Findings Over 10 years, haemoglobin A 1c (HbA 1c) was 7•0% (6•2-8•2) in the intensive group compa... more Findings Over 10 years, haemoglobin A 1c (HbA 1c) was 7•0% (6•2-8•2) in the intensive group compared with 7•9% (6•9-8•8) in the conventional group-an 11% reduction. There was no difference in HbA 1c among agents in the intensive group. Compared with the conventional group, the risk in the intensive group was 12% lower (95% CI 1-21, p=0•029) for any diabetes-related endpoint; 10% lower (-11 to 27, p=0•34) for any diabetes-related death; and 6% lower (-10 to 20, p=0•44) for all-cause mortality. Most of the risk reduction in the any diabetes-related aggregate endpoint was due to a 25% risk reduction (7-40, p=0•0099) in microvascular endpoints, including the need for retinal photocoagulation. There was no difference for any of the three aggregate endpoints between the three intensive agents (chlorpropamide, glibenclamide, or insulin). Patients in the intensive group had more hypoglycaemic episodes than those in the conventional group on both types of analysis (both p<0•0001). The rates of major hypoglycaemic episodes per year were 0•7% with conventional treatment, 1•0% with chlorpropamide, 1•4% with glibenclamide, and 1•8% with insulin. Weight gain was significantly higher in the intensive group (mean 2•9 kg) than in the conventional group (p<0•001), and patients assigned insulin had a greater gain in weight (4•0 kg) than those assigned chlorpropamide (2•6 kg) or glibenclamide (1•7 kg). Interpretation Intensive blood-glucose control by either sulphonylureas or insulin substantially decreases the risk of microvascular complications, but not macrovascular disease, in patients with type 2 diabetes. None of the individual drugs had an adverse effect on cardiovascular outcomes. All intensive treatment increased the risk of hypoglycaemia.
Background Ovarian cancer continues to have a poor prognosis with the majority of women diagnosed... more Background Ovarian cancer continues to have a poor prognosis with the majority of women diagnosed with advanced disease. Therefore, we undertook the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) to determine if population screening can reduce deaths due to the disease. We report on ovarian cancer mortality after long-term follow-up in UKCTOCS. Methods In this randomised controlled trial, postmenopausal women aged 50-74 years were recruited from 13 centres in National Health Service trusts in England, Wales, and Northern Ireland. Exclusion criteria were bilateral oophorectomy, previous ovarian or active non-ovarian malignancy, or increased familial ovarian cancer risk. The trial management system confirmed eligibility and randomly allocated participants in blocks of 32 using computer generated random numbers to annual multimodal screening (MMS), annual transvaginal ultrasound screening (USS), or no screening, in a 1:1:2 ratio. Follow-up was through national registries. The primary outcome was death due to ovarian or tubal cancer (WHO 2014 criteria) by June 30, 2020. Analyses were by intention to screen, comparing MMS and USS separately with no screening using the versatile test. Investigators and participants were aware of screening type, whereas the outcomes review committee were masked to randomisation group. This study is registered with ISRCTN, 22488978, and ClinicalTrials.gov, NCT00058032.
In spite of significant policy interest in improving the integration of health and social care se... more In spite of significant policy interest in improving the integration of health and social care services, little is known about the economics of coordination across the two sectors. We specify a Markov queuing model and use data collected from administrative records to estimate the link between two proxy indicators of across-sector complexity of discharge arrangements and post-operative length of stay in hospital for older people undergoing hip replacements. The results suggest that the number of local authorities involved in care planning and commissioning of social care services for discharges from a given hospital is significantly positively correlated with longer post-operative lengths of stay. A particularly strong effect is found between variability through time in the number of authorities involved in discharges from a given hospital and lengths of stay. The results suggest that improving information systems and joint assessment processes used during the discharge of patients ...
KA, et al. Salmeterol added to inhaled corticosteroid therapy is superior to doubling the dose of... more KA, et al. Salmeterol added to inhaled corticosteroid therapy is superior to doubling the dose of inhaled corticosteroids: a randomized clinical trial.
To assess the within-trial cost-effectiveness of an NHS ovarian cancer screening (OCS) programme ... more To assess the within-trial cost-effectiveness of an NHS ovarian cancer screening (OCS) programme using data from UKCTOCS and extrapolate results based on average life expectancy. Within-trial economic evaluation of no screening (C) vs either (1) an annual OCS programme using transvaginal ultrasound (USS) or (2) an annual ovarian cancer multimodal screening programme with serum CA125 interpreted using a risk algorithm (ROCA) and transvaginal ultrasound as a second-line test (MMS), plus comparison of lifetime extrapolation of the no screening arm and the MMS programme using both a predictive and a Markov model. Using a CA125-ROCA cost of £20, the within-trial results show USS to be strictly dominated by MMS, with the MMS vs C comparison returning an incremental cost-effectiveness ratio (ICER) of £91 452 per life year gained (LYG). If the CA125-ROCA unit cost is reduced to £15, the ICER becomes £77 818 per LYG. Predictive extrapolation over the expected lifetime of the UKCTOCS women re...
World Scientific Handbook of Global Health Economics and Public Policy, 2016
This chapter considers the conceptual and many empirical problems associated with estimating heal... more This chapter considers the conceptual and many empirical problems associated with estimating health care costs. It does so by considering the estimation of such costs at different levels of aggregation — initially considering health costs incurred at the individual level, including those arising from treatments undergoing clinical trials, and then at the hospital level, the latter being the sector with the largest level of expenditure in most health care systems. The topics covered include the representativeness of sample populations, the importance of skew in the health care cost distribution, issues of censoring, and missing data and their relevance to the estimation process. The consistency of relevant estimators is assessed through discussion of transformation, linkage and general linear methods. Attention then turns to the hospital sector, where lack of knowledge of the underlying production process is a considerable drawback in specifying appropriate cost functions. The amendment of hospital cost functions to particular concerns, including the hospital's control of demand and reactions to demand uncertainty, are outlined. Given the importance of health care cost estimation in helping to risk adjust and predict future health care expenditure levels, as well as help determine reimbursement levels within the hospital sector, more attention needs to be given to this area of research.
Newer approaches to genetic counselling are required for population-based testing. We compare tra... more Newer approaches to genetic counselling are required for population-based testing. We compare traditional face-to-face genetic counselling with a DVD-assisted approach for population-based BRCA1/2 testing. A cluster-randomised non-inferiority trial in the London Ashkenazi Jewish population. Ashkenazi Jewish men/women >18 years; exclusion criteria: (a) known BRCA1/2 mutation, (b) previous BRCA1/2 testing and (c) first-degree relative of BRCA1/2 carrier. Ashkenazi Jewish men/women underwent pre-test genetic counselling prior to BRCA1/2 testing in the Genetic Cancer Prediction through Population Screening trial (ISRCTN73338115). Genetic counselling clinics (clusters) were randomised to traditional counselling (TC) and DVD-based counselling (DVD-C) approaches. DVD-C involved a DVD presentation followed by shorter face-to-face genetic counselling. Outcome measures included genetic testing uptake, cancer risk perception, increase in knowledge, counselling time and satisfaction (Genetic...
Very preliminary and incomplete draft Please do not quote without author permission Comments are ... more Very preliminary and incomplete draft Please do not quote without author permission Comments are very welcome
In the MOSAIC trial, oxaliplatin/5-fluoruracil/leucovorin (FOLFOX4) as adjuvant treatment of stag... more In the MOSAIC trial, oxaliplatin/5-fluoruracil/leucovorin (FOLFOX4) as adjuvant treatment of stage III colon cancer improved disease-free survival (DFS) at 4 years, compared to 5-fluorouracil/leucovorin (LV5FU2) (69.7% vs. 61.0%, p = 0.002). We analysed the cost-effectiveness of FOLFOX4 in the UK and Germany to a lifetime horizon, from a payer perspective. METHODS: We developed Kaplan-Meier estimates of DFS and overall survival (OS) to 4 years. DFS was extrapolated from 4 to 5 years with a Weibull model and thereafter from life tables, adjusting for age and gender, assuming no relapses after 5 years. Using DFS and observed survival after relapse, we predicted lifetime OS. Life-years accrued were assigned weights according to chemotherapy-related toxicities, recurrence and age, to estimate QALYs. Costs were estimated from trial data, accounting for censoring; while costs of relapse and subsequent management were estimated from literature. Costs and QALYs, discounted at 3.5% and 5% per annum for the UK and Germany respectively, were bootstrapped to estimate the ICER distribution. RESULTS: Patients on FOLFOX4 gained an estimated mean 0.68 (95% CI: 0.08-1.31) QALYs for the UK and 0.57 (95% CI: 0.04-1.10) for Germany, at mean incremental costs of £3267 and £5844 respectively, resulting in mean ICERs of £4805 per QALY gained for the UK and €10,199 for Germany. If the willingness to pay for additional QALYs were £20,000 in the UK and €50,000 in Germany, FOLFOX4 would be cost-effective with probabilities of 95% and 96% in these countries respectively. CONCLUSIONS: If the estimated survival benefit of oxaliplatin is confirmed, FOLFOX4 would cost around £4800 (approx. €6,700) per QALY gained in the UK and €10,200 in Germany, well within conventional limits of acceptability. The difference between countries was largely attributable to the discount rates used rather than differences in organisation of health care.
This essay introduces the present special issue on wisdom and moral education, which draws on a c... more This essay introduces the present special issue on wisdom and moral education, which draws on a conference held in Oxford in 2017. Some of the seven contributions (by Sanderse; Ferkany; and Hatchimonji et al.) make use of the Aristotelian concept of phronesis, or practical wisdom, while others focus more on the wisdom concept as it has developed in contemporary psychology (Huynh and Grossman; Ardelt; and Brocato, Hix and Jayawickreme). One (by Swartwood) straddles the distinction between the two. All the contributions, however, address in different ways practical questions about how wisdom can be evaluated and how it relates to issues of moral development and education.
A number of non-parametric estimators have been proposed to calculate average medical care costs ... more A number of non-parametric estimators have been proposed to calculate average medical care costs in the presence of censoring. This paper assesses their performance both in terms of bias and efficiency under extreme conditions using a medical dataset which exhibits heavy censoring. The estimators are further investigated using artificially generated data. Their variances are derived from analytic formulae based on the estimators' asymptotic properties and these are compared to empirically derived bootstrap estimates. The analysis revealed various performance patterns ranging from generally stable estimators under all conditions considered to estimators which become increasingly unstable with increasing levels of censoring. The bootstrap estimates of variance were consistent with the analytically derived asymptotic variance estimates. Of the two estimators that performed best, one imposes restrictions on the censoring distribution while the other is not restricted by the censoring pattern and on this basis the second may be preferred.
International Journal of Technology Assessment in Health Care, 2000
Economic guidelines recommend methods that should be employed in conducting economic evaluations ... more Economic guidelines recommend methods that should be employed in conducting economic evaluations of healthcare programs. The nature of the efficiency or equity goal underpinning economic guidelines is unclear. What is also unclear is how the methods recommended in the guidelines are linked to the underlying efficiency or equity goal being targeted. If it is unclear what efficiency/equity objectives are being pursued, then it is unlikely that even full implementation of economic guidelines will improve resource allocation.
The influence of economic incentives and regulatory factors on the adoption of treatment technolo... more The influence of economic incentives and regulatory factors on the adoption of treatment technologies: a case study of technologies used to treat heart attacks We analyse the adoption of three specific procedures applied to AMI patients: cardiac catheterization (CATH); coronary artery bypass grafting (CABG); percutaneous transluminal coronary angioplasty (PTCA). The TECH investigators chose to study AMI and these three procedures for several reasons. First, AMI is a relatively common and welldefined clinical condition worldwide allowing clear international comparison of diagnostic work-up and treatment. Secondly, most AMI patients are initially hospitalised providing reliable inpatient data across countries. Thirdly, care of AMI patients has changed rapidly in recent years allowing exploration of the diffusion patterns. Fourthly, the three technologies analysed are prevalent procedures involving high fixed and marginal costs with each use.
Little is known about costs related to the surveillance of patients that have undergone curative ... more Little is known about costs related to the surveillance of patients that have undergone curative resection of colorectal cancer. The aim of this study was to calculate the observed surveillance costs for 385 patients followed-up over a 3-year period, to estimate surveillance costs if French guidelines are respected, and to identify the determinants related to surveillance costs to derive a global estimation for France, using a linear mixed model. The observed mean surveillance cost was 713. If French recommendations were € strictly applied, the estimated mean cost would vary between 680 and 1 069 according to the frequency of abdominal ultrasound. € € The predicted determinants of the cost were: age, recurrence, duration of surveillance since diagnosis, and adjuvant treatments. For France, the surveillance cost represented 4.4 of the cost of colorectal cancer management. The cost of surveillance should now be % balanced with its effectiveness and compared with surveillance alternatives.
The United Kingdom Prospective Diabetes Study (UKPDS) has established that an intensive blood glu... more The United Kingdom Prospective Diabetes Study (UKPDS) has established that an intensive blood glucose control policy is effective in reducing the relative risk of any diabetes-related end point by 12 % and of microvascular complications by 25 % [1]. This landmark study has shown also that the use of metformin for intensive blood glucose control in overweight patients confers a 32 % risk reduction for any diabetesrelated end point and a 42 % risk reduction for diabetes-related deaths compared with a conventional policy, primarily with diet alone. Metformin would seem to be advantageous as a primary pharmacological therapy in diet-treated overweight patients [2]. Although the cost-effectiveness of intensive blood glucose control has been ascertained [3], no study has so far examined prospectively the costs and benefits of using metformin. One study has reported that metformin can attain higher treatment success rates at lower cost than insulin therapy but this used an intermediate outcome measure (HbA 1 c value) and was based on data from a retrospective chart review of a Diabetologia (2001) 44: 298±304
Aims/hypothesis We estimated the cost-effectiveness of atorvastatin treatment in the primary prev... more Aims/hypothesis We estimated the cost-effectiveness of atorvastatin treatment in the primary prevention of cardiovascular disease in patients with type 2 diabetes using data from the Collaborative Atorvastatin Diabetes Study (CARDS). Subjects and methods A total of 2,838 patients, who were aged 40 to 75 years and had type 2 diabetes without a documented history of cardiovascular disease and without elevated LDL-cholesterol, were recruited from 32 centres in the UK and Ireland and randomly allocated to atorvastatin 10 mg daily (n=1,428) or placebo (n=1,410). These subjects were followed-up for a median period of 3.9 years. Direct treatment costs and effectiveness were analysed to provide estimates of cost per endpoint-free year over the trial period for alternative definitions of endpoint, and of cost per life-year gained and cost per quality-adjusted lifeyear (QALY) gained over a patient's lifetime. Results Over the trial period, the incremental cost-effectiveness ratio (ICER) was estimated to be £7,608 per year free of any CARDS primary endpoint; the ICER was calculated to be £4,896 per year free of any cardiovascular endpoint and £4,120 per year free of any study endpoint. Over lifetime, the incremental cost per life-year gained was £5,107 and the cost per QALY was £6,471 (costs and benefits both discounted at 3.5%). Conclusions/interpretation Primary prevention of cardiovascular disease with atorvastatin is a cost-effective intervention in patients with type 2 diabetes, with the ICER for this intervention falling within the current acceptance threshold (£20,000 per QALY) specified by the National Institute for Health and Clinical Excellence (NICE).
Findings Over 10 years, haemoglobin A 1c (HbA 1c) was 7•0% (6•2-8•2) in the intensive group compa... more Findings Over 10 years, haemoglobin A 1c (HbA 1c) was 7•0% (6•2-8•2) in the intensive group compared with 7•9% (6•9-8•8) in the conventional group-an 11% reduction. There was no difference in HbA 1c among agents in the intensive group. Compared with the conventional group, the risk in the intensive group was 12% lower (95% CI 1-21, p=0•029) for any diabetes-related endpoint; 10% lower (-11 to 27, p=0•34) for any diabetes-related death; and 6% lower (-10 to 20, p=0•44) for all-cause mortality. Most of the risk reduction in the any diabetes-related aggregate endpoint was due to a 25% risk reduction (7-40, p=0•0099) in microvascular endpoints, including the need for retinal photocoagulation. There was no difference for any of the three aggregate endpoints between the three intensive agents (chlorpropamide, glibenclamide, or insulin). Patients in the intensive group had more hypoglycaemic episodes than those in the conventional group on both types of analysis (both p<0•0001). The rates of major hypoglycaemic episodes per year were 0•7% with conventional treatment, 1•0% with chlorpropamide, 1•4% with glibenclamide, and 1•8% with insulin. Weight gain was significantly higher in the intensive group (mean 2•9 kg) than in the conventional group (p<0•001), and patients assigned insulin had a greater gain in weight (4•0 kg) than those assigned chlorpropamide (2•6 kg) or glibenclamide (1•7 kg). Interpretation Intensive blood-glucose control by either sulphonylureas or insulin substantially decreases the risk of microvascular complications, but not macrovascular disease, in patients with type 2 diabetes. None of the individual drugs had an adverse effect on cardiovascular outcomes. All intensive treatment increased the risk of hypoglycaemia.
Background Ovarian cancer continues to have a poor prognosis with the majority of women diagnosed... more Background Ovarian cancer continues to have a poor prognosis with the majority of women diagnosed with advanced disease. Therefore, we undertook the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) to determine if population screening can reduce deaths due to the disease. We report on ovarian cancer mortality after long-term follow-up in UKCTOCS. Methods In this randomised controlled trial, postmenopausal women aged 50-74 years were recruited from 13 centres in National Health Service trusts in England, Wales, and Northern Ireland. Exclusion criteria were bilateral oophorectomy, previous ovarian or active non-ovarian malignancy, or increased familial ovarian cancer risk. The trial management system confirmed eligibility and randomly allocated participants in blocks of 32 using computer generated random numbers to annual multimodal screening (MMS), annual transvaginal ultrasound screening (USS), or no screening, in a 1:1:2 ratio. Follow-up was through national registries. The primary outcome was death due to ovarian or tubal cancer (WHO 2014 criteria) by June 30, 2020. Analyses were by intention to screen, comparing MMS and USS separately with no screening using the versatile test. Investigators and participants were aware of screening type, whereas the outcomes review committee were masked to randomisation group. This study is registered with ISRCTN, 22488978, and ClinicalTrials.gov, NCT00058032.
In spite of significant policy interest in improving the integration of health and social care se... more In spite of significant policy interest in improving the integration of health and social care services, little is known about the economics of coordination across the two sectors. We specify a Markov queuing model and use data collected from administrative records to estimate the link between two proxy indicators of across-sector complexity of discharge arrangements and post-operative length of stay in hospital for older people undergoing hip replacements. The results suggest that the number of local authorities involved in care planning and commissioning of social care services for discharges from a given hospital is significantly positively correlated with longer post-operative lengths of stay. A particularly strong effect is found between variability through time in the number of authorities involved in discharges from a given hospital and lengths of stay. The results suggest that improving information systems and joint assessment processes used during the discharge of patients ...
KA, et al. Salmeterol added to inhaled corticosteroid therapy is superior to doubling the dose of... more KA, et al. Salmeterol added to inhaled corticosteroid therapy is superior to doubling the dose of inhaled corticosteroids: a randomized clinical trial.
To assess the within-trial cost-effectiveness of an NHS ovarian cancer screening (OCS) programme ... more To assess the within-trial cost-effectiveness of an NHS ovarian cancer screening (OCS) programme using data from UKCTOCS and extrapolate results based on average life expectancy. Within-trial economic evaluation of no screening (C) vs either (1) an annual OCS programme using transvaginal ultrasound (USS) or (2) an annual ovarian cancer multimodal screening programme with serum CA125 interpreted using a risk algorithm (ROCA) and transvaginal ultrasound as a second-line test (MMS), plus comparison of lifetime extrapolation of the no screening arm and the MMS programme using both a predictive and a Markov model. Using a CA125-ROCA cost of £20, the within-trial results show USS to be strictly dominated by MMS, with the MMS vs C comparison returning an incremental cost-effectiveness ratio (ICER) of £91 452 per life year gained (LYG). If the CA125-ROCA unit cost is reduced to £15, the ICER becomes £77 818 per LYG. Predictive extrapolation over the expected lifetime of the UKCTOCS women re...
World Scientific Handbook of Global Health Economics and Public Policy, 2016
This chapter considers the conceptual and many empirical problems associated with estimating heal... more This chapter considers the conceptual and many empirical problems associated with estimating health care costs. It does so by considering the estimation of such costs at different levels of aggregation — initially considering health costs incurred at the individual level, including those arising from treatments undergoing clinical trials, and then at the hospital level, the latter being the sector with the largest level of expenditure in most health care systems. The topics covered include the representativeness of sample populations, the importance of skew in the health care cost distribution, issues of censoring, and missing data and their relevance to the estimation process. The consistency of relevant estimators is assessed through discussion of transformation, linkage and general linear methods. Attention then turns to the hospital sector, where lack of knowledge of the underlying production process is a considerable drawback in specifying appropriate cost functions. The amendment of hospital cost functions to particular concerns, including the hospital's control of demand and reactions to demand uncertainty, are outlined. Given the importance of health care cost estimation in helping to risk adjust and predict future health care expenditure levels, as well as help determine reimbursement levels within the hospital sector, more attention needs to be given to this area of research.
Newer approaches to genetic counselling are required for population-based testing. We compare tra... more Newer approaches to genetic counselling are required for population-based testing. We compare traditional face-to-face genetic counselling with a DVD-assisted approach for population-based BRCA1/2 testing. A cluster-randomised non-inferiority trial in the London Ashkenazi Jewish population. Ashkenazi Jewish men/women >18 years; exclusion criteria: (a) known BRCA1/2 mutation, (b) previous BRCA1/2 testing and (c) first-degree relative of BRCA1/2 carrier. Ashkenazi Jewish men/women underwent pre-test genetic counselling prior to BRCA1/2 testing in the Genetic Cancer Prediction through Population Screening trial (ISRCTN73338115). Genetic counselling clinics (clusters) were randomised to traditional counselling (TC) and DVD-based counselling (DVD-C) approaches. DVD-C involved a DVD presentation followed by shorter face-to-face genetic counselling. Outcome measures included genetic testing uptake, cancer risk perception, increase in knowledge, counselling time and satisfaction (Genetic...
Very preliminary and incomplete draft Please do not quote without author permission Comments are ... more Very preliminary and incomplete draft Please do not quote without author permission Comments are very welcome
In the MOSAIC trial, oxaliplatin/5-fluoruracil/leucovorin (FOLFOX4) as adjuvant treatment of stag... more In the MOSAIC trial, oxaliplatin/5-fluoruracil/leucovorin (FOLFOX4) as adjuvant treatment of stage III colon cancer improved disease-free survival (DFS) at 4 years, compared to 5-fluorouracil/leucovorin (LV5FU2) (69.7% vs. 61.0%, p = 0.002). We analysed the cost-effectiveness of FOLFOX4 in the UK and Germany to a lifetime horizon, from a payer perspective. METHODS: We developed Kaplan-Meier estimates of DFS and overall survival (OS) to 4 years. DFS was extrapolated from 4 to 5 years with a Weibull model and thereafter from life tables, adjusting for age and gender, assuming no relapses after 5 years. Using DFS and observed survival after relapse, we predicted lifetime OS. Life-years accrued were assigned weights according to chemotherapy-related toxicities, recurrence and age, to estimate QALYs. Costs were estimated from trial data, accounting for censoring; while costs of relapse and subsequent management were estimated from literature. Costs and QALYs, discounted at 3.5% and 5% per annum for the UK and Germany respectively, were bootstrapped to estimate the ICER distribution. RESULTS: Patients on FOLFOX4 gained an estimated mean 0.68 (95% CI: 0.08-1.31) QALYs for the UK and 0.57 (95% CI: 0.04-1.10) for Germany, at mean incremental costs of £3267 and £5844 respectively, resulting in mean ICERs of £4805 per QALY gained for the UK and €10,199 for Germany. If the willingness to pay for additional QALYs were £20,000 in the UK and €50,000 in Germany, FOLFOX4 would be cost-effective with probabilities of 95% and 96% in these countries respectively. CONCLUSIONS: If the estimated survival benefit of oxaliplatin is confirmed, FOLFOX4 would cost around £4800 (approx. €6,700) per QALY gained in the UK and €10,200 in Germany, well within conventional limits of acceptability. The difference between countries was largely attributable to the discount rates used rather than differences in organisation of health care.
This essay introduces the present special issue on wisdom and moral education, which draws on a c... more This essay introduces the present special issue on wisdom and moral education, which draws on a conference held in Oxford in 2017. Some of the seven contributions (by Sanderse; Ferkany; and Hatchimonji et al.) make use of the Aristotelian concept of phronesis, or practical wisdom, while others focus more on the wisdom concept as it has developed in contemporary psychology (Huynh and Grossman; Ardelt; and Brocato, Hix and Jayawickreme). One (by Swartwood) straddles the distinction between the two. All the contributions, however, address in different ways practical questions about how wisdom can be evaluated and how it relates to issues of moral development and education.
A number of non-parametric estimators have been proposed to calculate average medical care costs ... more A number of non-parametric estimators have been proposed to calculate average medical care costs in the presence of censoring. This paper assesses their performance both in terms of bias and efficiency under extreme conditions using a medical dataset which exhibits heavy censoring. The estimators are further investigated using artificially generated data. Their variances are derived from analytic formulae based on the estimators' asymptotic properties and these are compared to empirically derived bootstrap estimates. The analysis revealed various performance patterns ranging from generally stable estimators under all conditions considered to estimators which become increasingly unstable with increasing levels of censoring. The bootstrap estimates of variance were consistent with the analytically derived asymptotic variance estimates. Of the two estimators that performed best, one imposes restrictions on the censoring distribution while the other is not restricted by the censoring pattern and on this basis the second may be preferred.
International Journal of Technology Assessment in Health Care, 2000
Economic guidelines recommend methods that should be employed in conducting economic evaluations ... more Economic guidelines recommend methods that should be employed in conducting economic evaluations of healthcare programs. The nature of the efficiency or equity goal underpinning economic guidelines is unclear. What is also unclear is how the methods recommended in the guidelines are linked to the underlying efficiency or equity goal being targeted. If it is unclear what efficiency/equity objectives are being pursued, then it is unlikely that even full implementation of economic guidelines will improve resource allocation.
The influence of economic incentives and regulatory factors on the adoption of treatment technolo... more The influence of economic incentives and regulatory factors on the adoption of treatment technologies: a case study of technologies used to treat heart attacks We analyse the adoption of three specific procedures applied to AMI patients: cardiac catheterization (CATH); coronary artery bypass grafting (CABG); percutaneous transluminal coronary angioplasty (PTCA). The TECH investigators chose to study AMI and these three procedures for several reasons. First, AMI is a relatively common and welldefined clinical condition worldwide allowing clear international comparison of diagnostic work-up and treatment. Secondly, most AMI patients are initially hospitalised providing reliable inpatient data across countries. Thirdly, care of AMI patients has changed rapidly in recent years allowing exploration of the diffusion patterns. Fourthly, the three technologies analysed are prevalent procedures involving high fixed and marginal costs with each use.
Little is known about costs related to the surveillance of patients that have undergone curative ... more Little is known about costs related to the surveillance of patients that have undergone curative resection of colorectal cancer. The aim of this study was to calculate the observed surveillance costs for 385 patients followed-up over a 3-year period, to estimate surveillance costs if French guidelines are respected, and to identify the determinants related to surveillance costs to derive a global estimation for France, using a linear mixed model. The observed mean surveillance cost was 713. If French recommendations were € strictly applied, the estimated mean cost would vary between 680 and 1 069 according to the frequency of abdominal ultrasound. € € The predicted determinants of the cost were: age, recurrence, duration of surveillance since diagnosis, and adjuvant treatments. For France, the surveillance cost represented 4.4 of the cost of colorectal cancer management. The cost of surveillance should now be % balanced with its effectiveness and compared with surveillance alternatives.
The United Kingdom Prospective Diabetes Study (UKPDS) has established that an intensive blood glu... more The United Kingdom Prospective Diabetes Study (UKPDS) has established that an intensive blood glucose control policy is effective in reducing the relative risk of any diabetes-related end point by 12 % and of microvascular complications by 25 % [1]. This landmark study has shown also that the use of metformin for intensive blood glucose control in overweight patients confers a 32 % risk reduction for any diabetesrelated end point and a 42 % risk reduction for diabetes-related deaths compared with a conventional policy, primarily with diet alone. Metformin would seem to be advantageous as a primary pharmacological therapy in diet-treated overweight patients [2]. Although the cost-effectiveness of intensive blood glucose control has been ascertained [3], no study has so far examined prospectively the costs and benefits of using metformin. One study has reported that metformin can attain higher treatment success rates at lower cost than insulin therapy but this used an intermediate outcome measure (HbA 1 c value) and was based on data from a retrospective chart review of a Diabetologia (2001) 44: 298±304
Aims/hypothesis We estimated the cost-effectiveness of atorvastatin treatment in the primary prev... more Aims/hypothesis We estimated the cost-effectiveness of atorvastatin treatment in the primary prevention of cardiovascular disease in patients with type 2 diabetes using data from the Collaborative Atorvastatin Diabetes Study (CARDS). Subjects and methods A total of 2,838 patients, who were aged 40 to 75 years and had type 2 diabetes without a documented history of cardiovascular disease and without elevated LDL-cholesterol, were recruited from 32 centres in the UK and Ireland and randomly allocated to atorvastatin 10 mg daily (n=1,428) or placebo (n=1,410). These subjects were followed-up for a median period of 3.9 years. Direct treatment costs and effectiveness were analysed to provide estimates of cost per endpoint-free year over the trial period for alternative definitions of endpoint, and of cost per life-year gained and cost per quality-adjusted lifeyear (QALY) gained over a patient's lifetime. Results Over the trial period, the incremental cost-effectiveness ratio (ICER) was estimated to be £7,608 per year free of any CARDS primary endpoint; the ICER was calculated to be £4,896 per year free of any cardiovascular endpoint and £4,120 per year free of any study endpoint. Over lifetime, the incremental cost per life-year gained was £5,107 and the cost per QALY was £6,471 (costs and benefits both discounted at 3.5%). Conclusions/interpretation Primary prevention of cardiovascular disease with atorvastatin is a cost-effective intervention in patients with type 2 diabetes, with the ICER for this intervention falling within the current acceptance threshold (£20,000 per QALY) specified by the National Institute for Health and Clinical Excellence (NICE).
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Papers by Maria Raikou