Luftverkehrsprognosen stellen ein wichtiges Instrument dar, die Luftverkehrsinfrastruktur zu beeinflussen. Hinter vielen der Projekte, die von Luftverkehrsprognosen begleitet werden, stehen Interessen. Dies gilt insbesondere für Ausbauvorhaben von Flughäfen, die von eindeutigen Zielen und Wünschen getragen werden. Die Gutachter, die im Rahmen solcher Ausbauvorhaben tätig werden, sind der Gefahr ausgesetzt, beeinflusste Prognosen zu erstellen. Die Art und Intensität dieser Beeinflussung sowie die Methodik dieser Analysen sind Gegenstand dieses Aufsatzes. Zunächst wurden neuere Ergebnisse der OECD und EU erarbeitet und denen der Flughafenstudien gegenübergestellt. Nachfolgend wurde die Intensität der Beeinflussung auf Grundlage einer eigenen Untersuchung analysiert. Dabei wurden politische Entscheidungsträger im Rhein-Main-Gebiet nach Ihrer Verwendung von Studien und deren Ergebnisse befragt. Die Impact Study, als häufigste Forschungsmethodik, wurde in ihre Bestandteile zerlegt und mit der Full Cost-Benefit-Analyse, welche die durch die FAA empfohlene Methode ist, verglichen. Grundsätzlich sind solche Gutachten meist externe Analysen aus privatwirtschaftlicher Hand, die einerseits im Auftrag von regionalen Entscheidungsträgern, aber andererseits auch im Auftrag von Flughafen- und Fluggesellschaften angefertigt wurden. Die Unabhängigkeit der Prognosen ist damit gefährdet. Auf Grundlage der (neutralen) OECD- und EU-Ergebnisse zeigte sich, dass etwaige regionale Wirtschaftsimpulse und damit einhergehendes Beschäftigungswachstum durch erhöhten Flugverkehr nicht zu finden sind. Die kritische Analyse von „bezahlten Studien“ ist demnach von Bedeutung. Die Mehrzahl der politischen Amts- und Entscheidungsträger in Deutschland trifft allerdings Entscheidungen auf Basis keiner oder ausschließlich nicht-neutraler, bezahlter Auftragsstudien. Historisch betrachtet ist dies kein Novum. Bereits in den 60er Jahren kann man solche Studien und Entscheidungen nachweisen. Bezüglich des Forschungsdesign zeigte sich, dass Impact-Studien kaum für zur Beurteilung des Luftverkehrs geeignet sind. Sie beziehen die relevanten Effekte nur teilweise in ihre Berechnungen ein. Es wurde eine Reihe von systematischen Fehlern identifiziert. Die FAA-Richtlinien in den USA für methodisch korrekte Studien greifen nur wenig. Für weitere Forschung sehen wir die wichtige Aufgabe, die Methodik der Full Cost-Benefit-Analyse für die Prognose möglicher Effekte zur Anwendung zu bringen. / Aviation traffic forecasts and airport analyses are important instruments which influence decisions on aviation related infrastructure. Behind many of such infrastructure projects, which are supported by forecast analyses, one finds political interests. This is especially the case for aviation projects, such as infrastructure enlargement projects of airports, which are motivated by distinct goals and desires. Referees who act within this framework are exposed to the risk of producing biased results. The form and degree of intensity of such influence and manipulation, as well as the methodology of such forecast analyses, are the subject of this working paper. To begin with, newer research results by the OECD and the EU have been formulated and further compared to results of studies commissioned by airport operators. Subsequently, the degree of intensity of such influence has been analysed on the basis of our own research. A survey was thereby produced, investigating the application of neutral and non-neutral studies in the decision-making processes of the public administration in the Rhein-Main-area. Impact studies, which are currently the most used method, have been segmented and compared with studies using full cost-benefit-analysis, the recommended method by the FAA. With regard to these results, it can be argued that most forecast analyses are produced by private consultancies, by order of public entities but also by order of airport operators. The independence of such research and its results is therefore endangered. Recent OECD and EU research results have shown that eventual effects, such as regional economic stimulus and employment growth, are absent. Thus, care in the application of study results in this field is necessary. However, the majority of policy makers (in Germany) unfortunately base their decisions mostly on non-neutral studies. Historically seen, this is not a novelty. Regarding the research design, impact studies are hardly suitable for airport studies. Further, it can be shown that impact studies incorporate mostly only non-negative items in their cash flow calculations, compared to full cost-benefit-analyses which incorporate all relevant items. A number of systematic flaws are further identified. The regulation-guidelines by the FAA, which demand to incorporate all items, have had little impact on the research design of airport studies in the US so far. The promotion and fostering of full cost-benefit-analyses is necessary to lift the quality of airport studies.

本論文名為「行政效率測量標準與方法之研究」，除緒言外，共分七章。全文約十二萬字。 在「緒言」中，略述個人研究本文的動機與意旨，以及研究的重點與範圍。第一章「行政效率的概念」，首先闡述行政效率的性質、意義、辨正等。次論行政效率測量的意義，目的及其所遭遇的困難期澄清行政效率的基本概念，以利行政效率測量標準與方法的探討。第二章「行政效率測量標準」，就行政效率的性質，分成三個層次予以討論; 其一為機械性效率，凡行政機關工作屬於機械性者，適用機械性效率測量標準。筆者從各種角度提出七項測量標準，以供參考。其二為組織性效率，凡行政機關組織、人員、管理及運作情況的效率均屬之，適用組織性效率測量標準。筆者亦提出七項測量標準討論。其三為社會性效率，著重行政活動對社會所具的功能與價值等，適用社會性效率的測量標準。筆者提出討論的測量標準有三項。第三章為「行政效率測量方法」，採用統計分析方法與數理公式，論述行政效率測量的方法與技術。其中有的屬於理論性探討，有的則為現行測量辦法，筆者就此些辦法加以論列分析，並舉述實例，俾明其應用。第四章「我國行政效率測量的實施」，略論人事行政局與台北市政府的實施情形，並檢討其利弊，提出建議事項，以供參考改進。第五章「行政效率的測量人員」，鑒於「徒法不足以自行」，「為政在人」，故本章敘述如何遴任及訓練行政效率測量人員。期以人員的優點彌補制度的闕漏。第六章為「我國行政效率測量的展望」，闡明我國目前行政效率測量制度未臻完善，應從速謀求研究改進，加強實施工作簡化，計劃評核術與目標管理等新近管理技術，擬訂妥善的測量標準與方法。最後一章「結論」，綜合全文的研究心得提出報告，強調檢討現行制度缺點，力求改進，健全存政效率測量制度，增進行政效率，實現行政革新。本文研究方式，主要為理論性探討，並佐以若干實例，以求理論與實際相配合，研究範圍包括行政機關的組織、制度、人員及運作等，以求普遍討論效率測量標準與方法。筆者會去信美國當代名行政學者西蒙(Herbert A. Simon)教授，請教有關行政效率測量問題。西蒙教授謙虛表示，最近十幾年來，他的研究工作很少觸及行政效率、測量標準與方法。其主要觀點幾乎已盡括於「行政學士」(Public Adiministration 1956)一書中。但他指出美國這方面的研究趨向於「成本利益分析」(Cost-Benefit Analysis) 。西蒙教授並贈送筆者一書，名為「經由系統分析增進政府效率」(Efficiency in Government through Systems Analysis. by Roland N. Mckean, 1958) 其內容主要敘述利用成本利益分析以抉擇行政活動計劃，但與效率測量亦具有相當密切的關係，故本文會約略論及。

The objective of this thesis is to quantitatively understand the economic performance of protected area management strategies for forest and biodiversity conservation. Examples such as integrated conservation and development and eco tourism are assessed in terms of their ability to deliver on welfare benefits to local communities, and an assessment of the opportunity costs of forest conservation as a land use strategy. In addition the contribution of forest conservation in protected areas can make to poverty alleviation and economic development is also examined. The geographical focus of this study is the Albertine Rift region of East and Central Africa, stretching north from the southern end of Lake Tanganyika through the spine of Africa to the northern end of Lake Albert. The Albertine Rift is one of Africa’s most important landscapes for the conservation of forests and biodiversity. The overarching objective is addressed using a series of case studies empirically valuing the opportunity costs of conserving forests in a selection of sites in the central part of the Albertine Rift. The success of conservation is most often measured against progress in reducing habitat or species loss and not often in terms of the contribution of the protected area to poverty alleviation and local economic development. Achieving improvements of conservation strategies in the social dimension requires objective evidence on their effects. Economic valuation of protected area resources provides a quantitative means of assessing the promise and performance of conservation policies in achieving welfare benefits to local communities. This thesis provides three case studies each addressing current valuation and social issues in conservation and sets them in a context of managing protected areas in the broad dynamic setting of poverty alleviation and economic growth from a developing economy perspective. In addition two of the empirical studies are as concerned with methodological enquiry and the performance of novel environmental economic valuation techniques, such as the contingent valuation and choice modelling approaches, as the application of results to conservation questions. The empirical studies show that the benefits to local households and communities from their local forests may be greater than at first perceived. Across all protected area categories, biomes and income groups, households derived significant amounts of their overall income from their local protected area with large proportions of the value of goods harvested from forests being consumed in the home. Amongst income groups high income households often appropriated a greater share of the value of forest goods. There was no significant difference found between the household consumption and the sale of protected area products between income groups. The findings indicate that imposing reductions in forest use may increase poverty amongst local people whilst increasing household income will not necessarily reduce forest exploitation. This indicates that community conservation and integrated conservation and development programmes must target the poor forest adjacent households more actively to ensure poverty alleviation, whilst providing improved protection and law enforcement for effective conservation. It is also shown that biodiversity conservation can have an economic return through mountain gorilla eco-tourism. Findings show a disparity between what constitutes eco-tourism and the real values of tourists towards biodiversity conservation and local social benefits from protected areas. Despite showing a high marginal utility for biodiversity conservation, consumers are unwilling to pay for local community benefits from tourism as part of the permit price to view gorillas. Clearly the link between successful conservation and the welfare status of local communities is not sufficiently established in the minds of consumers to influence their spending decisions. The challenges of effectively mobilising communities to protect biodiversity are discussed in the context of the variable impacts of integrated conservation and development programs over the last three decades. Direct payment payments for conservation services schemes are discussed as an innovative tool to add to the gamut of community approaches currently on offer. Payments for conservation schemes are viewed with cautious optimism in terms of their possibility for success. Despite their allure of being more economically and socially efficient at achieving welfare and conservation objectives, given the complex nature of any society, no less research in to social and economic dynamics of protected area use by local communities would be needed to ensure success of such schemes. However, the overwhelming majority of benefits form protected areas are tied up in ecosystem services values. Mechanisms to generate funding and distribute payments for these benefits in terms of offsetting the local opportunity costs are essential to change local behavior and reduce forest degradation and destruction.

Efficient waste management enables the protection of human health, reducing environmental pollution, saving of natural resources, and achieving sustainable and profitable management of energy. In many countries, the general guidelines for waste management are set by national or local waste management plans. Various models provide local authorities with decision-making tools in planning long-term waste management scenarios.This study aims at providing a special model framework for the evaluation of ecological–economic efficiency (ECO-EE) of waste management. This will serve as an information support tool for decision making by actors of a solid waste management (SWM) scheme, primarily at the municipal and regional levels. The objective of this study is to apply the waste management’s efficient decision (WAMED) model along with the company statistical business tool for environmental recovery indicator (COSTBUSTER) model to SWM and municipal solid waste (MSW) schemes in general in order to evaluate and improve their ECO-EE. COSTBUSTER is a mathematical indicator for the size and extent of implementation costs of a certain SWM scheme, compared with the total size of the average financial budget of a SWM actor of a certain kind. In particular, WAMED is proposed for evaluating the suitability to invest in baling technology. Baling of solid waste is an emerging technology which is extensively used worldwide to temporarily store waste for either incineration or recovery of raw materials. The model for efficient use of resources for optimal production economy (the EUROPE model) is for the first time applied to emissions from baling facilities. It has been analysed how cost-benefit analysis (CBA) and full cost accounting (FCA) can facilitate environmental optimisation of SWM schemes. The effort in this work represents a continuation of such ambitions as an enlargement of the research area of CBA based modelling within SWM. In the thesis, certain theoretical and economic aspects of SWM were analysed as case studies. A shift of viewpoints within the field of waste management is presented. This shift is in accordance with the prevailing concept of sustainable development, as commonly understood. It is concluded that in the practical SWM context, the findings of the study point at the possibilities to modify the common CBA- and FCA-based methods by WAMED, COSTBUSTER, and EUROPE. Therefore, it can be said that estimations in a SWM scheme can be carried out by using certain economic model, if properly modified in a logical and plausible way. New principles for cost allocation to SWM residual products are presented in the current work. They imply strong industrial cost saving incentives through promoting the introduction of new and improved processing technologies for rest-waste. Such incentives then strongly promote investments that are likely to improve both the environment and the corporate profitability. Thereby, the occurrence of non-commercialised, and hence not utilized, wastes is reduced. This improves the short term corporate economy through saving raw materials such as solid waste fuel, spending less time for administrating waste flows, and less wear and tear of the plant machinery. Additional environmental advantages which affect the balance sheets in a favourable way are related to the long-term business economy and extended environmental goodwill. This is due to the recently introduced way of considering solid waste as regular goods in financial terms - the equality principle. If waste is seen as goods, and not wasted in landfills, the environment will improve. This, in turn, leads to an improved quality of life. Based on the current study, it is recommended to apply WAMED to SWM schemes in order to evaluate their ECO–EE to justify decision making and investments. Also, it is recommended to apply COSTBUSTER, based on the current WAMED outcome, to SWM schemes to determine their relative size and extent. It is recommended to apply EUROPE to the emissions in case of accidental burning, treatment of leachate, andabatement with odours at any SWM scheme, based on the induced economic incentives, in order to reduce unwanted substances and phenomena.

La théorie économique conduit à supposer que l’assurance santé accroît les consommations médicales en générant du risque moral ex-post, c'est-à-dire l’achat par les individus de soins dont la valeur est faible au regard de leur coût total. Certains économistes soulignent que tout ou partie de ce surplus de consommation peut résulter également d’une solvabilisation de la demande de soins du fait des remboursements, traduisant ainsi un meilleur accès aux soins. Comprendre lequel de ces effets prédomine représente un enjeu important en termes d’équité et d’efficience du système de santé. Cette thèse vise à mesurer l’ampleur de l’effet de l’assurance complémentaire santé sur les consommations médicales en France et à en comprendre la nature en s’appuyant sur trois articles. Le premier article analyse l’effet du fait d’être couvert par une complémentaire santé sur le recours aux médecins, le second évalue l’impact de la CMU-C sur les consommations médicales de ses bénéficiaires, enfin le troisième étudie l’effet d’une surcomplémentaire santé permettant de compléter les remboursements du contrat de base d’une mutuelle de fonctionnaire. En se focalisant sur l’assurance complémentaire et surcomplémentaire, ces articles permettent d’étudier l’effet d’une variation à la marge du niveau de couverture sur différentes catégories de population. / According to economic theory, health insurance raises medical care consumptions by inducing ex-post moral hazard behavior, it is to say the purchase of health care that individual value below their production cost. Nevertheless, among the economists community, some suggest that these additional consumptions may be the consequence of an increase of financial resources in case of illness due to reimbursements, reflecting a better access to health care. Understanding which of these effects dominates is a crucial issue to assess equity and efficiency of health care system. Based on three articles, this thesis aims to estimate how great the effect of complementary health insurance on health care consumptions is in France, and to understand the nature of this effect. The first article analyzes the effect of being covered by a complementary health insurance on the use of physician care, the second article assess how the CMU-C scheme affected health care consumptions of its beneficiaries, and the third article examines the effect of a supplementary health insurance contract that provides reimbursements in addition of the benefits of a basic complementary health insurance contract that covers civil servants. By focusing on complementary and supplementary health insurance, these articles offer the opportunity to study the effect of health insurance at the margin, on different populations.

Análise de custo-benefício (CBA) é um instrumento de avaliação de políticas que auxilia na tomada de decisão, empregada principalmente por gestores públicos. A CBA foi utilizada com o intuito de alcançar o objetivo principal desse estudo: verificar se a exportação de água virtual - água incorporada em um produto durante seu processo produtivo - embutida em 10 produtos do setor agropecuário brasileiro, no período de 2002 a 2016, está sendo benéfica ao Brasil. Os produtos estudados foram agrupados em 5 grupos, Açúcar, Café, Milho, Soja e Boi que, somados, desde o ano de 2012 têm representado mais de 20% do total das exportações brasileiras, em termos monetários, US$. Para qualquer análise custo-benefício é necessário que todos os impactos (custos e benefícios) sejam monetizados para se apurar o benefício líquido (BL), que é alcançado diminuindo-se os custos (C) dos benefícios (B), (BL=B-C). O estudo admitiu como custo os custos de produção, dos produtos estudados; a tarifa de armazenagem portuária; e, o valor da água virtual exportada pelo Brasil. Como benefício está sendo considerado o valor recebido com a exportação desses produtos, convertido em moeda nacional. Dessa forma, para alcançar o objetivo principal do estudo, foi necessário precificar a água virtual, um dos objetivos específicos do estudo. Ademais, o estudo apresenta ainda os principais parceiros importadores do Brasil, com relação aos produtos estudados; a importância brasileira como país exportador para esses parceiros importadores; a diferença no volume de água utilizado para produção, tanto no Brasil quanto nesses importadores; e, o volume e o valor total da água virtual exportada no período analisado. A hipótese central que norteou esse trabalho é que o Brasil obteve mais benefícios do que custos ao exportar água virtual, embutida na cesta de produtos agropecuários escolhida. Inclusive, essa hipótese pôde ser confirmada, uma vez que se identificou, por meio da CBA, benefícios totais líquidos positivos, no período de 2002 a 2016, isto é, os benefícios (valor das exportações) superaram os custos (custo de produção, tarifa portuária e valor da água virtual). No que tange aos benefícios líquidos por grupo de produto estudado, os mesmos apresentaram resultado negativo em alguns anos do período analisado. Como exemplo, para o grupo Milho, nos anos de 2005, 2006 e 2009 os benefícios líquidos foram negativos. Quanto aos benefícios totais líquidos, os mesmos foram de R$ 216.342.482.411,98 no período de 2002 a 2016. Em relação ao volume total de água virtual exportada, incorporada nos produtos abordados pelo estudo, no período analisado, o mesmo foi de 2.514.850,651 milhões de m3 de água. Em termos de valor monetário, o total apurado para esse volume de água foi de R$ 27.166.366.824,47. / Cost-benefit analysis (CBA) is a policy evaluation tool that assists in decision-making, used primarily by public managers. CBA was used in order to reach the main objective of this study: to verify if the export of virtual water - water contained in a product during its production process - embedded in 10 products of the Brazilian agricultural sector, from 2002 to 2016, is being beneficial to Brazil. The products studied were grouped into 5 groups: Sugar, Coffee, Corn, Soybean and Bovine, which, since the year of 2012, represented more than 20% of total Brazilian exports, in monetary terms, US$. For any cost-benefit analysis it is necessary that all impacts (costs and benefits) are monetized to determine the net benefit (NB), which is achieved by decreasing the costs (C) of the benefits (B), (NB = B-C). The study admitted as cost the costs of production, of the products studied; the port storage tariff; and, the value of virtual water exported by Brazil. As a benefit is being considered the value received with the export of these products, converted into national currency. Thus, to reach the main objective of the study, it was necessary to value the virtual water, one of the main objectives of the study. In addition, the study also analyses the main importing partners of Brazil, in relation to the products studied; the importance of Brazil as a leading agricultural exporting country for these importing partners; the difference in the volume of water used for production, both in Brazil and in the importing partners; and, the volume and total value of the virtual water exported in the analyzed period. The central hypothesis that guided this work is that Brazil obtained more benefits than costs when exporting virtual water embedded in the chosen basket of agricultural products. This hypothesis could even be confirmed, since the CBA identified positive total net benefits from 2002 to 2016, i.e., benefits (value of exports) exceeded costs (production cost, tariff port value and virtual water value). Regarding the net benefits per product group studied, they presented negative results in some years of the analyzed period, for example, for the Corn group, in the years 2005, 2006 and 2009 the net benefits were negative. As for the total net benefits, they were R$ 216,342,482,411.98 in the period from 2002 to 2016. In relation to the total volume of virtual exported water, incorporated in the products addressed by the study, during the analyzed period, it was 2,514,850,651 million m3 of water. In terms of monetary value, the total amount for this volume of water was R$ 27,166,366,824.47.

A Mucosite Oral é uma das principais e mais debilitantes complicações do Transplante de Medula Óssea. (Schubert et al., 1986; Borowski et al., 1994; Sonis, 1998; Peterson, 2004; Sonis, 2004; Scully, 2006; Sonis, 2009). Nessa terapia sua incidência varia entre 75-100%. (Wardley et al., 2000; Barasch; Peterson, 2003; Schubert et al., 2007; Blijlevens, 2008; Vokurka et al., 2009 ). A extensão e a severidade da Mucosite Oral estão significativamente correlacionadas com dias de narcótico injetável, alimentação parenteral, febre, risco de infecção importante, dias de hospitalização, custos hospitalares e mortalidade. (Sonis et al., 2001; Vera-Llonch et al., 2007). Nosso trabalho trata-se de um estudo de avaliação clínica e econômica, retrospectivo, de pacientes submetidos ao transplante de medula óssea no Hospital Israelita Albert Einstein, entre os anos de 2000 e 2008. Foram avaliados 167 pacientes, que foram divididos em dois grupos: Grupo I, composto por 91 pacientes que receberam atendimento odontológico e Laserterapia durante o TMO e Grupo II, composto por 76 pacientes que não receberam atendimento odontológico nem Laserterapia. Dados como idade, sexo, diagnóstico da doença de base, protocolo quimioterápico, tipo de transplante, uso de medicação para dor, dias de febre, utilização de alimentação parenteral, dias de internação, presença de infecção e grau de mucosite oral, com e sem atendimento odontológico, foram coletados e analisados. Uma análise descritiva, com base em tabelas de frequências e testes Qui-quadrado (ou exato de Fisher, quando este se mostrou mais apropriado), foi feita com o objetivo de verificar a associação estatística entre as variáveis de interesse. Estimativas dos riscos relativos, com intervalos de confiança de 95%, foram calculadas para avaliar a associação entre o desfecho (grau máximo) e as variáveis explicativas de interesse e o tempo médio de internação (em dias) nos diferentes grupos e tipos de transplantes foi comparado por meio de um modelo de análise de variância. Valores de p menores que 0,05 foram considerados como estatisticamente significantes. Pudemos concluir com esse trabalho que a extensão e a severidade da Mucosite Oral foram maiores no grupo sem atendimento Odontológico, sendo que o risco do paciente desse grupo apresentar grau III ou IV foi de 13 vezes maior que o grupo com Cirurgião-Dentista. Além disso, observamos que atendimento odontológico durante o TMO, quando praticado da forma descrita nesse estudo, é custo-efetivo, sendo capaz de reduzir as morbidades clínicas do TMO e que os benefícios do atendimento odontológico excederam os custos e, portanto, devem ser adotados. Foi constatado também que os pacientes que tiveram o acompanhamento do Cirurgião-Dentista apresentaram melhor qualidade de vida durante TMO e que o atendimento odontológico durante o TMO gerou economia para o hospital. / Oral mucositis is one of the main and most debilitating complications of Bone Marrow Transplants. In this therapy its incidence ranges between 75-100%. The extent and severity of Oral Mucositis are significantly correlated with the days of receiving injectable narcotics, parenteral feeding, fever, and risk of important infection, number of days of hospitalization, hospital costs and mortality. This study is a retrospective clinical and economic evaluation of patients submitted to bone marrow transplant at the \"Hospital Israelita Albert Einstein\", between the years 2000 and 2008. A total of 167 patients were evaluated, and were divided into two groups: Group I, composed of 91 patients who received dental treatment and Laser therapy during the BMT and Group II, composed of 76 patients who did not receive dental attendance or laser therapy. Data such as age, sex, diagnosis of the underlying disease, chemotherapy protocol, type of transplant, use of pain relief medication, days of fever, use of parenteral feeding, days of hospitalization, presence of infection and degree of oral mucositis, with and without dental attendance were collected and analyzed. A descriptive analysis, based on Frequency tables and Chi-square tests (or Fishers exact test, when this was shown to be more appropriate), was performed with the aim of verifying the statistical association among the variables of interest. Estimates of relative risks, with confidence intervals of 95% were calculated to evaluate the association between the outcome (maximum degree) and the explicative variables of interest and the mean time of hospitalization (in days) in the different groups and types of transplants was compared by means of an analysis of variance model. p- Values lower than 0.05 were considered statistically significant. By means of this study, it could be concluded that the extent and severity of Oral Mucositis were greater in the group without Dental attendance, as the risk of the patient in this group presenting Grade III or IV was 13 times higher than it was in the group attended by a Dentist. Moreover, it was observed that dental attendance during BMT, when performed in the manner described in this study, is cost-effective, as it is capable of reducing the clinical morbidities of BMT. Furthermore the benefits of dental attendance outweighed the costs, and therefore, must be adopted. It was also found that patients that were followed-up by the Dentist presented a better quality of life during BMT and that dental attendance during BMT resulted in savings for the hospital.

O câncer do colo do útero é o quarto tipo de câncer mais frequente em mulheres em todo mundo. No Brasil, estima-se que cerca de 16 mil novos casos ocorrem por ano. A redução deste tipo de câncer ao longo dos anos deve-se ao rastreamento das lesões intraepiteliais cervicais por meio do exame citológico de Papanicolaou. Em 2014, o Programa Nacional de Imunização (PNI) introduziu a vacina contra o papilomavírus humano (HPV) como prevenção primária deste câncer, uma vez que este vírus é uma causa necessária para o surgimento desta malignidade. A vacinação não substitui o rastreamento, visto que não há proteção contra todos os tipos de HPV de alto risco e nem imunização de toda a população. A incorporação do programa de vacinação interfere nos resultados do programa de rastreamento, pois leva a diminuição dos casos de câncer e lesões precursoras. Desta forma, existe a necessidade de explorar novas estratégias de rastreamento, considerando também outras tecnologias existentes. Objetivo: desenvolver um modelo do tipo Markov para realizar uma análise de custo-efetividade de estratégias de rastreamento do câncer do colo do útero para hipotéticas coortes imunizadas e não imunizadas contra o vírus do HPV no Brasil na perspectiva do Sistema Único de Saúde (SUS). Métodos: A primeira parte é a exploração e avaliação qualitativa de estudos de avaliação econômica sobre estratégias de rastreamento para prevenção do câncer do colo do útero que utilizaram um modelo do tipo Markov feita por meio de uma revisão sistemática. A reunião das várias abordagens utilizadas e das principais características destes modelos poderá auxiliar a construção de um modelo em cenários onde há poucos profissionais capacitados com esta técnica. Baseando-se nesta revisão e nas consultas a especialistas das áreas de ginecologia, virologia e epidemiologia, foi desenvolvido um modelo matemático de análise de decisão estático do tipo Markov que simula a história natural do câncer do colo do útero considerando a imunização contra o HPV. Este modelo simula o seguimento de uma coorte de mulheres, dos 10 anos até o óbito, cujos parâmetros foram estimados a partir de dados secundários (revisão da literatura, sistemas de informação em saúde e inquéritos populacionais) nacionais específicos do rastreamento e calibrados de forma a refletir as condições reais de rastreamento encontradas no Brasil. Resultados: A revisão dos modelos de Markov para avaliação econômica de estratégias de rastreamento do câncer do colo do útero mostrou que a declaração do problema e a descrição das estratégias a serem comparadas foram muito bem relatados. Em contrapartida, os itens de avaliação da incerteza e consistência do modelo e a consistência precisam melhorar o relato. Os resultados obtidos por meio da calibração do modelo se mostraram satisfatórios, pois alcançaram uma boa concordância com os dados empíricos. A análise do caso base sugeriu que a melhor estratégia foi o Teste HPV-DNA como triagem para o encaminhamento da citologia ou da colposcopia, com repetição a cada 5 anos, para mulheres entre 30 e 70 anos. Esta estratégia promove um ganho de 9,5 dias ao longo dos anos e detecta, a cada 100 mil mulheres, 6 casos a mais de câncer e 16 de NIC II/III. A razão de custo-efetividade incremental (RCEI) foi de R$16.056,94 por ano de vida ganho, na perspectiva do sistema de saúde. Conclusão: Estudos futuros devem considerar metodologias que levem em conta a incerteza, a heterogeneidade e a consistência no modelo de decisão e utilizar diretrizes validadas para o relato do estudo / Cervical cancer is the fourth most common cancer in women worldwide. In Brazil, it is estimated that around 16,000 new cases occur per year. The reduction of this type of cancer over the years owes to cervical intraepithelial lesions screening through pap smears. In 2014, the National Immunization Program (NIP) introduced a vaccine against human papillomavirus (HPV) as the primary prevention of this cancer, since this virus is a necessary cause for the onset of this malignancy. Vaccination does not replace screening because there is no protection against all types of high risk HPV nor immunization of the entire population. Incorporation of the vaccination program interferes with the results of the screening program, leading to a decreased number of cancer cases and precursor lesions. In this way, there is a need to explore new screening strategies, also considering other existing technologies. Objective: Determining a Markov based model to perform a cost-effectiveness analysis of cervical cancer screening strategies for hypothetical immunized and non-immunized cohorts against the HPV in Brazil from the perspective of the Unified Health System (UHS). Methods: The first part is a qualitative appraisal and assessment of economic evaluation studies on screening strategies for cervical cancer prevention using a Markov based model done through a systematic review. The combination of different approaches and of the main features of these models can be auxiliary in the construction of a model in scenarios where there are few professionals trained with this technique. Based on this review and consultations with specialists in the areas of gynecology, virology and epidemiology, a Markov model for decision analysis was developed, which simulates the natural history of cervical cancer considering immunization against HPV. This model simulates the follow-up of a cohort of women, from 10 years-old to death, whose parameters were estimated from secondary data, particular to screening and calibrated in order to reflect real screening conditions found in Brazil. Results: A review of Markov models for economic evaluation of cervical cancer screening strategies showed that the report of the problem statement and the description of the compared strategies were well conducted. In contrast, the uncertainties of the model and the consistency were the worst items. The results obtained by calibration of the model were satisfactory, since a good agreement with empirical data was achieved. The baseline case analysis suggested that the best strategy was the HPV-DNA Test as triage for cytology or colposcopy referral, repeated every 5 years, for women between 30 and 70 years-old. This strategy promotes a gain of 9.5 days over the years and detects, every 100,000 women, 6 cases of cancer and 16 of CIN 2/3. The incremental cost-effectiveness ratio (ICER) was R$16,056.94 per life years gained from the health system perspective. Conclusion: Future studies should consider methodologies that take into account uncertainty, heterogeneity and consistency in the decision model and use validated guidelines for the study report

Introdução: As avaliações econômicas completas do tipo custo-utilidade, suportadas por dados de efetividade do mundo real, permitem uma perspectiva diferenciada da avaliação de tecnologia em saúde. Objetivo: Realizar uma análise de custo-utilidade do uso de estatinas para a prevenção secundária de eventos cardiovasculares em portadores de doença cardiovascular isquêmica, e avaliar a variabilidade da efetividade e da razão de custo-efetividade incremental com diferentes classificações de usuários de estatina (incidentes e prevalentes). Método: Um modelo de microssimulação de Markov com 5 estados, ciclos anuais e horizonte temporal de 20 anos, com taxas de desconto de 5% foi desenvolvido. As probabilidades de transição para mortalidade por todas as causas foram extraídas após pareamento por escore de propensão dos dados e tratamento de dados ausentes de uma base secundária de registro assistencial com linkage determinístico com a base de mortalidade do Ministério da Saúde. As probabilidades dos desfechos não-fatais foram obtidas na literatura. As medidas de efetividade (QALY) foram calculadas com dados publicados dos domínios do SF-36 de um estudo realizado com a população do mesmo hospital, no mesmo período e com as mesmas condições clínicas e transformados em medidas de utilidade por modelo validado. Somente custos diretos na perspectiva do reembolso do SUS foram considerados. Resultados: 3.150 pacientes foram pareados após o escore de propensão, 1.050 não usuários de estatina, 1.050 usuários de estatinas classificados como prevalentes e 1.050 usuários de estatinas classificados como incidentes, com diagnóstico de doença cardiovascular isquêmica prévia, com seguimento médio de 5,1 anos. A efetividade das estatinas quando considerados todos os usuários em relação aos não usuários resultou em um HR para mortalidade de 0,992 (IC 95% 0,85; 0,96) e de 0,90 (IC 95% 0,85; 0,96) para os usuários incidentes. A RCEI comparando todos os usuários de estatinas versus não usuários foi de R$5.846,10/QALY e de R$7.275,61/QALY para os usuários incidentes. Conclusão: As estatinas diminuíram a mortalidade por todas as causas, e a análise incluindo usuários prevalentes diminui o tamanho do efeito. O tratamento possui custo-efetividade favorável dentro do limiar de disponibilidade a pagar definido, sendo modificado pela forma de extração do dado de efetividade / Background: The complete economic evaluations, such as cost-utility analysis, supported by real world data of effectiveness lead to a more realistic perspective of a health technology assessment. Objective: Perform a cost-utility analysis of statins for secondary prevention in ischemic cardiovascular disease patients based on effectiveness from real world data and evaluate the variability of effectiveness and incremental cost-effectiveness ratio (ICER) considering prevalent and incident users. Methods: A Markov microssimulation model with five states, annual cycle and time horizon (TH) of 20 years, with discount rate of 5% was developed. Transition probabilities for all cause mortality was derived from a secondary database of a teaching hospital after record linkage with national registry of mortality database and an analysis of propensity score matching and multiple imputation analysis for missing data. Non-fatal endpoints were derived from a published meta-analysis. Utility measures was calculated with a validated model to derive values from published domains of SF-36 QoL questionnaire, domains was measured for a published RCT in the same teaching hospital, over the same period, with similar age and diagnostic characteristics. Only direct costs were analyzed from the Brazilian public health reimbursement perspective. Results: 3150 patients were matched, 1050 non-statins users (CG), 1050 prevalent statins users (PSU) and 1050 incident statins users (ISU) with previous cardiovascular disease, with mean follow-up of 5,1 years. Treatment effects on the treatment group considering all statins users for all cause mortality had a hazard ratio of HR:0,992 (IC 95% 0,85 - 0,96) and HR: 0,90 (IC 95% 0,85 - 0,96) only for ISU. The ICER comparing all users with non-users was R$5.846,10 per QALY and for ISU was R$7.275,61 per QALY. Conclusion: Real world evidence demonstrated that statins are an effective treatment to reduce all cause mortality in secondary prevention and are a cost-effective strategy considering the willingness to pay established, but the prevalent users resulted in less effectiveness of the drug when included in the analysis and influenced the ICER

Les psychothérapies structurées sont des traitements des troubles de santé mentale recommandées par les guides de bonne pratique internationaux et dont l’efficacité et leur impact positif sur les coûts pour les régimes de santé ont été largement démontrés. Toutefois, actuellement en France, les psychothérapies effectuées par les professionnels de santé mentale non médecins exerçant en libéral, ne sont pas remboursées. L’évaluation financière de la prise en charge des psychothérapies a été effectuée à partir de la méthodologie du programme anglais Improving Access for Psychological Therapies 2005. Le coût de la séance a été estimé à 41€, le taux de remboursement par le régime obligatoire à 70% et 60% pour soigner les personnes de 18 à 75 ans souffrant de troubles de santé mentale courants chroniques et/ou sévères. Le coût de la prise en charge psychothérapeutique annuelle s’élèverait à 514 millions d’euros (entre 308 et 347 M€ pour le régime obligatoire), pour traiter 1,033 million de français, soit 2,3% de la population. Pour 1€ investi dans le traitement psychothérapeutique, le ratio coût-bénéfice s’élèverait, selon la symptomatologie, entre 1,14€ et 1,95€ épargnés par ce traitement. La France dispose des 14.300 professionnels nécessaires et habilités à effectuer des psychothérapies, pour traiter cette population. / Structured psychotherapies are treatments for mental health disorders that are recommended by international good practice guidelines. Their positive impact on the costs to healthcare funding bodies has been widely demonstrated. Nevertheless, in France today, psychotherapies delivered by non-medical mental health providers in private practice settings are not reimbursed to patients by health cover systems. A financial evaluation of covering the cost of psychotherapies was performed using the methodology of the British programme Improving Access for Psychological Therapies (2005). The cost of a session was estimated at 41€, the reimbursement rate by the compulsory health insurance system at 70% and 60% for the care of individuals aged 18 to 75 presenting common, chronic and/or severe mental disorders. The yearly cost for the cover of psychotherapeutic care was 514 million Euros (between 308M and 347M€ for the compulsory systems) to treat 1.033 million individuals in France, or 2.3% of the population. In terms of the cost-benefit ratio, 1€ invested in psychotherapeutic treatment could, depending on patient profile, save from 1.14€ to 1.95€. France has the 14 300 professionals qualified to deliver the psychotherapies required to treat this population.