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PubMed2006

Screening for Chlamydia trachomatis: a systematic review of the economic evaluations and modelling.

OBJECTIVE: To review systematically and critically, evidence used to derive estimates of costs and cost effectiveness of chlamydia screening. METHODS: Systematic review. A search of 11 electronic bibliographic databases from the earliest date available to August 2004 using keywords including chlamydia, pelvic inflammatory disease, economic evaluation, and cost. We included studies of chlamydia screening in males and/or females over 14 years, including studies of diagnostic tests, contact tracing, and treatment as part of a screening programme. Outcomes included cases of chlamydia identified and major outcomes averted. We assessed methodological quality and the modelling approach used. RESULTS: Of 713 identified papers we included 57 formal economic evaluations and two cost studies. Most studies found chlamydia screening to be cost effective, partner notification to be an effective adjunct, and testing with nucleic acid amplification tests, and treatment with azithromycin to be cost effective. Methodological problems limited the validity of these findings: most studies used static models that are inappropriate for infectious diseases; restricted outcomes were used as a basis for policy recommendations; and high estimates of the probability of chlamydia associated complications might have overestimated cost effectiveness. Two high quality dynamic modelling studies found opportunistic screening to be cost effective but poor reporting or uncertainty about complication rates make interpretation difficult. CONCLUSION: The inappropriate use of static models to study interventions to prevent a communicable disease means that uncertainty remains about whether chlamydia screening programmes are cost effective or not. The results of this review can be used by health service managers in the allocation of resources, and health economists and other researchers who are considering further research in this area.

Adolescent↗
PubMed2004

Systematic review and economic evaluation of a long-acting insulin analogue, insulin glargine.

OBJECTIVES: To evaluate the use of insulin glargine in its licensed basal-bolus indication in terms of both clinical and cost-effectiveness. DATA SOURCES: Electronic databases. REVIEW METHODS: A systematic review of the literature, involving a range of databases, was performed to identify all papers relating to insulin glargine. RESULTS: Nineteen studies met the inclusion criteria but full reports were available for only six. For type 1 diabetes patients, insulin glargine appears to be more effective than neutral protamine Hagedorn (NPH) in reducing fasting blood glucose (FBG) but not in reducing glycosylated haemoglobin (HbA1c) and there is some evidence that both insulins are as effective as each other in both FBG and HbA1c control. For type 2 patients for whom oral antidiabetic agents provide inadequate glycaemic control, there is no evidence that insulin glargine is more effective than NPH in reducing either FBG or HbA1c and some evidence that both insulins are as effective as each other in both FBG and HbA1c control. Evidence for control of hypoglycaemia is equivocal. In studies where insulin glargine is demonstrated to be superior to NPH in controlling nocturnal hypoglycaemia, this may be only apparent when compared with once-daily NPH and not twice-daily NPH. Further, this superiority of glargine over NPH in the control of nocturnal hypoglycaemia may relate to one formulation of insulin glargine (HOE901[80]) and not another (HOE901[30]). There is no conclusive evidence that insulin glargine is superior to NPH in controlling symptomatic hypoglycaemia and severe hypoglycaemia. Insufficient data are available to conclude whether insulin glargine is different from each of the commonly used NPH dosing regimens: once daily and more than once daily. Given the lack of a published evidence base for the cost-effectiveness of insulin glargine, the economic review concentrates on a review of the industry submission and an amended model. Three economic models are provided in the submission, two relating to type 1 diabetes and one relating to type 2 diabetes. All three models compare the cost--utility of insulin glargine against NPH insulin. In general, the structures of the models are poor and in all three models, mistakes relating to assumptions and calculations have been made. The assessment team believe that the cost per QALY estimates generated by the Aventis model may be an underestimate for several reasons. The cost-effectiveness of insulin glargine in both type 1 and type 2 diabetes is highly sensitive to the amount of utility associated with reducing the fear of hypoglycaemia. CONCLUSIONS: The evidence suggests that, compared with NPH insulin, insulin glargine is effective in reducing the number of nocturnal hypoglycaemic episodes, especially when compared with once-daily NPH. There appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes. Further research into insulin glargine is needed that addresses the quality of life issues associated with fear of hypoglycaemia and also the economic impact of balance of HbA1c control and incidence of hypoglycaemia achieved in practice. Studies examining the economic evidence on insulin glargine should be published.

Adult↗
PubMed1986

[PorkCHOP: an economic microcomputer replacement model for sows].

A computer model called PorkCHOP, was developed in an electronic spreadsheet on the microcomputer to help farmers, veterinarians and other livestock specialists reach economically sound culling decisions in swine breeding herds. It quantifies the benefits of a longer herd life and a shorter farrowing interval, calculates an economic index (Retention Pay-Off) to be used as a culling guide for individual sows within a herd and determines the maximum number of permissible services when sows fail to conceive following the first service. PorkCHOP runs with 'default' settings for the major factors affecting replacement economics, but the user can modify all variables to represent a specific herd more precisely.

Animal Husbandry↗
PubMed1995

Economic viability of a model rural family practice.

BACKGROUND AND OBJECTIVES: A model rural clinic was established by the Quincy Family Practice Residency Program with the financial support of sponsoring local hospitals. The purpose of the study was 1) to determine the financial viability of such a model practice and 2) to determine the practice's financial effect on the sponsoring hospitals. METHODS: The rural practice was established in a medically underserved area 30 miles from the sponsoring hospitals. A cost analysis of months 7-18 of operation was performed, including an analysis of charges generated at the sponsoring hospitals. Theoretical models of practice to enhance economic viability were explored. RESULTS: The 3,051 office visits fell short of expectations. These visits generated a net practice income of $18,596. Had the practice sought full payment for these visits instead of accepting Medicare assignments, the net income potential would have been $39,182. Growth of the practice until it reached the average size of a typical rural family practice (6,000 annual visits) would produce a net income of $67,113 with Medicare assignments and $103,578 if Medicare assignments were not accepted. Had the practice been a federally designated rural health clinic, a mid-level practitioner with physician supervision could have generated a net practice income of $53,640 for 3,051 visits or $138,863 for 6,000 visits. Referrals from the model clinic for laboratory work, radiology, and hospital admissions generated $9.17 in charges for the sponsoring hospitals for each dollar charged by the clinic. CONCLUSIONS: The financial viability of rural practices is adversely affected by the Medicare reimbursement system. Our model clinic had a positive economic effect on the sponsoring hospitals, suggesting that innovative collaborative sponsorship of such clinics may be mutually beneficial.

Costs and Cost Analysis↗
PubMed1997

Further analysis of choice between cocaine and food using the unit price model of behavioral economics.

Behavioral economics defines unit price (UP) as the ratio of the response requirement to magnitude of reinforcer. When applied to drug self-administration, the UP model defines UP as the ratio of the response requirement to the unit dose of drug. This model makes two predictions about drug self-administration: increasing UP decreases consumption and consumption at a given UP will be constant regardless of the response requirement and dose that make up the UP. In previous experiments conducted in rhesus monkeys allowed to choose between an i.v. injection of cocaine and food, the UP model has failed to adequately predict drug consumption in that consumption varied (increased with dose) at a given UP. However, previous experiments have allowed a fixed number of choice trials/day, thereby imposing a procedural ceiling on consumption that may have influenced conformity to the UP model. In the present experiment, the number of choice trials available was varied in such a way that constant drug consumption was possible over the range of UPs tested. The response requirement for cocaine was varied between 15 and 1200 lever presses/injection and the dose of cocaine was varied between 0.05 and 0.2 mg/kg/inj, yielding UPs from 300 to 5600 responses/mg/kg. The response requirement for food was always 30. As predicted by the UP model, cocaine consumption decreased as UP increased. Moreover, in contrast to previous experiments, consumption did not vary significantly across the response requirement/dose combinations that made up a UP. A detailed analysis suggested that a decrease in magnitude of the alternative reinforcer (one rather than three food pellets), rather than the increase in trials, was responsible for the improved conformity to the UP model in the present experiment relative to previous experiments. Taken together with previous experiments, the present experiment suggests that conformity to the UP model of drug consumption in a choice situation is dependent upon the magnitude of alternative reinforcers that are available. Consumption was best predicted by the UP model when the magnitude of the alternative reinforcer was small.

Animals↗
PubMed1991

Use of a simulation model to evaluate the influence of reproductive performance and management decisions on net income in beef production.

A stochastic dynamic model of reproduction and a deterministic cow-herd economic simulation model were used to evaluate how management decisions and reproductive performance interact to influence net income in a cow-calf operation (1,000 cows) for 1 yr of production. The stochastic model was used to determine herd performance when length of breeding season (45, 70, or 120 d) interacted with three postpartum intervals of anestrus (48, 65, or 90 d) and three conception rates at first service (60, 70, or 80%). Short, moderate, and long postpartum intervals were used to reflect differences in reproductive performance. In addition, replacement heifers were bred beginning either 3 wk ahead of the cow herd or at the same time as the cow herd. Fifty-four simulations were generated. Inputs into the economic model were herd performance, livestock and feed prices, nonfeed costs, and feed requirements for 1 yr of production. Feed requirements were calculated separately for each postpartum interval to reflect three different body condition scores, thin, moderate, and good, to correspond with long, moderate, and short postpartum intervals. Net income was greatest with 70-d breeding seasons when the postpartum interval was short or moderate. When the postpartum interval was long, net income was greatest with 120-d breeding seasons because pregnancy rates, as a result of the long breeding season, were highest and feed costs were lowest for thin cows. Overall, net income was greatest when cows were managed to have postpartum intervals of moderate length. Breeding heifers 3 wk before the cows provided the most economic benefit with long postpartum intervals.

Age Factors↗
PubMed1992

Population growth, human capital expenditures and economic growth: a macroeconometric analysis.

"The paper presents an econometrically estimated model where economic and demographic variables are determined simultaneously. It is used to quantify the importance of human capital expenditures in socioeconomic and demographic development as well as analyze the effects of rapid population growth on human capital expenditures. The simulation results indicate that human capital expenditures are important determinants of economic development, have appreciable negative effects on both fertility and infant mortality, hence, have negligible net effects on population in human capital expenditures per capita which implies a deteriorating quality of human capital."

Demography↗
PubMed1985

On the optimum theoretical rate of population growth.

"The paper seeks intuitively-satisfying models of optimum population growth. The authors build upon Phelps's model of endogenous technical progress plus the Steinmann-Simon extension, which imply that the per-person consumption growth rate depends positively and linearly upon the population growth rate, without bound.... They suggest that the consumption rate ultimately turns downwards as population growth increases because of decreasing adoption of available technology as labor cheapens relative to capital, and as high population growth overtaxes people's will and ability to respond. Including a convex-downward function in the model yields sensible results." (summary in GER)

Demography↗
PubMed2000

An economic approach to animal models of alcoholism.

Researchers have long sought an animal model for human alcohol consumption. This article describes an economic-based approach to a model of alcohol preference in rats. The procedures are based on an analogy between clinical accounts of human drinking and the economic analysis of consumption. Both clinical and economic investigators typically define consumption patterns in terms of the influence of negative consequences. For example, the clinical account emphasizes the persistence of heavy drinking despite mounting alcohol-related aversive consequences, and in economic analyses, the term "inelastic demand" is used to refer to the persistence of consumption despite large increases in prices. In the experimental procedure described here, rats worked for alcohol and food. Presses on one lever earned a drink of 10 percent alcohol plus saccharin, and presses on a second lever earned isocaloric drinks of a starch solution. After behavior stabilized, the response requirements (which are analogous to prices) for one or both drinks were increased. The rats maintained baseline alcohol consumption levels despite large increases in the "price" of alcohol. In contrast, the same price increases markedly reduced starch intake. That is, food consumption was sensitive to price hikes, but alcohol consumption was not. The results demonstrate that a common economic framework can be used to describe human and animal behavior and, hence, the possibility of an animal model of human alcohol consumption. The article also points out that economic concepts provide a framework for understanding a wide range of human drinking patterns, including controlled social drinking and excessive alcoholic drinking.

Alcoholic Beverages↗
PubMed1982

The impact of demographic changes on income distribution in a developing country.

"A common hypothesis regarding the distribution of income is that it tends to become more unequal in the initial and middle stages of economic development, in part because of demographic changes. However, previous studies of the effect of demographic changes on income distribution are not based on the underlying micro determinants of the income components." In the present paper, "the micro determinants of the probability of receipt and amount received conditional on receipt of four income components are estimated for three regions defined by the degree of urbanization. Five simulations of hypothetical demographic changes are conducted. The simulated effects on some of the regional income component distributions are fairly considerable in regard both to equalizing the distributions and increasing the shares of the poorest. However, the overall effects are regressive in both urban and rural regions."

Demography↗
PubMed2006

A Markov computer simulation model of the economics of neuromuscular blockade in patients with acute respiratory distress syndrome.

BACKGROUND: Management of acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) is clinically challenging and costly. Neuromuscular blocking agents may facilitate mechanical ventilation and improve oxygenation, but may result in prolonged recovery of neuromuscular function and acute quadriplegic myopathy syndrome (AQMS). The goal of this study was to address a hypothetical question via computer modeling: Would a reduction in intubation time of 6 hours and/or a reduction in the incidence of AQMS from 25% to 21%, provide enough benefit to justify a drug with an additional expenditure of $267 (the difference in acquisition cost between a generic and brand name neuromuscular blocker)? METHODS: The base case was a 55 year-old man in the ICU with ARDS who receives neuromuscular blockade for 3.5 days. A Markov model was designed with hypothetical patients in 1 of 6 mutually exclusive health states: ICU-intubated, ICU-extubated, hospital ward, long-term care, home, or death, over a period of 6 months. The net monetary benefit was computed. RESULTS: Our computer simulation modeling predicted the mean cost for ARDS patients receiving standard care for 6 months to be $62,238 (5%-95% percentiles $42,259-$83,766), with an overall 6-month mortality of 39%. Assuming a ceiling ratio of $35,000, even if a drug (that cost $267 more) hypothetically reduced AQMS from 25% to 21% and decreased intubation time by 6 hours, the net monetary benefit would only equal $137. CONCLUSION: ARDS patients receiving a neuromuscular blocker have a high mortality, and unpredictable outcome, which results in large variability in costs per case. If a patient dies, there is no benefit to any drug that reduces ventilation time or AQMS incidence. A prospective, randomized pharmacoeconomic study of neuromuscular blockers in the ICU to asses AQMS or intubation times is impractical because of the highly variable clinical course of patients with ARDS.

Computer Simulation↗