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On approximations in treatment costing.

As detailed costing may be a time-consuming and expensive exercise within an evaluation, economists will be conscious of the possibilities of taking short-cuts. To explore the viability of such approaches in the context of acute care (the surgical treatment for colorectal cancer), we compare the results of a detailed costing study with reduced list costing and econometric estimation. We conclude, first, that use of a reduced list is likely to generate substantial research economies only at the expense of inaccuracy. Second, crude costing, based upon average costs of the specialty, is acceptable when the frame of reference is the aggregate. Such crude costing, however, is vulnerable to bias when specific sub-samples of patients are to be considered. Finally, total costs are predictable from a restricted list of cost and event variables, and with a high degree of accuracy, although ex ante specification of the functional form is problematic.

Acute Disease↗

Curbing adolescent smoking: a review of the effectiveness of various policies.

Tobacco-related mortality is one of the biggest killers in American medicine. Evidence suggests that if adolescents can be kept tobacco-free, most will never start using tobacco. Therefore, tobacco control policies directed at the youth population could provide an effective method for sustaining long-term reductions in smoking in all segments of the population. Many forms of tobacco control policies have been implemented including restrictive laws, public campaigns, and taxation duties; there has been disagreement over which is most effective. We investigate the efficacy of various methods of tobacco control in youth and present a review of the published evidence. Econometric data for both youth access restrictions and environmental tobacco smoke restrictions afford ambiguous results. Results vary in a continuum from a moderate negative effect toward, ironically, a marginal positive effect on smoking. While information dissemination policies may be somewhat effective on the onset, they are limited in their effect and eventually diminish over time. We conclude that increases in price affect teen smoking to a great degree. Most estimates show that for a 10 percent increase in prices, which could be implemented by a tax per pack, a 15 percent decrease in cigarettes consumed could be accomplished. Taxation policies are an effective means of preventative medicine.

Adolescent↗

Macro-social influences: the effects of prices and tobacco-control policies on the demand for tobacco products.

For almost three decades, numerous econometric studies have researched the impact of prices and tobacco-control policies on cigarette smoking and other tobacco use. This paper reviews some of the difficulties inherent in that research, including the problems associated with available data, and methodological problems that arise in estimation. This is followed by a brief summary of the key findings from econometric studies of tobacco use. Particularly important for policymakers is the consistent evidence that emerges from these studies showing the effects of higher prices for cigarettes and other tobacco products, with growing evidence that youth and young adults are relatively more responsive to price than older adults. Similarly, these studies produce consistent evidence that stronger restrictions on smoking lead to reduced smoking. In addition, the mixed evidence on the impact of other tobacco control policies and advertising on demand is reviewed. The paper concludes with a discussion of areas where transdisciplinary collaborations and research could be particularly useful in improving our understanding of the impact of macro-social influences on tobacco use.

Adolescent↗

The impact of new drug launches on longevity: evidence from longitudinal, disease-level data from 52 countries, 1982-2001.

We perform an econometric analysis of the effect of new drug launches on longevity, using data from the IMS Health Drug Launches database and the WHO Mortality Database. Under conservative assumptions, our estimates imply that the average annual increase in life expectancy of the entire population resulting from new drug launches is about one week, and that the incremental cost effectiveness ratio (new drug expenditure per person per year divided by the increase in life-years per person per year attributable to new drug launches) is about $6750--far lower than most estimates of the value of a statistical life-year.

Diffusion of Innovation↗

Ageing of population and health care expenditure: a red herring?

This paper studies the relationship between health care expenditure (HCE) and age, using longitudinal rather than cross-sectional data. The econometric analysis of HCE in the last eight quarters of life of individuals who died during the period 1983-1992 indicates that HCE depends on remaining lifetime but not on calendar age, at least beyond 65+. The positive relationship between age and HCE observed in cross-sectional data may be caused by the simple fact that at age 80, for example, there are many more individuals living in their last 2 years than at age 65. The limited impact of age on HCE suggests that population ageing may contribute much less to future growth of the health care sector than claimed by most observers.

Aged↗

Medicare inpatient physician charges: an econometric analysis.

To control Medicare physician payments, Congress in 1989 established volume performance standards (VPS) that tie future physician fee increases to the growth in expenditures per beneficiary. The VPS risk pool is nationwide, and many observers believe it is too large to affect behavior. VPS could be modified by defining a separate risk pool for inpatient physician services and placing each hospital medical staff at risk for those services. Using a national random sample of 500,000 Medicare admissions, we explore the determinants of medical staff charges and comment on the policy implications. Multivariate analysis shows that charges increase with case mix and bed size but, surprisingly, decrease with the level of teaching activity. The teaching result is explained by the substitution of residents for physicians in these hospitals.

Analysis of Variance↗

An econometric analysis of the mental-health effects of major events in the life of older individuals.

Major events in the life of an older individual, such as retirement, a significant decrease in income, death of the spouse, disability, and a move to a nursing home, may affect the mental-health status of the individual. For example, the individual may enter a prolonged depression. We investigate this using unique longitudinal panel data that track labor market behavior, health status, and major life events, over time. To deal with endogenous aspects of these events we apply fixed effects estimation methods. We find some strikingly large effects of certain events on the occurrence of depression. We relate the results to the health care and labor market policy towards older individuals.

Aged↗

Quality safeguards and regulation of online pharmacies.

Using econometric evidence, this article confirms that distribution of medicines online is split into two market segments of very diverse quality, and identifies the factors that drive quality and quality assurance in this activity. Unlike fraudulent, 'rogue,' websites, which offer scant guarantees and usually sell just a few medicines without prescription, online pharmacies offering insurance coverage and linked to conventional pharmacies typically sell a whole range of drugs, require third-party medical prescriptions and provide abundant information to patients. It is shown that, where online pharmacies are allowed to act legally, market forces enhance quality, as private insurers require professional standards, and specialized third parties make a business of certifying them. Furthermore, older online pharmacies and those running conventional operations offer higher quality, probably because of reputational investments. Overall, this evidence supports licensing online pharmacies, especially considering that prohibiting them is ineffective against fraudulent sites.

Commerce↗

Variation in unit costs of hospitals in the English National Health Service.

OBJECTIVES: In England, the Department of Health places high priority on reducing the variation in unit costs of National Health Service (NHS) hospitals. Efficiency targets are set for hospitals to create incentives for relatively high cost hospitals to reduce their costs and shift performance closer to that of their lower cost counterparts. We examine empirically the dispersion in unit costs to assess the extent of variation in the productivity of hospitals and trends over time. METHODS: We use econometric panel data techniques on data from 235 NHS acute hospital trusts over a six-year period, 1994/95 to 1999/00, supplemented with information from semi-structured interviews with key individuals in hospitals and purchasing bodies. RESULTS: There appears to have been no reduction in variation during this period. Relative unit costs for individual trusts also appear stable, with little movement from relatively high cost to low cost. Judging from limited quantitative evidence outside health care, the variation in costs between NHS hospitals may be comparatively low. CONCLUSIONS: Given all the other aspects of hospital performance that government is seeking to change, reduction in the dispersion of unit costs per se should not be a major policy objective. It is far more important to examine variation in quality-adjusted unit costs.

Cost Allocation↗

Eliciting several willingness to pay in a single contingent valuation survey: application to health care.

The usual implementation of contingent valuation (CV), in the context of priorities setting for allocation of public funds in health care, is to develop as many surveys as there are programmes, i.e. to perform separate evaluations (SE). In the EuroWill project, three health programmes (for heart disease, breast cancer and a service of helicopter ambulance) were however simultaneously evaluated, i.e. a joint evaluation (JE) was performed. The paper examines the issue of the econometric techniques that should be used to estimate WTP values obtained in the context of JE by comparing the application of independent OLS regressions for each programme versus simultaneous estimations using seemingly unrelated regressions (SUR) on data of the French EuroWill survey. It shows that separate estimations may lead to misspecifications because they cannot take into account that JE exogenously provides a reference structure to the respondent which affects the estimates of WTP for each programme. Therefore, the potential advantage of JE versus SE as an elicitation technique in CV studies applied to health care (to better control the referents used by respondents for evaluating different programmes) only holds if simultaneous rather than independent techniques are used in the estimation of WTPs.

Air Ambulances↗

Government health expenditures and health outcomes.

This paper provides econometric evidence linking a country's per capita government health expenditures and per capita income to two health outcomes: under-five mortality and maternal mortality. Using instrumental variables techniques (GMM-H2SL), we estimate the elasticity of these outcomes with respect to government health expenditures and income while treating both variables as endogenous. Consequently, our elasticity estimates are larger in magnitude than those reported in literature, which may be biased up. The elasticity of under-five mortality with respect to government expenditures ranges from -0.25 to -0.42 with a mean value of -0.33. For maternal mortality the elasticity ranges from -0.42 to -0.52 with a mean value of -0.50. For developing countries, our results imply that while economic growth is certainly an important contributor to health outcomes, government spending on health is just as important a factor.

Child Mortality↗

Young people and alcohol: an econometric analysis.

AIMS: To analyse the determinants of youth drinking behaviour within an economic -theoretical framework. The paper focuses especially on the effects of (a) having parents willing to supply alcohol, (b) living in a single-parent household, (c) having parents who are currently unemployed and (d) having received education about alcohol, narcotics and tobacco. DESIGN, SETTING AND PARTICIPANTS: A Swedish cross-sectional survey data on 833 individuals aged 12-18 years was used to analyse the effects of the above variables on participation in drinking, frequency of drinking, intensity of drinking and binge drinking. Separate analyses were conducted for beer, wine and spirits. Care was taken in using appropriate econometric methods for the questions posed (negative binomial regression, censored regression and probit regression). FINDINGS: Having parents willing to supply alcohol increased frequency (P < 0.05) of beer, wine and spirits consumption, intensity (P < 0.05) of wine, spirits and illicit alcohol consumption, and increased probabilities (P < 0.10) of binge drinking and participation in drinking (P < 0.05). No effects were seen from living in a single-parent household. Having received education about alcohol, narcotics and tobacco had a negative association only with intensity (P < 0.10) of beer consumption. Having a father who was currently unemployed was associated with an increased (P < 0.05) probability of binge drinking but a reduced (P < 0.05) frequency of wine consumption. CONCLUSIONS: The positive effect of having parents willing to supply alcohol could reflect that these individuals face lower acquisition costs or lower psychological costs in consumption. It could also reflect a price effect, if the individual receives the alcohol free from his or her parents.

Adolescent↗

Testing efficacy with detection controlled estimation: an application to telemedicine.

Detection controlled estimation (DCE) is a powerful new econometric estimator in the family of missing data estimators. By collecting measures from a variety of inspectors or inspection technologies, DCE is able to make inferences about the entire population, even when that population is not directly observed. Using this innovative method, we were able to assess whether telemedicine technology could be substituted for in-person visits when providing maintenance care for patients with hypertension. Our findings indicate that there is no support for the proposition that telemedicine is less effective than in-person visits for determining whether patients have high blood pressure. Indeed, our results imply that telemedicine misses 7% fewer cases of high blood pressure than in-person visits do. The results of this study indicate that DCE may be an effective tool for use in cost-effectiveness or cost-benefit analysis in health care.

Aged↗

Does testing for prostate-specific antigen contribute to declining prostate cancer mortality? Estimating the broader economic influences on aggregate prostate cancer mortality rates.

Key variables associated with prostate cancer mortality were examined using Canadian province level time-series data over the period 1979-1999 in a multiple regression framework. The key variables driving the prostate cancer mortality rate are per capita income, per capita number of family physicians, rate of prostate cancer incidence, real per capita total health spending, and a time trend. As well, provincial dummy variables show that regional differences exist with higher rates of mortality in eastern Canada. Econometric results show a positive and significant relationship between incidence and mortality, suggesting that the increased amount of prostate-specific antigen (PSA) testing may not have been responsible for mortality declines. However, there is also a downward trend in mortality from prostate cancer when all other factors are controlled for that can be attributed partly to the onset of PSA testing given that the benefits should emerge over time. A 1% increase in incidence is associated with a 0.2% increase in mortality. A 1% increase in real per capita income is associated with a 0.5% increase in mortality when real per capita income is below Canadian dollars 20,054. A 1% increase in the per capita number of family physicians reduces the mortality rate by 0.5%. A 1% increase in real per capita total health expenditures is associated with a 0.7% decline in the mortality rate. Finally, by 1999 there were 4.74 fewer deaths per 100,000 population due to the effect of time after controlling for all other factors--a decrease of approx. 15%.

Aged↗

Self-insurance and worksite alcohol programs: an econometric analysis.

OBJECTIVE: The worksite is an important point of access for alcohol treatment and prevention, but not all firms are likely to find offering alcohol programs profitable. This study attempts to identify at a conceptual and empirical level factors that are important determinants of the profitability of worksite alcohol programs. A central question considered in the empirical analysis is whether firms' decisions about worksite alcohol programs are related to how employee group health insurance is provided. METHOD: The data used are from the 1992 National Survey of Worksite Health Promotion Activities (N = 1,389-1,412). The econometric analysis focuses on measures of whether the surveyed firms offer Employee Assistance Programs (EAPs), individual counseling, group classes and resource materials regarding alcohol and other substance abuse. RESULTS: Holding other factors constant, the probability that a self-insured firm offers an EAP is estimated to be 59%, compared to 51% for a firm that purchases market group health insurance for its employees. Unionized worksites and larger worksites are also found to be more likely to offer worksite alcohol programs, compared to nonunionized smaller worksites. Worksites with younger work-forces are less likely than those with older employees to offer alcohol programs. CONCLUSIONS: The empirical results are consistent with the conceptual framework from labor economics, since self-insurance is expected to increase firms' demand for worksite alcohol programs while large worksite is expected to reduce the average program cost. The role of union status and workforce age suggests it is important to consider workers' preferences for the programs as fringe benefits. The results also suggest that the national trend towards self-insurance may be leading to more prevention and treatment of worker alcohol-related problems.

Alcoholism↗

Eliciting women's preferences for a training program in breast self-examination: a conjoint ranking experiment.

OBJECTIVES: Although the clinical grounds for recommending breast self-examination (BSE) have been extensively debated in the literature, there has been no investigation into women's preferences for BSE training. The aim of this study was to test the conjoint ranking method using data on women's preferences for different BSE training programs. Different econometric specifications were tested and sample subgroup differences were investigated. METHODS: Postal data were collected from 1258 women with and without previous participation in a BSE training program. The women ranked eight hypothetical training programs that were defined in terms of three attributes. Inclusion of a payment attribute enabled the calculation of marginal willingness-to-pay (WTP) estimates. RESULTS: The marginal WTP for individual training in comparison to group training with 18 to 20 participants was estimated to be 225 Danish Kroner (DKK) to 462 DKK. The marginal WTP for training in groups of eight to 10 participants was 180 DKK to 270 DKK. The respondents also preferred to receive instruction using their own breasts, although this was valued lower than a small group size. The results were similar regardless of whether or not the women had previously participated in BSE training. Around 20% of respondents violated a basic assumption of economic theory, in which the cheaper of two otherwise identical goods should be preferred. CONCLUSIONS: Conjoint ranking can provide comprehensive information about benefit assessment. The approach is cognitively demanding, however, and may cause some respondents to violate the axiom of nonsatiation.

Breast Self-Examination↗

A comparison of the grade of membership measure with alternative health indicators in explaining costs for older people.

An important focus in empirical econometric studies of health care concerns estimation of the relationship with health. This paper describes a non-parametric technique, the grade of membership (GoM) procedure, which is used to construct summary indicators of health. Health status is also assessed using three alternative measures commonly employed in the literature: an index of problems of activities of daily living (ADL), an index of health conditions and overall self-rated health. Using data from a sample of frail older people, the relationship between costs and different measures of health are estimated using ordinary least squares (OLS) and instrumental variables (IV) methods. The results show that health influences costs more strongly than other variables, an effect which persists after controlling for potential endogeneity. It is shown that health can be usefully classified using GoM techniques. An alternative measure, based on an index of ADL, also performs well. Measures based on overall self-assessed health and the number of health conditions present were less satisfactory. Although health indicators derived from GoM techniques may be more theoretically attractive, in terms of capturing more fully the multidimensional nature of health, simpler alternatives such as those based on ADL indices may offer practical computational advantages.

Activities of Daily Living↗

Econometric feeding and management for first cycle phase two DeKalb Delta hens.

An experiment was conducted to determine the effect of feeding method (constant vs variable) and method of formulation (lysine vs protein) on the performance and profits of first cycle, phase 2 DeKalb Delta hens from 40 to 52 wk of age as influenced by egg and feed prices. Treatments 1 to 5 were formulated based on lysine to contain 0.65 to 0.81% TSAA and fed continuously regardless of feed consumption (constant feeding). Treatments 6 to 10 and 11 to 15 were formulated based on lysine to supply 570 to 650 mg TSAA and protein to supply 580 to 660 mg TSAA per hen per d, respectively, and fed based on feed intake. Dietary TSAA level had no overall significant effect on feed consumption, egg production, egg weight, mortality, or body weight. Hens fed diets using the constant method of feeding had significantly higher egg production, egg weight, egg specific gravity, and body weight than hens fed diets formulated based on lysine or protein using the variable method of feeding. When the treatments in the two variable feeding methods were compared, feed consumption was significantly higher for hens fed diets formulated based on protein whereas egg production, egg weight, egg specific gravity, and body weight were not different. It was concluded that method of formulation (lysine vs protein) and TSAA levels required for maximum profits can vary from at least 570 to 821 mg per hen per d depending upon energy and protein cost.

Animal Feed↗