The Republic of Singapore is an island city-state in Southeast Asia. Its population enjoys good health and the Singapore Ministry of Health's mission is to promote good health and reduce illness, ensure access to good and affordable health care, and pursue medical excellence. This is achieved through a healthcare system that includes both private and public sector elements. The financing philosophy of Singapore's healthcare delivery system is based on individual responsibility and community support. Health care in Singapore is financed by a combination of taxes, employee medical benefits, compulsory health savings, insurance, and out-of-pocket payment. The capability for health technology assessment in Singapore was developed concurrently with its medical device regulation system in the 1990s. The first formal unit with health technology assessment (HTA) functions was established in September 1995. Today, HTA features in decision making for the Standard Drug List, licensing of medical clinics, the Health Service Development Programme, healthcare subsidies, and policy development. The public sector healthcare delivery clusters have also recently started health services research units with HTA functions. Singapore is organizing the 6th Health Technology Assessment International (HTAi) Annual Meeting in June 2009. Bringing this prestigious international conference to Asia for the first time will help raise awareness of HTA in the region.

Objectives: The use and implementation of health technologies do influence and are influenced by organizational structures and processes as well as patient's experiences and actions. The objective of this study is to discuss the content and managing of organizational and patient-related assessments in HTAs.

Methods: Quantitative and qualitative analysis were performed based on a review of organizational and patient-related assessments included in a random sample of fifty HTA reports. The reports were identified from INAHTA members’ Web sites where homepages of HTA agencies where searched for full HTA reports, published in English or Scandinavian languages.

Results: HTA reports including organizational assessments mainly comprised issues related to process and structure, while issues such as control and evaluation of the technology were included less often. Cultural and environmental issues were included in a little over half of the reports. Reports including patient-related assessments mainly comprised psychological issues. Patients’ perceptions of the technology's effect on their health, patient-information, and social and ethical issues were included less often. Few reports included implications for the patient's significant others. There was considerable variation in how comprehensive the issues were managed as there was in the methodological transparency of the HTA reports.

Conclusions: There is room for improvement in the assessments of organizational and patient-related issues. Absence of a description of the considerations made when determining the content and methods of the assessments limits the usefulness of an HTA. The reader is left uncertain of the relevance and validity of the organizational and patient-related assessments.

Objectives: The aim of this study was to benchmark the proposal forms used by a sample of Italian hospitals to inform the budget process for the adoption of new technology to understand the relationship with the guidelines provided by the Health Technology Assessment (HTA) literature.

Methods: A literature review was first undertaken to identify the frameworks developed to support decision making regarding new technology at a hospital level. A checklist of criteria drawn up according to five main perspectives (technology, patient, organization, economics, and level of evidence) has been formalized to review and compare the collected proposal forms.

Results: The “technology” perspective appears to have been broadly covered. The “patient” perspective has focused to clinical issues and partially neglects other dimensions such as patient satisfaction and potential adverse events. The “organization” dimension has paid little attention to change management. The “economics” dimension has been broadly covered, even though a sensitivity analysis has not been considered. The “level of evidence” that is required for submitting the proposal form is little.

Conclusions: The proposal forms used to inform the budget process regarding the adoption of new technology are accountable for a limited set of dimensions from among those proposed in literature. Further research is required to understand how to render technology assessment multidimensional, multidisciplinary, evidence-based, and accountable at a hospital level.

A pilot study was done to assess the feasibility of reducing the hospital stays of patients with total hip replacement (THR). The length of hospital stay for these patients depends largely on how rehabilitation, mostly physical therapy, is organized. This study shows that not more than a half hour per postoperative day was devoted to care services and rehabilitation activities. It is feasible and less expensive to reduce substantially hospital stay by planned physical therapy in the patient's home. These results have prompted a randomized controlled clinical trial to assess hospital versus home rehabilitation.

Objectives: To determine the cost-effectiveness (CE) and cost-utility (CU) of drug-eluting stents (DES) compared to bare metal stents (BMS) in Ontario using a large prospective “real-world” cohort study and determine the extent to which results vary by patient risk subgroups.

Methods: A field evaluation was conducted based on all stent procedures in the province of Ontario between December 1, 2003, and March 31, 2005, with a minimum subject follow-up of 1 year. Effectiveness data from the study using a propensity-score matched cohort were combined with resource utilization and cost data and quality of life (QOL) data from the published literature in a decision analytic modeling framework to determine 2-year cost-effectiveness (cost per revascularization avoided) and cost-utility (cost per quality-adjusted life-year ([QALY] gained). Stochastic model parameter uncertainty was expressed using probability distributions and analyzed using a probabilistic model. Modeling assumptions were assessed using traditional deterministic sensitivity analysis.

Results: Significant differences in revascularization rates were found for patients with two or more high risk factors. Despite these differences, the CE and CU of DES remained high (e.g., $419,000 per QALY gained in the most favorable patient risk subgroup). In sensitivity analysis, the difference in cost between DES and BMS had an impact on the CE and CU results. For example, at a price differential of $500, the CU of DES was $20,000/QALY for one patient subgroup and DES was dominant (i.e., less costly and more effective) in another.

Conclusions: At current prices, the CE/CU of DES compared with BMS is high even in patient high risk subgroups. As the relative price of DES decrease, the value for money attractiveness of DES increases, especially for selected high risk patients.

Objective: The aim of this study was to assess the incremental cost-effectiveness of on-demand versus prophylactic hemophilia therapy in Iran from a third-party payers’ perspective.

Methods: A retrospective chart review of twenty-five type A hemophiliacs who were treated in three hemophilia treatment centers was conducted. The patients were boys 0–9 years old receiving one of two treatments: (i) prophylaxis with concentrate at clinic; (ii) concentrate at clinic as on-demand. Fourteen boys received on-demand infusions for bleeding events, and eleven boys received infusions prophylaxis. Data were extracted from documents in the hemophilia treatment centers during a period of approximately 6 months.

Results: The patients receiving prophylactic treatment had fewer bleeding events each month (mean, 0.26 versus 2.74) but used more concentrate (225.31 versus 87.20 units/kg per month). Average monthly cost per patient in the prophylaxis group was approximately 1.9 times higher than in the on-demand group. Compared with on-demand infusion, prophylaxis costs 3,201,656 Rials (€213.45) per bleeding event prevented.

Conclusion: Prophylactic care markedly reduces the number of bleeding episodes, but at considerable cost.

Objectives: Health technology reassessment (HTR) is a policy process to manage health technologies throughout their lifecycle and ensure their ongoing optimal use. However, within an ever-evolving field, HTR is only one of many concepts associated with the optimization of health technologies. There is limited understanding of how other concepts and processes might differ and/or be interrelated. This study aims to describe the concepts underlying the various technology optimization processes and to reconcile their relationships within the HTR process.

Methods: A synthesis of the literature on approaches to HTR was completed. An inductive synthesis approach was completed to catalogue common concepts and themes. Expert stakeholders were consulted to develop a schematic to diagrammatically depict the relationships among concepts and frame them within the HTR process.

Results: A practical schematic was developed. Common concepts and themes were organized under six major domains that address the following discussion questions: (i) what is the value of the existing technology?; (ii) what is the current utilization gap?; (iii) what are the available tools and resources?; (iv) what are the levers for change?; (v) what is the desired outcome?; and (vi) who are the foundational actors?

Conclusions: Using these six questions to frame the issues faced by HTR will advance the common understanding of HTR, as well as improve implementation of HTR initiatives. These questions will clearly identify the process required to move forward within a complex healthcare system.

Objectives: Little is known about the costs and the effects of cardiovascular prevention programs targeted at medical and behavioral risk factors. The aim was to evaluate the cost-utility of a cardiovascular prevention program in a general sample of highly educated adults after 1 year of intervention.

Methods: The participants were randomly assigned to intervention (n = 208) and usual care conditions (n = 106). The intervention consisted of medical interventions and optional behavior-change interventions (e.g., a tailored Web site). Cost data were registered from a healthcare perspective, and questionnaires were used to determine effectiveness (e.g., quality-adjusted life-years [QALYs]). A cost-utility analysis and sensitivity analyses using bootstrapping were performed on the intermediate results.

Results: When adjusting for baseline utility differences, the incremental cost was €433 and the incremental effectiveness was 0.016 QALYs. The incremental cost-effectiveness ratio was €26,910 per QALY.

Conclusions: The intervention was cost-effective compared with usual care in this sample of highly educated adults after 1 year of intervention. Increased participation would make this intervention highly cost-effective.

Objectives: Stereotactic radiosurgery (SRS) is used to treat intracranial lesions and vascular malformations as an addition or replacement to whole brain radiotherapy and microsurgery. SRS can be delivered by hardware and software appended to standard linear accelerators (Linacs) or by dedicated systems such as Gamma Knife, which has been proposed as a more accurate and user friendly technology. Internationally, dedicated systems have been funded, despite limitations in evidence. However, some countries including Australia have not recommended additional reimbursement for dedicated systems. This study compares the costs of Linac radiosurgery with Gamma Knife radiosurgery.

Methods: Due to limited evidence on comparative effects, the economic analysis was restricted to a cost evaluation. The base-case analysis assumed a modified Linac was used only to treat SRS patients. However, because a modified Linac could be used to treat other radiotherapy patients, a second analysis assumed spare time was used to meet other radiotherapy needs, and Linac capital costs were apportioned according to SRS use.

Results: The incremental cost of Gamma Knife versus a modified Linac was estimated as AU$209 per patient. This result is sensitive to variations in assumptions. A second analysis proportioning capital costs according to SRS use showed that Gamma Knife may cost up to AU$1673 more per patient.

Conclusions: Gamma Knife may be cost competitive only if demand for SRS services is high enough to fully use equipment working time. However, given low patient demand and competing radiotherapy needs, Gamma Knife appears more costly and further evidence of survival or quality of life advantages may be required to justify reimbursement.

Performance-based managed entry agreements (PB-MEAs) might allow patient access to new medicines, but practical hurdles make competent authorities for pricing and reimbursement (CAPR) reluctant to implement PB-MEAs. We explored if the feasibility of PB-MEAs might improve by better aligning regulatory postauthorization requirements with the data generation of PB-MEAs and by active collaboration and data sharing. Reviewers from seven CAPRs provided structured assessments of the information available at the European Medicines Agency (EMA) Web site on regulatory postauthorization requirements for fifteen recently authorized products. The reviewers judged to what extent regulatory postauthorization studies could help implement PB-MEAs by addressing uncertainty gaps. Study domains assessed were: patient population, intervention, comparators, outcomes, time horizon, anticipated data quality, and anticipated robustness of analysis. Reviewers shared general comments about PB-MEAs for each product and on cooperation with other CAPRs. Reviewers rated regulatory postauthorization requirements at least partly helpful for most products and across domains except the comparator domain. One quarter of responses indicated that public information provided by the EMA was insufficient to support the implementation of PB-MEAs. Few PB-MEAs were in place for these products, but the potential for implementation of PB-MEAs or collaboration across CAPRs was seen as more favorable. Responses helped delineate a set of conditions where PB-MEAs may help reduce uncertainty. In conclusion, PB-MEAs are not a preferred option for CAPRs, but we identified conditions where PB-MEAs might be worth considering. The complexities of implementing PB-MEAs remain a hurdle, but collaboration across silos and more transparency on postauthorization studies could help overcome some barriers.

Background: The evidence supporting the use of new, or established, interventions may be derived from either (or both) experimental or observational study designs. Although a rigorous examination of the evidence base for clinical and cost-effectiveness is essential, it is never sufficient, and those undertaking a health technology assessment (HTA) also have to exercise judgments.

Methods: The basis for this discussion is largely from the author's experience as chairman of the national Institute for Health and Clinical Excellence (NICE).

Results: The judgments necessary for HTA to make are twofold. Scientific judgments relate to the interpretation of the science. Social value judgments are concerned with the ethical principles, preferences, culture, and aspirations of society.

Conclusions: How scientific and social value judgments might be most appropriately captured is a challenge for all HTA agencies. Although competent HTA bodies should be able to exercise scientific judgments they have no legitimacy to impose their own social values. These must ultimately be informed by the general public.

Magnetic resonance (MR) imaging is an exciting new diagnostic modality that has created tremendous interest in the medical profession. Although not unparalleled, the excitement engendered by MR imaging conjures up memories of the “CAT fever” induced by introduction of X-ray computed tomography (CT) scanners in 1973 (19).

Objectives: There are very few descriptions on how familial hypercholesterolemia (FH), a genetic disorder with an increased risk of coronary heart disease (CHD), affects older patients. The aim of this study was to analyze the health-related quality of life (HRQoL) of elderly patients with FH.

Methods: All FH patients with the same FH North Karelia-mutation aged 65 and over living in North Karelia province in Eastern Finland were asked to participate in the study in 2003. They were compared with age-standardized controls from the Finnish general population. A total of forty-three elderly FH patients were identified and thirty-seven of them (aged 65 to 84 years, M/F 10/27) agreed to participate. Most of them (27/37) had been diagnosed with CHD. All but one of these FH patients had been using statins for approximately 15 years. HRQoL was assessed with the RAND-36 (SF-36) and 15D instruments.

Results: Despite the clear cardiovascular morbidity and low socioeconomic status, these FH patients enjoyed a similar HRQoL as the age-standardized controls in the general population.

Conclusions: Lifelong hypercholesterolemia was not associated with poorer HRQoL in elderly survivors of FH. These elderly FH individuals were characterized by their healthy lifestyle and long-term statin treatment.

Introduction: The supplementation of alanyl-glutamine dipeptide in critically ill patients necessitating total parenteral nutrition (TPN) improves clinical outcomes, reducing mortality, infection rate, and shortening intensive care unit (ICU) hospital lengths of stay (LOSs), as compared to standard TPN regimens.

Methods: A Discrete Event Simulation model that incorporates outcomes rates from 200 Italian ICUs for over 60,000 patients, alanyl-glutamine dipeptide efficacy data synthesized by means of a Bayesian random effects meta-analysis, and national cost data has been developed to evaluate the alternatives from the cost perspective of the hospital. Simulated clinical outcomes are death and infection rates in ICU, death rate in general ward, and hospital LOSs. Sensitivity analyses are performed by varying all uncertain parameter values in a plausible range.

Results: The internal validation process confirmed the accuracy of the model in replicating observed clinical data. Alanyl-glutamine dipeptide on average results more effective and less costly than standard TPN: reduced mortality rate (24.6% ± 1.6% vs. 34.5% ± 2.1%), infection rate (13.8% ± 2.9% vs. 18.8% ± 3.9%), and hospital LOS (24.9 ± 0.3 vs. 26.0 ± 0.3 days) come at a lower total cost per patient (23,409 ± 3,345 vs. 24,161 ± 3,523 Euro).Treatment cost is completely offset by savings on ICU and antibiotic costs. Sensitivity analyses confirmed the robustness of these results.

Conclusions: Alanyl-glutamine dipeptide is expected to improve clinical outcomes and to do so with a concurrent saving for the Italian hospital.