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PubMed2002

Modelling the economics of gaming in South Africa.

This paper considers the application of two models for determining the optimal location and characteristics of a casino in a post-apartheid South Africa. The intention in developing the models was to allow provinces a facility for considering how to maximize the return to the stakeholders in the license award process, namely society at large, as represented by the provincial government, and the casino operator. The Allocation Model works on an estimate of total potential gambling spend and how that may be best distributed amongst a number of casinos. The Profitability model takes the estimated gaming spend from the allocation model and assesses the appropriate size and characteristics of the casino best suited to this level of gaming spend. It can then simulate levels of profitability for different proposed sizes and characteristics of proposed casinos. Together these models represent a powerful assessment mechanism for a country considering the introduction or radical changing of gaming legislation.

Disruptive, Impulse Control, and Conduct Disorders↗
PubMed2005

Alternative futures for health economics: implications for nursing management.

As nursing has been subject to successive waves of 'managerialism' there has been a drive on the part of government and elements within the profession to enhance the science base and promote cost-effective health care interventions. This has generated new interest in the 'economics of nursing' as efficiency and 'value for money' are viewed as necessary precondition for the provision of a high quality nursing service. As an academic subject health economics has brought an elegant set of theories to bear on the topic of health and health care. However, mainstream health economics is premised on a series of simplifying assumptions that, if applied uncritically, can induce a range of unintended and adverse consequences. This paper asks how ideas developed in one sphere (health economics) can be become influential in another (nursing management and practice) and it seeks explanations in the theories of Michel Foucault, specifically in his exploration of the reciprocal relationship between power and knowledge. How are our assumptions about what is possible and desirable shaped, how far do mechanisms of surveillance and self-subjugation extend? A range of alternative economic approaches have been developed which challenge many mainstream health economics assumptions. Some of these are better suited to the complex social environment present within health care. Nurses, nurse managers and researchers should question the assumptions of dominant economic models and explore a range of economic frameworks when planning services and evaluating their practice.

Attitude to Health↗
PubMed2005

A review of economic tools for the assessment of animal disease outbreaks.

This paper demonstrates how currently underutilised economic modelling techniques can enrich the analysis of animal disease problems. Increasingly, analyses of animal health programmes are expected to address a range of economic and social questions. These expectations can be addressed by better integration of epidemiological modelling with economic techniques whose application to animal health has not been thoroughly discussed in past reviews. This paper describes a range of economic models that can be applied in animal health research and provides guidance for determining the appropriate method given the issues at hand. The complexity of some of these approaches underlines the importance of multidisciplinary research and education.

Animal Diseases↗
PubMed1981

The short-run dynamics of inter-state migration: a space-time economic adjustment model of in-migration to fast growing states.

"Interregional migration is analyzed with respect to its short-run responsiveness to economic fluctuations and its efficiency as a spatial labour market allocation mechanism. Using a space-time analytical framework, in-migration to four fast growing States of the United States is analyzed over the period 1958-1975. It is shown via a time-series model, employing a Koyck-distributed lag methodology, that short-run in-migration is in fact responsive to economic fluctuations." (SUMMARY IN FRE, GER)

Americas↗
PubMed2001

The potential unintended economic consequences of the Medicine Equity and Drug Safety Act of 2000.

BACKGROUND: The Medicine Equity and Drug Safety (MEDS) Act of 2000 was passed by Congress in October 2000 in response to the perception that US pharmaceutical prices and expenditures were rising too quickly and that many people could no longer afford their medication. The Act was terminated at the end of December 2000 for lack of the congressionally required certification by the Department of Health and Human Services of 2 key conditions written into the law. Under the terms of the MEDS Act, pharmacists and wholesalers would have been able to reimport lower-priced pharmaceuticals into the United States from other countries. OBJECTIVE: In this article, we formulate an economic model as the basis for determining the probable unintended effects of the MEDS Act and propose an alternative policy that would achieve the objectives of the MEDS Act. METHODS: An economic model of parallel trade in the pharmaceutical industry was used to demonstrate the likely effects of the MEDS Act. RESULTS: Although in most markets the effects of parallel trade would increase economic efficiency, in the pharmaceutical industry parallel trade would be detrimental to long-term economic efficiency. By encouraging parallel trade into the United States, the Congress would, in effect, be introducing pharmaceutical price controls from other countries that have price controls. Parallel trade erodes price differences across countries and hence undermines the most efficient pricing mechanism for paying for research and development. CONCLUSION: Although the MEDS Act was terminated, important policy lessons can be learned for consideration in the creation of any similar future legislation designed to control pharmaceutical prices.

Cost Control↗
PubMed2001

Cost-benefit analysis of social work services in the emergency department: a conceptual model.

OBJECTIVE: To describe an economic model for formal cost-benefit analysis of emergency department (ED)-based social services. METHODS: The varied monetary costs and benefits associated with ED-based social work services were projected for three hypothetical levels of ED volume (30,000, 60,000, and 90,000 patients/year). Primary benefits included the prevention of return ED visits, the prevention of "social" hospital admissions, and the protection of doctor and nurse time. The primary cost was salary support for full-time social work staffing. Sensitivity analysis was performed to account for varying estimates. RESULTS: For a small-volume ED, total benefits to offset costs ranged from $43,869 to $81,504, yielding a net cost of $99,936 up to $137,571 for full-time social work coverage. For a moderate-size ED, total benefits ranged from $87,660 to $162,930, yielding a net cost of only $18,510 on the high end of the sensitivity analysis, and $87,668 on the low end. For a large-volume ED, total benefits ranged from $131,529 to $247,434, yielding a net cost of $49,911 on the low end of the sensitivity analysis, but a net benefit of $65,994 on the high end. CONCLUSIONS: Dedicated social work staffing of EDs may yield net economic benefits, especially in large urban centers. Moderate-size EDs may almost "break even" in economic terms, and small EDs may realize a net cost, but in either case, the cost of social services can be significantly offset by decreased utilization of hospital and ED services, and by more efficient use of medical staff time.

Cost-Benefit Analysis↗
PubMed1988

Participation in a dual economy and adjustment to retirement.

Past studies of adjustment to retirement have generally accepted social structure as a given, and have instead focused upon individual level variables. Based upon criticisms of the white-collar/blue-collar depiction of the work world, an alternative model of the economic system is introduced in an attempt to interject variability in the area of social structure. Utilizing a national sample of men derived from the National Opinion Research Center (1972-1977 inclusive), this dual economic model is employed to assess the effects of sectorial placement of workers on subsequent retirement satisfaction. Findings from multiple regression analysis suggest that such placement renders two qualitatively different groups of retirees, one which is primarily concerned with health, and one for which financial adequacy is more important for retirement adjustment. Overall, it was concluded that structural components must be included in research on the retirement process. In addition, the variability among the different scales used to indicate adjustment to retirement suggests that these may have to be altered to adequately reflect the process of adjustment for each of the groups of retirees. These changes must be based on the structural aspects of the economic order which mandate very different work experiences.

Anomie↗
PubMed1997

A spatial equilibrium model for region size, urbanization ratio, and rural structure.

"Earlier economic models of city size have either focused on urban agglomeration effects while ignoring the spatial structure of the rural hinterland, or made unrealistic assumptions (for example, uniform rural population distribution) so as to simplify the problem. Following the classic von Thunen framework, we present a two-sector spatial equilibrium model of a city located at the center of an agricultural hinterland. The city produces industrial goods, and the rural area produces agricultural goods. Both goods are consumed both by urban and by rural residents. Market equilibrium for these goods determines: (1) the spatial size of the region, (2) the urbanization ratio (urban to total population) and the population size of the city, and (3) the rural spatial structure (wage, population distribution, land rent, and agricultural yield). Given various sets of exogenous parameters pertaining to the industrial, agricultural, and transportation production functions and to population preferences, the model is solved numerically, and response functions are estimated and analyzed."

Agriculture↗
PubMed2006

Etanercept and efalizumab for the treatment of psoriasis: a systematic review.

OBJECTIVES: To evaluate the clinical effectiveness, safety, tolerability and cost-effectiveness of etanercept and efalizumab for the treatment of moderate to severe chronic plaque psoriasis. DATA SOURCES: Major electronic databases and several Internet resources were searched up to April 2004. REVIEW METHODS: Systematic reviews were undertaken of the efficacy, safety and economic reviews of etanercept and efalizumab. An existing systematic review of the efficacy and safety of other treatments was also updated. Economic models supplied by the manufacturers of etanercept and efalizumab were critiqued. An economic model was then developed of etanercept and efalizumab in the treatment of moderate to severe chronic plaque psoriasis. RESULTS: The review of the clinical evidence identified a total of 39 published and three unpublished studies: eight randomised controlled trials (RCTs) of the efficacy of etanercept (three trials) and efalizumab (five); 10 studies of the adverse effects of the interventions; and 24 RCTs of the efficacy of the other treatments for moderate to severe psoriasis. The trials of the efficacy of the interventions were all double-blind and placebo-controlled trials and generally of good quality, but three of the five efalizumab trials were poorly reported. A total of 1347 patients were included in the etanercept trials and 2963 in the efalizumab trials. Data on the efficacy of etanercept 25 mg twice a week for 12 weeks were available from three RCTs. On average, active treatment resulted in 62% of patients achieving a Psoriasis Area and Severity Index (PASI) 50, 33% achieving a PASI 75, 11% achieving a PASI 90 and 40% were assessed as clear or almost clear. These figures are not adjusted for changes relative to placebo. Improvement in quality of life as assessed by mean percentage change in Dermatology Life Quality Index (DLQI) was around 59% with etanercept 25 mg twice a week compared with 9% with placebo, and all mean differences that could be calculated were statistically significantly in favour of etanercept. Data on the efficacy of etanercept 50 mg twice a week for 12 weeks were available from two RCTs. Across the two trials, the proportion of patients achieving PASI 50, 75 and 90 was 76, 49 and 21%, respectively; the pooled relative risks were all statistically significantly in favour of etanercept. The findings for mean PASI after treatment, mean percentage change in PASI from baseline and mean percentage change in DLQI also demonstrated the efficacy of etanercept treatment. Evidence from one RCT indicates that the response to etanercept is maintained post-treatment, at least in the medium term, and data from uncontrolled follow-up phases reflect and extend these findings. Efalizumab at a dose of 1 mg/kg once a week subcutaneously was studied in five RCTs. Across these trials, 12 weeks of active treatment resulted in an average of 55% of patients achieving PASI 50, 27% PASI 75, 4.3% PASI 90 and 27% clear or minimal psoriasis status. These figures are not adjusted for changes relative to placebo. There is no evidence from RCTs that the response to efalizumab 1 mg/kg once a week is maintained when treatment continues beyond 12 weeks, and long-term follow-up data relate to a range of doses and are poorly reported and so cannot be used to draw even tentative conclusions regarding the long-term efficacy of efalizumab. Uncontrolled data from trial follow-up suggest that time to relapse may be around 60 days. No data indicating the existence or absence of any rebound in psoriasis after discontinuation of efalizumab were identified. There is no evidence relating to the efficacy of efalizumab upon retreatment. A mixed treatment comparison analysis found a higher response rate in terms of PASI 50, 75 and 90 with etanercept than with efalizumab. Injection site reactions appear to be the most common adverse effects of etanercept. Overall, etanercept appears to be well tolerated in short- and long-term use, although many of the long-term data are not from patients with psoriasis. Headache, chills and, to a lesser extent, nausea, myalgia, pain and fever are the common adverse events associated with efalizumab. Overall, withdrawal rates due to adverse events are low. Longer term data for efalizumab are not readily available for evaluation, but the adverse events data up to 3 years appear to reflect those over 12 weeks and to remain stable. Unfortunately, few data for serious infections and serious adverse events with efalizumab are available. For the primary analysis comparing etanercept, efalizumab and supportive care, the results of the York Model suggest that the biological therapies would only be cost-effective for all patients with moderate to severe psoriasis if the NHS were willing to pay over pound 60,000 per QALY gained. In patients with poor baseline quality of life (fourth quartile DLQI), efalizumab, etanercept 25 mg (intermittent), etanercept 25 mg (continuous) and etanercept 50 mg (intermittent) would be cost-effective as part of a treatment sequence if the NHS were willing to pay pound 45,000, pound 35,000, pound 45,000 and pound 65,000 per QALY gained, respectively. In patients who are also at high risk of inpatient hospitalisation (21 days per annum), these therapies would be cost-effective as part of a sequence as long as the NHS were willingness to pay pound 25,000, pound 20,000, pound 25,000 and pound 45,000 per QALY gained, respectively. As part of a secondary analysis including a wider range of systemic therapies as comparators, the York Model found that it would only be cost-effective to use etanercept and efalizumab in a sequence after methotrexate, ciclosporin and Fumaderm. CONCLUSIONS: Clinical trial data indicate that both etanercept and efalizumab are efficacious in patients who are eligible for systemic therapy, but the economic evaluation demonstrates that these biological therapies are likely to be cost-effective only in patients with poor baseline QoL and who are at risk of hospitalisation. Efficacy trials conducted in the specific population for which etanercept and efalizumab are licensed are required, as are long-term comparisons of etanercept and efalizumab with other treatments for moderate to severe psoriasis. Long-term efficacy trials and safety/tolerability data for patients treated with etanercept or efalizumab are required, as are trials on the response of specific subtypes of psoriasis to different drugs. Research on the rate of inpatient hospitalisation in patients with moderate to severe psoriasis is warranted, and the effect of treatment on this rate.

Antibodies, Monoclonal↗
PubMed1998

Economists, public provision, and the market: changing values in policy debate.

Among health services researchers, an "economizing model" of health care has eclipsed two traditional models, "social conflict" and "collective welfare." The older models emphasized social solidarity and distributive justice, but the newer one focuses on improving efficiency, minimizing risks borne by third-party payers, constraining cost increases, and improving the functioning of markets. This article examines one source of the economizing model, the work of several early and persistently prominent economists of health care, especially Mark Pauly, Martin Feldstein, and Joseph Newhouse and his colleagues at the Rand Corporation. In particular, it explores their role in transforming perceptions of health care from a set of special services into an ordinary commodity, in giving currency to apparently dispassionate as opposed to overtly value-laden analysis, and in according priority, among health services researchers and policy makers, to economists' traditional interest in fostering smoothly functioning markets. It exhibits their principal policy recommendation-income-graduate cost sharing-the sources and character of their modes of analysis, and the character of their influence on policy makers. The article concludes that the supposedly value-free economic analysis of health care rests on a cluster of values that inhibit the expression of social solidarity and the formulation of policies intended to foster distributive justice.

Attitude to Health↗
PubMed2004

Trial application of a Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS) to assist priority setting in stroke.

BACKGROUND AND PURPOSE: Cost-effectiveness data for stroke interventions are limited, and comparisons between studies are confounded by methodological inconsistencies. The aim of this study was to trial the use of the intervention module of the economic model, a Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS) to facilitate evaluation and ranking of the options. METHODS: The approach involves using an economic model together with added secondary considerations. A consistent approach was taken using standard economic evaluation methods. Data from the North East Melbourne Stroke Incidence Study (NEMESIS) were used to model "current practice" (base case), against which 2 interventions were compared. A 2-stage process was used to measure benefit: health gains (expressed in disability-adjusted life years [DALYs]) and filter analysis. Incremental cost-effectiveness ratios (ICERs) were calculated, and probabilistic uncertainty analysis was undertaken. RESULTS: Aspirin, a low-cost intervention applicable to a large number of stroke patients (9153 first-ever cases), resulted in modest health benefits (946 DALYs saved) and a mean ICER (based on incidence costs) of US 1421 dollars per DALY saved. Although the health gains from recombinant tissue-type plasminogen activator (rtPA) were less (155 DALYs saved), these results were impressive given the small number of persons (256) eligible for treatment. rtPA dominates current practice because it is more effective and cost-saving. CONCLUSIONS: If used to assess interventions across the stroke care continuum, MORUCOS offers enormous capacity to support decision-making in the prioritising of stroke services.

Acute Disease↗
PubMed1998

First International Pharmacoeconomic Conference on Alzheimer's Disease: report and summary.

The First International Pharmacoeconomic Conference on Alzheimer's Disease (AD) was held in Amsterdam in July 1998. The meeting was held under the auspices of the International Working Group for Harmonization of Dementia Drug Guidelines (http://dementia.ion.ucl.ac.uk/harmon), bringing together academics, clinicians, purchasers, and representatives from industry. Presentations were given on the methodology of pharmacoeconomic studies in AD, particularly focusing on caregiver burden, quality of life (QOL), and resource utilization. Three economic models of AD were presented based on data from the United States, Canada, and the United Kingdom. In two studies, these data were then used to model the cost-effectiveness and effect on cost of treatment with donepezil. Both studies suggested a possible cost advantage for the use of donepezil, when compared with no placebo or treatment, particularly when donepezil is used appropriately in mild-to-moderate AD. These data need to be interpreted with care, as none of the cost or utility information were collected during the clinical trials. Additional data from a 2-year clinical trial of selegiline and vitamin E suggest that cognitive measures may be poor predictors of economic outcome, which is better measured directly. Both economic models of donepezil rely on short-term cognitive data to predict long-term outcome, a methodf that may not be useful in predicting economic savings. The issues facing pharmacoeconomists, researchers, clinicians, and families in the future were addressed in a series of workshops using a method of strategic futuring. The workshops attempted to see 7 years into the future for a range of areas, including consumer and caregiver use of pharmacoeconomic data; early detection and prevention; Japanese perspectives; activities of daily life and what will be daily life activities; caregiver burden; QOL at the end of life; new uses for new information and communication technology in clinical research; and physicians' use of pharmacoeconomic data. A range of exciting futures were predicted, although common themes that arose when considering barriers to achieving these futures included cost, education, political will, confidentiality, privacy, and ethics. The first conference was deemed to have been a success, having attracted more than 160 delegates and many distinguished speaker. A second conference is planned for the year 2000. Over the next 2 years, research needs to be broadened particularly in the methodological areas of resource utilization, QOL, and caregiver burden. Data from clinical trials with relevant economic and QOL outcomes will be needed by purchasers if drug treatments for dementia are to gain widespread use. It is also hoped that the models described at the meeting may become more freely available to politicians, purchasers, clinicians, and caregivers to help them make better decisions about treatment.

Aged↗
PubMed2002

Willingness to pay for flood and ecological risk reduction in an urban watershed.

Urban watershed managers frequently must address alternative policy goals; flood control and ecological risk reduction. This study combines hydrologic models of flood control and biotic models of ecologic risk with economic models of willingness-to-pay and psychological models of risk processing and planned behavior to evaluate these two alternative policy objectives. The findings reveal that flood risk exposure, especially for those individuals who would remain outside the 100 year flood plain if the project were enacted, does influence the financial support that local residents would be willing to make to a flood control project. Other important determinants include demographic factors such as income, and attitudinal measures of the respondent. Expanding the scope of the project to include ecological risk reduction does not, however, appear to change the average willingness-to-pay for a project.

Demography↗
PubMed2003

The incorporation of potential confounding variables in Markov models.

OBJECTIVE: To improve the quality of the methods used in Markov modelling studies by increasing the external validity by means of the incorporation of confounding variables. STUDY DESIGN: The concepts were illustrated using a hypothetical Markov model for Parkinson's disease. METHODS: The methodology consisted of incorporation of an extra explanatory variable in the Markov health states by means of health state-specific relationships between this explanatory variable and costs as well as time-dependent values of the extra explanatory variable. In addition, we determined the relevance of the incorporation of an extra explanatory variable by means of various sensitivity analyses. RESULTS: The results showed that the outcomes of a health economic model may be severely biased, when a confounding effect of an extra explanatory variable is not taken into account. Hence the external validity of Markov models may be limited, and consequently the results of the model are not an accurate reflection of reality. CONCLUSION: This study proves the need for the incorporation of all relevant explanatory variables in a health economic model.

Antiparkinson Agents↗
PubMed2005

Spatial planning for adapting to climate change.

During the past decades human interference in regional hydrologic systems has intensified. These systems act as an integrating medium. They link climate, human activities and ecologic processes through groundwater and surface water interactions. For simulating these linkages an integrated regional hydrologic model has been coupled to an ecologic evaluation model. The simulated ecologic effects of climate change on mesotrophic riverine grasslands are clearly positive. Simulation results also indicate a high sensitivity of the peak discharges to the precipitation. For modelling the long-term development of land use and water management an integrated 'bio-economic' model has been constructed. It includes a model for the development of agriculture. Results for the autonomous development in reaction to climate change indicate a strong increase of field drainage by agriculture. This development would substantially reduce the predicted positive effects of climate change on riverine grasslands. The challenge is to guide regional developments in such a manner that opportunities for improving nature are not lost, but that at the same time the peak discharges are kept under control. Flow retardation in the 'fine arteries' of the upstream areas appear to be a viable option for the latter. The bio-economic model can provide help in anticipating on climate change through spatial planning.

Agriculture↗
PubMed2003

Cost effectiveness and cost utility model of public place defibrillators in improving survival after prehospital cardiopulmonary arrest.

OBJECTIVE: To determine the cost effectiveness and cost utility of locating defibrillators in all major airports, railway stations, and bus stations throughout Scotland. DESIGN: Economic modelling exercise with data from Heartstart (Scotland). Parameters used in economic model included direct costs derived for increased accident and emergency attendances, increased hospital bed days, purchase and maintenance of defibrillators, and training in their use; life years gained calculated from increased discharges from hospital and mean survival after discharge; utility (quality of life) obtained from published data. Sensitivity analyses tested the robustness of model. Future gains discounted at 1.5% a year and future costs at 6%. SETTING: Whole of Scotland. SUBJECTS: Records of all prehospital cardiac arrests due to presumed heart disease that occurred in a major airport, railway, or bus station between May 1991 and March 1998 and were not witnessed by ambulance or medical staff. MAIN OUTCOME MEASURES: Observed survival to hospital admission and observed survival to discharge. Predicted survival calculated by applying observed survival in patients attended by ambulance staff within three minutes to those who waited longer. RESULTS: The total discounted direct costs were 18 325 pounds sterling a year. The cost per life year gained was 29 625 pounds sterling (49 625 dollars, 43 151 Euros) and the cost per quality adjusted life year (QALY) gained was pound 41 146 (68 924 dollars, 59 932 Euros). More widespread provision of public place defibrillators would increase these figures. CONCLUSIONS: The cost per QALY calculated for public place defibrillators represents poorer value for money than some alternative strategies for improving survival after prehospital cardiopulmonary arrest, such as the use of other trained first responders. The figure exceeds the commonly discussed cut off levels for funding in the United Kingdom and United States of pound 30 000 and 50 000 dollars per QALY, respectively.

Cost-Benefit Analysis↗