individuals Place on Generous Insurance Coverage of Severe Diseases: A Stated Preference Survey of Adults Diagnosed With and Without Lung Cancer

ObjectivesTo compare the ex ante willingness to pay (WTP) of healthy individuals for generous insurance coverage of novel lung cancer treatments to the WTP for coverage of such treatment among individuals with lung cancer. MethodsA survey was administered to 2 cohorts of US adults: (1) healthy individuals without cancer and (2) individuals diagnosed with lung cancer. A multiple random staircase survey design was used to elicit respondent WTP for coverage of novel lung cancer therapy associated with survival gains. ResultsOf the 84 937 healthy individuals invited, 300 completed the survey. Of the 36 249 in the lung cancer cohort invited, 250 completed the survey. Mean age by cohort was 50.0 (SD 14.6) and 48.4 (SD 16.8) years, and 55.2% and 47.2% were female, respectively. Respondents in the healthy and lung cancer cohorts were willing to pay $97.52 (95% confidence interval (CI) $89.89-$105.15) and $22 304 (95% CI $20 194-$24 414) per month, respectively, for coverage of a novel therapy providing 5-year survival of 15% versus standard-of-care therapy with a 5-year survival of 4%. After accounting for the likelihood that healthy individuals are diagnosed with lung cancer in the future, we estimated that 89.8% of the total value of new lung cancer treatments comes from the WTP healthy individuals place on generous insurance coverage. ConclusionsTotal societal willingness to pay for lung cancer is much higher than conventionally thought, as most healthy individuals are risk-averse and highly value having lung cancer treatments available to them in the future.