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PubMed2004

Do routine eye exams improve vision?

We use a longitudinal national sample of Medicare claims linked to the National Long-Term Care Survey (NLTCS) to assess the productivity of routine eye examinations. Although such exams are widely recommended by professional organizations for certain populations, there is limited empirical evidence on the productivity of such care. We measure two outcomes, the ability to continue reading, and no onset of blindness or low vision, accounting for potential endogeneity of frequency of eye exams. Using instrumental variables, we find a statistically significant and beneficial effect of routine eye exams for both outcomes. Marginal effects for reading ability are large, but decline in the number of years with eye exams. Effects for blindness/low vision are smaller for the general elderly population, but larger for persons with diabetes. Instrumental variables provide a useful approach for assessing the productivity of particular interventions, particularly in situations in which randomized controlled trials are expensive or perhaps unethical and difficult to conduct over a lengthy time period.

Cost-Benefit Analysis↗
PubMed2004

A risk-adjusted approach to comparing the return on investment in health care programs.

The league table approach to rank ordering health care programs according to the incremental cost-effectiveness ratio is a common method to guide policy makers in setting priorities for resource allocation. In the presence of uncertainty, however, ranking programs is complicated by the degree of variability associated with each program. Confidence intervals for cost-effectiveness ratios may be overlapping. Moreover, confidence intervals may include negative ratios and the interpretation of negative cost-effectiveness ratios is ambiguous. We suggest to rank mutually exclusive health care programs according to their rate of return which is defined as the net monetary benefit over the costs of the program. However, how does a program with a higher expected return but higher uncertainty compare to a program with a lower expected return but lower risk? In the present paper we propose a risk-adjusted measure to compare the return on investment in health care programs. Financing a health care program is treated as an investment in a risky asset. The risky asset is combined with a risk-free asset in order to construct a combined portfolio. The weights attributed to the risk-free and risky assets are chosen in such a manner that all programs under consideration exhibit the same degree of uncertainty. We can then compare the performance of the individual programs by constructing a risk-adjusted league table of expected returns.

Cost-Benefit Analysis↗
PubMed2004

New evidence on hospital profitability by payer group and the effects of payer generosity.

This study provides (a) new estimates of U.S. hospital profitability by payer group, controlling for hospital characteristics, and (b) evidence about the intensity of care for particular diseases associated with the generosity of the patient's payer and other payers at the same hospital. The conceptual framework is a variant of the well-known model of a local monopolist selling in a segmented market. Effects of two kinds of regulation are considered. The data are taken from hospital accounting reports in four states in FY2000, and detailed discharge summaries from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. The profitability of inpatient care for privately insured patients was found to be about 4% less than for Medicare, but 14% higher than for Medicaid and only 9% higher than for self-pay patients. We found significant direct associations but not external effects of payer generosity on the intensity of care.

Facility Regulation and Control↗
PubMed2004

Deductibles and health care expenditures: empirical estimates of price sensitivity based on administrative data.

OBJECTIVE: To estimate the price sensitivity of demand for health care by analysing the relation between deductibles and expenditures found in an administrative database. DATA: Data are from 100,048 privately insured in the Netherlands. Information is available on expenditures in 1996, demographic variables, deductibles, and both diagnoses from hospitalisations and pharmacy costs for the years 1993-1995. The data are unique because prior pharmacy costs are good predictors of future expenditures while in the three years concerned these costs were covered by a separate national, mandatory insurance scheme. Therefore, these costs are not affected by deductibles and can be seen as excellent proxies for health status, which this study uses to correct for the existing adverse selection with respect to the choice of deductible. METHODS: For the group of insured without deductibles an expenditure model is estimated which is subsequently used to estimate expected expenditures for insurance policies with various levels of deductible. From the difference between actual and expected expenditures the impact of deductibles on expenditures is estimated, and from this price sensitivity. RESULTS: The principal finding is an estimated price elasticity of -0.14. The highest price sensitivity is found for GP care (-0.40) and physiotherapy (-0.32), and the lowest for specialist care (-0.12) and prescription drugs (-0.08); hospital care was hardly affected.

Adult↗
PubMed2004

How did dentists respond to the introduction of global budgets in Taiwan? An evaluation using individual panel data.

In response to the introduction of global budgets, dentists might alter their supply behaviour, changing the number of visits, the amount of expenditure, and the type of services provided. We develop two-way fixed effects models to estimate these effects using a panel data constructed from outpatient dental care expenditures claims from the Taiwanese National Health Insurance system. The availability of a long panel allows us to estimate a "policy effect" for each dentist in the panel. The overall effect of global budgets is to constrain costs but there is evidence of a change in the mix of services. Male and younger dentists have higher policy effects than female and older dentists. Global budgets favour dentists in deprived areas and there is some evidence of increases in the expenditure per visit and the volume of composite resin fillings.

Age Factors↗
PubMed2004

Hospital competition under regulated prices: application to urban health sector reforms in China.

We develop a model of public-private hospital competition under regulated prices, recognizing that hospitals are multi-service firms and that equilibria depend on the interactions of patients, hospital administrators, and physicians. We then use data from China to calibrate a simulation model of the impact of China's recent payment and organizational reforms on cost, quality and access. Both the analytic and simulation results show how providing implicit insurance through distorted prices leads to over/under use of services by profitability, which in turn fuels cost escalation and reduces access for those who cannot afford to self-pay for care. Simulations reveal the benefits of mixed payment and expanded insurance cover for mitigating these distortions.

China↗
PubMed2004

A simulation model of hospital management based on cost accounting analysis according to disease.

Since a little before 2000, hospital cost accounting has been increasingly performed at Japanese national university hospitals. At Kumamoto University Hospital, for instance, departmental costs have been analyzed since 2000. And, since 2003, the cost balance has been obtained according to certain diseases for the preparation of Diagnosis-Related Groups and Prospective Payment System. On the basis of these experiences, we have constructed a simulation model of hospital management. This program has worked correctly at repeated trials and with satisfactory speed. Although there has been room for improvement of detailed accounts and cost accounting engine, the basic model has proved satisfactory. We have constructed a hospital management model based on the financial data of an existing hospital. We will later improve this program from the viewpoint of construction and using more various data of hospital management. A prospective outlook may be obtained for the practical application of this hospital management model.

Accounting↗
PubMed2003

Pharmacoeconomics of mild cognitive impairment.

There is little written about the pharmacoeconomics of mild cognitive impairment (MCI), particularly with regard to intervention. The aim of the paper is to highlight methodological issues and to present some results that are of importance when drug interventions of MCI are discussed. There is a relationship between severity of dementia and costs, but to what extent such results can be extrapolated to MCI is not known. Even if it is logical to consider a postponement of the shift from MCI to dementia as cost effective, this statement must be proven, particularly in light of the insufficient knowledge about the effects of anti-dementia drugs on survival. From the Kungsholmen project in Sweden, there are indications that the postponement between MCI and manifest dementia may result in short-term benefits (a few years) of about SEK50,000 (5300 US dollars).

Canada↗
PubMed2000

Efficiency in provision of public dental services in Norway.

The paper examines productivity in the provision of public dental services in Norway. The main responsibility of the public dental services is to provide care for all children up to 18 years of age. Most dental care is provided by public dental officers. Productivity was measured by estimating a stochastic production frontier from input and output data from the public dental service in Norway. The results indicate that there are increasing returns to scale. Our measure of technical efficiency showed that the level of inefficiency is fairly small. However, the inefficiency is greater when estimated from a deterministic production frontier rather than from a stochastic frontier. One limitation of the present methodology is that it does not say anything about the level of efficiency in the Norwegian public dental service in absolute terms. A greater level of inefficiency would have been identified if a few counties had performed clearly better than the rest.

Adolescent↗
PubMed2000

The efficiency of the community dental service in England: a data envelopment analysis.

OBJECTIVES: To assess the efficiency with which health authorities' Community Dental Services provide dental care in England. METHODS: A data envelopment analysis of inputs (hours worked by dental officers, therapists, hygienists and others) and outputs (screening, treatment, prevention) of the Community Dental Service (CDS) was conducted. Relative efficiency ratings of the CDS by health authority were further analysed in order to identify external factors which effect efficiency and are outside the control of the Community Dental Service. RESULTS: The relative efficiency of the CDS varies widely in England--on average the CDS is operating at 75% of efficient levels compared to best-practice services. This could not be explained by plausible factors outside the CDS's control, such as differences in deprivation and urban-rural differences between health authorities. CONCLUSIONS: These results, if validated by further studies, should be disturbing since many Community Dental Services services appear to be under-performing. However, this data-driven study could not uncover the detailed context of an individual service's performance. A useful next step would be detailed case-studies of several "star" and under-performing services to search for deeper reasons underpinning relative performance levels.

Benchmarking↗
PubMed2006

Small company mergers--good for whom?

An analysis of 105 mergers among small UK biotech companies over a 10-year period shows that the improvement of shareholder positions, rather than product pipelines or business opportunities, is the main motivation for such transactions.

Biotechnology↗
PubMed1999

A model for analysing the cost of autologous peripheral blood progenitor cell (PBPC) transplantation.

Data from autologous peripheral blood progenitor cell (PBPC) transplant recipients were used for cost analysis and modelling so as to link the main intervention procedures and clinical events to resource use and costs. This cohort consisted of 64 patients from 4 to 62 years old at transplantation (mean, 36.9 years) who underwent a first transplant between August 1994 and May 1997. The main indications for transplantation were non-Hodgkin's lymphomas (47%), multiple myeloma (30%) and Hodgkin's lymphomas (15%). The course of a patient during the whole transplant procedure was modelled using a Markov chain of six states of health: (1) mobilisation and recovery of PBPC; (2) post-mobilisation phase; (3) conditioning and transplant; (4) critical haematological reconstitution; (5) non-critical haematological reconstitution; (6) death. The probability of transition between the different health states, together with the estimated costs, were the input for the Markov model. The model also managed transition probabilities depending both on the current health state and on various demographic, clinical and procedure-related covariates unique to the patient. The expected time spent in each clinical state and the expected total cost were, therefore, estimated. This analysis gave an actual total cost per transplanted patient of $26,600 (95% range: $24,700 to $43,500) while mean duration was 197 days. The expenses for in-hospital stay accounted for 80% of the costs. Both the probability of staying in the different states, and the consequent cost were dependent on the number of CD34-positive cells collected, the phase and the type of the disease, the subset of patients (either children or adults), and the post-transplant G-CSF prophylaxis. The sensitivity of the estimates to alternative assumptions was studied, and the method of comparing alternative future scenarios by the model was explored.

Adolescent↗
PubMed2006

Using contrast sensitivity to estimate the cost-effectiveness of verteporfin in patients with predominantly classic age-related macular degeneration.

AIMS: To re-evaluate the cost-effectiveness of photodynamic therapy with verteporfin (Visudyne, Novartis AG, Switzerland) in patients with predominantly classic and classic choroidal neovascularization (CNV) owing to age-related macular degeneration (AMD), using new evidence on the impact of contrast sensitivity on health status. METHOD: A health economic model is used to synthesise the evidence on contrast sensitivity and treatment rates from the TAP Investigation with health state utilities and costs. Impairment of visual function is estimated using a Markov model to predict transitions between states of contrast sensitivity. Each state is associated with costs and a health state utility. Total expected costs and benefits for a cohort of patients over a defined number of cycles are calculated. The expected health state utility for each disease state was estimated using results from a study of 209 patients with AMD in Sheffield. The model includes the costs associated with treatment and monitoring in the verteporfin treatment arm and costs offset by delaying the deterioration of visual function. RESULTS: Beyond 3 years, the annual costs of the verteporfin arm are estimated to be less than the annual costs of the control arm, owing to the cost associated with higher blindness prevalence in the control arm. Over time, the results show that both the incremental utility and cost decreases. By 10 years, the estimated incremental cost-effectiveness is approximately pound20 996 per Quality-Adjusted Life Years. CONCLUSION: The results of this study suggest that the verteporfin therapy in the treatment for patients with predominantly classic and classic CNV owing to AMD is encouraging.

Aged↗
PubMed2006

A new approach to assessing the health benefit from obesity interventions in children and adolescents: the assessing cost-effectiveness in obesity project.

OBJECTIVE: To report on a new modelling approach developed for the assessing cost-effectiveness in obesity (ACE-Obesity) project and the likely population health benefit and strength of evidence for 13 potential obesity prevention interventions in children and adolescents in Australia. METHODS: We used the best available evidence, including evidence from non-traditional epidemiological study designs, to determine the health benefits as body mass index (BMI) units saved and disability-adjusted life years (DALYs) saved. We developed new methods to model the impact of behaviours on BMI post-intervention where this was not measured and the impacts on DALYs over the child's lifetime (on the assumption that changes in BMI were maintained into adulthood). A working group of stakeholders provided input into decisions on the selection of interventions, the assumptions for modelling and the strength of the evidence. RESULTS: The likely health benefit varied considerably, as did the strength of the evidence from which that health benefit was calculated. The greatest health benefit is likely to be achieved by the 'Reduction of TV advertising of high fat and/or high sugar foods and drinks to children', 'Laparoscopic adjustable gastric banding' and the 'multi-faceted school-based programme with an active physical education component' interventions. CONCLUSIONS: The use of consistent methods and common health outcome measures enables valid comparison of the potential impact of interventions, but comparisons must take into account the strength of the evidence used. Other considerations, including cost-effectiveness and acceptability to stakeholders, will be presented in future ACE-Obesity papers. Information gaps identified include the need for new and more effective initiatives for the prevention of overweight and obesity and for better evaluations of public health interventions.

Adolescent↗