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Cuddington K, McAuliffe WHB. Optimising rabies vaccination of dogs in India. Epidemiol Infect 2023; 151:e164. [PMID: 37606523 PMCID: PMC10600733 DOI: 10.1017/s0950268823001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/27/2023] [Accepted: 08/13/2023] [Indexed: 08/23/2023] Open
Abstract
Dog vaccination is the key to controlling rabies in human populations. However, in countries like India, with large free-roaming dog populations, vaccination strategies that rely only on parenteral vaccines are unlikely to be either feasible or successful. Oral rabies vaccines could be used to reach these dogs. We use cost estimates for an Indian city and linear optimisation to find the most cost-effective vaccination strategies. We show that an oral bait handout method for dogs that are never confined can reduce the per dog costs of vaccination and increase vaccine coverage. This finding holds even when baits cost up to 10x the price of parenteral vaccines, if there is a large dog population or proportion of dogs that are never confined. We suggest that oral rabies vaccine baits will be part of the most cost-effective strategies to eliminate human deaths from dog-mediated rabies by 2030.
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Affiliation(s)
- Kim Cuddington
- Department of Biology, University of Waterloo, Waterloo, ON, Canada
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Kwon J, Squires H, Franklin M, Young T. Systematic review and critical methodological appraisal of community-based falls prevention economic models. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:33. [PMID: 35842721 PMCID: PMC9287934 DOI: 10.1186/s12962-022-00367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 07/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Falls impose significant health and economic burdens on community-dwelling older persons. Decision modelling can inform commissioning of alternative falls prevention strategies. Several methodological challenges arise when modelling public health interventions including community-based falls prevention. This study aims to conduct a systematic review (SR) to: systematically identify community-based falls prevention economic models; synthesise and critically appraise how the models handled key methodological challenges associated with public health modelling; and suggest areas for further methodological research. METHODS The SR followed the 2021 PRISMA reporting guideline and covered the period 2003-2020 and 12 academic databases and grey literature. The extracted methodological features of included models were synthesised by their relevance to the following challenges: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering equity issues. The critical appraisal assessed the prevalence of each feature across models, then appraised the methods used to incorporate the feature. The methodological strengths and limitations stated by the modellers were used as indicators of desirable modelling practice and scope for improvement, respectively. The methods were also compared against those suggested in the broader empirical and methodological literature. Areas of further methodological research were suggested based on appraisal results. RESULTS 46 models were identified. Comprehensive incorporation of non-health outcomes and societal intervention costs was infrequent. The assessments of heterogeneity and dynamic complexity were limited; subgroup delineation was confined primarily to demographics and binary disease/physical status. Few models incorporated heterogeneity in intervention implementation level, efficacy and cost. Few dynamic variables other than age and falls history were incorporated to characterise the trajectories of falls risk and general health/frailty. Intervention sustainability was frequently based on assumptions; few models estimated the economic/health returns from improved implementation. Seven models incorporated ethnicity- and severity-based subgroups but did not estimate the equity-efficiency trade-offs. Sixteen methodological research suggestions were made. CONCLUSION Existing community-based falls prevention models contain methodological limitations spanning four challenge areas relevant for public health modelling. There is scope for further methodological research to inform the development of falls prevention and other public health models.
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Affiliation(s)
- Joseph Kwon
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Hazel Squires
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Matthew Franklin
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
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Hynninen Y, Vilkkumaa E, Salo A. Operationalization of Utilitarian and Egalitarian Objectives for Optimal Allocation of Health Care Resources. DECISION SCIENCES 2021. [DOI: 10.1111/deci.12448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Yrjänä Hynninen
- Systems Analysis Laboratory Department of Mathematics and Systems Analysis Aalto University School of Science P.O.Box 11100 Aalto 00076 Finland
| | - Eeva Vilkkumaa
- Department of Information and Service Management Aalto University School of Business (EV) P.O.Box 11100 Aalto 00076 Finland
| | - Ahti Salo
- Systems Analysis Laboratory Department of Mathematics and Systems Analysis Aalto University School of Science P.O.Box 11100 Aalto 00076 Finland
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Optimal Allocation of Chemotherapy Schemes for Metastatic Colon Cancer in Colombia. Value Health Reg Issues 2021; 26:105-112. [PMID: 34166882 DOI: 10.1016/j.vhri.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/10/2020] [Accepted: 01/16/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study aims to determine the optimal proportion for different chemotherapy schemes in patients with metastatic colorectal cancer who have undergone surgical resection in Colombia. METHODS A linear programming model was used to quantify the optimal proportion of the chemotherapy schemes that maximize quality-adjusted life-years (QALYs). The model was evaluated in 6 different scenarios using parametric and dynamic optimization with different budget restriction constraints. The results were compared to the current mixture of schemes used in our country. RESULTS The results show that 63%, 37%, and 0.8% of the population should receive the FOLFOXIRI scheme (fluorouracil + leucovorin + oxaliplatin + irinotecan), FOLFIRI (irinotecan + leucovorin + fluorouracil), and FOLFIRI plus cetuximab, respectively. With these proportions, 8734 QALYs and universal coverage of the population are obtained. In an optimistic scenario (high QALYs, low costs, and budget of $40 million), the entire population should receive the FOLFIRI scheme. A pessimistic scenario (low QALYs, high costs, and budget of $15 million) would benefit only 46% of the population with the fluorouracil plus leucovorin scheme. In the other 3 scenarios with higher budget constraints, 52%, 69%, and 86% of the population should receive FOLFIRI, respectively. Dynamic optimization revealed that FOLFIRI and FOLFOX (oxaliplatin + leucovorin + fluorouracil) schemes are more likely to generate higher QALYs with lower costs and a limited budget. CONCLUSIONS The current use of chemotherapy schemes is not optimal. An increasing proportion of FOLFIRI, FOLFOX, and FOLFOXIRI should be used more often as schemes to treat metastatic colorectal cancer in Colombia.
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Knerer G, Currie CSM, Brailsford SC. Reducing dengue fever cases at the lowest budget: a constrained optimization approach applied to Thailand. BMC Public Health 2021; 21:807. [PMID: 33906628 PMCID: PMC8080389 DOI: 10.1186/s12889-021-10747-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/25/2021] [Indexed: 01/08/2023] Open
Abstract
Background With the challenges that dengue fever (DF) presents to healthcare systems and societies, public health officials must determine where best to allocate scarce resources and restricted budgets. Constrained optimization (CO) helps to address some of the acknowledged limitations of conventional health economic analyses and has typically been used to identify the optimal allocation of resources across interventions subject to a variety of constraints. Methods A dynamic transmission model was developed to predict the number of dengue cases in Thailand at steady state. A CO was then applied to identify the optimal combination of interventions (release of Wolbachia-infected mosquitoes and paediatric vaccination) within the constraints of a fixed budget, set no higher than cost estimates of the current vector control programme, to minimize the number of dengue cases and disability-adjusted life years (DALYs) lost. Epidemiological, cost, and effectiveness data were informed by national data and the research literature. The time horizon was 10 years. Scenario analyses examined different disease management and intervention costs, budget constraints, vaccine efficacy, and optimization time horizon. Results Under base-case budget constraints, the optimal coverage of the two interventions to minimize dengue incidence was predicted to be nearly equal (Wolbachia 50%; paediatric vaccination 49%) with corresponding coverages under lower bound (Wolbachia 54%; paediatric vaccination 10%) and upper bound (Wolbachia 67%; paediatric vaccination 100%) budget ceilings. Scenario analyses indicated that the most impactful situations related to the costs of Wolbachia and paediatric vaccination with decreases/ increases in costs of interventions demonstrating a direct correlation with coverage (increases/ decreases) of the respective control strategies under examination. Conclusions Determining the best investment strategy for dengue control requires the identification of the optimal mix of interventions to implement in order to maximize public health outcomes, often under fixed budget constraints. A CO model was developed with the objective of minimizing dengue cases (and DALYs lost) over a 10-year time horizon, within the constraints of the estimated budgets for vector control in the absence of vaccination and Wolbachia. The model provides a tool for developing estimates of optimal coverage of combined dengue control strategies that minimize dengue burden at the lowest budget. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10747-3.
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Affiliation(s)
- Gerhart Knerer
- Mathematical Sciences, University of Southampton, Highfield, Southampton, SO17 1BJ, UK.
| | - Christine S M Currie
- Mathematical Sciences, University of Southampton, Highfield, Southampton, SO17 1BJ, UK
| | - Sally C Brailsford
- Southampton Business School, University of Southampton, Highfield, Southampton, SO17 1BJ, UK
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Standaert B, Van Vlaenderen I, Van Bellinghen LA, Talbird S, Hicks K, Carrico J, Buck PO. Constrained Optimization for the Selection of Influenza Vaccines to Maximize the Population Benefit: A Demonstration Project. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:519-531. [PMID: 31755016 PMCID: PMC7347519 DOI: 10.1007/s40258-019-00534-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Influenza is an infectious disease causing a high annual economic and public health burden. The most efficient management of the disease is through prevention with vaccination. Many influenza vaccines are available, with varying efficacy and cost, targeting different age groups. Therefore, strategic decision-making about which vaccine to deliver to whom is warranted to improve efficiency. OBJECTIVE We present the use of a constrained optimization (CO) model to evaluate targeted strategies for providing influenza vaccines in three adult age groups in the USA. METHODS CO was considered for identifying an influenza vaccine provision strategy that maximizes the benefits at constrained annual budgets, by prioritizing vaccines based on return on investment. The approach optimizes a set of predefined outcome measures over several years resulting from an increasing investment using the best combination of influenza vaccines. RESULTS Results indicate the importance of understanding the relative differences in benefits for each vaccine type within and across age groups. Scenario and threshold analyses demonstrate the impact of changing budget distribution over time, price setting per vaccine type, and selection of outcome measure to optimize. CONCLUSION Significant gains in cost efficiency can be realized for a decision maker using a CO model, especially for a disease like influenza with many vaccine options. Testing the model under different scenarios offers powerful insights into maximum achievable benefit overall and per age group within the predefined constraints of a vaccine budget.
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Siegel KR, Ali MK, Zhou X, Ng BP, Jawanda S, Proia K, Zhang X, Gregg EW, Albright AL, Zhang P. Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008? Diabetes Care 2020; 43:1557-1592. [PMID: 33534729 DOI: 10.2337/dci20-0017] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/03/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.
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Affiliation(s)
- Karen R Siegel
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mohammed K Ali
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,Hubert Department of Global Health and Department of Family and Preventive Medicine, Emory University, Atlanta, GA
| | - Xilin Zhou
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Boon Peng Ng
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,College of Nursing and Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL
| | - Shawn Jawanda
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Krista Proia
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xuanping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann L Albright
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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Stuart RM, Khan O, Abeysuriya R, Kryvchun T, Lysak V, Bredikhina A, Durdykulyieva N, Mykhailets V, Kaidashova E, Doroshenko O, Shubber Z, Wilson D, Zhao F, Fraser-Hurt N. Diabetes care cascade in Ukraine: an analysis of breakpoints and opportunities for improved diabetes outcomes. BMC Health Serv Res 2020; 20:409. [PMID: 32393341 PMCID: PMC7212677 DOI: 10.1186/s12913-020-05261-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022] Open
Abstract
Background Diabetes is one of the leading causes of poor health and high care costs in Ukraine. To prevent diabetes complications and alleviate the financial burden of diabetes care on patients, the Ukrainian government reimburses diabetes medication and provides glucose monitoring, but there are significant gaps in the care continuum. We estimate the costs of providing diabetes care and the most cost-effective ways to address these gaps in the Poltava region of Ukraine. Methods We gathered data on the unit costs of diabetes interventions in Poltava and estimated expenditure on diabetes care. We estimated the optimal combination of facility-based and outreach screening and investigated how additional funding could best be allocated to improve glucose control outcomes. Results Of the ~ 40,000 adults in diabetes care, only ~ 25% achieved sustained glucose control. Monitoring costs were higher for those who did not: by 10% for patients receiving non-pharmacological treatment, by 61% for insulin patients, and twice as high for patients prescribed oral treatment. Initiatives to improve treatment adherence (e.g. medication copayment schemes, enhanced adherence counseling) would address barriers along the care continuum and we estimate such expenditures may be recouped by reductions in patient monitoring costs. Improvements in case detection are also needed, with only around two-thirds of estimated cases having been diagnosed. Outreach screening campaigns could play a significant role: depending on how well-targeted and scalable such campaigns are, we estimate that 10–46% of all screening could be conducted via outreach, at a cost per positive patient identified of US$7.12–9.63. Conclusions Investments to improve case detection and treatment adherence are the most efficient interventions for improved diabetes control in Poltava. Quantitative tools provide essential decision support for targeting investment to close the gaps in care.
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Affiliation(s)
- Robyn Margaret Stuart
- Department of Mathematical Sciences, University of Copenhagen, Universitetsparken 5, København Ø, 2300, Copenhagen, Denmark.
| | - Olga Khan
- The World Bank Group, Washington, DC, USA
| | | | | | | | | | | | | | | | | | | | | | - Feng Zhao
- The World Bank Group, Washington, DC, USA
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Stuart RM, Grobicki L, Haghparast-Bidgoli H, Panovska-Griffiths J, Skordis J, Keiser O, Estill J, Baranczuk Z, Kelly SL, Reporter I, Kedziora DJ, Shattock AJ, Petravic J, Hussain SA, Grantham KL, Gray RT, Yap XF, Martin-Hughes R, Benedikt CJ, Fraser-Hurt N, Masaki E, Wilson DJ, Gorgens M, Mziray E, Cheikh N, Shubber Z, Kerr CC, Wilson DP. How should HIV resources be allocated? Lessons learnt from applying Optima HIV in 23 countries. J Int AIDS Soc 2019; 21:e25097. [PMID: 29652100 PMCID: PMC5898225 DOI: 10.1002/jia2.25097] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 03/05/2018] [Indexed: 12/01/2022] Open
Abstract
Introduction With limited funds available, meeting global health targets requires countries to both mobilize and prioritize their health spending. Within this context, countries have recognized the importance of allocating funds for HIV as efficiently as possible to maximize impact. Over the past six years, the governments of 23 countries in Africa, Asia, Eastern Europe and Latin America have used the Optima HIV tool to estimate the optimal allocation of HIV resources. Methods Each study commenced with a request by the national government for technical assistance in conducting an HIV allocative efficiency study using Optima HIV. Each study team validated the required data, calibrated the Optima HIV epidemic model to produce HIV epidemic projections, agreed on cost functions for interventions, and used the model to calculate the optimal allocation of available funds to best address national strategic plan targets. From a review and analysis of these 23 country studies, we extract common themes around the optimal allocation of HIV funding in different epidemiological contexts. Results and discussion The optimal distribution of HIV resources depends on the amount of funding available and the characteristics of each country's epidemic, response and targets. Universally, the modelling results indicated that scaling up treatment coverage is an efficient use of resources. There is scope for efficiency gains by targeting the HIV response towards the populations and geographical regions where HIV incidence is highest. Across a range of countries, the model results indicate that a more efficient allocation of HIV resources could reduce cumulative new HIV infections by an average of 18% over the years to 2020 and 25% over the years to 2030, along with an approximately 25% reduction in deaths for both timelines. However, in most countries this would still not be sufficient to meet the targets of the national strategic plan, with modelling results indicating that budget increases of up to 185% would be required. Conclusions Greater epidemiological impact would be possible through better targeting of existing resources, but additional resources would still be required to meet targets. Allocative efficiency models have proven valuable in improving the HIV planning and budgeting process.
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Affiliation(s)
- Robyn M Stuart
- Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark.,Burnet Institute, Melbourne, VIC, Australia
| | - Laura Grobicki
- Institute for Global Health, University College London, London, UK
| | | | - Jasmina Panovska-Griffiths
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK.,Department of Applied Health Research, University College London, London, UK.,Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
| | - Zofia Baranczuk
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Institute of Mathematics, University of Zurich, Zurich, Switzerland
| | - Sherrie L Kelly
- Burnet Institute, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | - David J Kedziora
- Burnet Institute, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,School of Physics, University of Sydney, Sydney, NSW, Australia
| | | | | | | | - Kelsey L Grantham
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Richard T Gray
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Xiao F Yap
- Burnet Institute, Melbourne, VIC, Australia
| | | | | | | | | | | | | | | | | | | | - Cliff C Kerr
- Burnet Institute, Melbourne, VIC, Australia.,School of Physics, University of Sydney, Sydney, NSW, Australia
| | - David P Wilson
- Burnet Institute, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Earnshaw SR. Are We Ready to Use Constrained Optimization in Health Outcomes Research? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1029-1030. [PMID: 30224104 DOI: 10.1016/j.jval.2018.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 07/16/2018] [Indexed: 06/08/2023]
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Systematic Review of Clinician-Reported Barriers to Provision of Smoking Cessation Interventions in Hospital Inpatient Settings. J Smok Cessat 2018. [DOI: 10.1017/jsc.2017.25] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: Although the hospital inpatient setting arguably provides an ideal opportunity to engage patients in smoking cessation interventions, this is done infrequently. We therefore aimed to systematically review the perceived barriers to the implementation of smoking cessation interventions in the hospital inpatient setting.Methods: A systematic literature search was conducted specific to hospital-based healthcare workers’ perceived barriers to implementing smoking cessation interventions. Reported barriers were categorised using the capability, opportunity and motivation (COM-B) framework.Results: Eighteen studies were selected for inclusion, which consisted of cross-sectional surveys and interviews. The most commonly identified barrier in capability was lack of knowledge (56% of studies); in Opportunity, it was a lack of time (78%); while in Motivation, a lack of perceived patient motivation to quit smoking (44%). Seventeen other barriers were also endorsed, but less frequently.Conclusion: Healthcare workers report a plethora of barriers to providing smoking cessation interventions in hospital settings, which cover all aspects of the COM-B framework. These impediments need to be addressed in a multidisciplinary approach, at clinical, educational, and administrative levels, to improve intervention provision.
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Crown W, Buyukkaramikli N, Thokala P, Morton A, Sir MY, Marshall DA, Tosh J, Padula WV, Ijzerman MJ, Wong PK, Pasupathy KS. Constrained Optimization Methods in Health Services Research-An Introduction: Report 1 of the ISPOR Optimization Methods Emerging Good Practices Task Force. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:310-319. [PMID: 28292475 DOI: 10.1016/j.jval.2017.01.013] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 05/26/2023]
Abstract
Providing health services with the greatest possible value to patients and society given the constraints imposed by patient characteristics, health care system characteristics, budgets, and so forth relies heavily on the design of structures and processes. Such problems are complex and require a rigorous and systematic approach to identify the best solution. Constrained optimization is a set of methods designed to identify efficiently and systematically the best solution (the optimal solution) to a problem characterized by a number of potential solutions in the presence of identified constraints. This report identifies 1) key concepts and the main steps in building an optimization model; 2) the types of problems for which optimal solutions can be determined in real-world health applications; and 3) the appropriate optimization methods for these problems. We first present a simple graphical model based on the treatment of "regular" and "severe" patients, which maximizes the overall health benefit subject to time and budget constraints. We then relate it back to how optimization is relevant in health services research for addressing present day challenges. We also explain how these mathematical optimization methods relate to simulation methods, to standard health economic analysis techniques, and to the emergent fields of analytics and machine learning.
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Affiliation(s)
| | - Nasuh Buyukkaramikli
- Scientific Researcher, Institute of Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Alec Morton
- Professor of Management Science, Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, UK
| | - Mustafa Y Sir
- Assistant Professor, Health Care Policy & Research, Information and Decision Engineering, Mayo Clinic Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Deborah A Marshall
- Canada Research Chair, Health Services & Systems Research; Arthur J.E. Child Chair in Rheumatology Research; Director, HTA, Alberta Bone & Joint Health Institute; Associate Professor, Department Community Health Sciences, Faculty of Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jon Tosh
- Senior Health Economist, DRG Abacus, Manchester, UK
| | - William V Padula
- Assistant Professor, Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maarten J Ijzerman
- Professor of Clinical Epidemiology & Health Technology Assessment (HTA); Head, Department of Health Technology & Services Research, University of Twente, Enschede, The Netherlands
| | - Peter K Wong
- Vice President and Chief Performance Improvement Officer, Illinois Divisions and HSHS Medical Group, Hospital Sisters Health System (HSHS), Belleville, IL. USA
| | - Kalyan S Pasupathy
- Associate Professor - Healthcare Policy & Research, Lead, Information and Decision Engineering, Mayo Clinic Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
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Abstract
The standard decision rules of cost-effectiveness analysis either require the decision maker to set a threshold willingness to pay for additional health care or to set an overall fixed budget. In practice, neither are generally taken, but instead an arbitrary decision rule is followed that may not be consistent with the overall budget, lead to an allocation of resources that is less than optimal, and is unable to identify the program that should be displaced at the margin. Recent work has shown how mathematical programming can be used as a generalization of the standard decision rules. The authors extend the use of mathematical programming, first to incorporate more complex budgetary rules about when expenditure can be incurred, and show the opportunity loss, in terms of health benefit forgone, of each budgetary policy. Second, the authors demonstrate that indivisibility in a patient population can be regarded as essentially a concern for horizontal equity and represent this and other equity concerns as constraints in the program. Third, the authors estimate the different opportunity costs of a range of equity concerns applied to particular patient populations, and when imposed on all patient populations. They apply this framework of analysis to a realistic and policy-relevant problem. Key words: cost-effectiveness analysis; cost-benefit analysis; mathematical programming; resource allocation. (Med Decis Making 2007;27:128—137)
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Demarteau N, Morhason-Bello IO, Akinwunmi B, Adewole IF. Modeling optimal cervical cancer prevention strategies in Nigeria. BMC Cancer 2014; 14:365. [PMID: 24885048 PMCID: PMC4057561 DOI: 10.1186/1471-2407-14-365] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 05/15/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aims to assess the most efficient combinations of vaccination and screening coverage for the prevention of cervical cancer (CC) at different levels of expenditure in Nigeria. METHODS An optimization procedure, using a linear programming approach and requiring the use of two models (an evaluation and an optimization model), was developed. The evaluation model, a Markov model, estimated the annual number of CC cases at steady state in a population of 100,000 women for four alternative strategies: screening only; vaccination only; screening and vaccination; and no prevention. The results of the Markov model for each scenario were used as inputs to the optimization model determining the optimal proportion of the population to receive screening and/or vaccination under different scenarios. The scenarios varied by available budget, maximum screening and vaccination coverage, and overall reachable population. RESULTS In the base-case optimization model analyses, with a coverage constraint of 20% for one lifetime screening, 95% for vaccination and a budget constraint of $1 per woman per year to minimize CC incidence, the optimal mix of prevention strategies would result in a reduction of CC incidence of 31% (3-dose vaccination available) or 46% (2-dose vaccination available) compared with CC incidence pre-vaccination. With a 3-dose vaccination schedule, the optimal combination of the different strategies across the population would be 20% screening alone, 39% vaccination alone and 41% with no prevention, while with a 2-dose vaccination schedule the optimal combination would be 71% vaccination alone, and 29% with no prevention. Sensitivity analyses indicated that the results are sensitive to the constraints included in the optimization model as well as the cervical intraepithelial neoplasia (CIN) and CC treatment cost. CONCLUSIONS The results of the optimization model indicate that, in Nigeria, the most efficient allocation of a limited budget would be to invest in both vaccination and screening with a 3-dose vaccination schedule, and in vaccination alone before implementing a screening program with a 2-dose vaccination schedule.
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Affiliation(s)
- Nadia Demarteau
- Health Economics, Global Vaccines Development, GlaxoSmithKline Vaccines, Avenue Fleming 20 B-1300, Wavre, Belgium
| | - Imran O Morhason-Bello
- Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria
| | - Babatunde Akinwunmi
- Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria
| | - Isaac F Adewole
- Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria
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Smoking Cessation in Long-Term Conditions: Is There “An Opportunity in Every Difficulty”? ACTA ACUST UNITED AC 2013. [DOI: 10.1155/2013/251048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ghitza UE, Wu LT, Tai B. Integrating substance abuse care with community diabetes care: implications for research and clinical practice. Subst Abuse Rehabil 2013; 4:3-10. [PMID: 23378792 PMCID: PMC3558925 DOI: 10.2147/sar.s39982] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cigarette smoking and alcohol use are prevalent among individuals with diabetes in the US, but little is known about screening and treatment for substance use disorders in the diabetic population. This commentary discusses the scope and clinical implications of the public health problem of coexisting substance use and diabetes, including suggestions for future research. Diabetes is the seventh leading cause of death in the US, and is associated with many severe health complications like cardiovascular disease, stroke, kidney damage, and limb amputations. There are an estimated 24 million adults in the US with type 2 diabetes. Approximately 20% of adults aged 18 years or older with diabetes report current cigarette smoking. The prevalence of current alcohol use in the diabetic population is estimated to be around 50%-60% in epidemiological surveys and treatment-seeking populations. Cigarette smoking is associated with an increased risk of type 2 diabetes in a dose-dependent manner and is an independent modifiable risk factor for development of type 2 diabetes. Diabetic patients with an alcohol or other drug use disorder show a higher rate of adverse health outcomes. For example, these patients experience more frequent and severe health complications as well as an increased risk of hospitalization, and require longer hospital stays. They are also less likely to seek routine care for diabetes or adhere to diabetes treatment than those without an alcohol or other drug use disorder. The Affordable Care Act of 2010 and the Mental Health Parity Act and Addiction Equity Act of 2008 provide opportunities for facilitating integration of preventive services and evidence-based treatments for substance use disorders with diabetes care in community-based medical settings. These laws also offer emerging areas for research.
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Affiliation(s)
- Udi E Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Betty Tai
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
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Can cost-effectiveness analysis integrate concerns for equity? Systematic review. Int J Technol Assess Health Care 2012; 28:125-32. [PMID: 22494637 DOI: 10.1017/s0266462312000050] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The aim of this study was to promote approaches to health technology assessment (HTA) that are both evidence-based and values-based. We conducted a systematic review of published studies describing formal methods to consider equity in the context of cost-effectiveness analysis (CEA). METHODS Candidate studies were identified through an unrestricted search of the Pub Med and EMBASE databases. The search closed on January 20, 2011. We identified additional studies by consulting experts and checking article bibliographies. Two authors independently reviewed each candidate study to determine inclusion and extracted data from studies retained for review. In addition to documenting methods, data extraction identified implicit and explicit notions of fairness. Data were synthesized in narrative form. Study quality was not assessed. RESULTS Of the 695 candidate articles, 51 were retained for review. We identified three broad methods to facilitate quantitative consideration of equity concerns in economic evaluation: integration of distributional concerns through equity weights and social welfare functions, exploration of the opportunity costs of alternative policy options through mathematical programming, and multi-criteria decision analysis. CONCLUSIONS Several viable techniques to integrate equity concerns within CEA now exist, ranging from descriptive approaches to the quantitative methods studied in this review. Two obstacles at the normative level have impeded their use in decision making to date: the multiplicity of concepts and values discussed under the rubric of equity, and the lack of a widely accepted normative source on which to ground controversial value choices. Clarification of equity concepts and attention to procedural fairness may strengthen use of these techniques in HTA decision making.
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Demarteau N, Breuer T, Standaert B. Selecting a mix of prevention strategies against cervical cancer for maximum efficiency with an optimization program. PHARMACOECONOMICS 2012; 30:337-353. [PMID: 22409292 DOI: 10.2165/11591560-000000000-00000] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Screening and vaccination against human papillomavirus (HPV) can protect against cervical cancer. Neither alone can provide 100% protection. Consequently it raises the important question about the most efficient combination of screening at specified time intervals and vaccination to prevent cervical cancer. OBJECTIVE Our objective was to identify the mix of cervical cancer prevention strategies (screening and/or vaccination against HPV) that achieves maximum reduction in cancer cases within a fixed budget. METHODS We assessed the optimal mix of strategies for the prevention of cervical cancer using an optimization program. The evaluation used two models. One was a Markov cohort model used as the evaluation model to estimate the costs and outcomes of 52 different prevention strategies. The other was an optimization model in which the results of each prevention strategy of the previous model were entered as input data. The latter model determined the combination of the different prevention options to minimize cervical cancer under budget, screening coverage and vaccination coverage constraints. We applied the model in two countries with different healthcare organizations, epidemiology, screening practices, resource settings and treatment costs: the UK and Brazil. 100,000 women aged 12 years and above across the whole population over a 1-year period at steady state were included. The intervention was papanicolaou (Pap) smear screening programmes and/or vaccination against HPV with the bivalent HPV 16/18 vaccine (Cervarix® [Cervarix is a registered trademark of the GlaxoSmithKline group of companies]). The main outcome measures were optimal distribution of the population between different interventions (screening, vaccination, screening plus vaccination and no screening or vaccination) with the resulting number of cervical cancer and associated costs. RESULTS In the base-case analysis (= same budget as today), the optimal prevention strategy would be, after introducing vaccination with a coverage rate of 80% in girls aged 12 years and retaining screening coverage at pre-vaccination levels (65% in the UK, 50% in Brazil), to increase the screening interval to 6 years (from 3) in the UK and to 5 years (from 3) in Brazil. This would result in a reduction of cervical cancer by 41% in the UK and by 54% in Brazil from pre-vaccination levels with no budget increase. Sensitivity analysis shows that vaccination alone at 80% coverage with no screening would achieve a cervical cancer reduction rate of 20% in the UK and 43% in Brazil compared with the pre-vaccination situation with a budget reduction of 30% and 14%, respectively. In both countries, the sharp reduction in cervical cancer is seen when the vaccine coverage rate exceeds the maximum screening coverage rate, or when screening coverage rate exceeds the maximum vaccine coverage rate, while maintaining the budget. As with any model, there are limitations to the value of predictions depending upon the assumptions made in each model. CONCLUSIONS Spending the same budget that was used for screening and treatment of cervical cancer in the pre-vaccination era, results of the optimization program show that it would be possible to substantially reduce the number of cases by implementing an optimal combination of HPV vaccination (80% coverage) and screening at pre-vaccination coverage (65% UK, 50% Brazil) while extending the screening interval to every 6 years in the UK and 5 years in Brazil.
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Affiliation(s)
- Nadia Demarteau
- Health Economics, Global Vaccine Development, GlaxoSmithKline Biologicals, Wavre, Belgium.
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Koffijberg H, de Wit GA, Feenstra TL. Communicating uncertainty in economic evaluations: verifying optimal strategies. Med Decis Making 2012; 32:477-87. [PMID: 22374111 DOI: 10.1177/0272989x12436725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In cost-effectiveness analysis (CEA), it is common to compare a single, new intervention with 1 or more existing interventions representing current practice ignoring other, unrelated interventions. Sectoral CEAs, in contrast, take a perspective in which the costs and effectiveness of all possible interventions within a certain disease area or health care sector are compared to maximize health in a society given resource constraints. Stochastic league tables (SLT) have been developed to represent uncertainty in sectoral CEAs but have 2 shortcomings: 1) the probabilities reflect inclusion of individual interventions and not strategies and 2) data on robustness are lacking. The authors developed an extension of SLT that addresses these shortcomings. METHODS Analogous to nonprobabilistic MAXIMIN decision rules, the uncertainty of the performance of strategies in sectoral CEAs may be judged with respect to worst possible outcomes, in terms of health effects obtainable within a given budget. Therefore, the authors assessed robustness of strategies likely to be optimal by performing optimization separately on all samples and on samples yielding worse than expected health benefits. The approach was tested on 2 examples, 1 with independent and 1 with correlated cost and effect data. RESULTS The method was applicable to the original SLT example and to a new example and provided clear and easily interpretable results. Identification of interventions with robust performance as well as the best performing strategies was straightforward. Furthermore, the robustness of strategies was assessed with a MAXIMIN decision rule. CONCLUSION The SLT extension improves the comprehensibility and extends the usefulness of outcomes of SLT for decision makers. Its use is recommended whenever an SLT approach is considered.
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Affiliation(s)
- H Koffijberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (HK, GAdW)
| | - G A de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (HK, GAdW),Center for Prevention and Health Services Research, National Institute of Public Health and the Environment, Bilthoven, The Netherlands (GAdW, TLF)
| | - T L Feenstra
- Center for Prevention and Health Services Research, National Institute of Public Health and the Environment, Bilthoven, The Netherlands (GAdW, TLF),Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands (TLF)
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Afzali HHA, Karnon J, Gray J, Beilby J. A model-based evaluation of collaborative care in management of patients with type 2 diabetes in Australia: an initial report. AUST HEALTH REV 2012; 36:258-63. [DOI: 10.1071/ah11084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 02/12/2012] [Indexed: 11/23/2022]
Abstract
Objectives.
To analyse the short- and long-term costs and benefits of alternative models of primary care for the management of patients with type 2 diabetes in Australia. The models of care reflect differential uptake of primary care-based incentive programs, including reminder systems and involvement of practice nurses in management. This paper describes our study protocol and its progress.
Methods.
We are undertaking an observational study using a cluster sample design that links retrospective patient data from a range of sources to estimate costs and intermediate outcomes (such as the level of glycosylated haemoglobin (HbA1c)) over a 3-year time horizon. We use the short-term data as a basis to estimate lifetime costs and benefits of alternative models of care using a decision analytic model.
Initial report.
We recruited 15 practices from a metropolitan area (Adelaide) and allocated them to three models of care. Three hundred and ninety-nine patients agreed to participate. We use multilevel analysis to evaluate the association between different models of care and patient-level outcomes, while controlling for several covariates.
Discussion/conclusions.
Given the large amount of funding currently used to maintain primary care-based incentives in general practices in Australia, the results of this study generate the knowledge required to promote investment in the most cost-effective incentives.
What is known about the topic?
Collaborative models of care can improve the outcomes in patients with chronic diseases such as type 2 diabetes (T2D), and the large amount of funding is currently used to maintain primary care-based initiatives to provide incentives for general practices to take a more multidisciplinary approach in management of chronic diseases.
What does this paper add?
There are few model-based studies of the cost-effectiveness of alternative models of care defined on the basis of the uptake of financial incentives within Australian primary care settings for diabetes management. Using routinely collected data, this project evaluates the effectiveness of alternative models of care and estimates long-term costs and benefits of various models of care.
What are the implications for practitioners?
This study explores opportunities for the use of linked, routinely collected data to evaluate clinical practice, and identifies the optimal model of care in management of patients with T2D, with respect to differences in long-term costs and outcomes.
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Feenstra TL, van Baal PM, Jacobs-van der Bruggen MO, Hoogenveen RT, Kommer GJ, Baan CA. Targeted versus universal prevention. a resource allocation model to prioritize cardiovascular prevention. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2011; 9:14. [PMID: 21974836 PMCID: PMC3200148 DOI: 10.1186/1478-7547-9-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 10/06/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes mellitus brings an increased risk for cardiovascular complications and patients profit from prevention. This prevention also suits the general population. The question arises what is a better strategy: target the general population or diabetes patients. METHODS A mathematical programming model was developed to calculate optimal allocations for the Dutch population of the following interventions: smoking cessation support, diet and exercise to reduce overweight, statins, and medication to reduce blood pressure. Outcomes were total lifetime health care costs and QALYs. Budget sizes were varied and the division of resources between the general population and diabetes patients was assessed. RESULTS Full implementation of all interventions resulted in a gain of 560,000 QALY at a cost of €640 per capita, about €12,900 per QALY on average. The large majority of these QALY gains could be obtained at incremental costs below €20,000 per QALY. Low or high budgets (below €9 or above €100 per capita) were predominantly spent in the general population. Moderate budgets were mostly spent in diabetes patients. CONCLUSIONS Major health gains can be realized efficiently by offering prevention to both the general and the diabetic population. However, a priori setting a specific distribution of resources is suboptimal. Resource allocation models allow accounting for capacity constraints and program size in addition to efficiency.
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Affiliation(s)
- Talitha L Feenstra
- Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
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Mehrotra S, Kim K. Outcome based state budget allocation for diabetes prevention programs using multi-criteria optimization with robust weights. Health Care Manag Sci 2011; 14:324-37. [PMID: 21674143 DOI: 10.1007/s10729-011-9166-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 05/20/2011] [Indexed: 11/28/2022]
Abstract
We consider the problem of outcomes based budget allocations to chronic disease prevention programs across the United States (US) to achieve greater geographical healthcare equity. We use Diabetes Prevention and Control Programs (DPCP) by the Center for Disease Control and Prevention (CDC) as an example. We present a multi-criteria robust weighted sum model for such multi-criteria decision making in a group decision setting. The principal component analysis and an inverse linear programming techniques are presented and used to study the actual 2009 budget allocation by CDC. Our results show that the CDC budget allocation process for the DPCPs is not likely model based. In our empirical study, the relative weights for different prevalence and comorbidity factors and the corresponding budgets obtained under different weight regions are discussed. Parametric analysis suggests that money should be allocated to states to promote diabetes education and to increase patient-healthcare provider interactions to reduce disparity across the US.
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Affiliation(s)
- Sanjay Mehrotra
- Industrial Engineering and Management Science, Northwestern University, 2145 Sheridan Road, Evanston, IL 60208, USA.
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Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes Care 2010; 33:1872-94. [PMID: 20668156 PMCID: PMC2909081 DOI: 10.2337/dc10-0843] [Citation(s) in RCA: 298] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To synthesize the cost-effectiveness (CE) of interventions to prevent and control diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic review of literature on the CE of diabetes interventions recommended by the American Diabetes Association (ADA) and published between January 1985 and May 2008. We categorized the strength of evidence about the CE of an intervention as strong, supportive, or uncertain. CEs were classified as cost saving (more health benefit at a lower cost), very cost-effective (<or=$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001 to $50,000 per LYG or QALY), marginally cost-effective ($50,001 to $100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). The CE classification of an intervention was reported separately by country setting (U.S. or other developed countries) if CE varied by where the intervention was implemented. Costs were measured in 2007 U.S. dollars. RESULTS Fifty-six studies from 20 countries met the inclusion criteria. A large majority of the ADA recommended interventions are cost-effective. We found strong evidence to classify the following interventions as cost saving or very cost-effective: (I) Cost saving- 1) ACE inhibitor (ACEI) therapy for intensive hypertension control compared with standard hypertension control; 2) ACEI or angiotensin receptor blocker (ARB) therapy to prevent end-stage renal disease (ESRD) compared with no ACEI or ARB treatment; 3) early irbesartan therapy (at the microalbuminuria stage) to prevent ESRD compared with later treatment (at the macroalbuminuria stage); 4) comprehensive foot care to prevent ulcers compared with usual care; 5) multi-component interventions for diabetic risk factor control and early detection of complications compared with conventional insulin therapy for persons with type 1 diabetes; and 6) multi-component interventions for diabetic risk factor control and early detection of complications compared with standard glycemic control for persons with type 2 diabetes. (II) Very cost-effective- 1) intensive lifestyle interventions to prevent type 2 diabetes among persons with impaired glucose tolerance compared with standard lifestyle recommendations; 2) universal opportunistic screening for undiagnosed type 2 diabetes in African Americans between 45 and 54 years old; 3) intensive glycemic control as implemented in the UK Prospective Diabetes Study in persons with newly diagnosed type 2 diabetes compared with conventional glycemic control; 4) statin therapy for secondary prevention of cardiovascular disease compared with no statin therapy; 5) counseling and treatment for smoking cessation compared with no counseling and treatment; 6) annual screening for diabetic retinopathy and ensuing treatment in persons with type 1 diabetes compared with no screening; 7) annual screening for diabetic retinopathy and ensuing treatment in persons with type 2 diabetes compared with no screening; and 8) immediate vitrectomy to treat diabetic retinopathy compared with deferred vitrectomy. CONCLUSIONS Many interventions intended to prevent/control diabetes are cost saving or very cost-effective and supported by strong evidence. Policy makers should consider giving these interventions a higher priority.
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Affiliation(s)
- Rui Li
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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McKenna C, Chalabi Z, Epstein D, Claxton K. Budgetary policies and available actions: a generalisation of decision rules for allocation and research decisions. JOURNAL OF HEALTH ECONOMICS 2010; 29:170-181. [PMID: 20018396 DOI: 10.1016/j.jhealeco.2009.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 11/12/2009] [Indexed: 05/28/2023]
Abstract
The allocation problem in health care can be characterised as a mathematical programming problem but attempts to incorporate uncertainty in costs and effect have suffered from important limitations. A two-stage stochastic mathematical programming formulation is developed and applied to a numerical example to explore and demonstrate the implications of this more general and comprehensive approach. The solution to the allocation problem for different budgets, budgetary policies, and available actions are then demonstrated. This analysis is used to evaluate different budgetary policies and examine the adequacy of standard decision rules in cost-effectiveness analysis. The research decision is then considered alongside the allocation problem. This more general formulation demonstrates that the value of further research depends on: (i) the budgetary policy in place; (ii) the realisations revealed during the budget period; (iii) remedial actions that may be available; and (iv) variability in parameters values.
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Affiliation(s)
- Claire McKenna
- Centre for Health Economics, University of York, Heslington, York YO10 5DD, United Kingdom.
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Brownson CA, Hoerger TJ, Fisher EB, Kilpatrick KE. Cost-effectiveness of Diabetes Self-management Programs in Community Primary Care Settings. DIABETES EDUCATOR 2009; 35:761-9. [DOI: 10.1177/0145721709340931] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this study is to estimate the cost-effectiveness of diabetes self-management programs in real-world community primary care settings. Estimates incorporated lifetime reductions in disease progression, costs of adverse events, and increases in quality of life. Methods Clinical results and costs were based on programs of the Diabetes Initiative of the Robert Wood Johnson Foundation, implemented in primary care and community settings in disadvantaged areas with notable health disparities. Program results were used as inputs to a Markov simulation model to estimate the long-term effects of self-management interventions. A health systems perspective was adopted. Results The simulation model estimates that the intervention does reduce discounted lifetime treatment and complication costs by $3385, but this is more than offset by the $15 031 cost of implementing the intervention and maintaining its effects in subsequent years. The intervention is estimated to reduce long-term complications, leading to an increase in remaining life-years and quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio is $39 563/QALY, well below a common benchmark of $50 000/QALY. Sensitivity analyses tested the robustness of the model’s estimates under various alternative assumptions. The model generally predicts acceptable cost-effectiveness ratios. Conclusions Self-management programs for type 2 diabetes are cost-effective from a health systems perspective when the cost savings due to reductions in long-term complications are recognized. These findings may justify increased reimbursement for effective self-management programs in diverse settings.
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Affiliation(s)
- Carol A. Brownson
- National Program Office of the Robert Wood Johnson Foundation
Diabetes Initiative, Division of Health Behavior Research, Washington University
School of Medicine in St Louis, St Louis, Missouri,
| | - Thomas J. Hoerger
- Research Triangle Institute International (RTI), RTI-University
of North Carolina Center of Excellence in Health Promotion Economics, Research
Triangle Park, North Carolina
| | - Edwin B. Fisher
- National Program Office of the Robert Wood Johnson Foundation
Diabetes Initiative and Peers for Progress, Department of Health Behavior
and Health Education, Gillings School of Global Public Health, University
of North Carolina at Chapel Hill
| | - Kerry E. Kilpatrick
- Department of Health Policy and Management, Gillings
School of Global Public Health, University of North Carolina at Chapel Hill
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Abstract
Computer simulation models are mathematical equations combined in a structured framework to represent some real or hypothetical system. One of their uses is to allow the projection of short-term data from clinical trials to evaluate clinical outcomes and costs over a long-term period. This technology is becoming increasingly important to assist decision making in modern medicine in situations where there is a paucity of long-term clinical trial data, as recently acknowledged in the American Diabetes Association Consensus Panel Guidelines for Computer Modeling of Diabetes and its Complications. The Mount Hood Challenge Meetings provide a forum for computer modelers of diabetes to discuss and compare models and identify key areas of future development to advance the field. The Fourth Mount Hood Challenge in 2004 was the first meeting of its kind to ask modelers to perform simulations of outcomes for patients in published clinical trials, allowing comparison against "real life" data. Eight modeling groups participated in the challenge. Each group was given three of the following challenges: to simulate a trial of type 2 diabetes (CARDS [Collaborative Atorvastatin Diabetes Study]); to simulate a trial of type 1 diabetes (DCCT [Diabetes Control and Complications Trial]); and to calculate outcomes for a hypothetical, precisely specified patient (cross-model validation). The results of the models varied from each other and for methodological reasons, in some cases, from the published trial data in important ways. This approach of performing systematic comparisons and validation exercises has enabled the identification of key differences among the models, as well as their possible causes and directions for improvement in the future.
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Earnshaw SR, Dennett SL. Integer/linear mathematical programming models: a tool for allocating healthcare resources. PHARMACOECONOMICS 2003; 21:839-851. [PMID: 12908840 DOI: 10.2165/00019053-200321120-00001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
In today's environment, the demand for efficient healthcare resource allocation is increasing. As new technologies become available, allocation decisions become more complex and tools to assist decision makers in determining efficient allocations of healthcare resources are encouraged. Mathematical programs have multiple properties that are desirable for healthcare decision makers such as the simultaneous consideration of multiple constraints and a built-in sensitivity analysis. These models have been well researched and are considered invaluable in other industries. Mathematical programming has also become increasingly visible in facilitating the allocation of healthcare resources in the health services research sector. However, the use of mathematical programming tools has been limited in economic evaluations of new technologies. Budget allocations, such as formulary, drug development, and pricing decisions may benefit greatly from the use of mathematical programs. As an increasing number of expensive new technologies become available and pressure grows to contain healthcare costs, these tools may help guide a more efficient allocation of resources for technologies under budgetary and other constraints.
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Affiliation(s)
- Douglas K Owens
- VA Health Care System (111A), 3801 Miranda Avenue, Palo Alto, CA 94304, USA.
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