O aumento de custos em saúde tem sido um tema relevante tanto pelo seu aspecto econômico quanto político, e uma de suas causas principais é a adoção de novas tecnologias de tratamento e medicamentos. O objeto deste estudo é um exemplo: o ganciclovir, uma tecnologia padrão, comparado ao valganciclovir oral, a tecnologia substitutiva. Simulações computacionais são formas de auxiliar a avaliação de custo-efetividade de um tratamento novo e a espinha dorsal desta dissertação. O conjunto de métodos para as simulações vão desde a coleta e estruturação do banco de dados, passando pelas estimativas dos parâmetros e a modelagem computacional em si, que fornecem material necessário para a análise de sobrevivência e custo-efetividade, assuntos abordados nesta pesquisa. Os principais usos da modelagem aqui realizada são: a racionalização de recursos aliadas a melhores resultados para os usuários (com menor exposição de riscos aos pacientes), menores gastos em pesquisas bem como subsídios de orientação do gestor de recursos em saúde / The increase in health costs has been a relevant issue both for its economic and political aspects, and one of its main causes is the adoption of new treatment technologies and medicines. The object of this study is an example: ganciclovir, a standard technology, compared to oral valganciclovir, the substitutive technology. Computational simulations are ways of helping to evaluate the cost-eectiveness of a new treatment and the backbone of this dissertation. The set of methods for the simulations range from the collection and structuring of the database, through the parameter estimates and the computational modeling itself, which provide the material needed for the survival and cost-eectiveness analysis, subjects addressed in this research. The main uses of the modeling carried out here are: the rationalization of allied resources to better results for users (with less risk exposure to patients), lower research expenditures as well as guidance subsidies for the health resource manager

Conselho Nacional de Desenvolvimento Científico e Tecnológico / As ações de prevenção, diagnóstico e tratamento da hepatite C crônica integram as agendas das políticas de saúde do Brasil e do mundo, pois se trata de uma doença com grande número de acometidos, com alto custo tratamento e que ocasiona graves desfechos e incapacidade, o que acaba por onerar seu custo social. Os protocolos clínicos e diretrizes terapêuticas demonstram os esforços de inúmeras entidades no combate da hepatite C, pois informam aos profissionais de saúde, pacientes e familiares e cidadãos em geral, qual seria a melhor forma, comprovada cientificamente, de se proceder frente a uma infecção desta natureza. Realizouse uma análise de custoefetividade, sob a perspectiva do SUS, das estratégias: tratamento e retratamento com a terapia dupla, tratamento com a terapia dupla e retratamento com a terapia tripla e tratamento com a terapia tripla. Através de modelo de simulação baseado em cadeias Markov foi criada uma coorte hipotética de 1000 indivíduos adultos, acima de 40 anos, de ambos os sexos, sem distinção declasse socioeconômica, com diagnóstico confirmado para hepatite C crônica, monoinfectados pelo genótipo 1 do VHC e com ausência de comorbidades. A simulação foi iniciada com todos os indivíduos portando a forma mais branda da doença, tida como a classificação histológica F0 ou F1 segundo a escala Metavir. Os resultados demonstram que as duas opções, ou seja, a terapia dupla/tripla e a terapia tripla estão abaixo do limiar de aceitabilidade para incorporação de tecnologia proposto pela OMS (2012) que é de 72.195 (R$/QALY) (IBGE, 2013; WHO, 2012). Ambas são custoefetivas, visto que o ICER da terapia dupla/tripla em relação alinha de base foi de 7.186,3 (R$/QALY) e o da terapia tripla foi de 59.053,8 (R$/QALY). Entretanto o custo incremental de terapia tripla em relação à dupla/tripla foi de 31.029 e a efetividade incremental foi de 0,52. Em geral, quando as intervenções analisadas encontramse abaixo do limiar, sugerese a adoção do esquema de maior efetividade. A terapia tripla, apesar de ter apresentado uma efetividade um pouco acima da terapia dupla/tripla, apresentou custo muito superior. Assim, como seria coerente a adoção de uma ou da outra para utilização no SUS, visto que este sistema apresenta recursos limitados, indicase a realização de um estudo de impacto orçamentário para obterse mais um dado de embasamento da decisão e assim poder apoiar o protocolo brasileiro existente ou sugerir a confecção de novo documento. / The prevention, diagnosis and treatment of chronic hepatitis C integrates health policies in Brazil and worldwide. This disease affect many people, features high cost treatment and cause severe outcomes and disability, increasing social cost. We performed a costeffectiveness analysis under the perspective of SUS, with the following strategies: treatment and retreatment with dual therapy, treatment with dual therapy and retreatment with triple therapy and treatment with triple therapy. A Markov model was developed with a hypothetical cohort of 1000 adults, over 40 years, of both sexes, with confirmed diagnosis for chronic hepatitis C, monoinfected by HCV genotype 1 and absence of comorbidities.The simulation started with all individuals carrying the milder form of the disease, considered F0 or F1, according to Metavir histological classification. The results demonstrate the dual/triple therapy and triple therapy are below the acceptable threshold for embedding technology proposed by the WHO. Both are costeffective. ICER of dual/triple therapy compared with base line was 7186.3 (R$/QALY) and the triple therapy compared with dual/triple therapy was 59053.8 (R$/QALY). However, the incremental cost of triple therapy compared to dual/triple therapy was 31,029 and incremental effectiveness was 0.52. Triple therapy, despite having a little more effectiveness than the dual/triple therapy, showed much highercost. Thus, as would be consistent adopt one or the other for use in the SUS, since this system has limited resources, is better indicate the realization a budget impact analysis to have one more data information to support the decision to continue adopting the Brazilian guideline existing or suggest making another one.

No description available.

Objetivo: Análise da relação custo-efetividade do tratamento com o uso do DCI - Desfibrilador Cardioversor Implantável comparado com o tratamento clínico alternativo através de medicamentos. Revisão de literatura: O estudo contemplou a revisão da conceituação das técnicas de avaliação econômica e de apropriação de custos de procedimentos hospitalares, bem como experiências sobre a análise da relação custo-efetividade aplicadas às intervenções médicas consideradas na pesquisa. Métodos: O estudo utilizou a unidade de Custo por AVG - Ano de Vida Ganho, como expressão do indicador de custo-efetividade. A metodologia compreendeu a definição da perspectiva da pesquisa (Sistema Único de Saúde na qualidade de principal financiador do implante de DCIs, no Brasil), elaboração dos protocolos padrões de tratamento, cálculo dos custos totais dos tratamentos baseados em indicadores praticados por hospitais de referência, os quais encontram-se estimados para o período de dez anos e ajustados para valor presente à taxa de desconto de 6% ao ano. No âmbito da efetividade, foram utilizados parâmetros da literatura, os quais encontram-se baseados nos anos de vida ganhos do tratamento com o uso do DCI, em relação ao tratamento clínico. Resultados: O custo por AVG alcançado pelo estudo foi de R$ 20.530,00, cerca de US$ 9.550. Esse indicador de efetividade foi calculado com base nos parâmetros de custo incremental de R$ 54.200,00 e expectativa de vida de 2,64 anos, decorrentes do uso do DCI comparado com o tratamento clínico. Discussão: O estudo considerou comparações com indicadores da literatura, faixas de atratividade, análises de sensibilidade, impactos sobre financiamento e limitações da pesquisa. Conclusões: O índice de custo-efetividade do tratamento com DCI mostrou-se favorável, sob as condições de atratividade ajustadas à realidade brasileira, embora enfrente dificuldades de financiamento por parte do SUS, considerando o substancial impacto financeiro das indicações de uso do referido tratamento. / Objective: Cost-effectiveness analysis of implantable cardioverter defibrillator therapy (ICD) compared with conventional drug therapy. Literature review: The study comprised the conceptualization of techniques of economic evaluation, the methodology of appropriation of hospital procedure costs and different experiences on cost-effectiveness analysis applied to medical interventions considered in this research. Methods: The study used the unit Cost per Life-Year Gained (LYG) as an index of cost-effectiveness. The methodology included the definition of the research scope (Sistema Único de Saúde as the main payor of the ICD\'s implant, in Brazil), creation of standard protocols of treatment, and calculation of treatment total cost based on indicators used by well known hospitals, which are estimated for ten years and adjusted to a discount rate of 6% a year. Concerning effectiveness, some parameters from the literature were applied, which are demonstrated by LYG with the implant of ICD, compared to the alternative drug therapy. Results: The cost per life-year gained reached by the study was of R$ 20,530.00, approximately US$ 9,550. This ratio of effectiveness was calculated on the basis of the parameters of additional cost of R$ 54,200.00 and the life expectancy of 2.64 years with the use of ICD compared to the drug treatment. Discussion: The study considered comparisons with indicators comprised in the literature, range of attractiveness, sensitivity analysis, impact over financing and limitations of research. Conclusions: The chosen cost-effectiveness indicator for ICD therapy was favorable, under the adjusted attractiveness conditions adapted to the actual Brazilian health care sector. This conclusion holds in spite of the present financial difficulties experienced by SUS, and the substantial financial impact this kind of therapy may generate.

O aumento de custos em saúde tem sido um tema relevante tanto pelo seu aspecto econômico quanto político, e uma de suas causas principais é a adoção de novas tecnologias de tratamento e medicamentos. O objeto deste estudo é um exemplo: o ganciclovir, uma tecnologia padrão, comparado ao valganciclovir oral, a tecnologia substitutiva. Simulações computacionais são formas de auxiliar a avaliação de custo-efetividade de um tratamento novo e a espinha dorsal desta dissertação. O conjunto de métodos para as simulações vão desde a coleta e estruturação do banco de dados, passando pelas estimativas dos parâmetros e a modelagem computacional em si, que fornecem material necessário para a análise de sobrevivência e custo-efetividade, assuntos abordados nesta pesquisa. Os principais usos da modelagem aqui realizada são: a racionalização de recursos aliadas a melhores resultados para os usuários (com menor exposição de riscos aos pacientes), menores gastos em pesquisas bem como subsídios de orientação do gestor de recursos em saúde / The increase in health costs has been a relevant issue both for its economic and political aspects, and one of its main causes is the adoption of new treatment technologies and medicines. The object of this study is an example: ganciclovir, a standard technology, compared to oral valganciclovir, the substitutive technology. Computational simulations are ways of helping to evaluate the cost-eectiveness of a new treatment and the backbone of this dissertation. The set of methods for the simulations range from the collection and structuring of the database, through the parameter estimates and the computational modeling itself, which provide the material needed for the survival and cost-eectiveness analysis, subjects addressed in this research. The main uses of the modeling carried out here are: the rationalization of allied resources to better results for users (with less risk exposure to patients), lower research expenditures as well as guidance subsidies for the health resource manager

abstract: Payments for ecosystem services (PES) are transactions between landholders and the beneficiaries of the services their land provides. PES schemes are growing worldwide with annual transactions over ten billion dollars (Salzman et al., 2018). Much can be learned from looking at oldest and best funded PES schemes on working agricultural land. Initiated in 1985, the USDA’s Conservation Reserve Program (CRP) is the oldest private conservation PES program in the United States. CRP incentivizes farmers to put their land into conservation through an annual payment. In Iowa, CRP has been a source of extra income and a way for farmers to buffer the fluctuating costs of cash crops, such as corn and soy. The dominance of agriculture in Iowa poses many challenges for water quality. A potential solution to the problem, implemented through CRP, is the use of conservation practices to mitigate the negative effects of agricultural run-off. This dissertation considers three aspects of the problem: 1. the relationship between changes in land cover due to CRP enrollment and changes in water quality, controlling for a range of factors known to have an effect on the filtering role of different land covers; 2. the inter-annual variability in water quality measures and enrollment in different CRP conservation practices to examine the cost-effectiveness of specific conservation practices in mitigating lake sedimentation and eutrophication; 3. discrete choice models to identify what characteristics drive the enrollment by farmers into specific conservation practices. Results indicate that land cover and CRP have different impacts on different indicators of lake water quality. In addition, conservation practices that were cost-effective for one water quality variable tended to be cost-effective for the other water quality variables. Farmers are making decisions to enroll in CRP based on the opportunity cost of the land. Therefore, it is necessary to alter financial incentives to promote productive land being putting into CRP through continuous sign-up. The United States Department of Agriculture (USDA) needs a more effective way to calculate the payment level for practices in order to be competitive with the predicted value of major crops. / Dissertation/Thesis / Doctoral Dissertation Biology 2019

Dementia is a chronic disorder that affects approximately 40 million individuals throughout the globe. This study provides a preliminary description of psychotherapeutic treatment for the management of dementia. This study compares treatment outcomes by both modality (individual, family, and mixed) and provider type. Results found that therapy is a low-cost treatment, however, it is not being often used for people with dementia, or their family members. Participants (n=327) include individuals with ages ranging from 46-95(M=70.52, SD=12.16). Females made up 57.5% (n=188), while males made up 42.5% (n=139) of the sample. Descriptive statistics found that the number of sessions ranged from 1-62 (M=3.17, SD=5.24). The average cost of care for one episode of care was $155.21(SD=276.16), and estimated cost-effectiveness was 207.31 (490.84). There were significant differences found when comparing modality type, with mixed therapy being significantly different than both family and individual therapy across all treatment outcomes. The only significant difference in groups of provider types was in the number of sessions in an episode of care. Findings suggest that although talk therapy treatment has been shown to be cost-effective treatment, it is not used often in treatment.

El presente trabajo de investigación tiene por finalidad identificar los posibles impactos financieros en las empresas de seguros para el ramo de rentas vitalicias por el efecto de transición de la norma aún vigente de los contratos de seguros NIIF 4, a la nueva norma NIIF17, la cual, debido a su complejidad entrará en vigencia en enero 2022. La NIIF 17 presenta mayores indicadores para medir los activos y pasivos de las empresas de seguros, con lo que permitirá la comparabilidad de los EEFF en el sector. Este trabajo se encuentra basado en el sector seguros, específicamente en las empresas que ofrecen productos de rentas vitalicias. Consideramos como tema importante que las empresas de seguros tengan en cuenta los cambios que presentará el uso de esta nueva norma, que, si bien su uso obligatorio se ha prolongado para el 2022, la complejidad de la norma hace necesario un estudio anticipado para evaluar todos los posibles impactos a las diferentes áreas de las compañías con lo que permita anticiparse a las limitaciones de la disponibilidad de recursos que la compañía requiera para la adaptación de la nueva norma. Para validar nuestras hipótesis utilizamos instrumentos cualitativos, tales como entrevistas a profundidad, los cuales fueron realizados a expertos del sector de seguros, miembros de la firma más importante de servicios financieros en el Perú, así como a personas involucradas en el sector. Asimismo, presentaremos tres (3) casos prácticos, que simularan los efectos de la transición de la NIFF, en los cuales evaluaremos el impacto financiero en los Estados Financieros en las empresas del sector seguros. / The objective of this research work is to guide the results on the profitability of insurance companies for the life annuity branch due to the effect of the transition from the current standard of insurance contracts IFRS 4 to the new standard IFRS17. IFRS 17 presents major indicators to measure the assets and liabilities of insurance companies, with the possibility of comparing the Financial Statements in the sector. This work is based on the insurance sector, specifically on companies that offer life annuity products. Consider as an important issue that insurance companies take into account the changes that present the use of this new standard, which although its mandatory use is extended to 2022, the complexity of the rule requires an early study to evaluate all possible effects to the different areas of the companies with what can be anticipated to the limitations of the availability of the resources that the company requires for the adaptation of the new norm. To validate our hypotheses we use qualitative instruments, stories such as in-depth interviews, those that were carried out by experts in the insurance sector, members of the most important financial services firm in Peru, as well as people involved in the sector. Likewise, we will present three (3) practical cases, which will simulate the effects of the transition of the NIFF, in which we evaluate the financial impact in the Financial Statements in the companies of the insurance sector. / Tesis

This thesis analyzes the influence of specialized cancer hospitals in Florida on the outcomes of the mortality risk, length of stay, and charges of care among patients diagnosed with cancer, and performed a mastectomy, lumpectomy or radical prostatectomy, after controlling for age, gender, race, severity, type of hospital ownership, payment options, type of admission, and presence or absence of residency programs. The Florida Agency for Health Care Administration inpatient hospital discharge dataset of 2005 was used to extract data. Analysis of covariance was used to compute the differences on the three outcomes as a function of the specialization/volume of the treatment facility. The treatment facility categories were defined as (1) specialized cancer hospital; (2) general hospital with high volume (100 or more cancer treatment discharges per defined cancer); (3) general hospital with medium volume (50 to 99 cancer treatment discharges per defined cancer); (4) general hospital with low volume (25 to 49 cancer treatment discharges per defined cancer); and (5) general hospital with very low volume (less than 25 cancer treatment discharges per defined cancer). There were no deaths in any of the three procedures at specialized cancer hospitals. Being hospitalized at a specialty cancer hospital for a radical prostatectomy for prostate cancer was associated with 0.93 fewer days in mean length of stay (mean = 2.68 overall), but length of stay was not significantly different for mastectomy and lumpectomy (mean = 2.21 and 1.86 overall respectively) compared to general hospitals with very low volumes. Charges for care were not significantly different for lumpectomy and radical prostatectomy (mean = $22,097 and $25,220 overall respectively) for a specialty cancer hospital compared to general hospitals with very low volumes, where for mastectomies it was $4,850 on average lower (mean = $24,608 overall). In this study, patients managed at specialized cancer hospitals sometimes had better outcomes (i.e. shorter lengths of stay for radical prostatectomies and lower charges for mastectomies) compared to very low volume hospitals, while not having any significantly worse outcomes.

This study examined if physician assistants (PAs) are cost-beneficial to employers. In an era of cost accountability, questions arise about whether a visit to a PA for an episode of care differs from a visit to a physician, and if PAs erode their cost-effectiveness by the manner in which they manage patients. Four common acute medical conditions seen by PAs and physicians within a large health maintenance organization were identified to study. An episode approach was undertaken to identify all laboratory, imaging, medication and provider costs for these diagnoses. Over 12,700 medical office visits were analyzed and assigned to each type of provider and medical department. Patient variables included age, gender, and health status. A multivariate analysis identified significant cost differences in each cohort of patients. In every condition managed by PAs, the total cost of the visit was less than that of a physician in the same department. This was significant for episodes of shoulder tendinitis, otitis media, and urinary tract infections. In no instance were PAs statistically different from physicians in use of laboratory and imaging costs. In each instance the total cost of the episode was less when treated by a PA. Sometimes PAs ordered fewer laboratory tests than physicians. There were no differences in the rate of return visits for a diagnosis between physicians and PAs. Patient differences were held constant for age, gender, and health status. This study affirms that PAs are not only cost-effective from a labor standpoint but are also cost-beneficial to those who employ them. In most cases, they order resources for diagnosis and treatment in a manner similar to physicians for an episode of care, but the cost of an episode of an illness is more economical overall when the P A delivers the care. This study validates the federal policy of support for primary care P A education and suggests that PA employment should be expanded in many sectors of the health care system. These findings and the results of this cost-benefit model are evidence of its validity in predicting health care costs.