The overarching aim of this dissertation is to use health services research methods to address three problems in behavioral health services. This dissertation seeks to address the knowledge gaps in behavioral health services through the generation of evidence intended to support evidence-based practices (EBP). Previous work has examined epidemiology of behavioral health disorders in the ED, but they have not attempted to examine disorders by the cause of injury. Chapter 2 examines the epidemiology of psychiatric disorders among adults who seek care in the emergency department (ED) by cause of injury. Data from a national hospital discharge survey was analyzed using logistic and multinomial regression. Estimates are given as average marginal effects (AME) to simplify the interpretation and application. Intentionally-caused injury and undetermined cause of injury are significantly associated with psychiatric disorders. Patients with undetermined cause of injury were more likely to be diagnosed with anxiety disorders, depressed mood, and psychoses relative to patients with unintentional injuries Since there are several treatment options for obsessive-compulsive disorder (OCD), including cognitive behavioral therapy (CBT), serotonin reuptake inhibitors (SRIs), and combinations of these, a comparison of treatment effects denominated in dollars is helpful when comparing risks and benefits. Chapter 3 builds on previous randomized control trials of treatments for OCD in children and adolescents by ranks the cost-benefits of first-line treatments. The analysis aggregates treatment effects from published trials in meta-analytic framework and a Monte Carlo simulation of 100,000 hypothetic children and adolescents to derive ranked cost-benefit. Treatments strategies starting with CBT, but not CBT and SRIs concurrently, were the most cost-beneficial. The relationship between cost-sharing and utilization of behavioral health services has been studied in the aggregate, but there has been little work examining the relationship by disorder and treatment modality. The aim of Chapter 4 is to examine the association between cost-sharing and utilization of psychotherapy and adherence to pharmacotherapy among insured adults with OCD. This chapter utilizes the Truven MarketScan Commercial Claims and Encounters dataset to perform zero-inflated negative binomial regression and logistic regression analyses. Increased cost-sharing was significantly, negatively associated with psychotherapy intensity and dose, but not associated with SRI adherence. This dissertation examined three different research questions to address gaps in the behavioral health services research. The findings of these chapters have implications for patients, clinicians, insurers, and policymakers. The results can be used to improve aspects of cost, quality, access, and efficiency of behavioral health services.

Background: Over the last twenty years the incidence of herpes zoster (HZ) infection, also known as shingles, has been increasing among adults for unknown reasons. The economic burden of HZ is currently estimated at over $1 billion per year in the United States (U.S.) and is expected to increase as the susceptible adult population ages. HZ is caused by a re-activation of the varicella zoster virus (VZV), chicken pox, and more than 95% of adults living today carry the virus with a lifetime risk of 1 in 3 for developing HZ. In 2006 the FDA approved a vaccine for the prevention of HZ in adults 60 years and older and in 2011 approval was expanded to include adults age 50-59 years. Since 2006 rates of adult immunization for HZ have been modest, as of 2015 approximately two-thirds of the US population ≥ 60 are still unvaccinated and more than 94% of those ages 50-59 have not been vaccinated. There is now accumulating evidence of a significantly elevated risk of ischemic stroke (IS) within the first 12 months following infection with HZ. Every 40 seconds someone in the U.S. suffers a stroke with an estimated 795,000 strokes per year. In the U.S. stroke is a significant cause of disability with costs estimated at $33 billion per year including cost of healthcare, medication, and lost productivity. As the population in the U.S ages, the risk of both HZ infection and stroke will increase significantly thus impacting mortality, morbidity, and healthcare costs. The CDC Advisory Committee for Immunization Practices (ACIP) currently recommends routine vaccination against HZ for adults ≥ 60 but does not recommend vaccination for adults age 50-59 years and does not provided any guidance or recommendations for adults who may be at increased risk of stroke associated with HZ infection. The current ACIP vaccination recommendations for HZ are predominately based on clinical trial efficacy data and cost-effectiveness analyses (CEAs) in adults ≥ 60. These prior analyses did not included costs associated with the recent evidence demonstrating increased risk of stroke up to one year following HZ infection. Aims: The objectives of this study were as follows; 1) To assess the cost-effectiveness of a targeted HZ vaccination strategy for adults age 50-59 years at increased cardiovascular (CV) risk in whom vaccination is approved but not recommended; 2) To develop a white paper directed at payers, providers, and policy makers translating the findings from the analysis into appropriate population health dissemination, implementation, and adoption priority recommendations. Methods: A decision analytic Markov Model (MM) was used to compare costs and outcomes between two vaccination strategies; usual-care (no current vaccine recommendation) and targeted vaccination in adults age 50-59 years with cardiovascular disease (CVD) in a hypothetical cohort of 100,000 adults age 50-59 years. The private payer perspective was used as it best represents this population of adults age 50-59 years who are predominately employed and covered under employer sponsored commercial insurance. The simulated cohort was assessed for incidence of IS within 12 months following HZ infection occurring within the fifth decade of life. Risk was assessed from the age at entry to the analysis, median age 55, up to age 60 using TreeAge Pro 2017 software. The cohort was then aged out to 100 years or death, whichever came first. Costs were calculated using 2016 U.S. dollars. Findings: As it relates to aim one, compared to usual-care targeting HZ vaccination in adults age 50-59 years with prevalent CVD was cost-effective with an incremental cost-effectiveness ratio (ICER) of $55,517 per quality of life-year (QALY) gained which falls well below the standard willingness-to-pay (WTP) threshold of $100,000 utilized in previous HZ CEAs (Le & Rothberg, 2015, 2016; Pellissier, Brisson, & Levin, 2007). The incremental cost of vaccinating the target population using a benchmark vaccination rate of 60% was $30.59 per person compared to $12.98 in the usual-care group with ICERs of $55,517 and $55,470 respectively. Moreover, when comparing the cost of universal vaccination in the entire 50-59 year old cohort cost-effectiveness was maintained with an incremental cost of $176.51 per person and an ICER of $55,523. Adopting the targeted strategy resulted in 162 fewer cases of HZ and 14 fewer strokes per 100,000 persons. Regarding aim two, following safety and efficacy, cost-effectiveness analysis are considered an essential metric in vaccine policy making and a substantial driver of vaccine adoption by policymakers, payers, and providers. Translating these favorable cost-effectiveness findings to policymakers, payers, and providers is necessary to help close the adoption curve gap in order to facilitate and inform effective and timely implementation strategies for HZ vaccination in this targeted population. Conclusions: This study demonstrated that targeted HZ vaccination in patients age 50-59 years at increased CV risk is cost-effective and thus updating ACIP policy recommendations regarding vaccination in this population for whom the vaccine is currently FDA approved but not recommended should be considered. Furthermore, this study showed that universal vaccination in the general 50-59 year old population is cost-effective. Given the very limited data on cost-effectiveness of HZ vaccination in adults age 50-59 years, which has resulted in a lack of recommendation for this population, and recent evidence of IS risk the results of this study demonstrating cost-effectiveness of a targeted HZ vaccination strategy directly support the National Adult Immunization Plan (NAIP) to improve adult immunization uptake by providing economic evaluations which can be used to inform policymakers, payers, and providers.

No description available.

Thesis (M.A.)--State University of New York at Binghamton, Department of Philosophy, 2006. / Includes bibliographical references.

The performance of different pavement maintenance treatments were evaluated by investigating practical projects collected from Tennessee Pavement Management System (PMS) and Long Term Pavement Performance (LTPP) database. The influence of factors on the effectiveness, cost-effectiveness and cracking initiation of different treatment were evaluated by “Optime”, multiple linear regression and parametric survival analysis. Pavement roughness, pavement serviceability index (PSI) and the initiation time of cracking were used as pavement performance indicators. Investigation on the pavement maintenance projects in Tennessee by Optime and multiple linear regression analysis indicated that HMA overlay had the highest effectiveness, followed by mill & fill and micro surfacing. Due to the relatively low cost, micro surfacing was the most cost-effective treatment, followed by HMA overlay and mill & fill. The effectiveness and cost-effectiveness decreased with the increase of traffic level and pre-treatment pavement condition. Investigation on the LTPP resurfacing treatments indicated that thick overlay and milling reduced the roughness after rehabilitation. Thin overlay, high traffic level and poor pre-rehabilitation pavement condition increased the deterioration rate of new overlay. Using reclaimed asphalt material did not influence the treatment performance but was cost-effective in reducing the roughness of new overlay. For a certain deterioration rate, there was an optimized pre-rehabilitation roughness value or time for applying maintenance treatment. Survival analysis on the crack initiation of asphalt overlay indicated that high traffic level accelerated the initiation of cracking. Thick overlay delayed the initiation of cracking except for the non-wheel path longitudinal crack. Mill retarded the occurrence of the non-fatigue cracks, whereas severe freeze thaw condition accelerated the occurrence of the two types of cracking. Using 30% RAP accelerated the initiation of longitudinal fatigue crack on wheel path but did not cause serious fatigue problem. The performance curves of HMA resurfacing treatments used in Tennessee were calibrated by investigating the influence of different factors on the slopes and intercepts of post-treatment performance curves. The analysis indicated that pavement with high pre-treatment PSI, thick overlay and deep milling had low deterioration rate, whereas pavement with higher traffic level deteriorated faster.

No description available.

Abdominal aortic aneurysm (AAA) is a common disease that is life threatening when rupture occurs. The aims of this thesis were to study (I) the long-term survival after AAA repair, (II) the cost of repair with open (OR) and endovascular (EVAR) technique, (III) the effect of different statistical methods on interpretation of cost data, (IV) the prevalence of the disease among patients with suspected arterial disease referred to the vascular laboratory, and (V) the cost-effectiveness of selective high-risk screening. Analyses of data from the Swedish vascular registry (Swedvasc), local patient registries, patient records and hospital cost registries form the basis of this thesis. Short- and long-term survival after intact AAA repair improved over the past two decades, despite increasing patient age and rate of comorbidities over time. Compared to a general population adjusted for age, sex and calendar year, the relative 5-year survival was 90% among those surviving repair. While short-term survival improved over time after ruptured repair, relative long-term survival was stable. Despite differences in patient selection and cost structure, the total cost of AAA repair with EVAR and OR was similar in a population based setting (€28,193). There was lack of consistency in the methods used in cost-analysis in the current literature, and p-values were highly dependent on test method. The practice of selective (non-population-based) screening for AAA among patients referred to the vascular laboratory was studied. The prevalence of AAA was 4.2% among male and 1.5% among female patients. AAA was associated with high age and prevalence of arterial stenosis. Of AAAs detected through selective screening, 21.5% had undergone elective repair at 7.5 years follow-up. In a health-economic evaluation, the incremental cost-effectiveness ratio of selective screening was €11,084 per life year gained. In conclusion, survival after intact AAA repair has improved over time, despite changes in case-mix. Results of health economic reports on cost of AAA repair can be highly dependent on patient selection as well as presentation of data and the statistical methods used. Selective screening for AAA among patients referred to the vascular laboratory is cost-effective.

Favorable price trends and increasing demand for renewable energy sources portend accelerating integration of solar photovoltaic (PV) generation into traditional electric power system networks. Managing the variable output of massive PV resources makes system frequency regulation more complex and expensive. ISOs must procure additional regulation and load following capacity, while power plants must supply more regulation work. In contrast to costly physical storage solutions, this thesis proposes to address the issue by reconfiguring the electricity market pricing structure to translate all power imbalances into real-time market price signals. More accurately determining the instantaneous value of energy, electric power markets could reward participants who can quickly respond to frequency fluctuations. By utilizing short term forward markets to monetize the risk associated with intermittency, the true cost of reliability is determined and could reduce wasteful capacity payments. This market redesign is an ideal open platform for disparate smart grid technologies which could encourage all suppliers, loads and generator, to offer supply or reduce consumption when it is needed most and could vastly improve frequency performance metrics.

To stay competitive on today’s market and satisfy the constantly increasing customer requirements, working with continuous and cost-effective improvement is a requirement. The purpose of this thesis is to develop a model to continuously and cost-effectively improve the quality of a management system within trading business, taking the environmental aspect and impact of organizational changes up on personnel in consideration. The model has been developed based on theoretical management strategies and improvement methodologies: Process management, Change management, TQM, Lean, Continuous and cost-effective improvement, PDCA and Kaizen. The developed model should result in a high-qualitative management system that continuously should be improved and maintained, to streamline the supply chain and in turn be profitable. In order to enhance the sustainability of the model, it has been tested at a case company. From the results, conclusions can be drawn that concrete outcomes of the model implementation takes time, but it serve its purpose and generates in great results.

The companies ought to care about OEE because it is a measure that shows the effect of the performance and quality related losses on the system or equipment. In order to improve OEE, they focus on defining the losses under each OEE elements and try to eliminate these losses.This study aims to enhance raw material inventory management in order to eliminateinventory management related losses and improve OEE.  Lack of raw material and improperstorage of raw material are main problems related to inventory management. A model isdeveloped and tested in order to prevent these problems and eliminate these losses.Performance rate can be improved by preventing idle time due to lack of raw material, andquality rate can be improved by standardization and improving raw material storageprocedure. In the result of model testing, it is shown that raw material inventory managementhas an effect on OEE and OEE can be improved by enhancing raw material inventorymanagement.