A strategy for accurate collection of incremental cost data for cost-effectiveness analyses in field trials. Pawtucket's minimal contact cholesterol education intervention

With many community field trials or education interventions, the cost-effectiveness analyses are not given a high priority. However, this type of evaluation is important for purposes of future adoption of the intervention. The accurate measurement of costs can best be served by prospective collection of data. This article describes a methodology for collection of cost data that coincides with the intervention implementation. This cost analysis strategy has seven discrete steps. The Minimal Contact Education for Cholesterol Change study is used as an example of the use of this strategy. This intervention provides cholesterol education at six different levels of intensity at four different sectors. The intensity levels vary along a continuum from very little education input to a maximum level of intervention that might be practical in a screening setting. The cost-effectiveness analysis component of the study will identify the incremental cost-effectiveness of each intervention along the continuum.     

Cost-benefit and cost-effectiveness analysis of drug abuse treatment services

The foundations of cost-benefit analysis and cost-effectiveness analysis (CB/CEA) for drug abuse treatment are developed. An economic model of addict choice and drug markets is presented. This model is synthesized with the current "cost of illness" methods used to measure the burden of the disease to society. The problem of doing cost-effectiveness studies in the presence of large nonhealth benefits is examined, and guidance is offered to clinical studies with a cost-effectiveness component or to stand-alone cost-effectiveness studies. References and an extensive bibliography on drug abuse treatment-related CB/CEA studies are appended.     

Should we provide oral health training for staff caring for people with intellectual disabilities in community based residential care? A cost-effectiveness analysis

Oral health training is often introduced into community-based residential settings to improve the oral health of people with intellectual disabilities (ID). There is a lack of appropriate evaluation of such programs, leading to difficulty in deciding how best to allocate scarce resources to achieve maximum effect. This article reports an economic analysis of one such oral health program, undertaken as part of a cluster randomized controlled trial. Firstly, we report a cost-effectiveness analysis of training care-staff compared to no training, using incremental cost-effectiveness ratios (ICERs). Effectiveness was measured as change in knowledge, reported behaviors, attitude and self-efficacy, using validated scales (K&BAS). Secondly, we costed training as it was scaled up to include all staff within the service provider in question. Data were collected in Dublin, Ireland in 2009. It cost between €7000 and €10,000 more to achieve modest improvement in K&BAS scores among a subsample of 162 care-staff, in comparison to doing nothing. Considering scaled up first round training, it cost between €58,000 and €64,000 to train the whole population of staff, from a combined dental and disability service perspective. Less than €15,000–€20,000 of this was additional to the cost of doing nothing (incremental cost). From a dental perspective, a further, second training cycle including all staff would cost between €561 and €3484 (capital costs) and €5815 (operating costs) on a two yearly basis. This study indicates that the program was a cost-effective means of improving self-reported measures and possibly oral health, relative to doing nothing. This was mainly due to low cost, rather than the large effect. In this instance, the use of cost effectiveness analysis has produced evidence, which may be more useful to decision makers than that arising from traditional methods of evaluation. There is a need for CEAs of effective interventions to allow comparison between programs. Suggestions to reduce cost are presented.     

CURBSIDE RECYCLING IN THE PRESENCE OF ALTERNATIVES

We measure the extent to which curbside access affects quantity recycled. We use novel data to distinguish between new recycling and material diverted from other recycling modes. We find that the marginal impact of expanding curbside programs on total recycled quantities is small, in part because curbside programs significantly cannibalize returns from drop-off recycling centers. Failure to account for cannibalization from other modes may substantially overestimate the benefits of curbside programs. We conclude with simple cost-effectiveness comparisons. Results suggest that incremental expansion of curbside access may not be cost-effective. ( JEL Q53, Q58, H72)     

Cost-effectiveness analysis of the New South Wales adult drug court program

In New South Wales, Australia, a cost-effectiveness evaluation was conducted of an adult drug court (ADC) program as an alternative to jail for criminal offenders addicted to illicit drugs. This article describes the program, the cost-effectiveness analysis, and the results. The results of this study reveal that, for the 23-month period of the evaluation, the ADC was as cost-effective as were conventional sanctions in delaying the time to the first offense and more cost-effective in reducing the frequency of offending for those outcome measures selected. Although the evaluation was conducted using the traditional steps of a cost-effectiveness analysis, because of the complexity of the program and data limitations it was not always possible to adhere to textbook procedures. As such, each step involved in undertaking the cost-effectiveness analysis is discussed, highlighting the key issues faced in the evaluation.     

Cost–benefit analysis of a PMTCT program in Mozambique

The costs and benefits of a HIV/AIDS PMTCT program in a Mozambican city were calculated. The provision and non-provision of infant feeding formula were considered, along with voluntary counselling and testing, and anti-retroviral treatment with Nevirapine. Costs were calculated in monetary units and benefits as deaths averted and disability-adjusted life years. The UNAIDS cost-effectiveness tool for evaluating ARV drug and substitute feeding interventions was used. The costs of the program were compared with the costs of treating HIV-infected children. With no infant feeding formula, there would be a total savings of US$5242 and a negative cost per DALY of US$1.53 without infant feeding formula. With formula, net annual costs would be US$141,268 and cost per DALY US$38.69. Citywide, each year 132 infant deaths would be averted by use of Nevirapine and eight averted by the breastmilk replacement program. All program options have reasonable cost-effectiveness ratios.     

INPUT CHOICES UNDER PRICE UNCERTAINTY

Theory shows that, depending on risk preferences and technological parameters, price uncertainty may alter firms' choice of capital intensity. This paper presents an empirical analysis of the effect of price uncertainty on firms' choices of capital and labor stocks. Empirical results from a cross-section of manufacturing industries, as well as within-industries over time, show that greater price uncertainty increases an industry's capital-labor ratio. It appears that risk aversion does not dominate firms' decision making. These empirical findings have implications for the analysis of factor demand and productivity, and capacity utilization rates.     

SIMILARITY JUDGMENTS AND ANOMALIES IN INTERTEMPORAL CHOICE

This article demonstrates that choices based on similarity judgments will exhibit not only common ratio and reflection effects under uncertainty but also common difference and reflection effects in intertemporal contexts.     

A model for a comparative cost-effectiveness evaluation of two mental health partial care programs.

This study provides a model for comparing the cost-effectiveness of two mental health programs. The example cited examines the cost-effectiveness of a hospital-based and a community-based partial care program. Using each group as its own control, the authors compare patients' use of inpatient hospitalisation and emergency room services during one year prior to and one year subsequent to first admission in day care. In both day care programs, patients substantially reduced their number of inpatient admissions and days. Neither program, however, showed a significant decrease in patients' use of the emergency room. Reflecting the substantially lower costs of the community-based program, the benefit-cost and cost-effectiveness ratios were significantly better in the community-based program than in the hospital-based program. Based on this evidence the authors conclude that the lower-cost, equally effective community-based program should be carefully considered as an alternative for more partial care patients.     

Software development for the evaluation of the ergonomic compatibility on the selection of advanced manufacturing technology

Advanced Manufacturing Technology (AMT) is one of the most relevant resources that companies have to achieve competitiveness and best performance. The selection of AMT is a complex problem which involves significant amount of information and uncertainty when multiple aspects must be taken into consideration. Actual models for the selection of AMT are found scarce of the Human Factors and Ergonomics perspective which can lead to a more complete and reliable decision. This paper presents the development of software that enhances the application of an Ergonomic Compatibility Evaluation Model that supports decision making processes taking into consideration ergonomic attributes of designs. Ergonomic Compatibility is a construct used in this model and it is mainly based in the concept of human-artifact compatibility on human compatible systems. Also, an Axiomatic Design approach by the use of the Information Axiom was evolved under a fuzzy environment to obtain the Ergonomic Incompatibility Content. The extension of this axiom for the evaluation of ergonomic compatibility requirements was the theoretical framework of this research. An incremental methodology of four stages was used to design and develop the software that enables to compare AMT alternatives by the evaluation of Ergonomic Compatibility Attributes.     

Cost-effectiveness of family-based substance abuse treatment

In order to compete in a financially sensitive health care system, family systems-based treatments must demonstrate effective clinical results as well as cost-effectiveness. Cost-effectiveness research can demonstrate to health care insurers and policy makers which treatments are viable options for implementation. The present literature review identified eight cost-effectiveness family-based substance abuse treatment studies. The results suggest that certain family-based treatments are cost-effective and warrant consideration for inclusion in health care delivery systems.     

Preference reversals and the analysis of income distributions

It is known from the literature on uncertainty that in cases where individuals express a preference for a high win-probability bet over a bet with high winnings they nevertheless will bid more to obtain the bet with high winnings. We investigate whether a similar phenomenon applies in the parallel social-choice situation. Here decisions are to be made between a distribution with a large group of high-income people and a distribution with a small group of very high-income people. Results from a number of experimental designs are analysed. We are grateful for helpful comments from three referees of this journal, Peter Dolton, Graham Loomes, Dirk Van der gaer and seminar participants at the LSE and the University of Gent. We also thank Guillermo Cruces for computational assistance.     

Noise analysis in professional office chairs

The noise caused by the movement of users on their chairs in the work environment may indicate structural weaknesses and risk, and still significantly reduce productivity by increasing employees stress level. By understanding the activities to be developed in a work place one may understand what should be necessary to a good development, thereafter a search for improvement of labor activity with the aim of better use of resources in the operation of product use may be done. The analysis of the incremental variation of noise in professional chairs aims to identify its origin and the time the emission of noise starts during the period of use, its development and the major causative agents. Determining the characteristics of the sound of different materials and adjustments mechanisms of the chair can determine how different materials interact with each other. The measurement of these noises in an acoustic isolated room using directional microphones, if recorded and analyzed properly makes it possible to investigate and orientate to suspect elements in order to propose solutions and identify the quality of other similar chairs. Based on the results recommendations can be established for the orientation of users, managers and people responsible for the acquisition of the products, inducing them to review the employment of materials and the choice of the processes of production. These aspects are not covered in the Brazilian ergonomics norms and standards in the use of chairs.     

The Uneconomic Growth of Computing

A variety of models have been posited to account for the diffusion of computing technologies; the most widely accepted of these posits the cost-effectiveness of computing as the key inducement to investment in the technology. Alternative models stress less strictly rational considerations. These models have strikingly different implications for the repercussions of computing on staffing and efficiency in organizations. Other researchers have studied these relationships through cross-sectional analysis of aggregate data, without conclusive result. The panel study presented here pursues these relationships over time within 82 private-sector organizations. The analyses presented here do not support expectations that computerization reduces staffing or increases cost-effectiveness of operations.     

Approaches to caring, essential elements for a quality service and cost-effectiveness in South Africa

By 2010 there will be close to two million orphans in South Africa, mainly as a result of HIV/AIDS. This paper assesses different approaches to the care and support of children orphaned by AIDS and other vulnerable children, as well as the cost-effectiveness of each approach. Using a typology of care and essential elements of care, six approaches are evaluated: informal, non-statutory foster care; community-based support; home-based care; unregistered residential care; statutory adoption and fostering; and statutory residential care. A cost-effectiveness analysis assessed actual programs and the costs of providing a minimum standard of care for the six approaches. High costs are associated with formal models of care. Informal approaches may lack the resources to meet children's rights. Resources should be largely allocated to the more cost-effective, informal, community-based structures, but formal models will still be needed for those children who cannot be placed elsewhere.     

Report on the cost-benefit/effectiveness of treatment at the Johns Hopkins Center for Pathological Gambling

It is mandatory that programs, particularly social programs, generate evidence of efficacy, safety, and cost-effectiveness of the treatment of illness. Thus a study was conducted to determine the cost-effectiveness of treatment of pathological gamblers at the Johns Hopkins Center for Pathological Gambling. This Center provides two types of treatment programs: an intensive residential program, and an out-patient program. Although abstinence is but one measure of the success of these programs, they have demonstrated an 80 percent and 90 percent abstention rate respectively, measured at an average of six months after completion of treatment for the residential programs and after six months while in treatment in the out-patient program. Similar high success rates were obtained for the stabilization, maintenance, and/or restoration of families, initiation and maintenance of restitution, indictments saved by restitution or other plans, and return to employment. Data from the Johns Hopkins Center for Pathological Gambling, indicates the benefit to cost ratio of treatment in excess of 20:1. Pathological gambling not only ranks amongst the most expensive illnesses afflicting society, but also is the least expensive to treat and the most cureable when treated. Without public education, and awareness, and without dollars for treatment and research, untreated pathological gambling will far surpass the costs of other catastrophic illnesses as the latter remain the focus of our health care expenditures while the former is ignored.     

Medical Uncertainty in Students Entering Medical School

Abstract

Uncertainty is a fundamental characteristic of medical practice. Renee Fox described three types of uncertainty: limitations in the body of medical knowledge, incomplete mastery of existing knowledge, and distinguishing between limitations and mastery of knowledge. This investigation administered ten Likert-format questions about uncertainty to 171 incoming medical students at one state medical school Items were reliable over a six week test-retest, and validity was supported by correlations with an Intolerance of Ambiguity scale. Entering students recognized that uncertainty exists in medical knowledge and mastery of medical knowledge. Factor analysis of the ten item uncertainty scale revealed three dimensions: uncertainty of the profession, practice certainty, and growth in uncertainty. No significant differences in the uncertainty items, scale, or factors existed by demographic characteristics or medical specialty preferences. These findings suggest that students are aware of issues surrounding uncertainty in medicine as they begin medical school, but medical uncertainty at this early stage in medical socialization is not sufficiently powerful to be associated with medical specialty preference.     

Financial planning and management of health programmes in India

In this paper, the author deals with the financial planning and control of health programmes in India. The techniques of cost-effectiveness analysis and of performance budgeting are highly useful aids to management for implementation of monitoring and review of performance of the programmes are also essential for gauging the progress.     

Weathering Risk: Uncertainty,Weather Forecasting,and Expertise

Bridging the sociology of uncertainty and weather, this review paper provides a sociological examination of the weather forecasting enterprise in order to illustrate how expert decision makers negotiate high uncertainty. It begins with an outline of the literature on uncertainty and risk, particularly as it regards the modern experience. It then fleshes out and expands the discussion through an examination of weather forecasting practice. The final section reprises the theme of expert decision making under uncertainty, this time focusing on the communication of risk and uncertainty, and it concludes with a few thoughts on the future of the field.     

Social class variation in risk: a comparative analysis of the dynamics of economic vulnerability1

A joint concern with multidimensionality and dynamics is a defining feature of the pervasive use of the terminology of social exclusion in the European Union. The notion of social exclusion focuses attention on economic vulnerability in the sense of exposure to risk and uncertainty. Sociological concern with these issues has been associated with the thesis that risk and uncertainty have become more pervasive and extend substantially beyond the working class. This paper combines features of recent approaches to statistical modelling of poverty dynamics and multidimensional deprivation in order to develop our understanding of the dynamics of economic vulnerability. An analysis involving nine countries and covering the first five waves of the European Community Household Panel shows that, across nations and time, it is possible to identify an economically vulnerable class. This class is characterized by heightened risk of falling below a critical resource level, exposure to material deprivation and experience of subjective economic stress. Cross‐national differentials in persistence of vulnerability are wider than in the case of income poverty and less affected by measurement error. Economic vulnerability profiles vary across welfare regimes in a manner broadly consistent with our expectations. Variation in the impact of social class within and across countries provides no support for the argument that its role in structuring such risk has become much less important. Our findings suggest that it is possible to accept the importance of the emergence of new forms of social risk and acknowledge the significance of efforts to develop welfare states policies involving a shift of opportunities and decision making on to individuals without accepting the ‘death of social class’ thesis.