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PubMed2005

Use of evidence in decision models: an appraisal of health technology assessments in the UK since 1997.

OBJECTIVES: To review the sources and quality of evidence used in the development of economic decision models in health technology assessments (HTAs). METHODS: All economic decision models developed as part of the NHS Research and Development HTA Programme between 1997 and 2003 were reviewed. Quality of evidence was assessed using a hierarchy of data sources developed for economic analyses. RESULTS: Decision models are parameterized using diverse sources of evidence (e.g. randomized controlled trials, observational studies, expert opinion). Evidence on the main clinical effect was mostly identified and quality assessed as part of the companion systematic review/meta-analysis of the HTA and therefore reported in a transparent and reproducible way. For the other model inputs (i.e. adverse events, baseline clinical data, resource use and utilities), the search strategies for identifying relevant evidence were rarely made explicit and in a number of reports the sources of specific evidence were unclear due to poor reporting. CONCLUSIONS: A more formal and replicable approach to identification and assessment of quality of model inputs is required to reduce the 'black box' nature of decision models, and lead to less scepticism regarding model outputs.

Biomedical Technology↗
PubMed1997

Preserving community in health care.

There are two prominent trends in health care today: first, increasing demands for accountabilty, and second, increasing provision of care through managed care organizations. These trends promote the question: What form of account-ability is appropriate to managed care plans? Accountability is the process by which a party justifies its actions and policies. Components of accountability include parties that can be held or hold others accountable, domains and content areas being assessed, and procedures of assessment. Traditionally, the professional model of accountability has operated in medical care. In this model, physicians establish the standards of accountability and hold each other accountable through professional organizations. This form of accountability seems outdated and inapplicable to managed care plans. The alternatives are the economic and the political models of accountability. In the economic model, medicine becomes more like a commodity, and "exit" (consumers changing providers for reasons of cost and quality) is the dominant procedure of accountability. In the political model, medicine becomes more like a community good, and "voice" (citizens communicating their views in public forums or on policy committees, or in elections for representatives) is the dominant procedure of accountability. The economic model's advantages affirm American individualism, make minimal demands on consumers, and use a powerful incentive, money. Its disadvantages undermine health care as a nonmarket good, undermine individual autonomy, undermine good medical practice, impose significant demands on consumers to be informed, sustain differentials of power, and use indirect procedures of accountability. The political model's advantages affirm health care as a matter of justice, permit selecting domains other than price and quality for accountability, reinforce good medical practice, and equalize power between patients and physicians. Its disadvantages include inefficiency in decision making, capture by extremists or experts, intractable value conflicts, fragmentation of community, and oppression of minorities. The political model is the model we should endorse. Its disadvantages can be minimized by proper institutional design. In addition, recent research on managed care plans suggests that the political model may be the best for a competitive marketplace because it can ensure that tough allocation decisions are addressed and improve health through changes in nonmedical aspects of community life.

Advisory Committees↗
PubMed1988

Population growth and economic development in the very long run: a simulation model of three revolutions.

The authors propose an economic model capable of simulating the 4 main historical stages of civilization: hunting, agricultural, industrial, and postindustrial. An output-maximizing society to respond to changes in factor endowments by switching technologies. Changes in factor proportions arise through population growth and capital accumulation. A slow rate of exogenous technical process is assumed. The model synthesizes Malthusian and Boserupian notions of the effect of population growth on per capita output. Initially the capital-diluting effect of population growth dominates. As population density increases, however, and a threshold is reached, the Boserupian effect becomes crucial, and a technological revolution occurs. The cycle is thereafter repeated. After the second economic revolution, however, the Malthusian constraint dissolves permanently, as population growth can continue without being constrained by diminishing returns to labor. By synthesizing Malthusian and Boserupian notions, the model is able to capture the salient features of economic development in the very long run.

Agriculture↗
PubMed1985

A unified approach to incorporating demographic or other effects into demand systems.

"A general method of introducing demographic effects into any demand system, using modifying functions, is described which permits complicated interactions of demographic variables with prices and expeditures. Theorems give properties the modifying functions must have to ensure integrability of the resulting system. Demand equations of the new system are given explicitly as functions of the original demand equations and the modifying functions. The procedure is interpreted as altering a household's technology, and is shown to encompass adult equivalent scales and related methods. Examples of modifying functions are derived and applications of the technique to uses other than demographic variation are considered."

Costs and Cost Analysis↗
PubMed2000

Preventative maintenance and unscheduled downtime from an economic perspective.

A spreadsheet-based model for economically characterizing the operation of a radiation treatment program has been used to perform a quantitative financial analysis of scheduled and unscheduled downtime. The incremental cost of downtime is broken down into three categories: remuneration of in-house or third party service technologists, decreased patient capacity, and local operating procedures for dealing with downtime. Different service arrangements and operating procedures are simulated to demonstrate the financial cost of treatment machine unavailability due to either preventative maintenance or unexpected breakdown. Depending on the service arrangement and operating policies for accommodating downtime, the combined cost of scheduled and unscheduled downtime (at 5%) can exceed 10% of the total cost of the radiation treatment program. It has also been demonstrated that the greatest cost component of downtime is decreased patient capacity, which can exceed $400,000 (CAN) when unscheduled downtime reaches 5%. The interpretation of this cost depends on the funding environment. Although the emphasis of this study has been the financial consequences of downtime, there are other factors which must be considered when developing policies and procedures for accommodating downtime such as effects on treatment, patient convenience and quality of life for staff. Even though the numerical results are strictly valid only within the context of the simulations performed, they do provide a broad framework within which medical physicists can make recommendations regarding service support and downtime.

Canada↗