The science of making better decisions about health: Cost-effectiveness and cost-benefit analysis

Despite spending far more on medical care, Americans live shorter lives than the citizens of other high-income countries. The situation has been getting worse for at least three decades. This paper describes the main scientific methods for guiding the allocation of resources to health - cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA), sketches their methodological progress over the last several decades, and presents examples of how medical practice in other high-income countries, where people live longer, follows the priorities indicated by cost-effectiveness analysis. CEA and CBA support democratic decision-making processes, which have themselves benefited from scientific inquiry; these are touched on at the end of the paper

Medicare's prospective payment system for hospitals: new evidence on transitions among health care settings

Previous studies of Medicare’s prospective payment system for hospitals (PPS), introduced in 1983, evaluated only its first few years, using data collected during the hospital stay to control for patients’ health. We examine transitions among health care settings over a full decade following implementation of PPS, using survival models and a national longitudinal survey with independent information on health. We find that the rate of discharge from hospitals to nursing homes continued to rise as PPS matured, hospital readmissions from the community dropped after the early years, and risk of nursing home admission from the community soon after hospital discharge tripled. Evaluations of new payment systems for one type of provider need to be comprehensive in order to capture the full effects on other providers

New Evidence on Medicare?s Prospective Payment System: A Survival Analysis based on the NHANES I Epidemiologic Followup Study

Medicare?s prospective payment system (PPS), introduced in 1983, pays hospitals a fixed price for each stay rather than reimbursing costs. Previous studies evaluated its first few years using endogenous measures to control for heterogeneity in patients? health. We examine PPS over a full decade using competing risks Cox survival models and a national longitudinal survey with independent information on patients? health. New findings include: risk of death in hospital increased; risk of discharge to a nursing home continued to increase as PPS matured; and risk of nursing home admission from the community following hospital discharge rose. HMOs may have contributed to these outcomes

Urban vertical air pollution gradient and dynamics investigated with low-cost sensors and large-eddy simulations

A network of five low-cost air pollution sensor (LCS) nodes was deployed vertically on the exterior of the H. C. Ørsted Institute at the University of Copenhagen, Denmark, to investigate the transport of pollution from the road below. All LCS nodes measured PM2.5, NO2, and O3 at 1-min time resolution, and one of them also measured noise. Traffic was monitored with a webcam, where traffic type and levels were derived using a machine-learning algorithm. We investigated how well traffic-related air pollution, noise, and real-time traffic counts serve as proxies for one another. The correlations between NO2, noise, and traffic count exhibited relatively low values when considering all the data. However, these correlations significantly increased under southwesterly wind direction and low wind speed, reaching R2 = 0.40 for NO2 and noise, R2 = 0.51 for NO2 and traffic volume, and R2 = 0.70 for noise and traffic volume. These results indicate a common source, namely traffic, for all three parameters. The five LCS nodes spanning 25 m vertically had extremely low intervariability with minimum R2-values of 0.98 for PM2.5, 0.89 for NO2, and 0.97 for O3. The system could not detect a vertical gradient in pollution levels. Large-eddy simulation model runs using the PALM model system generally supported the lack of gradient observed in measured observations. Under slightly unstable stratification, concentration remained relatively constant with height for southwesterly and southerly winds. Conversely, winds from the north, west, and northwest showed an increase in concentration with height. For other wind directions, the concentration decreased with height by approximately 40 % to 50 %, which is not as strong as for neutral stratification, attributed to enhanced vertical mixing under unstable stratification. Based on the measurements and modeling, we conclude that the vertical concentration profile is very sensitive to stratification, and under these conditions, the concentration outside the window of a fifth-floor office is almost the same as for an office on the ground floor

Willingness-to-pay to avoid the time spent and discomfort associated with screening colonoscopy

The screening colonoscopy process requires a considerable amount of time and some discomfort for patients

A reconnaissance survey of farmers’ awareness of hypomagnesaemic tetany in UK cattle and sheep farms

Hypomagnesaemic tetany (HypoMgT) in ruminants is a physiological disorder caused by inadequate intake or impaired absorption of magnesium (Mg) in the gut. If it is not detected and treated in time, HypoMgT can cause the death of the affected animal. A semi-structured questionnaire survey was conducted from July 2016–2017 to assess farmers’ awareness of HypoMgT in cattle and sheep in the UK. The questionnaire was distributed to farmers at farm business events and agricultural shows, and through a collaborative group of independent veterinary practices to their clients. Farmers were asked about (i) the incidence of presumed HypoMgT (PHT); (ii) their strategies to treat or prevent HypoMgT; (iii) mineral tests on animals, forage and soil, and (iv) farm enterprise type. A total of 285 responses were received from 82 cattle, 157 mixed cattle and sheep, and 46 sheep farmers, of whom 39% reported HypoMgT in their livestock, affecting 1–30 animals. Treatment and/or prevention against HypoMgT was reported by 96% respondents with PHT and 79% of those without. Mineral tests on animal, forage, and soil was conducted by 24%, 53%, and 66% of the respondents, respectively, regardless of PHT. There was a highly significant association between the use of interventions to tackle HypoMgT and the incidence of PHT (p < 0.01). The top three treatment/prevention strategies used were reported as being free access supplementation (149), in feed supplementation (59) and direct to animal treatments (drenches, boluses and injections) (45) although these did vary by farm type. Although some (9) reported using Mg-lime, no other pasture management interventions were reported (e.g., Mg-fertilisation or sward composition). Generally, the results indicate that UK farmers are aware of the risks of HypoMgT. A more integrated soil-forage-animal assessment may improve the effectiveness of tackling HypoMgT and help highlight the root causes of the problem

Quantified evaluation for decisions : measuring achievement of environmental goals and analyzing trade-offs

Federal legislation requires that governmental programs be evaluated on a wide set of criteria to provide policymakers with information on the achievement or lack of achievement of goals and/or objectives. A methodology to identify and quantify measures of achievement is described. In addition, the methodology is designed to facilitate the comparison of alternatives in terms of trade-offs among conflicting goals and/or objectives. An example is presented for quantifying and evaluating the achievement of environmental goals and objectives in water quality improvement projects. The trade-offs between environmental quality and economic well-being are discussed and the usefulness of the methodology for providing assistance to policymakers in making such trade-offs described.Published November 1982. Facts and recommendations in this publication may no longer be valid. Please look for up-to-date information in the OSU Extension Catalog: http://extension.oregonstate.edu/catalo

Magnesium biofortification of Italian ryegrass (Lolium multiflorum L.) via agronomy and breeding as a potential way to reduce grass tetany in grazing ruminants

© 2019, The Author(s). Aim: Magnesium (Mg) deficiency (known as grass tetany) is a serious metabolic disorder that affects grazing ruminants. We tested whether Mg-fertiliser can increase Mg concentration of Italian ryegrasses (Lolium multiflorum L.) including a cultivar (cv. Bb2067; ‘Magnet’), bred to accumulate larger concentrations of Mg. Methods: Under controlled environment (CE) conditions, three cultivars (cv. Bb2067, cv. Bb2068, cv. RvP) were grown in low-nutrient compost at six fertiliser rates (0–1500μM MgCl2.6H2O). Under field conditions, the three cultivars in the CE condition and cv. Alamo were grown at two sites, and four rates of MgSO4 fertiliser application rates (0–200kgha−1 MgO). Multiple grass cuts were taken over two-years. Results: Grass Mg concentration increased with increasing Mg-fertiliser application rates in all cultivars and conditions. Under field conditions, cv. Bb2067 had 11–73% greater grass Mg concentration and smaller forage tetany index (FTI) than other cultivars across the Mg-fertiliser application rates, sites and cuts. Grass dry matter (DM) yield of cv. Bb2067 was significantly (p < 0.05) smaller than cv. Alamo. The effect of Mg-fertiliser rate on DM yield was not significant (p ≥ 0.05). Conclusions: Biofortification of grass with Mg through breeding and agronomy can improve the forage Mg concentration for grazing ruminants, even in high-growth spring grass conditions when hypomagnesaemia is most prevalent. Response to agronomic biofortification varied with cultivar, Mg-fertiliser rate, site and weather. The cost:benefit of these approaches and farmer acceptability, and the impact on cattle and sheep grazing on grasses biofortified with Mg requires further investigation

Comparison of static and dynamic models of maternal immunization to prevent infant pertussis in Brazil.

BACKGROUND: This paper compares cost-effectiveness results from two models of maternal immunization to prevent pertussis in infants in Brazil, one static, one dynamic, to explore when static models are adequate for public health decisions and when the extra effort required by dynamic models is worthwhile. METHODS: We defined two scenarios to explore key differences between static and dynamic models, herd immunity and time horizon. Scenario 1 evaluates the incremental cost/DALY of maternal acellular pertussis (aP) immunization as routine infant vaccination coverage ranges from low/moderate up to, and above, the threshold at which herd immunity begins to eliminate pertussis. Scenario 2 compares cost-effectiveness estimates over the models' different time horizons. Maternal vaccine prices of $9.55/dose (base case) and$1/dose were evaluated. RESULTS: The dynamic model shows that maternal immunization could be cost-saving as well as life-saving at low levels of infant vaccination coverage. When infant coverage reaches the threshold range (90-95%), it is expensive: the dynamic model estimates that maternal immunization costs $2 million/DALY at infant coverage > 95$9.55/dose; at $1/dose, cost/DALY is$200,000. By contrast, the static model estimates costs/DALY only modestly higher at high than at low infant coverage. When the models' estimates over their different time horizons are compared at infant coverage < 90-95%, their projections fall in the same range. CONCLUSIONS: Static models may serve to explore an intervention's cost-effectiveness against infectious disease: the direction and principal drivers of change were the same in both models. When, however, an intervention too small to have significant herd immunity effects itself, such as maternal aP immunization, takes place against a background of vaccination in the rest of the population, a dynamic model is crucial to accurate estimates of cost-effectiveness. This finding is particularly important in the context of widely varying routine infant vaccination rates globally. CLINICAL TRIAL REGISTRY: Clinical Trial registry name and registration number: Not applicable