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PubMed2006

Integrated modelling for river basin management: the influence of temporal and spatial scale in economic models of water allocation.

The increasing use of integrated optimization or simulation models to guide river basin management has placed greater attention on the roles that the temporal and spatial scale of each model play in determining a model's suitability and effectiveness. This is especially the case in "economic" models that incorporate monetary incentives and the optimizing behaviour of economic agents to address decisions about the sources and levels of consumptive and non-consumptive water usage within the basin. With respect to spatial scale, models that aggregate behaviour over entire river basins may prove useful for examining inter-sectoral allocations of water, but are unlikely to provide useful information about how these water allocations influence-and are influenced by-choices of crops or of technologies in irrigation, for example. With respect to temporal scale, very short-run models can illustrate options for water management within an irrigation season should unforeseen water surpluses or deficits arise. Conversely, long-run models can allow adjustment time for investments in machinery, infrastructure and changes in land uses and cropping patterns. The basin management alternatives and choices generated by models on each scale are likely to vary considerably. The paper provides specific illustrative examples from recent models of Alberta's Bow River Basin.

Alberta↗
PubMed2001

An economic model to calculate farm-specific losses due to bovine respiratory disease in dairy heifers.

This paper describes a personal-computer-based model estimating the economic losses associated with clinical bovine respiratory disease in replacement heifers raised on individual dairy farms. The model is based on the partial-budgeting technique, and calculates the losses for two types of the disease separately: calf pneumonia and a seasonal outbreak. Model input includes farm-specific data such as the incidence of bovine respiratory disease, prices, and effects of the disease on the heifers' productivity. The input database was linked directly with the economic model. For all input parameters, default values used are available to the user and can be modified easily. Losses considered by the model include treatment expenditures and costs associated with increased mortality, increased premature culling, reduced growth, reduced fertility and reduced milk production in first lactation. Uncertainty is taken into account for parameters related to disease incidence, mortality and culling.Basic calculations for a typical Dutch dairy farm with 60% of the heifers (<3 months) affected, indicated total annual losses due to pneumonia average 31.2 per heifer present on the farm (range 18.4-57.1). The estimated losses for one seasonal outbreak with heifers up to 15-months old affected were 27.0 per heifer present (range 17.2-43.1). For both BRD types, the model's outcome was most sensitive to the number of heifers affected. Most of the parameters that had a major impact on the total losses were related to treatment or to the effects on the heifers' productivity. The model is user-friendly and flexible, and can be used as an interactive tool by farmers and veterinarians in the (economic) decision-making process regarding on-farm prevention and control of bovine respiratory disease.

Animals↗
PubMed2000

Establishing benchmarks for creation of a pro-forma economic model to evaluate filmless PACS operation.

The purpose of this study was to establish data points (benchmarks) to incorporate into a pro-forma cost analysis model, comparing film-based and filmless modes of operation. Prospective data were collected over a 6-year period at the Baltimore VA Medical Center (BVAMC) immediately before and after implementation of a hospital-wide PACS. These data were in turn compared with local and national VA centers during comparable time periods, to establish reference data between manual film-based (without PACS) and filmless operations (using PACS). Benchmarks utilized for the study fell into 2 broad categories: operational costs and revenues generated. Factors contributing to operational costs include space requirements, equipment, supplies, personnel, and maintenance. Factors contributing to revenues generated included examination volume, modality mix, and reimbursement rates. Collectively, these data points were incorporated into a pro-forma model that allows prospective PACS customers to compare total cost of ownership for film-based and filmless operations dependent on the unique variables of the respective institution.

Benchmarking↗
PubMed1995

Economic modeling to assess the costs of treatment with finasteride, terazosin, and transurethral resection of the prostate for men with moderate to severe symptoms of benign prostatic hyperplasia.

OBJECTIVES: We developed a decision analytic model to compare the costs of treatment for an initial 2-year period with finasteride, terazosin, and transurethral resection of the prostate (TURP) in men with at least moderate symptoms of benign prostatic hyperplasia (BPH). Outcome measures were BPH treatment costs, duration of symptomatic improvement, and lost productivity days (work or other customary activity). METHODS: Patterns of health care resource use associated with the treatment of moderate to severe BPH and BPH-related complications were evaluated by a survey of urologists and validated by a urology consensus panel. BPH safety and efficacy studies in the published literature were used to provide probabilities of treatment success. Both a national health care resource database (Systemetrics) and Medicare data were used to estimate the costs of specific health care services (such as physician services and laboratory tests). RESULTS: The probabilities of first-year success (defined as symptomatic improvement) for surgery, finasteride, and terazosin were 88%, 67%, and 74%, respectively. The most expensive intervention was surgery, followed by finasteride and terazosin, at estimated 24-month costs of $6411, $2860, and $2422 for private insurance and $3874, $2161, and $1820 for Medicare, respectively. Duration of symptom improvement was comparable for the three treatments. Estimates of usual activity days lost (work or other customary activity) were 22, 8, and 8 days for surgery, finasteride, and terazosin, respectively. CONCLUSIONS: As a primary intervention for patients considering conventional clinical approaches to BPH treatment, pharmacotherapy is expected to be less expensive than TURP over the initial 2 years of therapy.

Adrenergic alpha-Antagonists↗
PubMed2002

Cost effectiveness of treatment for benign prostatic hyperplasia: an economic model for comparison of medical, minimally invasive, and surgical therapy.

PURPOSE: To evaluate the cost effectiveness of minimally invasive therapy relative to medical (alpha-blocker) therapy and transurethral resection (TURP) for patients with moderate to severe symptoms of benign prostatic hyperplasia (BPH). METHODS: We constructed a decision-analytic Markov model for a hypothetical cohort of 65-year-old men with moderate to severe BPH symptoms. Microwave thermotherapy was selected to represent minimally invasive treatment. Cost-effectiveness analysis was performed with 25 health states using the 3 treatments, 5 short-term clinical events, and 17 possible long-term outcomes. Each health state had an associated cost and utility. Quality of life (QoL) and utility estimates were obtained by interviewing 13 men with BPH symptoms using the standard gamble reference methods. Patients were classified as risk averse (RA) or non-risk averse (NRA) on the basis of their attitudes to risk. We calculated the incremental cost effectiveness of microwave thermotherapy relative to medical therapy and TURP over 5 years after treatment initiation. Event probabilities were obtained from the literature, a consensus panel, and published randomized clinical trials. RESULTS AND CONCLUSIONS: The utility values generated were internally consistent and externally valid for a hypothetical cohort of 10,000 RA patients. Microwave thermotherapy was preferred by the NRA group, while medical therapy was preferred by the RA group. Surgery was least preferred by both groups. Microwave thermotherapy had a small incremental cost but improved QoL in comparison with medical therapy. Microwave thermotherapy had a higher utility and lower cost than TURP and thus was dominant over TURP. This analytical method can be applied to evaluate the cost effectiveness of any BPH therapy.

Aged↗
PubMed1998

Economic models to help periodontists evaluate their practices: how to analyze a practice to assess the potential impact of managed care contracts.

The purpose of this article is to examine 10 steps analyzing the financial impact on a periodontal practice accepting a proposed managed care dental plan. It is emphasized that this analysis should be conducted before formally agreeing to accept the proposed plan. The procedures for examining the 10 steps include the use of hypothetical data for a periodontal practice confronted with a discounted fee plan. Each step is identified, discussed, and the hypothetical data are used to develop results presented in a set of tables. The steps in the analysis process include constructing a practice profit and loss statement and developing a dataset of practice characteristics and productivity measures. Other estimates should be made of covered lives, new patient utilization, existing patient utilization, utilization of non-covered services, estimating other sources of revenue and expense, and the impact on capacity utilization of operatories and practice staff. Results are presented in a set of analysis tables. The importance of multiple analyses is discussed as is the importance of analyzing the impact on results from changing assumptions. Some of the higher risk variables faced by the practitioner are identified for submission to risk evaluation to examine the sensitivity of results. Finally, the relationship between the proposed plan and the additional time required by the periodontist to meet the plan's specifications is examined in light of the data developed in the 10 steps and the results tables.

Contract Services↗
PubMed2002

Development of an economic model to assess the cost effectiveness of asthma management strategies.

BACKGROUND AND OBJECTIVE: Asthma is a chronic-episodic disease characterised by acute, symptomatic episodes of varying severity. We developed a Markov model that can be used to estimate the cost effectiveness of alternative asthma treatments. Because of the costs they incur, asthma exacerbations ('attacks') requiring intervention by a healthcare professional were a central consideration in the development of the model. METHODS: Treatment success was assessed as asthma control, a composite measure based on goals defined in world-wide asthma management guidelines and in terms of quality-adjusted life-years (QALYs). The data from which the transition probabilities were derived came from patients with asthma who received either salmeterol/fluticasone propionate combination (SFC) 50/100microg or fluticasone propionate (FP) 100microg, administered twice daily via an inhaler, in a 12-week, randomised, double-blind, clinical trial. Costs were estimated from resource profiles defined for each of the model states. A key aspect of the model was the use of probabilistic sensitivity analysis techniques to examine the uncertainty in the cost-effectiveness results. Distributions were fitted to transition probabilities and to cost input parameters and values were sampled at random from these distributions using a second order Monte Carlo simulation technique. This produced a distribution for incremental cost effectiveness that was employed to construct 95% uncertainty intervals and to construct cost effectiveness acceptability curves. RESULTS: In this analysis, the model was run over a 12-week period using transition probabilities derived from the trial data. The results showed that treatment with SFC resulted in a higher proportion of successfully controlled weeks per patient than treatment with FP (66 vs 47%), and higher mean weekly direct asthma management costs (pound sterling 15.77 vs pound sterling 11.83; 2000 values). The average incremental cost per successfully controlled week with SFC was pound sterling 20.83. Probabilistic sensitivity analysis showed that the 95% uncertainty intervals for the incremental cost-effectiveness ratio was - pound sterling 64.94 to pound sterling 112.66. In approximately 25% of cases, SFC was dominant (more effective and less costly), but in the remaining cases, it was both more effective and more costly. It was shown that if decision makers are willing to pay approximately pound sterling 45 for an additional successfully controlled week, SFC will be the more cost-effective strategy in this patient population for 80% of the time. CONCLUSIONS: This is one of the first decision-analytic models of asthma to incorporate probabilistic sensitivity analysis techniques to explore uncertainty. The model's flexible yet standardised framework permits the cost effectiveness of alternative asthma management strategies in different healthcare settings to be established.

Adolescent↗
PubMed2003

Economic model of first-line drug strategies to achieve recommended glycaemic control in newly diagnosed type 2 diabetes mellitus.

OBJECTIVE: To assess the short-term direct medical costs and effectiveness associated with achieving recommended glycaemic goals using commonly prescribed first-line oral antihyperglycaemic medications in type 2 diabetes mellitus. MATERIALS AND METHODS: A literature-based, decision-tree model was developed to project the number of patients achieving glycosylated haemoglobin values of <7% on oral therapies and the associated costs over a 3-year timeframe. For each first-line strategy, patients could progress to combination therapy using two or more agents prior to the introduction of insulin. The overall cost of treatment included costs (2001/2002 values; US dollars) of comprehensive medical care, laboratory tests, patient education, drug therapy, home glucose monitoring and adverse events. RESULTS: At 3 years, the overall cost of treatment for the various first-line strategies was 6,106 US dollars for glipizide gastrointestinal therapeutic system, 6,727 US dollars for metformin immediate release, 6,826 US dollars for metformin extended release, 7,141 US dollars for glibenclamide (glyburide)/metformin, 7,759 US dollars for rosiglitazone and 9,298 US dollars for repaglinide. Costs of comprehensive routine medical care ranged from approximately 1,538-2,128 US dollars in year 1 and from approximately 952-1,543 US dollars in subsequent years, for controlled and uncontrolled patients, respectively. Adverse events represented <1%, and drug therapies represented approximately 50%, of the overall cost, respectively. Substantial cost differences between the strategies were seen within the first year. Regardless of first-line therapy, patients progressed quickly to combination therapies, with effectiveness among the agents being similar. CONCLUSIONS: Short-term costs required to provide comprehensive diabetes care and achieve glycemic goals can be substantial. The model suggests a sulphonylurea strategy may provide similar effectiveness with cost savings over other agents and should be considered when selecting an initial drug therapy in newly diagnosed patients with type 2 diabetes mellitus.

Carbamates↗
PubMed2005

Development of an economic model to assess the cost effectiveness of treatment interventions for chronic obstructive pulmonary disease.

OBJECTIVE: To develop a Markov model that allows the cost effectiveness of interventions in patients with chronic obstructive pulmonary disease (COPD) to be estimated, and to apply the model to investigate the cost effectiveness of an inhaled corticosteroid/long-acting beta(2)-adrenoceptor agonist (beta(2)-agonist) combination (salmeterol/fluticasone propionate) versus usual care. METHODS: A Markov model consisting of four mutually exclusive disease states was constructed (mild, moderate and severe disease, and death). The transition probabilities of disease progression (for smokers and ex-smokers) and death were derived from the published medical literature. The model outputs were costs, exacerbations, survival, QALYs and cost effectiveness. The model was made fully probabilistic to reflect the joint uncertainty in the model parameters. Efficacy data for the combination of inhaled salmeterol/fluticasone propionate 50/500microg twice daily in poorly reversible COPD patients with a history of exacerbations were obtained from the 1-year TRISTAN (TRial of Inhaled STeroids ANd long-acting beta-agonists) study and applied to the model, based on patient profiles representative of COPD clinical trials. RESULTS: According to the model, the mean life expectancy with usual care alone (placebo group) was 8.95 years, which decreased to 4.08 QALYs once adjusted for quality and discounted, at a lifetime discounted cost of Can 16,415 dollars per patient (year 2002 values). Assuming that salmeterol/fluticasone propionate reduced exacerbation frequency only (base case analysis), the estimated mean survival time remained unchanged but there was an increase in the number of QALYs (4.21) for an estimated lifetime cost of Can 25,780 dollars, resulting in a cost-effectiveness ratio of Can 74,887 dollars per QALY (95% CI 21,985, 128,671) versus usual care. If a survival benefit was assumed for salmeterol/fluticasone propionate, the incremental cost per QALY was Can11,125 dollars (95% CI 8710, dominated) versus usual care. If the combination achieved around a 10% improvement in forced expiratory volume in 1 second, leading to delayed progression to more severe disease states, the benefits translated into an incremental cost per QALY of Can 49,928 dollars (95% CI 37 269, 66,006) versus usual care. CONCLUSIONS: This Markov model allows, for the first time, a means of estimating the long-term cost effectiveness and cost utility of interventions for COPD. Initial evidence suggests that for patients with poorly reversible COPD and a documented history of frequent COPD exacerbations, the addition of salmeterol (a long-acting beta(2)-agonist) to fluticasone propionate (an inhaled corticosteroid) is potentially cost effective from the Canadian healthcare payer's perspective. However, the precision of this estimate will be improved when additional data are available from clinical trials such as the ongoing TORCH (TOwards a Revolution in COPD Health) study.

Adrenergic beta-Agonists↗