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PubMed1995

Measuring the cost-effectiveness of cancer care.

Historically, new therapeutic strategies for cancer have been evaluated on the basis of safety and clinical efficacy. However, the current national emphasis on efficiency of resource allocation has led to the inclusion of economic assessments in oncology studies. Economic assessments measure patients' health status and resource consumption associated with a therapeutic strategy, and combine these in a cost-effectiveness analysis. Study design can include prospective analysis of clinical trials, retrospective analysis of a clinical trial or administrative databases, or a decision analytic model. Economic analysis is being used increasingly in oncology and will continue to provide meaningful data to assist clinicians in determining the optimal treatment strategies for cancer patients and to help inform health policy decision-makers about the importance of specific cancer therapeutic strategies.

Cost-Benefit Analysis↗
PubMed2003

A literature review of the epidemiology and treatment of acute gout.

BACKGROUND: Gout is the most common cause of inflammatory arthritis in men aged >40 years and is frequently encountered in clinical practice. OBJECTIVE: The goal of this article was to review the published literature on the epidemiology, treatment, and estimated burden of illness of acute gout. METHODS: Articles on gout published in English between 1980 and June 2002 were identified through a MEDLINE search. Relevant clinical studies and review articles were found using the text- and keyword-search term gout alone and in combination with epidemiology, prevalence, incidence, complications, outcome, quality of life, economics, cost, prevention or drug therapy. The reference lists of identified articles, especially review articles, were checked for any additional studies that might have been missed in the original MEDLINE search. RESULTS: The epidemiology of gout in various geographic regions has been well documented. Data suggest that environmental, racial, and hereditary factors may influence the development of gout, and that the prevalence of gout appears to be on the rise worldwide. Evidence from well-designed clinical studies evaluating drug therapies for gout is limited. Therapies for acute gout include corticotropin, corticosteroids, colchicine or, more often, nonsteroidal anti-inflammatory drugs (NSAIDs), which have shown comparable efficacy. A recent study suggests that etoricoxib, a new cyclooxygenase-2-selective inhibitor, may be as effective as and better tolerated than traditional NSAIDs in the treatment of gout. Urate-lowering therapy, prophylactic colchicine, and low-dose NSAIDs are used for the long-term prophylaxis of gout. However, all acute and prophylactic therapies are associated with adverse events. Using an economic model for gout, the annual direct burden of illness for new cases of acute gout can be estimated at 27,378,494 US dollars in the United States. CONCLUSIONS: Gout is an increasingly prevalent condition worldwide and creates a heavy economic burden. Available treatments are generally effective; however, they are not devoid of adverse events. Well-designed, long-term, controlled clinical trials evaluating the comparative efficacy and tolerability of treatments for gout are needed.

Acute Disease↗
PubMed2004

Time to death and health expenditure: an improved model for the impact of demographic change on health care costs.

BACKGROUND: Obtaining well-founded estimates of the effect of demographic change on future health expenditures is a pressing issue in all developed countries. Thus far, expenditure projections have examined the effect of age on health care costs, but fail to account for the influence of remaining life expectancy on costs. OBJECTIVE: This paper seeks to create a more accurate projection model that considers the concentration of costs towards the end of life, and to compare this model with the more traditional approach that holds age- and sex-specific per capita expenditures constant. METHODS: We used a longitudinal hospital dataset which followed 90 929 patients aged 65 and older from 1970 to death, to create an economic model of hospital costs based on patient age and time remaining to death. We then applied the model to England population projections to predict the effect of demographic changes on hospital expenditures from 2002 to 2026. RESULTS: The decline in age-specific mortality rates over time postpones death to later ages, pushing back death-related costs. Accounting for this in expenditure projections gave a predicted annual growth rate of 0.40%-half of the rate predicted with a traditional method. CONCLUSIONS: Using richer data and more refined methods than have hitherto been employed, this study strongly confirms that the pressure of population increases and ageing demographic structure on hospital expenditures will be partially countered by the postponement of death-related hospital costs to later in life-a finding consistent with emerging epidemiological evidence, and heartening for policy makers and physicians alike.

Adolescent↗
PubMed1984

Racial and ethnic succession in four cities.

"The concept of succession is well established in both ecological and economic models of urban residential change, yet much remains unknown about the determinants of succession in urban neighborhoods. Employing longitudinal census tract data for four [U.S.] cities, this article predicts racial composition of neighborhoods as a function of earlier-period racial, ethnic, socioeconomic, and physical characteristics. There is support for aspects of the ecological and filtering models of succession, although many elements of the process are not generally applicable across time and place."

Americas↗
PubMed2003

Cost effectiveness of myeloid growth factors in cancer chemotherapy.

Healthcare 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. Although under-reported, FN often occurs early in the course of chemotherapy and contributes substantially to the morbidity, mortality, and cost of treatment. The risk of FN and its complications are associated with treatment intensity, age, and various comorbidities. Myeloid growth factors (MGFs) have been used effectively in a variety of clinical settings to prevent or treat FN and assist patients receiving dose-intensive chemotherapy with or without stem cell support. A meta-analysis of the available randomized controlled trials has confirmed the efficacy of prophylactic MGFs. The cost of these agents, along with their large-scale clinical use, has prompted several economic investigations. Economic models based on measures of resource use derived from randomized controlled trials have provided estimates of expected treatment costs, along with FN risk threshold estimates for the cost-saving use of prophylactic MGF. Recent studies have demonstrated the potential value of targeting MGFs toward patients at greatest risk based on accurate and valid predictive models. Although an emerging role has become apparent for MGFs in managing adult leukemia and supporting high-dose therapy with stem cell transplantation in adults, their value in the support of children in these settings remains unclear. Continuing clinical and economic evaluation, along with an updating of clinical practice guidelines because of rapid technologic and clinical advances, is encouraged.

Antineoplastic Agents↗
PubMed2002

Performance tests and disability: developing an objective index of mobility-related limitation in older populations.

BACKGROUND: Disability reflects physiological limitations, social and environmental barriers, and "sickness" behavior. Being able to measure these influences separately would greatly assist interpretation of disability comparisons over time or between populations. This study aimed to identify an index of mobility-related limitations composed of physiological measures that are most closely associated with reported mobility disability in elders. METHODS: Data from the Third National Health and Nutrition Examination Survey (NHANES III) were used. Participants aged 60 and older were included in this analysis. Participants included 6596 respondents who were interviewed in their homes, and 5724 (87%) of these attended a further examination. Domains of measurements included body measurements, bone densitometry, physical examination, spirometry, fundus photography, and physical performance measures. Multivariate models were developed on a random half subsample of the data and were validated on the other half. Receiver operating characteristic (ROC) areas and logit rank slopes were used to evaluate sets of measures. RESULTS: In weighted logistic regression models, six and five measures were significantly associated with difficulty and inability in walking a quarter of a mile, respectively. These mainly included measures of lower extremity and lung function. A relatively minimal loss of sensitivity and specificity occurred from using more economical models, employing a subset of the identified measures. CONCLUSIONS: Subsets of measures associated with reported mobility disability could provide objective indices of mobility-related limitation for comparing populations or long-term population health monitoring.

Aged↗
PubMed2004

The brain and the law.

Much has been written about how law as an institution has developed to solve many problems that human societies face. Inherent in all of these explanations are models of how humans make decisions. This article discusses what current neuroscience research tells us about the mechanisms of human decision making of particular relevance to law. This research indicates that humans are both more capable of solving many problems than standard economic models predict, but also limited in ways those models ignore. This article discusses how law is both shaped by our cognitive processes and also shapes them. The article considers some of the implications of this research for improving our understanding of how our current legal regimes operate and how the law can be structured to take advantage of our neural mechanisms to improve social welfare.

Behavior↗
PubMed1989

The health policy implications of international trade in alcohol and tobacco products.

The aim of national alcohol and tobacco preventive health policy is to reduce consumption in order to reduce harm. However, the level of domestic consumption depends upon the interaction of international demand and supply and the development of international trade policy. Trade policy may conflict with or act as a constraint on the implementation of preventive health policy. Trends in alcohol and tobacco trade and developments in international trade policy affecting these products are examined in this paper in relation to health policy goals. Economic models of the links between trade flows, quantities consumed and health effects are then outlined as a preliminary step towards identifying the complex interaction between alcohol and tobacco trade and production, consumption, health and welfare. It is shown that consideration of the economic trade links are an important factor in the development of international and domestic health policy.

Alcoholic Beverages↗
PubMed1999

Cost effectiveness of quinolones in hospitals and the community.

In hospitals, oral quinolone therapy has lower daily associated costs (acquisition and administration) than most intravenous regimens. In addition, oral switch therapy shortens the duration of hospital stay for most patients. However, randomised trials are required to measure the economic impact of the switch to oral therapy in terms of hospital care costs and the burden imposed on community health services, on relatives or carers and on the patient. Evidence about the reliability of absorption of quinolones in hospitalised patients is more likely to be obtained from large population kinetic studies than randomised effectiveness trials. The existing literature on cost effectiveness of quinolones in the community is disappointing. The principal problems are poor definition of diagnostic criteria, inclusion of irrelevant comparator drugs and a failure to include infections caused by bacteria that are resistant to the comparator. Consequently, there is little evidence to support the use of economic models to determine the consequences of antibiotic resistance in the community.

4-Quinolones↗
PubMed2000

Genomic imprinting, sibling solidairity and the logic of collective action.

Genomic imprinting has been proposed to evolve when a gene's expression has fitness consequences for individuals with different coefficients of matrilineal and patrilineal relatedness, especially in the context of competition between offspring for maternal resources. Previous models have focused on pre-emptive hierarchies, where conflict arises with respect to resource allocation between present and future offspring. Here we present a model in which imprinting arises from scramble competition within litters. The model predicts paternal-specific expression of a gene that increases an offspring's fractional share of resources but reduces the size of the resource pool, and maternal-specific expression of a gene with opposite effects. These predictions parallel the observation in economic models that individuals tend to underprovide public goods, and that the magnitude of this shortfall increases with the number of individuals in the group. Maternally derived alleles are more willing than their paternally derived counterparts to contribute to public goods because they have a smaller effective group size.

Animals↗
PubMed1989

Sources of small area variations in the use of medical care.

This paper develops an economic model of physician care utilization which incorporates the uncertainty and practice style hypotheses proposed by Wennberg and others as explanations of the substantial intermarket variations in per capita utilization rates of many medical and surgical procedures. Practice style, which is distinguished from inducement, is modeled as a set of physician beliefs about the production function of health. In the model, per capita utilization is decomposed into a first occurrences demand and an intensity demand. It is argued that the influence of practice style affects primarily the intensity with which physicians treat their patients. Alternative tests are proposed and carried out on a comprehensive aggregated measure of physician care utilization for market areas in Michigan. Although practice style is undoubtedly important for some individual procedures, the empirical results indicate that it is unimportant in determining either an aggregated index of market area utilization or the average intensity with which patients are treated by physicians.

Catchment Area, Health↗
PubMed2004

Pharmaco-economic evaluation of targeted hepatitis A vaccination for children of ethnic minorities in Amsterdam (The Netherlands).

OBJECTIVE: Estimate cost-effectiveness of vaccination against hepatitis A virus (HAV) for children of ethnic minorities in Amsterdam. BACKGROUND: Pharmaco-economic analysis is relevant for motivating reimbursement of vaccination costs in the framework of a programmatic approach to vaccination of ethnic minorities. DESIGN: Pharmaco-economic modeling. METHOD: In cost-effectiveness analysis, costs, benefits and health gains were estimated for a large-scale HAV-vaccination for children of Turkish and Maroccan origin. Analysis was performed from the societal perspective, as recommended in the Dutch guidelines for pharmaco-economic research. This implies that indirect costs of production losses are included in the analysis. Cost-effectiveness was expressed in net costs per adult HAV-infection averted in incremental and aggregate analysis. Incremental analysis compares targeted vaccination with the current limited-scale HAV-vaccination that exists, whereas aggregate analysis compares targeted vaccination with the sheer absence of vaccination. RESULTS: Net aggregate costs of targeted HAV-vaccination for Turkish and Maroccan children in Amsterdam amounts to 61.000. Cost-effectiveness was estimated, in aggregate and incremental analysis, at 13.500 and 11.100 respectively per adult HAV-infection averted. Uni- and multivariate sensitivity analyses show that major impact on cost-effectiveness may be expected from reductions in the vaccine price through economies of scale. Probabilistic sensitivity analysis indicates possible large fluctuations in cost-effectiveness from 1 year to another, related to varying incidence of disease. CONCLUSION: HAV-vaccination for children from ethnic minorities in Amsterdam is not cost saving, but may have a favourable cost-effectiveness. Such a vaccination program fits into the recent Dutch policy of specific vaccinations directed at groups of ethnic minorities, such as for hepatitis B.

Adult↗
PubMed1993

Forecasting areawide hospital utilization: a comparison of five univariate time series techniques.

Time series analysis is one of the methods health services researchers, managers and planners have to examine and predict utilization over time. The focus of this study is univariate time series techniques, which model the change in a dependent variable over time, using time as the only independent variable. These techniques can be used with administrative healthcare databases, which typically contain reliable, time-specific utilization variables, but may lack adequate numbers of variables needed for behavioral or economic modeling. The inpatient discharge database of the Department of Veterans Affairs, the Patient Treatment File, was used to calculate monthly time series over a six-year period for the nation and across US Census Bureau regions for three hospital utilization indicators: average length of stay, discharge rate, and multiple stay ratio, a measure of readmissions. The first purpose of this study was to determine the accuracy of forecasting these indicators 24 months into the future using five univariate time series techniques. In almost all cases, techniques were able to forecast the magnitude and direction of future utilization within a 10% mean monthly error. The second purpose of the study was to describe time series of the three hospital utilization indicators. This approach raised several questions concerning Department of Veterans Affairs hospital utilization.

Analysis of Variance↗
PubMed1975

Enfranchisement and rationing: effects of Medicare on discretionary hospital use.

This study examines the effects of Medicare on hospital output using an economic model in which market demand for hospital care is treated as the sum of demands in separable markets. Results indicate that Medicare affected utilization patterns by the elderly, but in terms of an increased level of admissions and increased lengths of stay, not in terms of case mix or (apparently) in the level of the nondiscretionary component of care. However, the results also show the Medicare resulted in rationing of hospital services to patients under 65 years of age: case-specific lengths of stay declined, and there appears to have been a distinct decline in the degree of discretionary hospital use by this patient group.

Economics, Hospital↗
PubMed2006

Cost-effectiveness of different diagnostic strategies to assess gastro-oesophageal reflux disease in patients with unexplained chronic persistent cough in Italy.

BACKGROUND: Chronic persistent cough is a common and disabling disorder and gastro-oesophageal reflux disease is considered to be the third leading cause, after asthma and postnasal drip. Therefore, patients with unexplained chronic persistent cough usually undergo a stepwise evaluation to establish the existence of a reflux disease. AIM: To identify the most cost-effective diagnostic approach to assess gastro-oesophageal reflux disease in patients with unexplained chronic persistent cough. METHODS: Direct and indirect costs associated with six diagnostic strategies using 24-h oesophageal pH-metry, oesophago-gastroduodenoscopy and the proton pump inhibitors test in different sequences, were evaluated using a decision tree model. If the first test was positive, the diagnostic work-up was stopped, if negative the patient proceeded to the second test, and so on. Clinical data from an observational prospective trial conducted in 51 patients with unexplained chronic persistent cough were used in the economic model. RESULTS: All six strategies had the same clinical effectiveness (78.4%). The diagnostic work-up with the lowest cost was the proton pump inhibitors test followed by pH-metry and then oesophago-gastroduodenoscopy with a total cost of euro 211.08 (direct euro 142.93, indirect euro 68.15). CONCLUSIONS: This study shows that the lowest cost is the strategy where proton pump inhibitors test is performed as first investigation. Implementation of this diagnostic work-up may lead to cost savings in the management of patients with chronic persistent cough.

Chronic Disease↗
PubMed2005

Integrating seasonal climate prediction and agricultural models for insights into agricultural practice.

Interest in integrating crop simulation models with dynamic seasonal climate forecast models is expanding in response to a perceived opportunity to add value to seasonal climate forecasts for agriculture. Integrated modelling may help to address some obstacles to effective agricultural use of climate information. First, modelling can address the mismatch between farmers' needs and available operational forecasts. Probabilistic crop yield forecasts are directly relevant to farmers' livelihood decisions and, at a different scale, to early warning and market applications. Second, credible ex ante evidence of livelihood benefits, using integrated climate-crop-economic modelling in a value-of-information framework, may assist in the challenge of obtaining institutional, financial and political support; and inform targeting for greatest benefit. Third, integrated modelling can reduce the risk and learning time associated with adaptation and adoption, and related uncertainty on the part of advisors and advocates. It can provide insights to advisors, and enhance site-specific interpretation of recommendations when driven by spatial data. Model-based 'discussion support systems' contribute to learning and farmer-researcher dialogue. Integrated climate-crop modelling may play a genuine, but limited role in efforts to support climate risk management in agriculture, but only if they are used appropriately, with understanding of their capabilities and limitations, and with cautious evaluation of model predictions and of the insights that arises from model-based decision analysis.

Climate↗
PubMed2000

[Health economics and evaluation of schizophrenic psychoses in Germany].

This paper presents a survey of economic analyses of schizophrenia in Germany. A recently published cost-of-illness study demonstrates the high financial burden to society caused by the disease. Ambulatory care and medication were remarkably less costly than in-patient treatment. Several other studies show that continuous in-patient treatment is less cost-effective than complementary care in the community. Two pharmaco-economic models evaluate drugs with special focus on long-term treatment. Drugs with better compliance rates seem to produce savings in the health care system by less hospital admissions, even if the drug is more expensive than other medication. In addition to the survey the problems of economic analysis of psychiatric disorders in Germany are discussed. There are difficulties caused by the structure of the German health care system. Other problems emerge from the measurement of outcomes, effectiveness, utilities and quality of life in psychiatric disorders.

Cost of Illness↗
PubMed1988

Economic assessment of crop damages due to air pollution: the role of quality effects.

Biological research has established that air pollution can affect the yield and quality of agricultural crops. Economic assessments of crop exposure to air pollution have focused on the yield effect. This study illustrates the implications of considering crop quality effects in addition to crop yield changes for the case of O3 impacts on soybeans. An economic model of US soybean, soybean oil, and soybean meal markets is used to simulate the impacts of increased soybean yields due to reduced O3 concentrations with and without changes in soybean quality. The simulations with quality effects are richer in their distributional implications and show larger increases in economic surplus than the simulations with yield effects only.

Journal Article↗