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Biomedical subjects

D S Shepard

Publications and source records attributed to D S Shepard.

At least 19 recordsLinked to original sources
PubMed1997

Assessment of the Massachusetts Medicaid managed Behavioral Health Program: year three.

This evaluation of the third year of the Massachusetts Medicaid managed Mental Health/Substance Abuse Program showed that overall utilization increased slightly and expenditures were nearly the same in FY1994 compared to FY1993; however, they were lower for disabled members. Providers believed that access to care, utilization, and quality of care were the same or better than a year earlier and that the clinical review process was improved. Client severity was higher. Aftercare planning improved but gaps in services persisted. Integration of care improved. Administrative and management problems continued. Lessons for similar, more recent initiatives are discussed.

Adult↗
PubMed1995

Setting priorities for the Children's Vaccine Initiative: a cost-effectiveness approach.

To help the Children's Vaccine Initiative (CVI) achieve its goal of new and improved children's vaccines, we developed and applied a cost-effectiveness model to set priorities for vaccine development. The model measures the health benefits in additional Quality-Adjusted Life Years (QALYs) gained by the combined birth cohorts of all developing countries over an assumed useful life of a proposed vaccine (generally 10 years). It measures costs as the net cost of developing, procuring, and administering the vaccine to the same population and time frame compared to the status quo (the current vaccine, if any). It weights each dollar of in-kind allocation of the existing health infrastructure less heavily than a dollar cash outlay to purchase new vaccine to reflect severe constraints on foreign exchange and non-personnel costs. It expresses cost-effectiveness as the net cost per QALY. The model was applied to 13 candidate vaccines selected by the CVI for initial analysis on the basis of their near-term feasibility. The five most cost-effective improvements, each of which could generate a QALY inexpensively (below $25 per QALY), were an early-administration or an early two-dose measles vaccine, slow release tetanus toxoid (for women), improved typhoid vaccine, and hepatitis B combined with diphtheria-tetanus-pertussis vaccine.

Child, Preschool↗
PubMed1995

Mental health/substance abuse treatment in managed care: the Massachusetts Medicaid experience.

Massachusetts was the first state to introduce a statewide specialty mental health managed care plan for its Medicaid program. This study assesses the impact of this program on expenditures, access, and relative quality. Over a one-year period, expenditures were reduced by 22 percent below predicted levels without managed care, without any overall reduction in access or relative quality. Reduced lengths-of-stay, lower prices, and fewer inpatient admissions were the major factors. However, for one population segment--children and adolescents--readmission rates increased slightly, and providers for this group were less satisfied than they were before managed care was adopted. Less costly types of twenty-four-hour care were substituted for inpatient hospital care. This experience supports the usefulness of a managed care program for mental health and substance abuse services, and the applicability of such a program to high-risk populations.

Cost Control↗
PubMed1995

Multivariate cost-effectiveness analysis: an application to optimizing ambulatory care for hypertension.

Cost-effectiveness analysis (CEA) is being used increasingly to allocate health resources efficiently. This paper develops an extension of CEA based on multivariate regression analysis and applies it to hypertension treatment. After assembling clinic and patient characteristics, outcomes, and costs for 2,439 randomly chosen patients in the 32 special hypertension clinics of the Department of Veterans Affairs (VA), we identified 19 significant predictors of cost and diastolic blood pressure (DBP) using multiple regression analysis. We classified these independent variables as "unambiguous" if a given change was associated with both lower cost and better DBP, or as "trade-off" variables if any change improving DBP entailed higher costs. The results suggest that fully implementing all unambiguous clinic changes would reduce costs by 33% while improving DBP. Multivariate CEA could help managed care companies and government programs with cost and outcome data to reduce costs and improve outcomes.

Ambulatory Care↗
PubMed1994

Economic analysis of investment priorities for measles control.

An investment strategy in measles control should strike an appropriate balance among three areas: implementation of existing vaccination programs with existing technology, operations research to improve the use of existing technology, and vaccine development. As a benchmark, the existing Schwarz vaccine costs approximately $17 per DALY (disability-adjusted life year), already making it one of the most cost-effective health interventions in developing countries. National measles vaccination campaigns, such as Brazil's, are a promising extension of this technology. Operations research is indicated to study the organization of campaigns, supplying and delivering vitamin A to hospitalized children, and other issues. The development and application of an early one-dose measles vaccine would be particularly cost-effective ($5 per DALY), as it could avoid the costs to families and health institutions of the separate visit at 9 months now required for measles vaccination. All three areas present opportunities for cost-effective investments and deserve a place in an investment strategy.

Child, Preschool↗
PubMed1994

Effectiveness and costs of veterans affairs hypertension clinics.

The effectiveness and costs of care for hypertension are examined in a stratified random sample of 3,087 patients from a network of 32 Veterans Affairs Hypertension Screening and Treatment Clinics (HSTP). During 2.5 years of follow-up, 66% and 88% of patients, respectively, had mean diastolic blood pressure (DBP) levels of 90 or 95 mm Hg or less; 73% remained fully in care; and the mean cost of ambulatory care per patient-year was $647 in 1989 dollars. Higher follow-up DBP levels were found in patients who were younger, had higher DBP levels, or were receiving medication on their first visits to a clinic, were receiving more intense treatment regimens at the beginning of the follow-up period, or had been under the care of the clinic for shorter periods. Patients who were more likely to remain in care were older, received more intense treatment regimens, had prior cardiovascular complications, or had been under the care of the clinic for a longer time. Higher annual costs were associated with higher entry DBP levels, shorter durations of care, more intense regimens, and prior cardiovascular complications. Overall, patient characteristics explained 13% of the variance in mean follow-up DBP, and 31% of variance in costs. Wide variations were found among clinics in clinical outcomes and costs. After controlling for differences in patient characteristics, clinic characteristics associated with better blood pressure control were more frequent clinic visits, shorter waiting times, more time spent in patient counseling, having therapists who had a single supervisor, and better staff satisfaction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Improving the cost-effectiveness of AIDS health care in San Juan, Puerto Rico.

In an era of decreasing availability of funds and increasing demand, the AIDS epidemic threatens to overwhelm health-care services in some countries. We describe a comprehensive model for the treatment of AIDS in San Juan, Puerto Rico, and compare it with traditional hospital-based services. Given the existing allocation of funds, the comprehensive model emphasised prevention, education, surveillance, early detection, and outpatient care to reduce hospital care. In 1987, the last year of the traditional system, there were 95 admissions of AIDS patients to hospital, and in 1988, the first year of the comprehensive model, there were 100 admissions. The mean length of stay of AIDS inpatients was reduced from 22.3 days in 1987 to 11.3 days in 1988, a 46.8% reduction (p = 0.001). The annual mean (SE) cost of inpatient care per AIDS patient fell from $15,118 (1699) in 1987 to $3869 (659) in 1988. Savings were used to improve non-hospital services, including outreach, education, emergency and outpatient care, laboratory and epidemiological services, and research, and to introduce an employee incentive scheme. Management strategies that reduce the length of inpatient care and provide less costly treatment alternatives can improve AIDS health care in developing nations.

Acquired Immunodeficiency Syndrome↗
PubMed1991

Treatment of tuberculosis by private general practitioners in India.

Early detection and optimal treatment constitute the most important measures in the control of tuberculosis. This study of prescriptions for tuberculosis recommended by 102 private doctors, practising in the slums of Bombay, shows a lack of awareness among doctors who treat tuberculosis patients in their own clinics about the standard drug regimens for treatment of tuberculosis recommended by national and international agencies. While there are a few standard, efficient, recommended regimens, 100 private doctors prescribed 80 different regimens, most of which were both inappropriate and expensive. The study highlights the need for effective communication between those implementing national tuberculosis programmes and the practising private doctors, continuing education of these doctors for updating their knowledge and their active participation in at least those national disease programme for which their curative functions could contribute significantly to control of a disease.

Antitubercular Agents↗
PubMed1991

The economic cost of malaria in Africa.

Although malaria is the major health problem in Africa, there is little research on its economic impact. This study adapts a framework for assessing the economic costs of illness to available data on malaria. Direct costs of illness are the costs of treatment and control activities, and indirect costs are the value of lost time due to morbidity and premature mortality. Direct costs were estimated by applying the average estimated health systems costs per case to the number of cases. Indirect costs were assessed by multiplying adult output per day times the estimated productive time lost through both adult and childhood cases. As data are not available to assess the economic impact of malaria in Africa as a whole, four case studies were performed on countries or regions for which needed data could be found. The four sites (Rwanda, Solenzo medical district of Burkina Faso, Mayo-Kebbi district, Chad, and Brazzaville, Congo) were chosen to illustrate the diversity in kinds of data which can be used (aggregate national health statistics versus household surveys) and in locations (urban versus rural). Costs were calculated for the recent past and were projected to 1995 based on recent epidemiological trends. Estimates for all sub-Saharan Africa were derived from the averages of these sites. In 1987, a case of malaria cost $9.84 (in 1987 US dollars)--$1.83 in direct costs and $ 8.01 in indirect costs. As the average value of goods and services produced per day in Africa was $0.82, this cost is equivalent to 12 days of output.(ABSTRACT TRUNCATED AT 250 WORDS)

Africa↗
PubMed1991

Economic cost of malaria in Rwanda.

Although malaria is widely recognized as a major public health problem in much of Africa, its impact on a specific national or regional economy has proved difficult to assess. This paper demonstrates the kind of analysis possible given available national aggregate statistics on epidemiology and economic indicators, the type of data most readily available. An economic model which applies the average cost of malaria per case to the known number of cases in Rwanda for 1989 estimated the total cost to be $ 2.88 per capita (in 1987 US dollars). Of this cost, $0.63 per capita represents the direct cost of treatment, including care of outpatients and hospitalized cases in both government and private facilities, as well as self-treatment. The other $ 2.25 per capita represents the indirect costs of productive time lost to malaria morbidity in adults and to care for sick children, and the cost of lifetime earnings lost through premature malaria mortality. The average output per day of the Rwandan economy was $0.83 in 1989. Thus, the per capita malaria cost equals 3.5 days of production or 1% of GDP. The average cost of each of the 1,722,271 reported malaria cases in 1989 was $11.82: $2.58 in direct and $9.24 in indirect cost. The direct cost per case is equal to 160% of the per capita budget of the Ministry of Health. Economic and epidemiological projections to 1995 yield an increase in malaria cases to over 4 million at a cost of $7.11 per capita. Direct costs are projected to rise over 200% due to increasing costs of drugs and supplies to treat increasingly drug-resistant cases. Indirect costs, which are tied to a declining economy, are projected to rise by just over 100%. By 1995, malaria is projected to cost 2.4% of the Rwandan GDP, exacerbating an already serious impact.

Costs and Cost Analysis↗
PubMed1991

Estimating the direct and indirect economic costs of malaria in a rural district of Burkina Faso.

Comprehensive estimates of the direct economic costs of malaria should include not only the costs of care at established health facilities, but also other expenditures, such as travel and out-of-pocket costs of drugs. They should include all episodes of illness, whether or not the patient attended a health facility. Also, the indirect economic costs, which are based on the value of time lost due to illness, consider seasonal variations in the marginal product of labor according to the agricultural season. A 1985 representative survey of 626 households in Solenzo medical district, Burkina Faso, provided household data on health service utilization, expenditures, and agricultural production with which to implement these refinements. Numbers of malaria deaths and cases were estimated by adjusting survey totals according to monthly patterns of reported malaria deaths. The marginal product of labor was valued according to typical activities in each of three agricultural seasons: brewing millet beer during the maintenance period (January-February), growing cotton during the cash crop season (March-April), and growing millet and sorghum during the food crop season (May-December). The resulting values were $0.28, $1.09, and $0.55 per day, respectively. Cost per case averaged $5.96 and cost per capita $1.15. Indirect cost due to mortality was the largest cost component ($0.79 per capita), followed by direct costs incurred by the user (e.g. transportation costs and drug purchases, $0.22 per capita). Direct costs paid by providers were small, only $0.04 per capita. A household survey provides the necessary data for more comprehensive population-based estimates of costs of malaria.

Adult↗
PubMed1991

Economic analysis of several types of malaria clinics in Thailand.

The costs of three types of malaria clinics in Maesot District, north-west Thailand, for a one-year period in 1985-86 were compared from the institutional, community and social (institutional plus community) perspectives. The greatest number of patients at the lowest average institutional cost per smear and per positive case diagnosed (US$ 0.82) were seen at the large central clinic in Maesot town. The peripheral clinic in Popphra, a subdistrict town, had moderate institutional costs per smear and per positive case (US$ 1.58). The periodic mobile clinic, which served five villages on a fixed weekly schedule, had low average institutional costs per smear, but the highest cost per positive case (US$ 3.53). Community costs (those paid by patients and their families) were lowest in the periodic clinic. Addition of a periodic clinic to a system of central and peripheral clinics increased the number of malaria cases treated, particularly those involving women and under-16-year-olds. Although the periodic clinic entailed a modest increase in institutional costs, it minimized social costs. The results of the study suggest that use of a combination of central, peripheral, and periodic clinics, which maximizes access to malaria treatment, minimizes the social costs of malaria.

Ambulatory Care Facilities↗
PubMed1989

Setting the price of essential drugs: necessity and affordability.

A method has been developed for fine tuning the selection of drugs to improve cost recovery, to promote appropriate drug use, and to make more drugs more affordable. This scheme is based on a classification of drug necessity (vital, essential, non-essential) and on the relative cost of complete courses of treatment so that expensive drugs can be subsidised by marking up inexpensive ones.

Child↗
PubMed1989

Reduction of enteric infectious disease in rural China by providing deep-well tap water.

Enteric infectious disease (EID), defined here as bacillary dysentery, viral hepatitis A, El Tor cholera, or acute watery diarrhoea, is an important public health problem in most developing countries. This study assessed the impact on EID of providing deep-well tap water (DWTW) through household taps in rural China. For this purpose, we compared the incidence of EID in six study villages (population, 10,290) in Qidong County that had DWTW with that in six control villages (population 9397) that had only surface water. Both the bacterial counts and chemical properties of the DWTW met established hygiene standards for drinking water. The incidence of EID in the study region was 38.6% lower than in the control region; however, the introduction of DWTW supplies did not significantly affect the incidence of bacillary dysentery. These results indicate that the construction and use of DWTW systems with household taps is associated with decreased incidences of El Tor cholera, viral hepatitis A, and acute watery diarrhoea. Since high construction costs have led many authorities to question the value of DWTW, we carried out a cost-benefit analysis of the programme. The cost of constructing a DWTW system averaged US $36,000 at 1983 prices, or US $10.50 per capita. The combined capital and operating costs of a DWTW system were US $1.46 per capita per annum over its 20-year estimated life. The benefits derived from reductions in cost of illness and savings in time to fetch water were 2.2 times the costs at present values Capital outlays were recouped in a 3.6-year payback period and the provision of DWTW proved highly beneficial in both economic and social terms.

Adolescent↗
PubMed1989

The Thai expanded programme on immunization: role of immunization sessions and their cost-effectiveness.

A cost-effectiveness study of the Thai expanded programme on immunization was carried out in district hospitals and health centres in Thailand during early 1987. The total annual spending on immunization was US $3852 in hospitals and US $813 in health centres. The percentage distribution of annual costs was similar in both facilities. Salaries were the largest component, followed by building and vaccine costs. The frequency of immunization sessions was the most important factor in determining total costs--immunization costs increasing with the frequency of sessions. In hospitals the average number of fully immunized children was 184, compared with 49 in health centres. The cost per fully immunized child varied widely from US $5.30 to US $33.20, and the most cost-effective facilities were those that immunized the greatest number of children. With the present number of health facilities in all areas of the country, which correspond to saturation levels, the most likely way for the Thai programme to reduce costs would be to make better use of staff time by decreasing the frequency of the services offered, thereby increasing the efficiency of each session. Hospitals should adjust the frequency of their immunization sessions according to the number of children being served, but health centres should offer sessions only monthly or once every two months.

Community Health Centers↗
PubMed1989

Cost-effectiveness of routine and campaign vaccination strategies in Ecuador.

A national household coverage survey of 3697 Ecuadorean children, carried out in July 1986, provided an opportunity for a cost-effectiveness analysis of (1) routine vaccination services based in fixed facilities and (2) mass immunization campaigns. A major purpose of the campaigns was to complement the routine services and to accelerate immunization activities. Based on the coverage survey, the Program for Reduction of Maternal and Childhood Illness (PREMI) and earlier campaigns increased the proportion of children under 5 years who were fully vaccinated from 43% to 64%. In one year, the PREMI campaign was responsible for fully vaccinating 11% of children under one year, 21% of 1-2-year-old children, and 13% of all children under 5 years. The campaign also helped ensure that vaccinations were completed when children were still very young and at greatest risk. The average cost per vaccination dose (in 1985 US$ prices) was approximately $0.29 for fixed facilities and $0.83 for the PREMI campaign. Total national costs were $675,000 and $1,665,000 for routine and campaign services respectively. The cost per fully vaccinated child (FVC) was $4.39 for routine vaccination services and $8.60 for the campaign. The cost per death averted was about $1900 for routine vaccination services, $4200 for the PREMI campaign, and $3200 for the combined programme. Because of Ecuador's lower mortality rates, the costs per death averted in Ecuador from both vaccination strategies are not as low as those from studies of vaccinations in Africa. The campaigns, though less cost-effective than routine services, significantly improved the vaccination coverage of younger children who had been missed by the routine services. The costs per FVC of both the campaign and the routine services compare favourably with such programmes in other countries.

Child↗