To ensure that the resources of the health care sector are used effectively, new technologies need to be evaluated before implementation to examine if they generate health outcomes at an acceptable cost. This information can be collected by performing health economic evaluations in which the costs and health outcomes of different technologies are compared. To estimate the effect on health care budgets, there is also a need for information about the prevalence of the specific disease. Health outcomes in health economic evaluations are often measured in quality-adjusted life years (QALYs), which are calculated by multiplying the remaining life years after an intervention by a weight representing the health-related quality of life (HRQoL) during those years. This thesis aims to provide deeper knowledge of the health economic aspects of diabetic retinopathy (DR), an eye complication that affects patients with diabetes and may in the worst case lead to blindness. The focus is on three empirical and two methodological health economic research questions. The empirical research areas cover prevalence, costs, and HRQoL related to patients with DR. The methodological research questions explore the performance of different methods for estimation of QALY weights. This is of interest since it has been argued that the most common methods for estimating QALY weights may not capture all relevant vision-related aspects of quality of life. The analyses comprehend the validity of different methods for estimating QALY weights among patients with DR and if the results of one of the specific methods for estimating QALY weights, the time trade-off (TTO) exercise, are affected by patients’ subjective life expectancy (SLE). The empirical results demonstrate that DR is seen in approximately 40% and 30% of patients with type I and type II diabetes respectively, indicating that the prevalence of DR has decreased in both of these patient groups. Healthcare costs vary considerably between different severity levels of the disease, being estimated at €26, €257, €216, and €433 per patient per year for background retinopathy, proliferative diabetic retinopathy (PDR), diabetic macular oedema (DMO), and PDR combined with DMO respectively. Blindness due to DR is associated with an increased use of transportation services, caregiving services, and assistive technologies as well as productivity losses. This suggests that preventing the progression of DR may lower healthcare costs. Patients with vision impairment due to DR have lowered HRQoL in various dimensions, but the diagnosis of DR in itself has only a limited effect on HRQoL. The results on the methodological research questions show that different methods for estimating QALY weights seem to give different results. In comparison to EQ-5D, the Health Utilities Index Mark 3 (HUI-3) is the most sensitive method for detecting differences in QALY weights due to DR, and if decisions are to be made based on values from the general public, it can be recommended for use in cost-utility analyses of interventions directed at DR. Neither of the direct methods, TTO and the visual analogue scale, seems to be sensitive to differences in visual function, and more research is needed concerning the role of vision in people’s responses to the TTO exercises. In TTO exercises with time frames based on actuarial life expectancy, the patients’ SLE has an effect on their willingness to trade off years for full health. Thus, applying time frames deviating from patients’ SLE may result in biased QALY weights. Such bias may appear stronger within patient populations than within the general public. In conclusion, this thesis offers estimates for prevalence, costs, and QALY weights that can be used in economic evaluations of interventions directed at DR and as benchmarks for future DR research in order to follow up consequences of changes in diabetes care. In addition, it demonstrates that the choice of method for estimating QALY weights may have an impact on whether an intervention is considered cost-effective.

Background: Health economic evaluations are becoming an increasingly important means of analysing which care alternative resource utilisation is the most cost effective. It is a new topic in the medical device industry that causes much uncertainty and unstructured use of the actors involved. Study questions: Why is it difficult to develop, implement and disseminate this standardized health economic evaluation models in medical technology? Is there a possibility to standardize health economic evaluations within the medical device industry? Purpose: The purpose of this study is to investigate the standardization issues for health economic evaluations within the medical device industry. Method: A qualitative approach was used in the form of interviews with five actors that are active or have a connection to the medical device industry. The data collection consists of journals, reports, Internet searches and literature among other things. Conclusion: It is possible to standardize, but with certain restrictions such as the county council's budget, influence of industry-specific factors, lack of knowledge and the important interaction between actors.

L’approche médico-économique dans les évaluations des systèmes de surveillance en santé publiqueMots clés : évaluation des systèmes de surveillance, évaluation médico-économique, méthode des choix discretsLa surveillance en santé publique et la veille sanitaire sont en lien direct avec l’action et la décision publique en fournissant des informations précises et validées aux autorités sanitaires afin que ces dernières mettent en œuvre les mesures de contrôle et de prévention appropriées. Dans un contexte d’émergences infectieuses et d’apparition de nouvelles menaces pour la santé des populations, la surveillance en santé publique doit disposer d’une capacité d’adaptation et de priorisation. Ce besoin d’adaptation dynamique est confronté au réalisme des ressources disponibles de plus en plus limitées et à la demande sociale en matière de santé publique et de protection contre les risques sanitaires croissants. L’évaluation des systèmes de surveillance en santé publique au regard de leur utilité et de leur performance technique est préconisée depuis plusieurs décennies. La question de l’efficience de ces systèmes de surveillance est plus récente et prend une dimension particulière au regard du contexte budgétaire contraint qui touchent tous les opérateurs de l’état.Ce travail s’est attaché, à montrer l’intérêt et la valeur ajoutée d’une démarche standardisée d’évaluation des systèmes de surveillance en maladies infectieuses au sein d’une agence nationale de santé publique. Fondée sur un protocole développé selon la méthodologie préconisée par les recommandations internationales, cette démarche a enrichi la stratégie de surveillance de l’institution et a permis d’initier de nouveaux travaux portant sur la valorisation des bénéfices engendrés par la surveillance et leur prise en considération pour la priorisation des ressources. Une revue systématique de la littérature scientifique a permis de dresser un état des lieux et des connaissances sur l’évaluation des bénéfices de la surveillance en santé publique. Outre le faible nombre d’études dans le domaine, cette revue montre que les bénéfices engendrés par la surveillance sont le plus souvent estimés par le coût des cas épargnés ou des vies sauvées grâce aux actions de contrôle et de réponse. Cette approche présente plusieurs limites. Elle est difficilement applicable pour les systèmes de surveillance ne nécessitant pas des mesures de contrôle immédiates. Elle ne prend pas en compte les valeurs d’existence en lien avec les effets non monétaires induits par la surveillance en santé publique et la veille sanitaire. Afin de prendre en compte toutes les dimensions de la surveillance, nous avons mené une étude exploratoire faisant appel à la méthode des choix discrets appliquée à des systèmes de surveillance de maladies infectieuses émergentes. Cette étude inédite dans le champ de la surveillance en santé publique réalisée sur un échantillon de convenance, montre l’importance de certains critères comme la prévalence ou la létalité. Des consentements à payer marginaux pour ces critères sont estimés pour la première fois et constituent une première indication. Les résultats de cette étude apportent quelques éléments de réponse à la question des bénéfices induits par un système de surveillance ou de veille sanitaire.L’approche médico-économique dans les évaluations des systèmes de surveillance reste un domaine peu exploré. L’actualisation des recommandations internationales sur l’évaluation des systèmes de surveillance serait utile et devrait intégrer une approche médico-économique. L’intérêt potentiel de la méthode des choix discrets pour la valorisation des bénéfices induits par les systèmes de surveillance et de veille sanitaire appliquée dans une étude exploratoire dans ce travail devrait être évalué sur une plus grande échelle. / Economic evaluations approach in the public health surveillance systems evaluationsKey word: public health surveillance system evaluation, economic evaluation, discrete choice experimentsPublic health surveillance is closely linked to action as it provides accurate and validated information to health authorities in order that these same authorities can implement appropriate prevention measures and control strategies. In a context of emerging infectious diseases and of new health threats occurring, priorities for public health surveillance need to be reviewed and adapted regularly. This need of constant adaptation is facing limited resources and an increasing social demand of health security and protection against all health risks. Assessing the usefulness and the technical performance of surveillance systems are the main objectives of public health surveillance system evaluations and this has been recognized for many years through international guidelines. The efficiency of a surveillance system is a more recent question and takes a particular dimension in the context of budgetary constraints that all national agencies are facing.This work aimed to underline the interest and the added value of an external and formal evaluation process of surveillance systems in a national public health agency. Based on a generic evaluation protocol drawn up in accordance with international recommendations, this evaluation process has improved the surveillance strategy of the institution and has brought new questions up about the estimations of benefits of surveillance systems and their impact in the surveillances prioritizing process. A systematic literature review has drawn a clear picture of the state of the art and the knowledges in the field of public health surveillance system benefits estimation and evaluation this systematic review indicates that, to date, very few economic evaluations of public health surveillance systems have been performed worldwide. It also shows that the benefits of surveillance are mainly assessed by the costs of the number of cases or deaths prevented by the response and control measures. This approach has certain limits. It cannot be applied when the primary objective of the surveillance activities is not linked to immediate response. It does not take into account the existence value of a Public health surveillance system. In order to take the dimensions of a public health surveillance system, we have conducted a pilot study using discrete choice experiments applied to different emerging infectious diseases surveillance systems. This study, novel in the field of public health surveillance, was performed among a convenient sample and shows the importance of certain criteria such as the prevalence and the case fatality ratio. For the first time, marginal willingness to pay for these criteria have been estimated and these results give some insights into the question of the benefits, a public health surveillance system can bring.Economic evaluations of public health surveillance system remain an area where little has been carried out to date. Updating international recommendations for public health surveillance systems would be useful and should include an economic approach. The potential interest of the discrete choice experiments for valuing benefits of a public health system used in this pilot study need to be confirmed in a larger scale.

Physical activity among children and adolescents around the world is decreasing and will imply negative effects on their current and future health, which also contributes to higher costs for the society. Interventions promoting physical activity among youths could increase their physical activity and, at the same time, reduce the costs for society. The purpose of this study is to evaluate interventions for increased physical activity targeted towards children and adolescents from a health economic perspective. The results indicate that there exist different types of interventions and that the choice of health economic evaluation method differs widely between studies. In order for policymakers to choose the most effective interventions that allocate the society’s scarce resources in the best way, there is a need for a more streamlined methodological approach for health economic evaluations of the interventions that promote psychical activity among children and adolescents. / Fysisk aktivitet minskar bland barn och ungdomar runt om i världen och kan medföra negativa effekter på deras nuvarande och kommande hälsa, vilket också bidrar till högre kostnader för samhället. En intervention som främjar fysisk aktivitet bland barn och ungdomar, kan öka den fysiska aktiviteten och samtidigt minska samhällets kostnader. Syftet med denna studie är att utvärdera interventioner som främjar fysisk aktivitet riktad mot barn och ungdomar ur ett hälsoekonomiskt perspektiv. Resultaten indikerar att det finns olika typer av interventioner och att valet av hälsoekonomisk utvärdering skiljer sig mellan interventioner. För att beslutsfattare ska kunna välja de mest effektiva interventioner som fördelar samhällets knappa resurser på bästa sätt finns det ett behov av gemensamma tillvägagångssätt i hälsoekonomiska utvärderingar på interventioner som främjar psykisk aktivitet bland barn och ungdomar.