Neonatal hearing screening: modelling cost and effectiveness of hospital- and community-based screening

BACKGROUND: Children with congenital hearing impairment benefit from early detection and management of their hearing loss. These and related considerations led to the recommendation of universal newborn hearing screening. In 2001 the first phase of a national Newborn Hearing Screening Programme (NHSP) was implemented in England. Objective of this study was to assess costs and effectiveness for hospital and community-based newborn hearing screening systems in England based on data from this first phase with regard to the effects of alterations to parameter values. METHODS: Design: Clinical effectiveness analysis using a Markov Model. Outcome measure: quality weighted detected child months (QCM). RESULTS: Both hospital and community programmes yielded 794 QCM at the age of 6 months with total costs of £3,690,000 per 100,000 screened children in hospital and £3,340,000 in community. Simulated costs would be lower in hospital in 48% of the trials. Any statistically significant difference between hospital and community in prevalence, test sensitivity, test specificity and costs would result in significant differences in cost-effectiveness between hospital and community. CONCLUSION: This modelling exercise informs decision makers by a quantitative projection of available data and the explicit and transparent statements about assumptions and the degree of uncertainty. Further evaluation of the cost-effectiveness should focus on the potential differences in test parameters and prevalence in these two settings

Comparing the clinical effectiveness of different new-born hearing screening strategies. A decision analysis

BACKGROUND: Children with congenital hearing impairment benefit from early detection and treatment. At present, no model exists which explicitly quantifies the effectiveness of universal newborn hearing screening (UNHS) versus other programme alternatives in terms of early diagnosis. It has yet to be considered whether early diagnosis (within the first few months) of hearing impairment is of importance with regard to the further development of the child compared with effects resulting from a later diagnosis. The objective was to systematically compare two screening strategies for the early detection of new-born hearing disorders, UNHS and risk factor screening, with no systematic screening regarding their influence on early diagnosis. METHODS: Design: Clinical effectiveness analysis using a Markov Model. Data Sources: Systematic literature review, empirical data survey, and expert opinion. Target Population: All newborn babies. Time scale: 6, 12 and 120 months. Perspective: Health care system. Compared Strategies: UNHS, Risk factor screening (RS), no systematic screening (NS). Outcome Measures: Quality weighted detected child months (QCM). RESULTS: UNHS detected 644 QCM up until the age of 6 months (72,2%). RS detected 393 child months (44,1%) and no systematic screening 152 child months (17,0%). UNHS detected 74,3% and 86,7% weighted child months at 12 and 120 months, RS 48,4% and 73,3%, NS 23,7% and 60,6%. At the age of 6 months UNHS identified approximately 75% of all children born with hearing impairment, RS 50% and NS 25%. At the time of screening UNHS marked 10% of screened healthy children for further testing (false positives), RS 2%. UNHS demonstrated higher effectiveness even under a wide range of relevant parameters. The model was insensitive to test parameters within the assumed range but results varied along the prevalence of hearing impairment. CONCLUSION: We have shown that UNHS is able to detect hearing impairment at an earlier age and more accurately than selective RS. Further research should be carried out to establish the effects of hearing loss on the quality of life of an individual, its influence on school performance and career achievement and the differences made by early fitting of a hearing aid on these factors

Cost-Effectiveness of New Cardiac and Vascular Rehabilitation Strategies for Patients with Coronary Artery Disease

Objective: Peripheral arterial disease (PAD) often hinders the cardiac rehabilitation program. The aim of this study was evaluating the relative cost-effectiveness of new rehabilitation strategies which include the diagnosis and treatment of PAD in patients with coronary artery disease (CAD) undergoing cardiac rehabilitation. Data Sources: Best-available evidence was retrieved from literature and combined with primary data from 231 patients. Methods: We developed a Markov decision model to compare the following treatment strategies: 1. cardiac rehabilitation only; 2. ankle-brachial index (ABI) if cardiac rehabilitation fails followed by diagnostic work-up and revascularization for PAD if needed; 3. ABI prior to cardiac rehabilitation followed by diagnostic work-up and revascularization for PAD if needed. Quality-adjusted-life years (QALYs), life-time costs (US $), incremental cost-effectiveness ratios (ICER), and gain in net health benefits (NHB) in QALY equivalents were calculated. A threshold willingness-to-pay of$75 000 was used. Results: ABI if cardiac rehabilitation fails was the most favorable strategy with an ICER of $44 251 per QALY gained and an incremental NHB compared to cardiac rehabilitation only of 0.03 QALYs (95$75 000/QALY. After sensitivity analysis, a combined cardiac and vascular rehabilitation program increased the success rate and would dominate the other two strategies with total lifetime costs of $30 246 a quality-adjusted life expectancy of 3.84 years, and an incremental NHB of 0.06 QALYs (95%CI:−0.24, 0.46) compared to current practice. The results were robust for other different input parameters. Conclusion: ABI measurement if cardiac rehabilitation fails followed by a diagnostic work-up and revascularization for PAD if needed are potentially cost-effective compared to cardiac rehabilitation only

Bisphenol A : Part 2. Recommendations for risk management

Alleen digitaal verschenenIn 2014 en 2015 zijn de Europese normen voor een veilige blootstelling aan Bisfenol A (BPA) van werknemers en consumenten aangescherpt. Het RIVM concludeert dat nieuwe inzichten voldoende aanleiding vormen om verdere aanscherping van de normen te overwegen en stelt voor op korte termijn aanvullende maatregelen te treffen die de blootstelling aan BPA verder verminderen. Bisfenol A (BPA) is een stof die in veel producten zit, zoals kassabonnen, bouwmaterialen (verf en coatings), verpakkingsmateriaal van voedsel, speelgoed en medische hulpmiddelen. BPA is bij een te hoge blootstelling schadelijk voor de vruchtbaarheid en kan effect op het hormoonsysteem hebben. Nieuwe studies laten zien dat BPA het immuunsysteem van de ongeboren vrucht of jonge kinderen kan schaden bij een lager blootstellingsniveau dan het niveau waarop de huidige normen zijn gebaseerd. Dit lagere blootstellingsniveau is van ongeveer dezelfde grootte als de dagelijkse blootstelling van consumenten en werknemers aan BPA. Als gevolg van deze blootstelling hebben mensen mogelijk meer kans om voedselintoleranties te ontwikkelen en kunnen ze gevoeliger voor infectieziekten worden. Op basis van deze nieuwe inzichten wordt de rijksoverheid geadviseerd waar mogelijk op korte termijn de blootstelling aan BPA te verminderen. De bescherming van kleine kinderen, zwangeren en vrouwen die borstvoeding geven verdient hierbij bijzondere aandacht. Kleine en ongeboren kinderen zijn namelijk gevoeliger dan volwassenen voor de effecten van BPA doordat hun lichaam sterk in ontwikkeling is. De blootstelling kan bijvoorbeeld worden verminderd door veilige alternatieven te ontwikkelen, of ervoor te zorgen dat er minder BPA vrijkomt uit producten waar deze stof in wordt gebruikt. Daarnaast kunnen werknemers tegen blootstelling aan BPA worden beschermd. Een lagere blootstelling is ook van belang voor dieren in waterbodems, die nadelige effecten ondervinden bij de huidige BPA-concentratie- niveaus.More stringent European standards for safe exposure of workers and consumers to bisphenol A (BPA) were proposed in 2014 and 2015. The Dutch National Institute for Public Health and the Environment (RIVM) has concluded that new insights sufficiently warrant consideration of even more stringent standards and has recommended taking supplementary measures in the near future for a further reduction of BPA exposure. Bisphenol A (BPA) is a substance that occurs in numerous products, such as cash register receipts, building materials (paint and coatings), food packaging materials, toys and medical devices. Excessive BPA exposure is harmful to fertility and can affect the hormone system. New studies show that BPA can impair the immune system of unborn and young children at a lower exposure level than the one on which the current standards are based. This lower level is roughly comparable to the current every day BPA exposure level of workers and consumers. As a result of this exposure, people could have a greater probability of developing food intolerances and could become more susceptible to infectious diseases. Based on these new insights RIVM advises the national government to reduce BPA exposure in the short term wherever possible. Special attention needs to be devoted to protecting small children, pregnant women and women who breastfeed. This is because developing unborn and young children are more sensitive than adults to the effects of BPA. Ways to reduce exposure include developing safe alternatives or ensuring that less BPA is released from products. Additionally, workers can be protected against BPA exposure. Lower exposure is also important for sediment-dwelling animals that experience adverse effects due to current BPA concentration levels.Ministerie van VWSMinisterie van I&MMinisterie van Sociale Zaken en Werkgelegenhei

The empirical relationship between ownership characteristics and audit fees

The present study examines the empirical relationship between ownership characteristics and audit fees. The basic premise is that the level of ownership sophistication and the extent to which ownership is large and substantial impact the effectiveness of stockholder monitoring on corporate affairs including the financial reporting process. Furthermore, high managerial ownership firms may experience a decline in agency problems in financial reporting due to a decrease in managerial propensity to misreport financial results. By employing a cross-sectional least squares regression analysis for a sample of 358 New York Stock Exchange-listed firms audited by the Big Five auditors, we find evidence of a significantly positive relationship between diffused institutional stock ownership (i.e., having less than 5% individual shareholding) and audit fees, and a significantly negative relationship between institutional blockholder ownership (i.e., having 5% or more individual shareholding) and audit fees. Finally, we document that managerial stock ownership is negatively associated with audit fees. We do not, however, find evidence of any relationship between noninstitutional blockholder ownership (with at least 5% individual stock ownership) and audit fees. The study's main results hold in various specification tests including when the effects of board-related and audit committee variables are factored in the analysis. Based on the observed relationship between the ownership variables and audit fees, we suggest that the ownership characteristics of a firm as a part of its governance mechanism constitute an important determinant of audit fees. Copyright Springer Science+Business Media, LLC 2007Diffused institutional stock ownership, Institutional and noninstitutional blockholder ownership, Managerial stock ownership, Audit fees, Agency problem, Corporate Governance,