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PubMed2003

Simulation modeling to derive the value-of-information for risky animal disease-import decisions.

Simulation modeling can be used in aiding decision-makers in deciding when to invest in additional research and when the risky animal disease-import decision should go forward. Simulation modeling to evaluate value-of-information (VOI) techniques provides a robust, objective and transparent framework for assisting decision-makers in making risky animal and animal product decisions. In this analysis, the hypothetical risk from poultry disease in chicken-meat imports was modeled. Economic criteria were used to quantify alternative confidence-increasing decisions regarding potential import testing and additional research requirements. In our hypothetical example, additional information about poultry disease in the exporting country (either by requiring additional export-flock surveillance that results in no sign of disease, or by conducting additional research into lack of disease transmittal through chicken-meat ingestion) captured >75% of the value-of-information attainable regarding the chicken-meat-import decision.

Animals↗
PubMedDate not supplied

Funding in higher education: where does nursing fit?

Resource allocation systems for higher education including funding formulas vary greatly with most models grounded in the traditional Arts and Sciences, that is, campus-based, large-classroom instruction. The implications for nursing, a clinical discipline, are monumental. Funding models in general use do not account for the requirements of nursing education related to clinical learning (vulnerable patients, liability, large number of contact hours in clinical laboratories). Little information related to funding issues in schools of nursing has appeared in nursing literature over the past 10 years, and there are limited data for administrators of nursing programs to use as benchmarks. Administrators in nursing education programs must acquire a better understanding of budget and finance systems in higher education at state and university levels. Likewise, nursing education leaders are challenged to collectively verify and clarify the unique needs of nursing education in the budget process and to become active in educating college and university administrators and state legislatures about these unique needs.

Budgets↗
PubMed2005

A review of UK housing policy: ideology and public health.

OBJECTIVES: The aim of this paper is to review UK public health policy, with a specific reference to housing as a key health determinant, since its inception in the Victorian era to contemporary times. REVIEW: This paper reviews the role of social and private housing policy in the development of the UK public health movement, tracing its initial medical routes through to the current socio-economic model of public health. The paper establishes five distinct ideologically and philosophically driven eras, placing public health and housing within liberal (Victorian era), state interventionist (post World War 1; post World War 2), neoliberal (post 1979) and "Third Way" (post 1997) models, showing the political perspective of policy interventions and overviewing their impact on public health. The paper particularly focuses on the contemporary model of public health since the Acheson Report, and how its recommendations have found their way into policy, also the impact on housing practice. CONCLUSIONS: Public health is closely related to political ideology, whether driven by the State, individual or partnership arrangements. The current political system, the Third Way, seeks to promote a sustainable "social contract" between citizens and the State, public, private and voluntary organizations in delivering community-based change in areas where health inequalities can be most progressively and successfully addressed.

Health Policy↗
PubMed2002

Drivers' response to the installation of road lighting. An economic interpretation.

An economic model of drivers' behaviour is introduced in order to explain recently published empirical findings telling us that road lighting increases speed, decreases concentration and reduces accidents. The model, combined with the empirical results, indicate that drivers perceive speed and concentration as complementary safety variables, while common sense suggests that speed and concentration influence real accident rate as substitutable safety means. If this holds, a positive but concave relationship between subjective and objective risks exists, which means that as the objective accident risk rises, it has less influence on perceived risk.

Attention↗
PubMed2002

Cost-effectiveness of preoperative positron emission tomography in ischemic heart disease.

BACKGROUND: Revascularization of patients with ischemic heart disease and poor left ventricular function for surgical procedures is expensive and carries considerable risks, but may improve survival for patients with hibernating myocardium. Positron emission tomography can detect hibernating myocardium, and may be cost-effective if used to select patients for operation. METHODS: An economic model was developed to compare the cost-effectiveness of three management strategies: (1) coronary artery bypass grafting for all patients; (2) using positron emission tomography to select candidates for coronary artery bypass grafting, those without hibernation remaining on medical therapy; and (3) medical therapy for all patients. The model used data from our hospital and the published literature. A sensitivity analysis was also undertaken. RESULTS: Positron emission tomography was cost-effective in selecting patients for operation. In a hypothetical population of 1,000 patients, using positron emission tomography saved marginally more life-years and cost approximately Pound Sterling 3 million less. Using positron emission tomography before coronary artery bypass grafting instead of all patients receiving medical treatment saved lives but was more expensive. The incremental cost per life-year saved was Pound Sterling 77,000. The sensitivity analysis showed that the prevalence of hibernation and the survival rate of patients refused revascularization on the basis of the positron emission tomography scan were the areas most likely to influence cost-effectiveness. CONCLUSIONS: Positron emission tomography may be cost-effective to select patients with poor left ventricular function for coronary artery bypass grafting.

Coronary Artery Bypass↗
PubMed2003

Economics of reducing menstruation with trimonthly-cycle oral contraceptive therapy: comparison with standard-cycle regimens.

OBJECTIVE: To evaluate whether, and under what circumstances, trimonthly-cycle oral contraceptive pill (OCP) therapy is cost saving over standard-cycle OCP therapy for reducing the severity of menstrual-related symptoms. METHODS: We created three economic models, with each model representing a unique cost perspective (societal, private third party, and patient), to estimate the incremental annual costs associated with women taking trimonthly-cycle rather than standard-cycle OCP. Direct costs considered were costs for OCP prescriptions, female hygiene products, generic over-the-counter pain relievers and iron tablets, home pregnancy tests, and physician visits for menstrual-related concerns. Indirect costs considered were lost wages due to menstruation-related disability and opportunity costs of physician visits. We derived base-case and sensitivity range estimates from prior literature, public use data, expert opinion, and cross-sectional survey data that we collected from 59 adult women taking standard-cycle OCP visiting a large, community-based gynecology office. All costs were adjusted to 2002 US dollars. RESULTS: Under base-case assumptions that both regimens were equivalently priced (1.16 US dollars/pill) and trimonthly OCP reduces hygiene product use by 50%, annual societal costs per person were 460 US dollars for trimonthly OCP and 501 US dollars for standard OCP (incremental cost savings = 41 US dollars). Assuming no difference in monthly drug copayment costs between the two regimens (5.00 US dollars), annual private third-party costs were nearly identical at 365 US dollars per regimen. Annual patient costs were 95 US dollars for trimonthly OCP and 136 US dollars for standard OCP. Trimonthly OCP remained cost saving to society as long its price remained below a 9% premium to standard OCP prices. The degree to which trimonthly OCP reduces hygiene product use also significantly influenced the cost difference between the two regimens. CONCLUSION: Compared with standard-cycle OCP, trimonthly-cycle OCP appears to be associated with significant societal and patient cost savings. These savings are highly conditional upon trimonthly OCP being priced similarly to standard OCP.

Adolescent↗
PubMed2000

The potential for treatment of idiopathic thrombocytopenic purpura with anti-D to prevent splenectomy: a predictive cost analysis.

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder affecting both children and adults that can be manifested by severe bleeding episodes. Adult ITP patients have a low rate of spontaneous remission, and symptomatic patients commonly undergo splenectomy; however, maintenance therapy may increase the rate of remission, allowing splenectomy to be avoided. Anti-D is a recently licensed treatment for ITP that has the potential to delay, and possibly avoid, the need for splenectomy. We used preliminary data from an ongoing clinical trial to evaluate the costs involved in using anti-D therapy for 1 year with the intent of avoiding the need for splenectomy. We accounted for different possible outcomes at the completion of the clinical trial. An economic model with a theoretical cohort of 100 patients was developed using the model of an ongoing clinical trial. The average wholesale price was used to determine the cost of an infusion of anti-D based on an average dose ($1,213 per infusion). The cost of splenectomy was determined by a literature review ($16,000). Costs were calculated for all known patient outcomes; where outcomes were unknown and likely to vary, all possible outcomes were accounted for (splenectomy or no splenectomy). In our theoretical cohort, 31 of 100 patients were taken off anti-D and received splenectomy, 32 of 100 were stable after receiving anti-D and would not need splenectomy, and 37 of 100 had Indeterminate outcomes after receiving anti-D. When compared with the cost of the hypothetical scenario of initially giving all 100 patients splenectomy ($1.6 million), a minimum of 47 patients would have to avoid splenectomy to result in a cost savings for our cohort of 100 patients. The group of 47 patients avoiding splenectomy would be composed of the 32 patients comprising the stable group and at least 15 of the 37 patients comprising the group with indeterminate outcomes. If all 37 of the patients in the group with indeterminate outcomes avoid splenectomy, $363,000 and 69 spleens would be saved. Our data suggest that in the phase III trial of maintenance anti-D therapy versus immediate splenectomy, anti-D therapy will be a cost-effective option if 47% or more of patients avoid splenectomy.

Adult↗
PubMed1998

Estimating multiple temporal mechanisms in human vision.

When studying human ability to perceive temporal changes in luminance it is customary to estimate either temporal impulse response shapes or temporal modulation transfer functions, the representation of the impulse response in the frequency domain. The advantages and limitations of previous methods are summarized. We then describe an approach based on use of an impulse response basis set that resolves some of those limitations. We next present psychophysical results for spatiotemporal signal detection in spatiotemporal noise, together with an economical model of performance. The model is based on accepted notions of psychophysical detection mechanisms and the filter basis set described in the first part of the paper. The best-fitting model requires only eight parameters, as opposed to the 198 parameters required to separately fit each psychometric function, and captures both qualitative and quantitative properties of the psychophysical data. Finally, the best-fitting model indicates that only two temporal filters are necessary to describe the performance of each of three subjects under the specific stimulus conditions employed here.

Humans↗
PubMed2002

Forest fire indicators and mercury deposition in an intense land use change region in the Brazilian Amazon (Alta Floresta, MT).

Black carbon, charcoal and mercury fluxes were measured from sediment cores taken in an artificial water dam in an intense land use change area in the Alta Floresta district in the Brazilian Amazon, in order to characterize the differences in the evolution of human occupation patterns in the region during the last 18 years. A positive correlation between the black carbon and charcoal particle fluxes and the evolution of the Brazilian gross domestic production (GDP) was observed. Mercury fluxes showed a positive correlation with gold production and exhibited a distinct evolution pattern when compared to in relation to the forest fires indicators and Brazilian GDP. The fluxes of forest fires markers showed an increase in deforestation activities in the region after 1993. Mercury deposition showed a substantial decrease after 1994. The patterns of distribution in both forest fires tracers and gold mining tracers indicate substitution of the regional economic model. It also marked different antropogenic impact type in the ecosystem.

Brazil↗
PubMed2000

Aspirin plus extended-release dipyridamole or clopidogrel compared with aspirin monotherapy for the prevention of recurrent ischemic stroke: a cost-effectiveness analysis.

OBJECTIVE: The goal of this health economic analysis was to asses the cost-effectiveness of a fixed combination of aspirin plus extended-release dipyridamole (ASA/ER-DP) or clopidogrel compared with ASA monotherapy for prevention of recurrent ischemic stroke. BACKGROUND: The second European Stroke Prevention Study (ASA/ESPS-2), a large-scale clinical trial, demonstrated that a new therapy--a fixed combination of ASA/ER-DP--is more effective than ASA monotherapy for the prevention of recurrent ischemic stroke. METHODS: We used data from ESPS-2 to create a health economic model that estimates the incremental cost and cost-effectiveness of ASA/ER-DP during the 2-year time frame after an ischemic stroke. The model was developed from a payor perspective. The analysis used direct cost estimates for stroke from a Medicare claims database analysis. Efficacy data were obtained from clinical trials to determine the incremental cost per stroke averted for ASA/ER-DP or clopidogrel versus ASA. Sensitivity analyses also were conducted to test the reliability and robustness of the model. RESULTS: The results of the analysis demonstrated that ASA/ER-DP was cost-effective compared with ASA monotherapy for the secondary prevention of stroke, with a cost-effectiveness ratio of $28,472. The model remained robust over a range of assumptions and cost estimates. Clopidogrel, however, was not cost-effective compared with ASA (cost per stroke averted, $161,316) in either the base-case analysis or any of the sensitivity analyses. CONCLUSION: ASA/ER-DP thus offers a cost-effective alternative to ASA monotherapy for the prevention of recurrent ischemic stroke.

Aspirin↗
PubMed2000

Health care is an individual necessity and a national luxury: applying multilevel decision models to the analysis of health care expenditures.

Health care is neither "a necessity" or "a luxury"; it is "both" since the income elasticity varies with the level of analysis. With insurance, individual income elasticities are typically near zero, while national health expenditure elasticities are commonly greater than 1.0. The debate over whether health care is or is not a luxury good arises primarily from the failure to specify levels of analysis clearly so as to distinguish variation within groups from variation between groups. Apparently, contradictory empirical results are shown to be consistent with a simple nested multilevel model of health care spending.

Health Care Rationing↗
PubMed2001

Cost-effectiveness study on influenza prevention in Hong Kong.

INTRODUCTION: Recent studies confirm that influenza vaccination confers health benefits and reduces direct and indirect costs associated with the illness. However, these studies did not examine the situation in southern China, a hypothetical influenza epicentre for the emergence of pandemic influenza viruses. METHODS: Surveillance data were collected in Hong Kong in 1993/94 and used economic model was used to estimate the medical and social costs associated with influenza-like illness (ILI) and to predict the cost-effectiveness of implementing an influenza prevention programme. FINDINGS: The estimated ILI incidence was 110/1000. It was highest in those between 1 and 25 years of age while the rate of hospitalization was highest in the elderly. Influenza occurred throughout the study period, which was a mild influenza year. The model predicted more than 660000 ILI cases in a non-epidemic year, in which influenza B virus predominated, with an average ILI-associated cost of HK$283/case (US$36) and vaccination-associated costs of HK$74 (US$9.50) per vaccinated individual. CONCLUSION: The medical, social and monetary costs of ILI in Hong Kong were not observed to be large when compared with those in more developed countries where there is a clearly defined influenza season and recognized disease burden. From the perspective of a susceptible individual, the vaccine was cost-effective but from the perspective of society it was not, even with the most cost-effective strategy of targeting the elderly. However, if the vaccine were effective in controlling newly emerging and highly virulent strains, targeted vaccination programmes might be highly cost-effective.

Adolescent↗
PubMed1998

Indigenous patterns of conserving biodiversity: pharmacologic implications.

The accelerating rate at which the world's botanical resources are being depleted today has inspired redoubled efforts on the part of global conservation programs. For the most part, this reflects the actions of outsiders who are culturally and politically detached from the threatened environments, and who identify species for conservation through western economic models. In view of this, ethnopharmacologists--and primarily those representing the social sciences--have drawn attention to the cogency of indigenous knowledge of biotic diversity and its conservation. This paper reviews how local paradigms of plant management promote conservation, and problematizes the issue specifically to the use of plants by Hausa peoples in northern Nigeria. The pharmacologic implications of indigenous patterns of plant use and conservation derive from the manifold and overlapping contexts in which plants, especially wild species, are used by local communities. These applications identify the importance of particular species and should be employed in assigning priority for the conservation of plants.

Conservation of Natural Resources↗
PubMed2001

[3H]Flunitrazepam binding to recombinant alpha1beta2gamma2S GABAA receptors stably expressed in HEK 293 cells.

The interaction of selected compounds with the binding of the benzodiazepine [3H]flunitrazepam to membranes isolated from human embryonic kidney (HEK) 293 cells, stably transfected with the aI( 2 2S subtype of GABAA receptors, was studied. This subtype of GABAA receptors is the most common type of GABAA receptor found in the brain, and benzodiazepines are drugs known to enhance the effects of the inhibitory neurotransmitter gamma-amino butyric acid (GABA) by binding to the benzodiazepine binding sites which are part of the GABAA receptor complex. Scatchard analysis of binding data revealed the existence of a single type of binding site for [3H]flunitrazepam. GABA and thiopental enhanced, while the antagonist of central benzodiazepine binding sites--flumazenil, benzodiazepines such as clonazepam, flunitrazepam and diazepam, and the triazolopyridazine CI 218,872--displaced with nanomolar potency the binding of [3H]flunitrazepam. A partial displacement was obtained with the antagonist of the peripheral benzodiazepine binding sites--PK 11195--and with the neurosteroid dehydroepiandrosterone sulfate. The potency of drugs to enhance or inhibit [3H]flunitrazepam binding mainly corresponded to that observed for the modulation of the binding of [3H]flunitrazepam to the native type 1 benzodiazepine binding sites. This, as well as a high density of expressed binding sites, makes the cell line under study a very reliable and economical model for the testing of effects of different compounds at the GABAA receptor.

Anti-Anxiety Agents↗
PubMed1997

Clinical realities and economic considerations: economics of intrathecal therapy.

The estimated annual cost of medical management of chronic back pain is $25 billion. Such management is often ineffective and overly costly. Most physicians who have employed intrathecal pain therapy attest to its efficacy in the management of intractable chronic pain. However, few economic analyses are available to evaluate the cost effectiveness of different modalities and to aid in clinical decision making and third-party reimbursement policies. Current analyses tend to focus on short-term cost-benefit measurements and to ignore variables such as quality of life and patient functioning. This bias has impaired the ability of payers to make appropriate decisions regarding the safety, cost effectiveness, and efficacy of intrathecal pain therapy in noncancer patients. Clinical data demonstrate that for cancer patients whose expectancies exceed 3 months, the overall costs of intrathecal pain therapy may be less than those of tunneled epidural catheters or external infusion devices. In nonmalignant pain, intrathecal therapy appears to be cost effective compared to conventional medical management at 22 months. Further debate and fine tuning of these economic models from all perspectives are required.

Analgesics, Opioid↗
PubMed2003

Endoscopic therapy for gastroesophageal reflux disease: what have we learned and what needs to be done?

GERD is a common, morbid, and expensive-to-treat disease. Clinicians have a clearly defined "therapeutic bar" for the efficacy of GERD therapy established from extensive study of current pharmacologic and surgical therapies. Endoscopic therapies for GERD are promising technologies that probably will find clinical application in subsets of patients with GERD. Integration of these new endoscopic GERD therapies into routine clinical practice requires more information from carefully performed and analyzed trials. Issues that still need to be addressed include the efficacy of these devices compared with placebo, efficacy compared with other endoscopic techniques, and efficacy versus current therapies. Addressing these issues requires the performance of well-designed, blinded studies using sham techniques and measuring clinically relevant outcomes using validated instruments. Once efficacy has been established, durability of response needs to be clearly determined. Intensive postmarketing surveillance, device registries, and long-term clinical follow-up studies will be able to document durability. The effect of retreatment for relapses or suboptimal initial treatment response should also be determined. Safety can best be established with extensive postmarketing surveillance and device registries. The impact of formal training programs on decreasing the learning curve and improving outcomes, including safety, should also be studied. Finally, the cost-effectiveness of these devices has to be determined either by economic models or clinical trials measuring actual costs. Despite these seemingly large hurdles, one, if not more, of these technologies should meet these criteria and soon be used as an effective, durable, safe, and cost-effective treatment option for patients with GERD.

Clinical Trials as Topic↗
PubMed1993

True costs of air medical vs. ground ambulance systems.

The economic model created in this paper replaces the existing University of Massachusetts Medical Center's New England Life Flight (NELF) helicopter ambulance service with a ground ambulance system to investigate comparative costs. The model is based on a less than 30-minute response time to the patient, similar medical team staffing and equal service area. The annual budgetary cost of the replacement ground network is $3,804,000 while the helicopter ambulance costs are $1,686,500 (based on 1991 dollars). The cost per patient transported is $4,475 for the ground system and $2,811 for the helicopter system. The comparison finds that the commonly held notion that condemns helicopters as an excessively expensive technology for patient transport is incorrect. Future research to address intermediate alternatives using similar analytical technology assessment techniques is recommended.

Aircraft↗