The general aim of this thesis is to describe and analyse the role of primary care in health care systems in terms of health, health care utilisation and costs, and to study the feasibility of retrieval of data from computerised medical records to monitor medical quality. The thesis includes five studies, a systematic literature review, a register study of utilisation of hospital and primary care, a study based on data from computerised medical records of individual patients cost for primary care, and two studies of management of respiratory infections in primary care based on data from computerised medical records of twelve health centres. The general findings of the literature review were that an expansion of the primary care component of the health care system would most likely result in better health, lower hospital care consumption and lower expenses for care. The personal physician and continuity of care were core elements to achieve this, and the significance of the way primary care is organised and funded was evident. In the register study fifty health centres were compared. Age and rates of outpatient hospital visits were the most important factors explaining the variation of rates of hospitalisations between the health centres’ areas. Hospital district also influenced hospitalisation rates in the different health centres’ areas, indicating that the health care structure in the district per se was an important factor. The rates of visits to general practitioners correlated negatively with rates of hospitalisations. The study of costs in primary care showed that the variation in the costs of the individual patients was substantial, also within age groups and within the diagnosis-related Adjusted Clinical Groups (ACG). Age and gender explained a smaller part of the variation in costs per patient in primary care. Adding the ACG weight had a major influence on improving the ability to explain the variation in costs at patient level. The ACG system might be of value in the calculation of weighted capitation in Swedish primary care, but appears to be sensitive to the thoroughness with which physicians register diagnoses. The retrieval of data from computerised medical records comprised a total number of 19 965 encounters for respiratory tract infections i.e. 199 per 1000 inhabitants during the year 2001. Most frequent diagnoses were common cold, acute tonsillitis, and acute bronchitis. The number of antibioticprescriptions was 7 961, accounting for 47% of the episodes. The most commonly prescribed antibiotics were phenoxymethylpenicillin (61%), tetracyclines (18%) and macrolides (8%). A rapid test was performed in 43% of the encounters: for C-reactive protein (CRP) in 31%; for Group A beta-haemolytic streptococci (StrepA) in 22%; and both tests were performed in 10% of the encounters. The findings in the study indicate that StrepA and CRP tests were used too frequently and often with minor contributions to patient management. The frequencies of tests and of antibiotic prescriptions varied greatly between health centres in a way that hardly could be explained by differences in morbidity. Computerised medical records provided a source of clinical information, which might be a feasible and pragmatic method for studying daily practice, and for follow-up of adherence to guidelines in general practice.

The aims of this thesis were to evaluate caries-preventive measures from a societal perspective, to demonstrate the use of resources in preventive dentistry, to develop and discuss techniques suitable for evaluating dental care costs and outcomes, and to test costs and consequences within a health economic decision model adapted to preventive dental care. The thesis is based on three separate studies with three separate cohorts. In the first study, performed at a single dental clinic, analysis was made of data on dental caries progression over four years in 92 adolescents, along with the use of resources for preventive treatment. In the second study, data from the intervention study “Evaluation of caries-preventive measures” (performed between 1995 and 1999 at 26 dental health clinics throughout Sweden) were used for economic evaluation. Three different approaches to calculating unit cost were discussed, each of which reflect the differences in treatment costs as influenced by the practitioner’s level of skill and competence (salary) and by methods of handling overhead cost allocation. These methods seem useful for evaluating costs in cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA). The CEA showed an incremental cost-effectiveness over four years of SEK 2 043* per averted decayed (D) enamel (e) and dentine caries, missing (M) and filled (F) surface (S) (DeMFS). In the third study, 82 19-year-old individuals agreed to participate in a pilot exploratory case-control study. Individuals with high caries experience formed the test group while the control group consisted of individuals with no caries experience. To explore whether any differences existed between these two groups in perceived oral health-related quality of life (OHRQOL), two OHRQOL measures were used. Additionally, the willingness of these individuals to pay (WTP) for a preventive strategy was elicited using the contingent valuation method (CVM) within a cost-benefit approach. Using these WTP values, the cost-benefit analyses showed positive net social benefit (NSB) values for both study groups, meaning that the benefits of prevention exceeded the costs. A new outcome measure, Value of Statistical Oral Health (VOSOH), was also presented. Consideration was also made, within the economic framework fundamental to this thesis, of the trend away from a strictly bio-medical paradigm towards a biopsychosocial perspective. The health economic decision model encompasses a number of different techniques for comparing costs with consequences, each with its own advantages and disadvantages and each with its own field of application. These techniques should be seen as complementary rather than competing. Preventive dentistry plays a central role in Swedish dental health care, and it is important that resources are used properly. Accurate evaluation methods are necessary in order to improve the basis for public decision-making; the methods proposed in this thesis seem to be of potential use in this endeavour. *SEK8.54 = US$1 (December 1999).

The purported costs of provincial autonomy in Canadian securities regulation have been well documented. Proposals for centralizing the securities regulatory regime, whether under a national regulator or through restricting the scope of provincial divergence from national standards, have consistently cited the costliness of the current regime. However, policymakers' cognitive biases lead them from time to time to overemphasize the need for decisive and swift action, which in turn causes them to abandon sound decision-making processes. Provincial autonomy ensures that policymaking with national reach is process-oriented and is more likely to be guided by facts and rational projections. Supporters of centralization discount or ignore these features of decentralization and are too sanguine about the ability of centralized regulators to adhere to process. Any further proposals for reform should properly account for these effects.

The purported costs of provincial autonomy in Canadian securities regulation have been well documented. Proposals for centralizing the securities regulatory regime, whether under a national regulator or through restricting the scope of provincial divergence from national standards, have consistently cited the costliness of the current regime. However, policymakers' cognitive biases lead them from time to time to overemphasize the need for decisive and swift action, which in turn causes them to abandon sound decision-making processes. Provincial autonomy ensures that policymaking with national reach is process-oriented and is more likely to be guided by facts and rational projections. Supporters of centralization discount or ignore these features of decentralization and are too sanguine about the ability of centralized regulators to adhere to process. Any further proposals for reform should properly account for these effects.

Aims: To assess effectiveness and economic benefit of the psychological treatment of anxiety disorders in order to compare them with the consumed resources of the treatment. Methods: Assessment of specific and non-specific symptoms and impairments in N=493 anxiety patients (DSM-IV) receiving cognitive behavior therapy pre, post, and one year after treatment with various measures. Additional analyses of costs of the treatment and the benefits due to reduced work disability and health care utilization after therapy (including a pilot study using a willingness-to-pay approach). The treatment setting can be characterised as clinically typical for everyday practice. Core results: a) effectiveness: Effect sizes ranged from 0.9 to 1.9. All improvements were significant and lasted until 1-year-follow-up. Rates of clinically significant therapy success ranged from 63% to 79% depending on outcome measure and success criteria. b) cost-effectiveness analysis: Cost-effectiveness-indices ranged from DM 8338.- to DM 10456.- for one successful treatment (average costs taking also the costs of unsuccessful treatments into account). c) cost-benefit-analysis: Cost reduction in the year after therapy was remarkable (inpatient costs about 25%, other cost factors 87%-100%), resulting in a benefit of DM 3026.- per patient and a cost-benefit-ratio of 1:0.58 in the first year after treatment. Assuming that the improvements are stable, the cost-benefit-ratio after five years would be estimated as 1:2.63. Discussion: The present study shows exemplarily for CBT of anxiety disorders that modern psychotherapy can produce remarkable results at reasonable costs. Furthermore, clinical-psychological treatment methods show an additional economic benefit. Clinical Psychology can benefit from focusing not only the promising developments in classification, etiology, and treatment but also taking over the cost perspective (which is relatively new in scientific evaluation of psychotherapy). (Appendix: Cost-Benefit-Calculator.htm; 8,97 KB -- Usage: Referat Informationsvermittlung/ SLUB) / Fragestellungen: Ermittlung von Effektivität und monetärem Nutzen psychologischer Behandlung von Angststörungen, die dann den für die Therapie aufgewendeten Ressourcen gegenübergestellt werden. Methoden: N=493 Patienten mit Angststörungen (DSM-IV), die eine ambulante störungsspezifische kognitive Verhaltenstherapie absolviert haben, wurden prä, post und zur 1-Jahres-Katamnese untersucht. Das Spektrum der Erhebungen umfasste störungsspezifische und störungsübergreifende Symptombelastung und Beeinträchtigungen in verschiedenen Lebensbereichen, sowie eine globale Therapieerfolgseinschätzung von Patienten und Therapeuten. In einer zweiten Studie wurden zusätzlich an einer Teilstichprobe Kosten-Nutzen-Aspekte untersucht (Einsparungen durch Reduktion von Gesundheitsleistungen und Arbeitsunfähigkeit; außerdem Pilotstudie zu willingness-to-pay-Ansatz). Das Behandlungssetting der Studie ist charakterisiert durch klinisch relevante Rahmenbedingungen und Praxisnähe. Zentrale Ergebnisse: a) Effektivität: Die Effektstärken reichten in Abhängigkeit von der Meßmethode von 0.9 bis 1.9. Die Verbesserungen waren durchgängig signifikant und blieben bis zur 1-Jahres-Katamnese stabil. Die Raten klinisch bedeutsamer Besserungen betrugen 63% - 79% in Abhängigkeit von Mess- und Auswertungsmethode. b) Kosten-Effektivitäts-Analyse: Die Kosten-Effektivitätivitäts-Indices betrugen DM 8338.- bis DM 10456.- (dieser Index gibt an, was eine erfolgreiche Behandlung durchschnittlich kostet, also unter Einbezug der nicht erfolgreichen Behandlungen in die Gesamtkosten). c) Kosten-Nutzen-Analyse: Im Jahr nach Therapie reduzierten sich die Kostenfaktoren der Störungen vor Therapie beträchtlich (stationäre Kosten um 25%, restliche Kostenfaktoren 87% - 100%). Die dadurch erzielten Einsparungen betrugen durchschnittlich DM 3026.- (Kosten-Nutzen-Verhältnis im ersten Jahr: 1 : 0.58). Unter der Annahme, dass die Auswirkungen der Therapie auch über die 1-Jahres-Katamnese hinaus stabil bleiben, kann man abschätzen, dass sich die Therapie innerhalb des zweiten Jahres amortisiert und das Kosten-Nutzen-Verhältnis nach fünf Jahren (diskontiert) 1 : 2.63 beträgt. Diskussion: Wie in dieser Arbeit anhand der kognitiven Verhaltenstherapie für Angststörungen gezeigt wird, kann moderne Psychotherapie bei vertretbarem Aufwand beachtliche Erfolge verbuchen. Klinisch-psychologische Behandlungsmethoden sind darüber hinaus auch wirtschaftlich, derart, dass sie über den reinen Behandlungserfolg hinaus zu Kosteneinsparungen beitragen könnten. Es ist erstaunlich, dass die Kosten-Perspektive der wissenschaftlichen Bewertung von Psychotherapie noch recht neu ist. Die Klinische Psychologie kann davon profitieren, diese Dimension (neben den beachtlichen Erkenntnisfortschritten in bezug auf Klassifikation, Ätiologie, Verlaufsforschung und Behandlungsverfahren) mehr herauszustellen. (Anlage: Cost-Benefit-Calculator.htm; 8,97 KB -- Nutzung: Referat Informationsvermittlung der SLUB)

Une communication honnête entre l’adolescent(e) et son parent est associée à un développement plus sain chez l’adolescent(e) (Stattin & Kerr, 2000). La présente étude s’intéresse à la façon dont les parents peuvent favoriser l’honnêteté chez leurs adolescents. En nous basant sur la Théorie de l’Autodétermination (Deci & Ryan, 2000), nous postulons que plus les parents soutiennent l’autonomie de leurs adolescents, plus ceux-ci sont honnêtes avec leurs parents. Nous postulons également qu’il y aurait deux variables médiatrices de cette relation : l’intégration de la valeur de l’honnêteté chez les adolescents ainsi que leur perception des coûts et des bénéfices vis-à-vis du fait d’être honnête avec leurs parents. Des analyses de modélisation par équations structurales se basant sur 174 dyades parent-adolescent ont démontré que plus les parents soutiennent l’autonomie de leurs adolescents, plus les adolescents intègrent la valeur de l’honnêteté et plus ils perçoivent des bénéfices élevés, et de faibles coûts, à être honnêtes avec leurs parents. L’intégration de la valeur de l’honnêteté et le fait de percevoir davantage de bénéfices que de coûts à être honnête prédisaient par la suite une communication plus honnête entre l’adolescent(e) et son parent. Le fait que le parent valorise l’honnêteté contribuait aussi à l’intégration de la valeur de l’honnêteté chez l’adolescent(e). / Honest communication in parent-adolescent relationships is a precursor of adolescents’ healthy development (Stattin & Kerr, 2000). This study investigates how parents can foster their adolescents’ honest communication. In line with self-determination theory (Deci & Ryan, 2000), we postulated that the more parents are autonomy supportive, the more their adolescents would be honest with them. We also postulated that this relation would be mediated by two variables: adolescents’ integration of the honesty value and their perception of the costs/benefits of being honest with their parents. Results from Structural Equation Modeling with 174 parent-adolescent dyads showed that the more parents were autonomy supportive, the more adolescents integrated the value of honesty and the more they perceived high benefits and low costs in being honest with their parents. These variables, in turn, were positively related to adolescents’ honest communication behaviors. Parental valuation of honesty also predicted adolescents’ integration of the honesty value.

This dissertation contains three independent essays relating energy economics. The first essay investigates price asymmetry of diesel in South Korea by using the error correction model. Analyzing weekly market prices in the pass-through of crude oil, this model shows asymmetric price response does not exist at the upstream market but at the downstream market. Since time-variant residuals are found by the specified models for both weekly and daily retail prices at the downstream level, these models are implemented by a Generalized Autoregressive Conditional Heteroskedasticity (GARCH) process. The estimated results reveal that retail prices increase fast in the rise of crude oil prices but decrease slowly in the fall of those. Surprisingly, retail prices rarely respond to changes of crude oil prices for the first five days. Based on collusive behaviors of retailers, this price asymmetry in Korea diesel market is explained. The second essay aims to evaluate the new incentive system for biodiesel in South Korea, which keeps the blend mandate but abolishes tax credits for government revenues. To estimate changed welfare from the new policy, a multivariate stochastic simulation method is applied into time-series data for the last five years. From the simulation results, the new biodiesel policy will lead government revenues to increases with the abolishment of tax credit. However, increased prices of blended diesel will cause to decrease demands of both biodiesel and blended diesel, so consumer and producer surplus in the transport fuel market will decrease. In the third essay, the Regression - Seasonal Autoregressive Integrated Moving Average (REGSARIMA) model is employed to predict the impact of air temperature on daily peak load demand in Houston. Compared with ARIMA and Seasonal Model, a REGARIMA model provides the more accurate prediction for daily peak load demand for the short term. The estimated results reveal air temperature in the Houston areas causes an increase in electricity consumption for cooling but to save that for heating. Since the daily peak electricity consumption is significantly affected by hot air temperature, this study makes a conclusion that it is necessary to establish policies to reduce urban heat island phenomena in Houston.

Det övergripande transportpolitiska målet i Sverige har sedan 1998 varit att säkerställa en samhällsekonomiskt effektiv och långsiktigt hållbar transportförsörjning för medborgarna och näringslivet i hela landet. Under perioden fram till 2010 har samhällsekonomiska underlag fått en allt tyngre roll i den formulerade transportpolitiken och den statliga styrningen av den långsiktiga planeringen som ett verktyg för att prioritera mellan investeringar i nya vägar och järnvägslänkar. I studien utforskades den samhällsekonomiska analysens roll i den formulerade transportpolitiken och dess styrning av den regionala infrastrukturplaneringen. Studien utgår ifrån ett konstruktivistiskt angreppssätt och en syn på relationen mellan vetenskap/expertis och politik som samproducerad. Det empiriska material som ligger till grund för analysen består av dokument och intervjutranskriptioner. De dokument som har analyserats är publikationer om den samhällsekonomiska analysmetoden, utgivna av myndigheten Statens institut för kommunikationsanalys (SIKA) och dels olika typer av transportpolitiska dokument. Intervjuerna genomfördes med tretton regionala beslutsfattare och en tjänsteman, vilka varit delaktiga i upprättandet av en regional infrastrukturplan i Västra Götaland. Studien visar att samhällsekonomisk analys är en värderingsmetod med stort inflytande i den formulerade transportpolitiken. Trots att den framställs som ett objektivt sätt att utvärdera den samhällsekonomiska effektiviteten hos väg- och järnvägsobjekt, och i förlängningen deras bidrag till det övergripande målet, utgör metodens grunder till stor del en svart låda i den transportpolitiska diskussionen. Detta gäller även hos de intervjuade beslutsfattarna, men de konstruerar den enskilde politikerns omdöme som den viktigaste grunden för beslut. / The study deals with applied cost-benefit analysis (CBA) and the significant role this method has acquired in transport policy in Sweden since 1998. It is a study of a valuation method at the intersection between neoclassical economics, expertise, Swedish transport policy, long term planning and regional decision makers. Specifically, it focuses on the co-production of expertise and politics and how boundaries are drawn between them in relation to valuation. Departing from a constructionist approach to science and expertise, the study is concerned with how CBA and valuation is depicted in various contexts. The empirical foundation of the study concists of documents dealing with CBA, several kinds of transport policy documents and interview transcripts resulting from interviews with thirteen regional decision makers and one regional official. The analysis shows the significant influence of CBA on transport policy. While this valuation method is depicted as an objective valuation tool in planning, its conceptual foundation tends to be black-boxed outside the domain of expertise. This applies also to the interviewed regional decision makers. However, they delimit the space for CBA as a sufficient decision support. In addition, they construct judgment as the most important basis for decisions on infrastructure. Still, it is argued, the black-boxing of CBA in transport policy affect the political landscape negatively: it entails a risk that important political issues are made more inaccessible for public debate.

This thesis addresses the issue of weighted cost-benefit analysis (WCBA). WCBA is a welfare evaluation model where income distribution effects are valued by distributional weighting. The method was developed already in the 1970s. The interest in and applications of this method have increased in the past decade, e.g. when evaluating of global environmental problems. There are, however, still unsolved problems regarding the application of this method. One such issue is the choice of the approach to the means of estimating of the distributional weights. The literature on WCBA suggests a couple of approaches, but gives no clues as to which one is the most appropriate one to use, either from a theoretical or from an empirical point of view. Accordingly, the choice of distributional weights may be an arbitrary one. In the first paper in this thesis, the consequences of the choice of distributional weights on project decisions have been studied. Different sets of distributional weights have been compared across a variety of strategically chosen income distribution effects. The distributional weights examined are those that correspond to the WCBA approaches commonly suggested in literature on the topic. The results indicate that the choice of distributional weights is of importance for the rank of projects only when the income distribution effects concern target populations with low incomes. The results also show that not only the mean income but also the span of incomes, of the target population of the income distribution effect, affects the result of the distributional weighting when applying very progressive non-linear distributional weights. This may cause the distributional weighting to indicate an income distribution effect even though the project effect is evenly distributed across the population. One rational for distributional weighting, commonly referred to when applying WCBA, is that marginal utility of income is decreasing with income. In the second paper, this hypothesis is tested. My study contributes to this literature by employing stated preference data on compensated variation (CV) in a model flexible as to the functional form of the marginal utility. The results indicate that the marginal utility of income decreases linearly with income. Under certain conditions, a decreasing marginal utility of income corresponds to risk aversion. Thus the hypothesis that marginal utility of income is decreasing with income can be tested by analyses of individuals’ behaviour in gambling situations. The third paper examines of the role of risk aversion, defined by the von Neumann-Morgenstern expected utility function, for people’s concern about the problem of ‘sick’ buildings. The analysis is based on data on the willingness to pay (WTP) for having the indoor air quality (IAQ) at home examined and diagnosed by experts and the WTP for acquiring an IAQ at home that is guaranteed to be good. The results indicate that some of the households are willing to pay for an elimination of the uncertainty of the IAQ at home, even though they are not willing to pay for an elimination of the risks for building related ill health. The probability to pay, for an elimination of the uncertainty of the indoor air quality at home, only because of risk aversion is estimated to 0.3-0.4. Risk aversion seems to be a more common motive, for the decision to pay for a diagnosis of the IAQ at home, among young people. Another rationale for distributional weighting, commonly referred to, is the existence of unselfish motives for economic behaviour, such as social inequality aversion or altruism. In the fourth paper the hypothesis that people have altruistic preferences, i.e. that they care about other people’s well being, is tested. The WTP for a public project, that ensures good indoor air quality in all buildings, have been measured in three different ways for three randomly drawn sub-samples, capturing different motives for economic behaviour (pure altruism, paternalism and selfishness). The significance of different questions, and different motives, is analysed using an independent samples test of the mean WTPs of the sub-samples, a chi-square test of the association between the WTP and the sample group membership and an econometric analysis of the decision to pay to the public project. No evidence for altruism, either pure altruism or paternalism, is found in this study.

Having been running for over 10 years, the Clean Development Mechanism (CDM) is considered an innovative and successful mitigation initiative. CDM has the dual aims of helping industrialised countries achieve compliance with their emission limitation and reduction commitments in a cost-effective way, while simultaneously assisting developing countries in sustainable development. This thesis does a comprehensive analysis of the dual aims of CDM and is intended to assist in discussions about the post-2012 regime regarding CDM. To analyse the aim of assisting mitigation in a cost-effective way, the prices of certified emission reductions (CERs) on the international carbon market was studied and the provision of CDM was tested by comparing the amount of CERs with the mitigation commitments of the Annex I countries. It was found that CDM plays an important role in maintaining the international carbon price at a low level and that the total amount of CERs alone had already reached up to 52.70% of the entire mitigation commitments of industrialized countries by the end of 2010 and was continuing to grow before 2012. A theoretical analysis of the impacts of CDM showed that CDM has a double mitigation effect in both developing countries and industrialised countries, without double counting at present. A quantitative evaluation of the effects of China’s CDM projects on China’s total emissions showed that the contribution of CDM projects to limiting total emissions is small due to the dominance of fossil fuels, but CDM’s role in stimulating renewable energy is significant, e.g. about 11% of hydropower and 93% of wind power was generated by CDM projects in 2010. The results provide strong evidence in support of CDM’s contribution under the current Kyoto Protocol mitigation regime. To analyse the aim of promoting sustainable development in developing countries, popular methods such as checklist, Multi-Criteria Analysis (MCA) and Cost-Benefit Analysis (CBA) were reviewed, a CBA of co-benefits of China’s CDM projects was carried out, and the Analytic Hierarchy Process (AHP) method was applied in an experimental study. The results showed that every method has its own advantages and problems. In other words, neither the CBA of co-benefits nor the AHP method alone is able to assess sustainable development in a completely satisfactory way. Currently, a bottom-up approach through engaging local stakeholders in CDM design and approval, combining a mandatory monitoring and evaluation of co-benefits, could be more effective for safeguarding local sustainable development than any consolidated standards. The future of the CDM is still unclear mainly due to uncertainties about the post-2012 regime. This thesis shows that there is more than sufficient reason for CDM to continue after 2012. Industrialised countries in general should make more substantial efforts to reduce their domestic emissions rather than blaming developing countries. For developing countries, learning from the CDM projects and further applying the knowledge, technology and experiences to their domestic development agenda could be more valuable than the present CER revenues. CDM can be an important starting point for developing countries to gradually make incremental greenhouse gas (GHG) reduction and limitation efforts. / QC 20110817