VALUE IN HEALTH REGIONAL ISSUES 4C (2014) 115116
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EDITORIAL
What Are the Challenges in Conducting Cost-of-Illness Studies?
Two important transitions occurred in Value in Health Regional
Issues (ViHRI) in 2014: the rst is shifting the journal to being an
online publication, and the second is the transition toward an
article-based publishing approach. This new policy allows an
article to be published online soon after its acceptance for
publication, with nal, citable pagination, speeding up the pub-
lication and dissemination process. Indeed, the number of ViHRI
page views and article downloads has substantially increased in
2014. Several articles from our rst issue of ViHRI devoted to
Central and Eastern Europe, Western Asia and Africa (CEEWAA)
published in 2013 have gained interest from other scholars and
are already among the top cited articles in the journal. These
articles focused on capacity building for health technology
assessment (HTA) in Hungary [1], the state and challenges in
implementing HTA in Cyprus [2], and an editorial addressing
further steps needed for the development of HTA, pharmacoeco-
nomics, and outcomes research in the CEEWAA region [3]. This
present volume features 19 high-quality articles and editorials
from 12 countries and includes economic evaluations and cost-
of-illness (COI) studies pertaining to various disease areas such as
cardiovascular disease, AIDS, and cancer; patient-reported out-
comes and quality-of-life assessments; and health policy ana-
lyses of pharmaceutical policies, adherence to medications,
and HTAs.
Several articles in this volume report on COI studies for various
health conditions. Two of the studies are population based [4,5],
providing the rst information on the economic burden of sub-
stance abuse and several types of cancers in the Russian Federa-
tion. Other studies estimated the COI in a sample of patients with
rheumatoid arthritis and its relation to disease severity [6]; the
cost related to work productivity of patients with ankylosing
spondylitis, rheumatoid arthritis, and psoriasis in the Czech
Republic [7]; the direct cost of HIV-infected patients in Greece [8];
and a single-center study from Ghana assessing the health facility
cost of Buruli ulcer wound infection [9]. Although all these studies
present a cost analysis, some may not be considered traditional
COI analyses because of their narrow scope.
The aim of COI studies is to assess the economic burden that a
specic health problem (e.g., colorectal cancer) or groups of
health conditions (e.g., all cancer types) impose on a society in
terms of utilization of health care services, and productivity
losses [10]. This research has the potential of informing policy-
makers and decision-makers on the relative impact of diseases at
the population level, assisting them in making projections of
future health care costs and in resource allocation decisions.
Although the rst COI analysis was published more than 60
years ago [11], it was only in the mid-1960 s that Dorothy Rice
[12,13] formalized the methodology for costing illness. Since then,
Source of nancial support: The authors have no other nancial relationships to disclose.
Conicts of interest: The authors have indicated that they have no conicts of interest with regard to the content of this article.
several taxonomies and guidelines for conducting and reporting
COI studies have been published in the health policy and health
economics literature [10,1417]. At the same time, several scho-
lars have criticized COI analyses, suggesting that they may lack
credibility, consistency, and relevance for decision makers [17].
Performing a COI analysis, as any other economic evaluation,
may be very challenging. The choice of cost methodology (i.e.,
top-down vs. bottom-up), for assessing both direct costs and
losses in productivity, is largely driven by data availability, which
varies among countries. This is also the case when epidemiolo-
gical data (i.e., disease prevalence, incidence, and associated
mortality) need to be used. Ideally, COI estimates should use a
database linking epidemiological data, resource utilization of
health services, and their actual cost (rather than list prices),
and demographic data. Big data and patient registries are rarely
available in CEEWAA countries. Nevertheless, even if these data
sources were available, valuation of important cost components,
such as patient out-of-pocket expenses and lost productivity of
informal caregivers, is rather difcult, and therefore may be
excluded, thus underestimating the true COI.
The accuracy of methods used for assessing losses of produc-
tivity due to an illness is even more complex and is also
contingent on data availability. Two main issues may arise here:
1) What method should be used: the human capital approach
(HCA) or the friction cost method (FCM)? The HCA values the
potential lost production because of an illness, whereas the FCM
may provide a more accurate estimate of the actual lost produc-
tion. Therefore, the ndings of Potapchiik and Popovich [4]
suggesting that the costs associated with substance abuse in
Russia are almost threefold higher when the HCA rather the FCM
was used are not surprising. Although very appealing, using the
FCM requires a tremendous amount of information that is both
not available and may change over time because the friction time
is heavily dependent, for example, on the unemployment rate in
the country. Indeed, Ignatyeva et al. [5] in their assessment of the
cost of selected cancers in Russia suggest that because accurate
data on the length of friction period were not available, they had
to rely on experts opinion in their calculations. 2) Should
analyses include losses due to absenteeism or also due to
presenteeism? Although the assessment of productivity losses
resulting from absenteeism may be relatively easy, this is not the
case when presenteeism is concerned, and these costs are
frequently omitted.
Although the International Society for Pharmacoeconomics
and Outcomes Research (ISPOR) has initiated task forces dealing
with various aspects of cost-effectiveness and budget-impact
analyses and published widely used recommendations, an effort
to improve the methodology of conducting and reporting COI
116 VALUE IN HEALTH REGIONAL ISSUES 4C (2014) 115116
studies is warranted. These guidelines, together with the improve-
ment in data availability and quality, may make these studies
credible and valid and increase their use among policy-makers.
Dan Greenberg, PhD
Faculty of Health Sciences and The Guilford Glazer Faculty of
Business and Management, Department of Health Systems Man-
agement, Ben-Gurion University of the Negev, Beer-Sheva, Israel
Mohamed Izham B. Mohamed Ibrahim, PhD
College of Pharmacy, Qatar University, Doha, Qatar
Imre Boncz, MD, MSc, PhD, Habil
Faculty of Health Sciences, Institute for Health Insurance, University
of Pcs, Pcs, Hungary
2212-1099/$36.00 see front matter Copyright & 2014,
International Society for Pharmacoeconomics and Outcomes
Research (ISPOR). Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.vhri.2014.08.003
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