Prospective payment system : consequences for hospital-physician interactions in the private sector

In 2004, French health authorities plan to introduce a prospective payment system for hospitals delivering acute care based on the DRG classification system. In this paper, we analyze the consequences of this switch from a retrospective to a prospective payment system on the ability of physicians and hospital managers to coordinate their activity in the production of hospital stays. Our analysis follows those of Dor and Watson (1995) and Custer et al. (1990) but is adapted to the context of the French hospital private sector. Different types of interactions are considered : non-cooperative, dominant-reactive, and cooperative. The main result of this analysis is that, in a context in which average per-patient fees are maintained, the change of payment system is potentially gainful for both partners. Although their fees are not concerned by the reform, physicians are even in a better position than hospitals tot ake advantage of the change of payment system. A minimum level of coordination is nevertheless required, i.e. either cooperative or dominant-reactive interactions. Furthermore, two elements limits the importance of these potential gains : these are only one-shot gains and hence depend on the ability to reduce the length of hospital stays. Finally, some extensions regarding competition between public and private hospitals and negotiation issues are discussed.prospective payment system; retrospective payment system; physician behabivour, for-profit hospitals

Modelos para implementar a vacinação contra dengue

In this work we propose a mathematical approach to estimate the dengue force of infection, the average age of dengue first infection, the optimum age to vaccinate children against dengue in a routine fashion and the optimum age interval to introduce the dengue vaccine in a mass vaccination campaign. The model is based on previously published models for vaccination against other childhood infections, which resulted in actual vaccination programmes in Brazil. The model was applied for three areas of distinct levels of endemicity of the city of Recife in Northeastern State of Pernambuco, Brazil. Our results point to an optimal age to introduce the dengue vaccine in the routine immunization programme at two years of age and an age interval to introduce a mass vaccination between three and 14 years of age.Neste trabalho propomos um modelo matemático para a estimativa da força de infecção, da idade média de primo-infecção, da idade ótima para vacinação de rotina e do intervalo ótimo de cobertura vacina em uma campanha para a introdução da vacina contra a dengue. O modelo baseia-se em publicações anteriores de desenhos de estratégias de vacinação contra outras infecções e que resultaram em estratégias de vacinação no Brasil. O modelo foi aplicado em três áreas com níveis endêmicos de dengue distintos na cidade de Recife, Pernambuco. Nossos resultados apontam para uma idade ótima de vacinação na rotina de dois anos de idade e para um intervalo de vacinação em campanha entre três e 14 anos

Adult pertussis vaccination strategies and their impact on pertussis in the United States: evaluation of routine and targeted (cocoon) strategies

A compartmental, age-structured mathematical model was developed and recent US pertussis epidemiology data were used to evaluate the impact on pertussis infection rates of routine and targeted adult immunization strategies. Model simulations predict that the implementation of adolescent immunization only could reverse the current rise in pertussis infection rates but may lead to a resurgence of pertussis in subsequent decades. In contrast, inclusion of a routine adult strategy is likely to lead to sustained control of pertussis. Routine adult vaccination could control the disease even with relatively low coverage rates of 40% for routine vaccination of all adults every 10 years, or 65% for a targeted vaccination of close contacts of newborns completed by one booster dose for all adults. The model also predicts that the optimal age for this booster dose is 40 years. These results support the 2006 American Academy of Immunization Practices' recommendations for adolescent and adult vaccination against pertussis

Some extensions in continuous models for immunological correlates of protection

Detail of results of case-cohort investigation. (DOCX 41 kb

Designing a vaccination strategy against dengue

In this work we propose a mathematical approach to estimate the dengue force of infection, the average age of dengue first infection, the optimum age to vaccinate children against dengue in a routine fashion and the optimum age interval to introduce the dengue vaccine in a mass vaccination campaign. The model is based on previously published models for vaccination against other childhood infections, which resulted in actual vaccination programmes in Brazil. The model was applied for three areas of distinct levels of endemicity of the city of Recife in Northeastern State of Pernambuco, Brazil. Our results point to an optimal age to introduce the dengue vaccine in the routine immunization programme at two years of age and an age interval to introduce a mass vaccination between three and 14 years of age

Adult Vaccination Strategies for the Control of Pertussis in the United States: An Economic Evaluation Including the Dynamic Population Effects

BACKGROUND: Prior economic evaluations of adult and adolescent vaccination strategies against pertussis have reached disparate conclusions. Using static approaches only, previous studies failed to analytically include the indirect benefits derived from herd immunity as well as the impact of vaccination on the evolution of disease incidence over time. METHODS: We assessed the impact of different pertussis vaccination strategies using a dynamic compartmental model able to consider pertussis transmission. We then combined the results with economic data to estimate the relative cost-effectiveness of pertussis immunization strategies for adolescents and adults in the US. The analysis compares combinations of programs targeting adolescents, parents of newborns (i.e. cocoon strategy), or adults of various ages. RESULTS: In the absence of adolescent or adult vaccination, pertussis incidence among adults is predicted to more than double in 20 years. Implementing an adult program in addition to childhood and adolescent vaccination either based on 1) a cocoon strategy and a single booster dose or 2) a decennial routine vaccination would maintain a low level of pertussis incidence in the long run for all age groups (respectively 30 and 20 cases per 100,000 person years). These strategies would also result in significant reductions of pertussis costs (between -77% and -80% including additional vaccination costs). The cocoon strategy complemented by a single booster dose is the most cost-effective one, whereas the decennial adult vaccination is slightly more effective in the long run. CONCLUSIONS: By providing a high level of disease control, the implementation of an adult vaccination program against pertussis appears to be highly cost-effective and often cost-saving

Estimating the global burden of endemic canine rabies

Background: Rabies is a notoriously underreported and neglected disease of lowincome countries. This study aims to estimate the public health and economic burden of rabies circulating in domestic dog populations, globally and on a country-by-country basis, allowing an objective assessment of how much this preventable disease costs endemic countries.<p></p> Methodology/Principal Findings: We established relationships between rabies mortality and rabies prevention and control measures, which we incorporated into a model framework. We used data derived from extensive literature searches and questionnaires on disease incidence, control interventions and preventative measures within this framework to estimate the disease burden. The burden of rabies impacts on public health sector budgets, local communities and livestock economies, with the highest risk of rabies in the poorest regions of the world. This study estimates that globally canine rabies causes approximately 59,000 (95% Confidence Intervals: 25- 159,000) human deaths, over 3.7 million (95% CIs: 1.6-10.4 million) disability-adjusted life years (DALYs) and 8.6 billion USD (95% CIs: 2.9-21.5 billion) economic losses annually. The largest component of the economic burden is due to premature death (55%), followed by direct costs of post-exposure prophylaxis (PEP, 20%) and lost income whilst seeking PEP (15.5%), with only limited costs to the veterinary sector due to dog vaccination (1.5%), and additional costs to communities from livestock losses (6%).<p></p> Conclusions/Significance: This study demonstrates that investment in dog vaccination, the single most effective way of reducing the disease burden, has been inadequate and that the availability and affordability of PEP needs improving. Collaborative investments by medical and veterinary sectors could dramatically reduce the current large, and unnecessary, burden of rabies on affected communities. Improved surveillance is needed to reduce uncertainty in burden estimates and to monitor the impacts of control efforts.<p></p&gt

European Seafloor Observatory Offers New Possibilities For Deep Sea Study

The Geophysical and Oceanographic Station for Abyssal Research (GEOSTAR), an autonomous seafloor observatory that collects measurements benefiting a number of disciplines during missions up to 1 year long, will begin the second phase of its first mission in 2000. The 6-8 month investigation will take place at a depth of 3400 m in the southern Tyrrhenian basin of the southern Tyrrhenian basin of the central Mediterranean. GEOSTAR was funded by the European Community (EC) for $2.4 million (U.S. dollars) in 1995 as a part of the Marine Science and Technology programme (MAST). The innovative deployment and recovery procedure GEOSTAR uses was derived from the "two-module" concept successfully applied by NASA in the Apollo and space shuttle missions, where one module performs tasks for the other, including deployment, switching on and off, performing checks and recovery. The observatory communication system, which takes advantage of satellite telemetry, and the simultaneous acquisition of a set of various measurements with a unique time reference make GEOSTAR the first fundamental element of a multiparameter ocean network. GEOSTAR's first scientific and technological mission, which took place in the summer of 1998 in the Adriatic Sea, verified the performance and reliability of the system. The mission was a success. providing 440 hours of continuous seismic magnetic and oceanographic data. Thje second phase of the mission, which was funded by the EC for$2 million (US dollars), will carry equipment for chemical, biological and isotopic analyses not used in the first phase, which will broaden the data collection effort.Published45, 48-492.5. Laboratorio per lo sviluppo di sistemi di rilevamento sottomariniN/A or not JCRreserve