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R J Labelle

Publications and source records attributed to R J Labelle.

10 recordsLinked to original sources
PubMed1994

In search of power and significance: issues in the design and analysis of stochastic cost-effectiveness studies in health care.

Application of techniques such as cost-effectiveness analysis (CEA) is growing rapidly in health care. There are two general approaches to analysis: deterministic models based upon assumptions and secondary analysis of retrospective data, and prospective stochastic analyses in which the design of a clinical experiment such as randomised controlled trial is adapted to collect patient-specific data on costs and effects. An important methodological difference between these two approaches is in the quantification and analysis of uncertainty. Whereas the traditional CEA model utilizes sensitivity analysis, the mean-variance data on costs and effects from a prospective trial presents the opportunity to analyze cost-effectiveness using conventional inferential statistical methods. In this study we explored some of the implications of moving economic appraisal away from deterministic models and toward the experimental paradigm. Our specific focus was on the feasibility and desirability of constructing statistical tests of economic hypotheses and estimation of cost-effectiveness ratios with associated 95% confidence intervals. We show how relevant variances can be estimated for this task and discuss the implications for the design and analysis of prospective economic studies.

Confidence Intervals↗
PubMed1992

Implications of basing health-care resource allocations on cost-utility analysis in the presence of externalities.

Cost-utility analysis is increasingly being advocated as a tool for helping to establish funding priorities among programs and services in the health-care sector. As currently conducted, however, cost-utility analysis is problematic as a basis for achieving allocative efficiency because it excludes externalities. The exclusion of externalities may bias program ranking in unpredictable ways, leading to a non-optimal allocation of resources. Consideration of externalities also raises a number of distributional issues for the evaluation of health services and highlights the important of developing economic evaluation methods that are consistent with the conceptual basis for allocating resources.

Canada↗
PubMed1989

Controlling health expenditures--the Canadian reality.

Canada and the United States have conducted a large-scale social experiment on the effects of alternative ways of funding expenditures for health care. Two very similar societies, with (until recently) very similar systems of providing health care, have adopted radically different systems of reimbursement. The results of this experiment are of increasing interest to Americans, because the Canadian approach has avoided or solved several of the more intractable problems facing the United States. In particular, overall health expenditures have been constrained to a stable share of national income, and universality of coverage (without user charges) eliminates the problems of uncompensated care, individual burdens of catastrophic illness, and uninsured populations. The combination of cost control with universal, comprehensive coverage has surprised some American observers, who have questioned its reality, its sustainability, or both. We present a comparison of the Canadian and American data on expenditures, identifying the sectors in which the experience of the two nations diverges most, and describing the processes of control. In any system, cost control involves conflict between providers and payers. Political processes focus this conflict, whereas market processes diffuse it. But the stylized political combat in Canada may result in less intrusion on the professional autonomy of the individual physician than is occurring in the United States.

Attitude of Health Personnel↗
PubMed1989

Do physicians induce demand for medical services?

In this paper we provide a critique of an article by Roger Feldman and Frank Sloan that appeared in the Summer 1988 issue of this journal. In that article, the authors contend that there is little evidence to support the notion of supplier-induced demand or the contention that physicians generate demand to avoid the impact on their incomes of government price controls. In this critique, we argue that the evidence on supplier-induced demand and physician responses to price controls does not support the conclusions drawn by Feldman and Sloan. We conclude with a discussion of the implications of the debate for policy formulation and future research.

Canada↗
PubMed1988

Fee controls as cost control: tales from the frozen North.

Uniform and binding fee schedules for physicians have been advanced as a cost-control strategy that can also improve patient access to care, as well as spread costs more equitably. Counter-arguments, however, predict very different effects on utilization and costs. Empirical evidence to challenge economic theories of physician behavior may be drawn from Canada. The experience of innovative policies of two provinces--within a national framework--emphasizes a multipronged approach to fees, practice patterns, and numbers of physicians; political will and ongoing negotiations are necessary.

British Columbia↗
PubMed1987

Economic evaluation of extracorporeal shock wave lithotripsy, percutaneous ultrasonic lithotripsy, and standard surgical treatment of urolithiasis--a Canadian perspective.

In order to provide information for decision making regarding urolithiasis treatment programs for the population of the Central West Region (population 1.8 million) of Ontario, we conducted an incremental cost-effectiveness analysis of standard surgery, percutaneous ultrasonic lithotripsy, and extracorporeal shock wave lithotripsy for the removal of renal and ureteric stones. Estimates of costs and effects were calculated for a 5-year period, beginning in 1985. Direct medical costs estimated were fees, both professional and technical, operating costs, and hospitalization costs for standard surgery, percutaneous ultrasonic lithotripsy, and extracorporeal shock wave lithotripsy. Capital costs, opportunity costs, and depreciation were included for extracorporeal shock wave lithotripsy, but not for standard surgery or percutaneous ultrasonic lithotripsy, thus creating a bias against extracorporeal shock wave lithotripsy. All costs were expressed in 1985 Canadian dollars; both costs and effects from years 2-5 were discounted using a rate of 5%. The effects estimated were disability days. Failure rates, complication rates, length of hospital stay, and disability days were median values reported in the medical literature. Assuming 400 procedures per year (based on previous experience in the Central West Region), the total 5-year costs in millions of dollars, were 8.86 for standard surgery, 7.84 for extracorporeal shock wave lithotripsy, and 7.51 for percutaneous ultrasonic lithotripsy. Costs per procedure were 4,429 for standard surgery, 3,918 for extracorporeal shock wave lithotripsy, and 3,756 for percutaneous ultrasonic lithotripsy. The total disability days generated were 69,098 for standard surgery, 18,184 for percutaneous ultrasonic lithotripsy, and 9,092 for extracorporeal shock wave lithotripsy. Because standard surgery costs more and generates more disability days than either percutaneous ultrasonic lithotripsy or extracorporeal shock wave lithotripsy, it is clearly the least desirable alternative. At 400 procedures per year, the cost of each disability day averted by extracorporeal shock wave lithotripsy, compared to percutaneous ultrasonic lithotripsy, is $35.60. At 500 procedures per year, extracorporeal shock wave lithotripsy costs less and generates fewer disability days than percutaneous ultrasonic lithotripsy and is therefore the desired alternative. Sensitivity analyses demonstrate that cost effectiveness results are most affected by the number of procedures performed, the length of stay, and the number of disability days generated.

Cost-Benefit Analysis↗
PubMed1986

Tobacco taxes and health care costs. Do Canadian smokers pay their way?

Through their health care utilization, smokers are generally perceived to be imposing a financial externality on non-smokers within health insurance systems. To investigate the empirical basis for this view, we estimated publicly financed health care expenditure attributable to smoking for the Canadian province of Ontario and compared it to tobacco taxes paid by Ontario smokers. Both initial estimates and the results of sensitivity analyses performed on key assumptions and parameters of the estimation methodology rejected the hypothesized existence of a financial externality arising from smokers' health care utilization.

Cost-Benefit Analysis↗
PubMed1985

Cost-effectiveness in the diagnosis and treatment of carcinoma of unknown primary origin.

Between 2% and 9% of patients with cancer present with metastatic nonsquamous cell carcinoma of unknown primary origin. Traditionally, a series of investigations is undertaken to locate the primary origin of the tumour, although many of these tests are often painful or distressing to patients, unsuccessful in locating the primary site and costly to the health care system. Moreover, even if a tumour is found it usually cannot be treated surgically. However, a small number of cancers of unknown primary origin can be cured, arrested or effectively palliated with systemic treatment. This study compares the costs and outcomes of the current practice of comprehensively searching for the primary tumour with those of an alternative, limited approach that identifies only the primary tumours for which relatively effective systemic therapy exists. Decision trees were constructed for the two diagnostic approaches and their associated therapeutic options. Costs and probabilities were integrated with published data on the survival of patients with each type of cancer. The results indicate that the comprehensive diagnostic strategy may increase 1-year survival rates from 11.0% to 11.5%. On the basis of Ontario cost data it is calculated that the additional costs of a comprehensive search for 1000 patients will range from approximately $2 million to $8 million, depending on the subsequent treatment strategy.

Carcinoma↗