THEBAUT Clemence

Background: Worldwide, around 50 million people live with dementia, of whom 58% live in low- and middle-income countries (LMICs). It is estimated that 84% of those older adults live with their families. In 2015 global dementia costs were estimated at $ 818 billion. With 40% attributed to informal care (up to 70% for some LMICs). In this study, we aimed at reviewing studies conducted on informal care costs of dementia in LMICs. Method: We searched bibliographic databases and grey literature resources in health, economics and social sciences. Two blind investigators evaluated the publications. Conflicts were discussed and settled with a third investigator. We excluded laboratories experimentations, non-original research and modelling studies. Result: Overall, 6,843 publications were assessed and 15 cost of dementia studies identified. Ten studies investigated informal care costs. They were all conducted in urban areas only, including 31 to 300 participants. Half of the studies mentioned caregiving time without further specification. The others listed items like lost-of-productivity for the caregiver, lost-of-productivity for the patient, activities of daily living, instrumental activities of daily living, supervision. Half of the studies used a standard tool like resource utilization in dementia (RUD) instrument with their own questionnaire to collect informal care. Caregiving time was usually valued by a cost replacement approach. Caregiving hour price was mainly based on the national minimum wage, but also on caregiver salary. Informal care costs, like other dementia costs, tend to increase with disease severity. Annual costs estimates per patient ranged from $145 to $6,926 in mild . from $453 to $8,872 in moderate. from $521 to $20,076 in severe dementia. Conclusion: Very few studies have been conducted on dementia costs across LMICs, with none so far in Africa. Meanwhile dementia is a major public health problem, it appears urgent to investigate its burden on families to guide health resources allocation.

Objective: To review studies conducted on the costs of dementia in low- and middle-income countries (LMICs), describe their methodology and summarize costs estimates. Methods: We conducted a systematic review, searching in bibliographic databases in health, economics and social sciences, and main grey literature resources. Publications were evaluated by two independent investigators, conflict discussed, and the final decision taken by a third investigator. We included all studies presenting costs of any aspect of dementia care. Results: Overall, 6,843 title and abstract, then 74 full texts articles evaluated. Finally, 15 single studies were included. Those were from only 9 out of the 156 LMICs: China (6). Brazil (2). and one from Argentina, Colombia, Iran, Peru, Romania, Thailand and Turkey. No study was from Africa. Studies focused mainly on Alzheimer’s disease. Studies investigated all three categories of cost-of-illness i.e., medical, social and informal care costs, but items, data collection and definitions in each category were highly variable. Dementia costs tend to increase with the severity of the disease with greater medical costs in the mild stage and higher social and informal care costs in the moderate and severe stages. Costs estimates varied widely: from $327.4 to $1,266.3 for annual medical costs, from $112.4 to $5,575.0 for social costs. and costs from $324.0 to $10,031.1 for informal care. Overall, dementia care cost up to $19,101 per year for a single patient, usually at the charge of families. Conclusion: Limited studies have been conducted on dementia costs in LMICs, with none so far in Africa. It appears urgent to provide accurate evidence of the disease burden in the region to guide public health policies.

Nothing is more important than human life": this principle stated by the President of the Republic in his speech of October 28, 2020 illustrates how much the Covid crisis has reshuffled the deck in terms of thinking about the cost of health care. The right level of public spending on health care has been the subject of intense debate for several decades. Whether it is to reimburse very expensive innovative therapies, to build a hospital, to organize systematic cancer screening, or to confine the country, the question is obvious: what is the right level of spending to protect health and save lives? This is the purpose of a discipline in its own right, which is now present in the health agencies of many countries: medico-economic evaluation, which is capable of comparing the costs of an investment with the health gains that it generates for the community. This evaluation is far from the cynicism that is sometimes attributed to it: it combines a utilitarian viewpoint of maximizing aggregate collective benefits with normative principles of social justice that value the protection of the most vulnerable. In France, academic reflection on these issues, as well as their operational implementation by the Haute Autorité de Santé, have advanced the debate and transformed practices since the early 2000s. But there is still a fundamental question that the public debate must address in order to better guide our collective choices: the expected benefit of increased spending. It is not a question of setting a ceiling on expenditure per patient profile or per type of care. The objective is to develop a tool to evaluate the benefits of a treatment for a patient in terms of time saved and quality of life. Below a certain threshold, which will have to be the subject of public deliberation, a health investment would be considered unfair, because it would divert resources away from other more relevant priorities, i.e. other patients. In a context of constrained resources, the value of a life saved remains an open question, on which public action in health needs to be better constructed today.

Background: Team-based and timely integrated palliative care is a gold standard of care in oncology, but issues concerning its optimal organization remain. Palliative Care in Day-Hospital (PCDH) could be one of the most efficient service model of palliative care to deliver interdisciplinary and multidimensional care addressing the complex supportive care needs of patients with advanced cancer. We hypothesize that, compared to conventional outpatient palliative care, PCDH allows the clinical benefits of palliative care to be enhanced. Methods/design: This study is a multicentre parallel group trial with stratified randomization. Patient management in PCDH will be compared to conventional outpatient palliative care. The inclusion criteria are advanced cancer patients referred to a palliative care team with an estimated life expectancy of more than 2 months and less than 1 year. The primary endpoint is health-related quality of life with deterioration-free survival based on the EORTC QLQ-C30 questionnaire. The secondary objectives are the following: increase in patient satisfaction with care using the EORTC PATSAT-C33 and OUT-PATSAT7 questionnaires, better understanding of the prognosis using the PTPQ questionnaire and advance care planning. decrease in the need for supportive care among relatives using the SCNS-P&C-F questionnaire, and reduction in end-of-life care aggressiveness. Patients will complete one to five questionnaires on a tablet before each monthly visit over 6 months and will be followed for 1 year. A qualitative study will take place, aiming to understand the specificity of palliative care management in PCDH. Cost-effectiveness, cost-utility and, an additional economic evaluation based on capability approach will be conducted from a societal point of view. Discussion: The first strength of this study is that it combines the main relevant outcomes assessing integrated palliative care. patient quality of life and satisfaction. discussion of the prognosis and advance care planning, family well-being and end-of-life care aggressiveness. The second strength of the study is that it is a mixed-method study associating a qualitative analysis of the specificity of PCDH organization, with a medical-economic study to analyse the cost of care.

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The recent advent of innovative and expensive therapies in various therapeutic fields raises important hopes from a public health perspective. However, providing equitable access to these innovations competes with other public investments that are also subject to strong social expectations. It therefore forces actors to define the maximum amount that the community is willing to spend for given health gains. The question then arises as to whether this maximum amount varies according to the circumstances surrounding individuals, such as the rarity of the disease, their lifestyles, and the social inequalities they have experienced throughout their lives. In this article, we focus on a particular priority, that given to the youngest populations, most often referred to, following Harris' work, as fair innings. We ask what might justify such prioritization. In this paper we examine three arguments. First, we propose to justify the fair innings criterion in the name of an objective of equalizing welfare opportunities in the population. Second, we propose to justify it on behalf of an objective of equalizing the time available to individuals to realize their life plans, in accordance with Rawls' theory of justice as fairness. Finally, we propose to justify it in the name of an objective of equalizing the time offered to individuals to accept death. There are, of course, many limitations to these three arguments and we highlight some of them. Our aim in this article is not to convince people of the superiority of one argument over the others. Rather, we seek to contribute to the discussion of prioritization criteria in health care by explaining what might justify one particular criterion: age.

Can the responses of social justice theories prior to the current health crisis be concretely used to guide the decisions of caregivers and institutional actors, given the context in which they found themselves during the first phase of the Covid-19 health crisis? What lessons can we learn from them from a theoretical point of view?

Background Epilepsy affects more than 50 million people worldwide, 80% of whom live in low- and middle-income countries (LMICs). In Southeast Asia, the prevalence is moderate (6‰), and the main public health challenge is reducing the treatment gap, which reaches more than 90% in rural areas. Methods This 12-month comparative study (intervention vs. control areas) assessed the community effectiveness of two different strategies for the identification and home follow-up of people with epilepsy by Domestic Health Visitors for epilepsy (DHVes). In Lao PDR, DHVes were health center staff covering several villages via monthly visits. in Cambodia, DHVes were health volunteers living in the villages. Findings At baseline, the treatment gap was >95% in Lao PDR and 100% in Cambodia. After 12 months, the treatment gap in Lao PDR decreased by 5·5% (range: 4·0–12·2) in the intervention area and 0·5% (range: 0·4–0·8) in the control area (p<0·0001). In Cambodia, the treatment gap decreased by 34·9% (range: 29·0–44·1) in the intervention area and 8·1% (range: 6·7–10·2) in the control area (p<0·0001). Among the PWEs followed at home by the DHVes, the proportion adhering to drug treatment was 85·2% in Lao PDR and 78·1% in Cambodia. The cost associated with strategy implemented in Cambodia, compared with the control area, was lower than the cost associated with strategy implemented in Lao PDR.” Interpretation The treatment gap was significantly reduced with both intervention strategies, but the effect was larger in Cambodia. The results of this cost analysis pave the way for scaling-up in rural areas of Lao PDR and Cambodia, and experimental adaptation in other LMICs.

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We evaluate the introduction of various forms of antihypertensive treatments in France with a distribution-sensitive cost-benefit analysis. Compared to traditional cost-benefit analysis, we implement distributional weighting based on equivalent incomes, a new concept of individual well-being that does respect individual preferences but is not subjectively welfarist. Individual preferences are estimated on the basis of a contingent valuation question, introduced into a representative survey of the French population. Compared to traditional cost-effectiveness analysis in health technology assessment, we show that it is feasible to go beyond a narrow evaluation of health outcomes while still fully exploiting the sophistication of medical information. Sensitivity analysis illustrates the relevancy of this richer welfare framework, the importance of the distinction between an ex ante and an ex post approach, and the need to consider distributional effects in a broader institutional setting.

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Health equivalent income concept [.].

We compare two approaches to measuring inequity in the health distribution. The first is the concentration index. The second is the calculation of the inequality in an overall measure of individual well-being, capturing both the income and health dimensions. We introduce the concept of equivalent income as a measure of well-being that respects preferences with respect to the trade-off between income and health, but is not subjectively welfarist since it does not rely on the direct measurement of happiness. Using data from a representative survey in France, we show that equivalent incomes can be measured using a contingent valuation method. We present counterfactual simulations to illustrate the different perspectives of the approaches with respect to distributive justice.

The aim of this article is to assess dilemma raised by adaptive preferences in the economic evaluation of growth hormone (GH) treatment for non-GH-deficient short children, and of bilateral cochlear implants for deaf children. Early implementation of both technologies and their irreversible consequences increase the potential conflicts faced by the assessors of health-related quality of life (HRQoL) states (on behalf of patients) who could be interviewed (parents, individuals with an experience of the same disability, or representative samples of the general public). Indeed, assessors' preferences may be influenced by their own situation and they are likely to vary according to age and the experience of disability. Three options are put forward which aim to resolve these moral dilemma and help economists make methodological choices that cannot be avoided in order to carry out this assessment. They are grounded on three specific egalitarian theories of social justice. The main contribution of this article is to show that a dialogue between ethics and economics, prior to an assessment, makes it possible to redefine the choice of effectiveness criteria (subjective well-being, capabilities or social outcomes), the choice of perspective (patients or the able-bodied), as well as the scope of assessment (medical and non-medical care).

Recent developments in welfare economics open the way to evaluation methods based on other models of social justice than utilitarianism. The feasibility of these methods in the daily practice of evaluating health interventions raises questions: the objective of this thesis is to contribute to answering them. To this end, we have focused on three practical cases. The aim of Chapter I is to compare the evaluation methodologies of three public evaluation agencies, the NICE (Great Britain), the IQWiG (Germany) and the KCE (Belgium), in order to identify the social justice positions that result from them. Chapter II proposes to study the moral dilemma that arises from the phenomenon of preference adjustment in the evaluation of two disability compensation schemes. Three options are put forward to solve this dilemma, based on egalitarian theories of social justice. Finally, Chapter III demonstrates the feasibility of the health-equivalent income approach, developed by Fleurabey, in public decision support, concerning antihypertensive treatments in primary prevention.

Welfare economics encompasses other public choice theories besides utilitarianism, like egalitarian social justice theory. Whether these economic frameworks provide practical tools that could be used in health technology assessment is an ongoing debate, and this study aim to contribute to answer this question. The aim of the first chapter is to review health economic evaluation guidelines and compare methods from three national health technology assessment agencies - NICE (England and Wales), IQWiG (Germany) and KCE (Belgium) - and to assess what social justice principles are implied by their methodological choices. The second chapter studies the moral dilemma raised by adaptive preferences in growth hormones treatment and bilateral cochlear implants. Three options are put forward to solve this dilemma: they are grounded on egalitarian social justice theories. The objective of the third chapter is to provide evidence about the feasibility of assessment based on equivalent income approach, developed by M. Fleurbaey, in the context of public decision making.