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Biomedical subjects

D S Shepard

Publications and source records attributed to D S Shepard.

At least 37 records · Page 2Linked to original sources
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↗
PubMed1989

Productivity loss due to deformity from leprosy in India.

The productivity loss in India due to deformity from leprosy was assessed in a random sample of 550 leprosy patients from a rural and an urban area in the state of Tamil Nadu. Logistic and log-linear regression analyses on these leprosy patients showed that elimination of deformity would: a) raise the probability of gainful employment from 42.2% to 77.6%; b) increase annual earnings per patient gainfully employed from Rs 2948 to Rs 6469; and c) raise overall earnings for all patients from Rs 1259 to Rs 5023 per year. The earnings of 550 control subjects (adult family members of the leprosy patients) were consistent with these predictions. Extrapolation to all of India's estimated 645,000 leprosy patients with deformity suggests that elimination of deformity would raise productivity by +130 million per year. The authors conclude that the development and evaluation of programs to eliminate deformity from leprosy deserve high priority.

Disability Evaluation↗
PubMed1987

Cholesterol reduction and life expectancy. A model incorporating multiple risk factors.

In deciding whether to undertake a dietary program to reduce serum cholesterol levels, a person must consider how much benefit to expect. We developed a model that assumes cholesterol reduction is effective and safe in reducing the risk for death from ischemic heart disease. In the model, we considered asymptomatic adults with total serum cholesterol levels between 180 and 300 mg/dL. We defined risk status on the basis of blood pressure, smoking habit, and high-density-lipoprotein cholesterol level. For persons aged 20 to 60 years who are at low risk, we calculate a gain in life expectancy of 3 days to 3 months from a lifelong program of cholesterol reduction. For persons who are at high risk, the calculated gain ranges from 18 days to 12 months. Knowledge of the magnitude of the calculated benefits in increased life expectancy afforded by cholesterol reduction can assist persons in making decisions about dietary change.

Age Factors↗
PubMed1986

Efficacy of pneumococcal vaccine in high-risk patients. Results of a Veterans Administration Cooperative Study.

We conducted a randomized, double-blind, placebo-controlled trial to test the efficacy of the 14-valent pneumococcal capsular polysaccharide vaccine in 2295 high-risk patients (patients with one or more of the following: age above 55 years and the presence of chronic cardiac, pulmonary, renal, or hepatic disease, alcoholism, or diabetes mellitus). Seventy-one episodes of proved or probable pneumococcal pneumonia or bronchitis occurred among 63 of the patients (27 placebo recipients and 36 vaccine recipients). Vaccine-serotype Streptococcus pneumoniae strains were recovered in association with 11 infections in the placebo group and 14 infections in the vaccine group. Pneumococcal infections occurred most frequently among patients with chronic pulmonary, cardiac, or renal diseases. Among vaccine recipients who subsequently had vaccine-type pneumonia or bronchitis, the majority did not make or sustain serum antibodies against their infecting organism in concentrations that were twice as high as the base-line values, or more than 400 ng of antibody nitrogen per milliliter, although their base-line levels were higher than those in subjects in whom infection did not develop. We were unable to demonstrate any efficacy of the pneumococcal vaccine in preventing pneumonia or bronchitis in this population. Our data suggest that chronically ill patients, who are most susceptible to infection, may have an impaired immune response to the pneumococcal vaccine.

Antibodies, Bacterial↗
PubMed1986

Cost-effectiveness of the expanded programme on immunization in the Ivory Coast: a preliminary assessment.

A preliminary calculation was made of the cost-effectiveness of the measles component of the Expanded Programme on Immunization (EPI) in the Ivory Coast. The calculation is based on existing data (program budgets, coverage surveys, counts of vaccinations provided and subjective estimates) and applies to the first three demonstration and training zones (Abidjan, Abengourou and Korhogo) with a combined population of 1.75 million people. The average annual cost of the measles program (assumed to be 75% of all EPI costs, including supplies, personnel and equipment) in these three zones was $527,000 at 1980 prices. Having achieved an average coverage rate of 61%, the cost per vaccine was moderately high, $12. Yet, vaccinees are a sufficiently small part of the population that the cost per capita is only $0.30. The program is estimated to prevent 38,000 cases of measles and 1100 deaths per year in these three zones. Thus, the cost per measles case averted is $14, and the cost per death averted is $479. This means that the measles component of the EPI Program is highly effective in preventing deaths for the sums expended compared to many alternative health programs in developing countries.

Cost-Benefit Analysis↗
PubMed1985

Treatment of diarrhoea in Indonesian children: what it costs and who pays for it.

The annual economic burden of diarrhoea in four subdistricts in Indonesia averaged $2.27 per child aged under 5 years when health centre, hospital, and private expenditures were all considered. The community itself spent $1.03 per child or 46% of the total; 96% of community payments went to the private sector, and 4% were for fees at government health centres and hospitals. The widespread availability of oral rehydration therapy has led to only partial abandonment of ineffective or marginally effective medications; non-rehydration medications amounted to 44% of total treatment expenditures. Most medication costs were for antimicrobial agents, such as tetracycline in the government sector and iodochlorhydroxyquin in the private sector. If the use of tetracycline at health centres could be restricted to 10% of episodes treated instead of the present 88%, their costs could be reduced by 50%.

Child↗
PubMed1983

Blood pressure reductions: correcting for regression to the mean.

Reductions in high blood pressure (BP) from participating in screening and treatment programs are often assessed by comparing BP measurements before and after participation. The interpretation of such changes in measured blood pressure is confounded by the tendency of high pressures to decline as a result of a statistical artifact--regression to the mean. The problem arises whenever baseline measurements are used both for selection of participants and for comparisons with pressures obtained later. We developed a statistical model which predicts the average decline due to regression for participants in a screening or treatment program. This regression effect must be subtracted from the observed reduction in BP (the difference between baseline and later measurements) to obtain the average net reduction in BP from the program. The regression effect is estimated as the product of two factors. The first factor is the proportion of the variance in the baseline (preprogram) measurement due to measurement error and the short-term variation (e.g., 0.24 for two replications averaged). The second factor is the difference between the mean baseline pressure of full participants and that of the underlying population of potential participants. The model was first illustrated with successive BP measurements from community screening programs, where the "program" was only remeasurement. The mean observed decline in diastolic BP between screens for 145 persons with elevated baseline BP was 7 mm Hg. After adjustment for regression to the mean, the net decline between screens was estimated to be 2 mm Hg. This decline is apparently due to the pressor effect, or stress of screening, and agrees with findings from other studies. Next the model was applied to the treatment phase of the Hypertension Detection and Follow-up Program. Overall, net reductions predicted by the model agree with those from independent measurements to within 0.1 mm Hg. The findings indicate the one can compute net reductions in BP from before-and-after comparisons in screening and treatment programs with reasonable accuracy, and these net reductions are generally much smaller than the crude BP declines.

Adult↗
PubMed1983

Estimating the effect of hospital closure on areawide inpatient hospital costs: a preliminary model and application.

A preliminary model is developed for estimating the extent of savings, if any, likely to result from discontinuing a specific inpatient service. By examining the sources of referral to the discontinued service, the model estimates potential demand and how cases will be redistributed among remaining hospitals. This redistribution determines average cost per day in hospitals that receive these cases, relative to average cost per day of the discontinued service. The outflow rate, which measures the proportion of cases not absorbed in other acute care hospitals, is estimated as 30 percent for the average discontinuation. The marginal cost ratio, which relates marginal costs of cases absorbed in surrounding hospitals to the average costs in those hospitals, is estimated as 87 percent in the base case. The model was applied to the discontinuation of all inpatient services in the 75-bed Chelsea Memorial Hospital, near Boston, Massachusetts, using 1976 data. As the precise value of key parameters is uncertain, sensitivity analysis was used to explore a range of values. The most likely result is a small increase ($120,000) in the area's annual inpatient hospital costs, because many patients are referred to more costly teaching hospitals. A similar situation may arise with other urban closures. For service discontinuations to generate savings, recipient hospitals must be low in costs, the outflow rate must be large, and the marginal cost ratio must be low.

Boston↗
PubMed1981

Estimating hospital costs by diagnosis for population-based analysis.

Knowledge of cost or charge for a discharge with a specified diagnosis to a given hospital is a prerequisite for population-based analysis of acute hospital utilization. As this information is not usually available directly for all discharges of residents of a geographical area, estimates are required. We compared alternative estimates derived from the data being assembled in many states--from hospital discharge data systems and routine cost and statistical reports. The independent variables were the name of the hospital, its total inpatient costs, and the diagnosis and length of stay for each discharge. We verified our estimates with data from Maine, for which charges were also available for many discharges. The estimate that used all three of the variables from the discharge data bank was most accurate. It explained 77.3 percent of the variability in hospital average charges per case for eight representative diagnoses. A simpler estimate, not requiring knowledge of diagnosis, proved almost as accurate. This estimate, defined as the product of cost per day for a hospital times length of stay for a case, explained 76.1 percent of the variability in individual charges per case, and 91.9 percent of the variability in average cost per case. Thus, per capita expenditures on hospital care for any diagnosis, and for inpatient care in total, can be estimated reliably by combining information from discharge data banks with routinely reported hospital per diem costs.

Catchment Area, Health↗