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PubMed2002

Cost-benefit analysis of granulocyte colony-stimulating factor in the management of elderly cancer patients.

Health care costs continue to rise, and hospitalization represents the single largest component of direct medical costs associated with cancer care. Neutropenia and its complications including febrile neutropenia (FN) remain the major dose-limiting toxicity of systemic cancer chemotherapy. The risk of FN varies considerably across treatment regimens but appears to be significantly higher among elderly patients. The colony-stimulating factors (CSFs) have been used effectively in a variety of clinical settings to prevent or treat FN and to assist patients receiving dose-intensive chemotherapy with or without stem cell support. Several randomized controlled trials (RCTs) have demonstrated the clinical efficacy of the prophylactic use of CSFs. A recently presented meta-analysis of the available RCTs has confirmed the efficacy of prophylactic CSFs. The cost of these agents, along with their large-scale clinical use, has prompted a number of economic investigations. Economic models based on measures of resource utilization derived from RCTs have provided FN risk threshold estimates for the cost-saving use of prophylactic CSF. A number of important studies concerning the clinical and economic impact of these agents in elderly cancer patients have been reported during the past year. Continuing clinical and economic evaluation along with an updating of clinical practice guidelines especially related to elderly patients is recommended because of rapid technologic and clinical advances.

Aged↗
PubMed2003

The neurobiology of visual-saccadic decision making.

Over the past two decades significant progress has been made toward understanding the neural basis of primate decision making, the biological process that combines sensory data with stored information to select and execute behavioral responses. The most striking progress in this area has been made in studies of visual-saccadic decision making, a system that is becoming a model for understanding decision making in general. In this system, theoretical models of efficient decision making developed in the social sciences are beginning to be used to describe the computations the brain must perform when it connects sensation and action. Guided in part by these economic models, neurophysiologists have been able to describe neuronal activity recorded from the brains of awake-behaving primates during actual decision making. These recent studies have examined the neural basis of decisions, ranging from those made in predictable sensorimotor tasks to those unpredictable decisions made when animals are engaged in strategic conflict. All of these experiments seem to describe a surprisingly well-integrated set of physiological mechanisms that can account for a broad range of behavioral phenomena. This review presents many of these recent studies within the emerging neuroeconomic framework for understanding primate decision making.

Animals↗
PubMed2004

Advances in migraine management: implications for managed care organizations.

Migraine headache is a disabling disease that poses a significant societal burden. Stratified care and early intervention are current strategies for migraine management. It has been shown that early treatment with triptans in select patients can improve treatment outcomes. Triptans are selective 5-HT receptor agonists that are specific and effective treatments in the management of migraine, and they meet the acute treatment goal of rapid relief with minimal side effects. Triptans are associated with improved quality of life. Factors such as speed of onset, need for a second triptan dose, and patient satisfaction should be considered in the selection of a specific triptan treatment. Appropriate treatment can decrease costs. The patient's migraine history and response to prior therapy should be considered when selecting acute treatment. Cost-effectiveness models can be used to understand the effect of treatment choices on health care budgets. The direct cost per migraine episode, driven primarily by the need for rescue medications, is important to include in economic models. All aspects of effectiveness (efficacy, tolerability, and cost) should be considered to reduce overall managed care expenditures for migraine treatment. The improved clinical profiles of the triptans provide substantial value to managed care organizations.

Cost-Benefit Analysis↗
PubMed2003

Prices, policies and youth smoking, May 2001.

Youth smoking continues to be an important public health problem. Many policy tools designed to reduce youth smoking are based on economic principles. This paper describes the economic and policy context of tobacco use aiming at reducing youth smoking and explains the economic rationale for tobacco control tools such as excise tax and price, clean indoor air laws, youth access laws and the broad provision of health information to the public. An overview of economic models of addiction provides the framework for empirical analysis of the impact of these policies. This is followed by a summary of the empirical evidence of the effectiveness of various tobacco control tools that are primarily economic in nature. The most consistent finding in this literature is that higher cigarette prices discourage youth smoking. Compared to the effects of cigarette taxation and price on youth smoking, the evidence on the effectiveness of the youth access laws and clean indoor air laws are still mixed and inconclusive. More research is needed to address issues such as: (1) the effects of gender, age, race and socio-economic status on the relationship between tobacco control policies and youth smoking; (2) better measurement of the outcome variables to account for the multi-dimensional nature of dependence; and (3) the effects of excise taxes and other tobacco control policies with regard to a host of dimensions of smoking such as initiation, cessation, and more generally the trajectories of tobacco use that would include patterns of progression, maintenance, regression, cessation, and relapse. More frequently collected longitudinal data than those currently available are needed to address the above issues. Understanding smoking behavior cannot be achieved without incorporating familial and other social contexts.

Adolescent↗
PubMed2002

A decision-tree to optimise control measures during the early stage of a foot-and-mouth disease epidemic.

A decision-tree was developed to support decision making on control measures during the first days after the declaration of an outbreak of foot-and-mouth disease (FMD). The objective of the tree was to minimise direct costs and export losses of FMD epidemics under several scenarios based on livestock and herd density in the outbreak region, the possibility of airborne spread, and the time between first infection and first detection. The starting point of the tree was an epidemiological model based on a deterministic susceptible-infectious-recovered approach. The effect of four control strategies on FMD dynamics was modelled. In addition to the standard control strategy of stamping out and culling of high-risk contact herds, strategies involving ring culling within 1 km of an infected herd, ring-vaccination within 1 km of an infected herd, and ring-vaccination within 3 km of an infected herd were assessed. An economic model converted outbreak and control effects of farming and processing operations into estimates of direct costs and export losses. Ring-vaccination is the economically optimal control strategy for densely populated livestock areas whereas ring culling is the economically optimal control strategy for sparsely populated livestock areas.

Animal Husbandry↗
PubMed2005

Behavioral economics and health policy: understanding Medicaid's failure.

This Article employs a behavioral economic analysis to understand why Medicaid has failed to improve the health outcomes of its beneficiaries. It begins with a formal economic model of health care consumption and then systematically incorporates a survey of psychosocial variables to formulate explanations for persistent health disparities. This methodology suggests that consulting the literature in health psychology and intertemporal decision theory--empirical sources generally excluded from orthodox economic analysis--provides valuable material to explain certain findings in health econometrics. More significantly, the lessons from this behavioral economic approach generate useful policy considerations for Medicaid policymakers, who largely have neglected psychosocial variables in implementing a health insurance program that rests chiefly on orthodox economic assumptions. The Article's chief contributions include an expansion of the behavioral economic approach to include a host of variables in health psychology, a behavioral refinement of empirical health economics, a behavioral critique of Medicaid policy, and a menu of suggested Medicaid reforms.

Behavioral Medicine↗
PubMed2005

Modelling the effect of function and disease activity on costs and quality of life in rheumatoid arthritis.

OBJECTIVE: When treatments with the potential to change the natural history of a disease are introduced, their longer-term effect on costs and quality of life (utility) has to be estimated using economic models. However, to remain useful tools, models must be updated when new information becomes available. Our earlier models in rheumatoid arthritis (RA) have been based on functional status, but it has recently been shown that disease activity might have an independent effect on utility. The objective of this study was to improve the model by incorporating the effect of a subjective measure of disease severity and activity (global VAS). METHODS: A Markov model was constructed with five states according to functional status (HAQ), and each state was subdivided according to the VAS (<40 and >40). Disease development (transition probabilities between the states) was taken from a longitudinal cohort study of patients with early RA in Sweden. A recent population-based survey of 616 patients with RA provided data on costs and utilities. The model incorporates the full distribution of costs and utilities from the survey, and long-term projections are made using Monte Carlo simulation. RESULTS: The global VAS had a highly significant effect on utilities independently of HAQ. For resource consumption, only HAQ was a significant predictor, with the exception of sick leave, which was correlated with the VAS but not with HAQ. Using the cohort distribution from the longitudinal study, expected mean costs per patient over 10 yr were 106 034 euros (s.d. 5091 euros) (1 euro = SEK 9.20) and the expected number of quality-adjusted life years (QALYs) was 5.08 (s.d. 0.09). Patients starting at HAQ <0.6 but with consistently high VAS scores would have expected costs of 102 830 euros and 4.96 QALYs, while patients with low VAS scores would have costs of 81 603 euros and 6.01 QALYs. CONCLUSION: Our new model incorporates for the first time the effect of a subjective measure of disease severity and activity on both costs and utility, making it a sensitive tool to estimate the cost-effectiveness of disease-modifying treatments. New data on resource consumption indicate a shift to higher direct costs, particularly in early disease, and lower indirect costs in more advanced disease. The large size of the data sets used in this model reduces the uncertainty and makes estimates very stable.

Adult↗
PubMed2002

Uncovering value in the Medicare+Choice marketplace.

Medicare managed care plans, now known as Medicare+Choice plans, have long been seen as a solution to Medicare's fiscal problems, including serving as a model for overall Medicare reform. Despite the challenges faced today, the M+C program provides a clear opportunity for the federal government to seek private innovation and experience in evolving Medicare to a more sustainable economic model, and for the private sector to tap into the vast product opportunities of serving a growing Medicare population.

Aged↗
PubMed2005

Determinants of health insurance ownership among South African women.

BACKGROUND: Studies conducted in developed countries using economic models show that individual- and household- level variables are important determinants of health insurance ownership. There is however a dearth of such studies in sub-Saharan Africa. The objective of this study was to examine the relationship between health insurance ownership and the demographic, economic and educational characteristics of South African women. METHODS: The analysis was based on data from a cross-sectional national household sample derived from the South African Health Inequalities Survey (SANHIS). The study subjects consisted of 3,489 women, aged between 16 and 64 years. It was a non-interventional, qualitative response econometric study. The outcome measure was the probability of a respondent's ownership of a health insurance policy. RESULTS: The chi2 test for goodness of fit indicated satisfactory prediction of the estimated logit model. The coefficients of the covariates for area of residence, income, education, environment rating, age, smoking and marital status were positive, and all statistically significant at p < or = 0.05. Women who had standard 10 education and above (secondary), high incomes and lived in affluent provinces and permanent accommodations, had a higher likelihood of being insured. CONCLUSION: Poverty reduction programmes aimed at increasing women's incomes in poor provinces; improving living environment (e.g. potable water supplies, sanitation, electricity and housing) for women in urban informal settlements; enhancing women's access to education; reducing unemployment among women; and increasing effective coverage of family planning services, will empower South African women to reach a higher standard of living and in doing so increase their economic access to health insurance policies and the associated health services.

Adolescent↗
PubMed2004

Economic effect of cholinesterase inhibitor therapy: implications for managed care.

The growing elderly population is at great risk for Alzheimer's disease (AD). In 1997, annual costs associated with AD were 100 billion dollars. Cholinesterase inhibitor (ChEI) therapy is most commonly used to manage patients with AD, but the economic implications arising from their use are not well known. A review of studies assessing the cost effectiveness of ChEIs suggests that ChEI therapy provides benefit at every stage of disease, with better outcomes resulting from persistent, uninterrupted treatment. The cost savings range from 73 dollars over two years to 3891 dollars over one year, depending on the type of study, drug evaluated, and economic model employed in the evaluation.

Aged↗
PubMedDate not supplied

The politics of health sector reform in developing countries: three cases of pharmaceutical policy.

This paper examines the political dynamics of health sector reform in poor countries, through a comparative study of pharmaceutical policy reform in Sri Lanka, Bangladesh, and the Philippines. The paper first reviews five reasons why policy reform is political. It then presents three political economic models of the policy reform process: the political will, political factions, and political survival models. Next, the paper describes the three cases of national pharmaceutical policy reform, and identifies common conditions that made these reforms politically feasible. The paper's analysis suggests that health sector reform is feasible at certain definable, and perhaps predictable, political moments, especially in the early periods of new regimes. The most important and manipulable political factors are: political timing, which provides opportunities for policy entrepreneurs to introduce their ideas into public debate, and political management of group competition, which allows leaders to control the political effects of distributional consequences and protect the regime's stability. A strong and narrow political coalition improves the capacity of political leaders to resist the pressures of concentrated economic costs (both inside and outside national boundaries). The paper argues that for reform to succeed, policy-makers need effective methods to analyze relevant political conditions and shape key political factors in favor of policy reform. The method of Political Mapping is briefly introduced as a technique that can help policy-makers in analyzing and managing the political dimensions of policy reform and in improving the political feasibility of reform.

Bangladesh↗
PubMed2006

Keeping it real--building an ROI model for an ambulatory EMR initiative that the physician practices espouse.

The ambulatory electronic medical record initiative at Magic Valley Regional Medical Center (MVRMC) in South Central Idaho underwent a rigorous product evaluation process that resulted in one of the market-leading EMR products being selected for implementation. MVRMC includes four business entities, including a 213-bed regional hospital and a 19-practice management services organization. Early in the process, the organization viewed buy-in from its physicians as a critical success factor. The physicians had been integral to product selection, and it was equally important for them to trust the economic model for its acquisition-especially because it was likely that they would be asked to put "some skin in the game." To make this initiative economically feasible, MVRMC received a grant from Agency for Healthcare Research and Quality based on the potential impact of the endeavor on healthcare delivery in the region. However, because the functional analysis did not result in the selection of the least expensive product, the AHRQ grant would only help defray the startup expenses, but not ongoing support and maintenance expenses after implementation; these costs would be borne by anticipated increases in the practice's revenue or reduction in its operating expenses. The ROI model would need to explain how each practice, from the single physician specialist to an almost 20-physician family practice, could pay for the desirable outcomes discussed during the selection phase of the project. The physicians, who had participated in technology initiatives in the past, were skeptical that cost-justifying an IT system was realistic, even though they recognized the potential benefits it could have on the quality and consistency of the care. Because some process standardization within and between practices would be needed to use electronic charting effectively, it was important that the ROI model did not outweigh the benefits of an as-yet untested operational workflow that leveraged interoperability. In addition, one of the key benefits of the initiative was the integration of ambulatory and inpatient information into a common patient-centric view of care. This outcome needed to be appropriately considered in the determination of the value of the initiative. To make the ROI model real, the physicians needed to be willing to take on the responsibility of delivering on the benefits. This report highlights the key aspects of using an ROI model in support of an electronic medical system implementation emphasizing improvements in intra-practice efficiencies, interoperability between multi-specialty practices and ambulatory and inpatient care events for a patient while ensuring that all stakeholders consider its mathematical estimates as accurate and achievable in the real world.

Ambulatory Care↗
PubMed1999

Health knowledge and smoking among South African women.

While several studies of developed countries have attempted to understand individual smoking using economic models, no such studies have been conducted in South Africa. The purpose of this paper is to identify which factors influence individual South African women's choice to smoke cigarettes and their knowledge of the health risks of smoking. To allow for the implied correlation between the unobservable components of the reduced form equations for these health inputs the model is estimated as a bivariate probit. In order to identify those women who are most at risk of becoming smokers and those who are most likely to benefit from health education, the results show how the probability of being an uninformed non-smoker or an uninformed smoker vary across different socio-economic groups.

Adult↗
PubMed1982

Economic evaluation of different vaccination programmes to prevent congenital rubella.

Vaccination against rubella was introduced in Norway in 1978. Without any vaccination policy the frequency of congenital rubella is estimated at 0.4 per 1000 births. In this paper the consequences and effectiveness of the various vaccination programmes are evaluated by applying a cost benefit model. Economically, all strategies to prevent congenital rubella turn out to be cost effective. However, based on the benefit/cost ratios and the net benefit the following recommendation can be made: vaccination, preferentially with the polyvalent vaccine, should be offered to all girls in puberty as a permanent running programme. In addition, this policy should be supplemented for one or two decades with a programme offering vaccination to non-immunized women after delivery and to women especially at risk of exposure. However, if the participation and acceptance rate of the vaccination is less than 100%, permanent vaccination offered at two different ages (i e in childhood and in puberty) gives the best results in the prevention of congenital cases.

Adolescent↗
PubMed2004

Treatment costs to prevent or treat upper gastrointestinal adverse events associated with NSAIDs.

The widespread use of nonselective NSAIDs and cyclo-oxygenase (COX)-2 inhibitors has a substantial impact on healthcare budgets worldwide. The cost of their gastrointestinal (GI) adverse effects is a major component of their direct cost and has received much attention in the literature. Published studies have often differed in their methodologies and results. It is important for decision makers to understand the reasons for these differences in order to make informed decisions. We conducted a literature review to summarise data that evaluate the direct costs of NSAID-related GI adverse effects worldwide. This resulted in 789 articles from which 29 studies met the inclusion criteria and were fully reviewed. Of these 29, the 9 studies that assessed the cost of COX-2 inhibitors were all based on decision economic models, compared with only 7 of the remaining 20 studies, which assessed the cost of nonselective NSAIDs. In most studies, the perspective was that of the healthcare payer and the costs assessed were reimbursement costs. Costs of GI events almost doubled between regular users and non-users of nonselective NSAIDs and were much higher in high-dose versus low-dose users. The ratio of the total cost of nonselective NSAIDs to their acquisition cost reported in all studies varied from 1.36 to 2.12. Both of these numbers were reported in one single study assessing several different NSAIDs in France. Thus, the GI adverse events attributable to nonselective NSAIDs are substantial, and their costs often exceed the cost of the nonselective NSAID itself.The acquisition cost of the COX-2 inhibitors was the main driver of their total cost. The GI adverse effects with the COX-2 inhibitors added 10-20% to their acquisition cost in North America, while this increase was about 50% in some European countries. Decision analysis models showed that the direct costs of COX-2 inhibitors were lower than those of nonselective NSAIDs in patients at risk of NSAID gastropathy but higher in patients at no to low risk of gastropathy. Thus, from an economic perspective, the healthcare system would benefit from treating patients at risk of NSAID gastropathy with COX-2 inhibitors, but not those at no to low risk.

Aged↗
PubMed1998

[Cost-benefit in perinatology--I. General views of western economists].

The mutual cost-benefit relationship of any activity is the main principle of the market mechanism where both these variables are expressed in monetary terms. According to western economists this system cannot be applied, or if so only partly, in the sphere of health services because health benefit can be only in exceptional instances expressed in monetary terms. This is why they recommended for evaluation of health care, incl. perinatal care, other economic models where the health benefit is evaluated by saved lives or improvement of the health status. With this aspect in mind the author described five recommended models for the evaluation of alternative procedures and for evaluation of programmes in perinatology. Each of them is supplemented by examples from clinical practice. Most frequently different views are held on the effectivity of costly screening programmes for early detection of threatened foetuses and intensive care of these neonates, i.e. procedures which are the main cause of rising costs of perinatal care. The author discusses reasons for controversial views on contemporary economic problems in perinatology.

Cost-Benefit Analysis↗
PubMed2006

Cost-effectiveness of intravenous thrombolysis with alteplase within a 3-hour window after acute ischemic stroke.

BACKGROUND AND PURPOSE: The aim of this study was to assess the costs and cost-effectiveness of intravenous thrombolysis treatment with alteplase (Actilyse) of acute ischemic stroke with 24-hour in-house neurology coverage and use of magnetic resonance imaging. METHODS: A health economic model was designed to calculate the marginal cost-effectiveness ratios for time spans of 1, 2, 3 and 30 years. Effect data were extracted from a meta-analysis of six large-scale randomized and placebo-controlled studies of thrombolytic therapy with alteplase. Cost data were extracted from thrombolysis treatment at Aarhus Hospital, Denmark, and from previously published literature. RESULTS: The calculated cost-effectiveness ratio after the first year was $55,591 US per quality-adjusted life-year (base case). After the second year, computation of the cost-effectiveness ratio showed that thrombolysis was cost-effective. The long-term computations (30 years) showed that thrombolysis was a dominant strategy compared with conservative treatment given the model premises. CONCLUSIONS: A high-quality thrombolysis treatment with 24-hour in-house neurology coverage and magnetic resonance imaging might not be cost-effective in the short term compared with conservative treatment. In the long term, there are potentially large-scale health economic cost savings.

Acute Disease↗
PubMed2003

Database studies in asthma pharmacoeconomics: uses, limitations and quality markers.

Asthma is a common chronic disease resulting in significant morbidity and health resource utilisation, and multiple therapeutic options exist. Clinicians and healthcare providers need accurate information on the clinical and cost- effectiveness of asthma treatments to make informed decisions on management strategies. Randomised, controlled trials demonstrate cause and effect relationships between treatments and outcomes, but their tight entry criteria and strict study protocols mean that their results cannot automatically be generalised or used for economic modelling. There is a need for observational data to examine the effectiveness of alternative interventions in routine practice. Clinical and administrative databases are a possible information source for observational studies, and are increasingly used in asthma clinical, epidemiological and economic research. This paper examines the types of database used, the advantages and limitations of such studies and considers quality markers. High quality database studies can provide important epidemiological and economic information that can be of value in understanding the causes and effective management of asthma.

Anti-Asthmatic Agents↗