published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Aims: To investigate the natural history of CHC, estimate the disease burden of CHC, and assess the cost-effectiveness of screening for CHC among immigrants living in Canada. Methods: A retrospective cohort study compared the prognosis of CHC between immigrant patients and native-born patients who had advanced fibrosis. A cross-sectional study assessed the association between obesity and hepatitis C viremia. The disease burden of CHC among immigrants was estimated through Markov cohort model. The cost-effectiveness of screening for CHC was assessed among immigrants. Results: The retrospective cohort study including 318 patients demonstrated that immigrant patients had significantly higher risk of hepatocellular carcinoma than Canadian-born patients (p=0.005). The hazard ratio associated with ‘immigrant’ for hepatocellular carcinoma in multivariate Cox proportional-hazards analyses reduced to the least and non-significant (p=0.318) after adjusting age and type 2 diabetes. The prevalence of obesity in 1118 individuals tested positive for hepatitis C antibody was 28.8%. Multiple regression analyses and propensity score methods suggested a significant association between obesity and hepatitis C viremia. The disease burden study estimated that immigrants with CHC had much shorter average life years (26.9 years vs. 39.1 years) and quality adjusted life years (20.6 years vs. 32.4 years) than the age matched immigrants without CHC. The cost-effectiveness study indicated that screening for CHC among immigrants from 183 countries (72.1% of immigrant population in Canada) had an incremental cost-effectiveness ratio less than $50,000 per quality adjusted life year gained. Conclusion: Immigrant patients with CHC could have a higher risk of HCC than native-born patients. The significant association between obesity and hepatitis C viremia could explain the observed high prevalence of type 2 diabetes in patients with CHC. CHC reduces the average life expectancy of immigrants with CHC more than 10 years. Screening for CHC is cost-effective among over 70% of immigrants living in Canada.

One of the common lessons learned from the 11 September Terrorist Attacks in 2001, Southeast Asia Tsunami in 2004 and Hurricane Katrina in 2005, was there were major command and control (C2) and information challenges during the crisis response efforts. The Department of Defense (DoD) is currently transitioning to face these global threats of terrorism and natural disasters, as well as support the goals of the new National Strategy, by developing new plans and procedures to improve the coordination, communications and operations between DoD and other entities when responding simultaneously to such complex humanitarian disasters (CHD). In searching for a mobile and adoptable communication solution for military operations, the DoD should consider a C2 system that utilizes advanced commercial-off-the-shelf (COTS) technology. Hastilyformed networks (HFN) could provide a global broadband network node with internet, voice, video and data capability in a rapidly deployable manner, which offer significant advantages to military and other crisis response activities. The focus of this thesis concentrates on the financial aspects of HFNs in support of humanitarian assistance and/or disaster relief (HA/DR) efforts by U.S. armed forces. This research and analysis of HFNs could present prospective benefits to DoD, which include cost-savings, enhanced emergency response capabilities and improved interagency/international relations. Additionally, this study will provide a recommended model methodology and iterations for future military-use of HFNs in support of the DoD's vision of "transformation."

This thesis explores the use of observational microdata in cost-effectiveness analysis. The application of econometric methods adjusting for selection bias is first reviewed and critically appraised in the economic evaluation literature using a structured template. Limitations of identified studies include lack of good quality evidence regarding the performance of different analytical approaches; inadequate assessment of the sensitivity of their results to violations of fundamental assumptions or variations to crucial estimator parameters; failure to combine the cost and effectiveness outcomes in a summary measure; and no consideration of stochastic uncertainty for the purpose of evaluating cost-effectiveness. Data from the Birthplace national cohort study are used in an attempt to address these limitations in the context of an empirical comparison of estimators relying on regression, matching, as well as the propensity score. It is argued that although these methods cannot address the potential impact of unobservable confounding, a novel approach to bias-corrected matching, combining entropy balancing with seemingly unrelated regression, still has the potential to offer important advantages in terms of analytical robustness. The net economic benefit is proposed as a straightforward way to exploit the strengths of rigorous econometric methodology in the development of reliable and informative cost-effectiveness analyses.

Abdominal Aortic Aneurysm (AAA) is a disease that mainly affects elderly men, and ruptured AAA (rAAA) is associated with a mortality of > 80%. AAA seldom gives any symptoms prior to rupture. The aims of this thesis were to investigate different aspects of how to affect mortality from rAAA. In Study I, we identified 849 patients treated for rAAA during 1987-2004, and studied the 30-day survival after surgery, depending on whether they came directly to the treating hospital (one-stop) or were transferred via another hospital (two-stop). A two-stop referral pattern resulted in a 27% lower population-based survival rate for patients 65-74 years of age. However, the consequences would be small even if a one-stop referral pattern could be generally accomplished, due to the huge over-all mortality related to rAAA, hence an argument to find and treat AAA before rupture, e.g. by screening. In Study II, we examined the AAA-prevalence and the risk factors for AAA among 70-year-old men. The screening-detected AAA-prevalence was 2.3%, thus less than half the predicted. The most important risk factor was smoking. In Study III, we compared the screening-detected AAA-prevalence, the attendance rate, and the rate of opportunistic detection of AAA, between almost 8000 65- and 6000 70-year-old men. There was no difference in the screening-detected prevalence; probably due to the fact that almost 40% of the AAAs among the 70-year-old were already known prior to screening, compared to roughly 25% in the 65-year-old. The attendance rate was higher among the 65-year-old men, 85.7% compared 84.0% in the 70-year-old. Thus, there is no benefit of screening for AAA among 70- instead of 65-year-old men. In Study IV, a cost-effectiveness analysis, we found that screening for AAA still appears to be cost-effective, despite profound changes in disease pattern and AAA-management. In conclusion, we found that mortality from rAAA is not affected in any substantial way by different referral patterns and hence centralisation of services for AAA/rAAA is not a solution. A better alternative is to prevent rupture through early detection by screening. Screening 65-year-old men for AAA still appears to be cost-effective, despite profound changes in disease pattern and AAA-management during the last decade. Screening 70- instead of 65-year-old men will not increase the efficacy of screening.

Background: All treatments, especially funded by social means, should be subject to cost-effectiveness studies to ensure that the best possible optimization decision it taken between different treatment options. Within the health care area this is a well-developed area. For odontology in general, and orthodontic treatment in specific, this is an unknown territory and cost-effectiveness studies are rare. Malocclusion can be treated with several different systems. The sales pitch from system providers for braces - such as self-ligated brackets (SLB) promises e.g. shorten treatment duration, shorter chairtime, fewer visits, but the purchase cost of SLB systems is higher. Due to lack of results from unbiased RCT there is no guidelines. It is up to the dentist to use the treatment method/system of their own choice. Purpose: The purpose of this thesis is to estimate the cost-effectiveness of SLB compared to conventional brackets (CB) to determine which of the two systems that should be considered as the preferred choice of treatment in a publicly funded system. Method: Through an incremental cost-effectiveness ratio (ICER) calculate the most costeffective system from a societal perspective which includes all costs. To estimate the health care cost, the Reference price list will be used as baseline for production cost for CB. With the use of secondary resources examine the cost driving components to estimate the production cost of SLB. To estimate the non-health care cost a matrix with downtime from work and travel costs was estimated accounting for travel to disclose the magnitude of these cost. The Outcome of the different treatment alternatives will be measured from different perspectives, such as state specific and general profiles. Treatment duration and foregone education will also be investigated. Conclusions: When all production costs for SLB has been adjusted it shows that the total cost of SLB is slightly cheaper. The reduced number of visits required, less chairtime and shorter treatment period are the positive sides of the higher purchase cost of the SLB. Most of the outcome results are not statistically significant, but there is a tendency, with better average values for SLB. SLB seems to be the cheaper and with more effective outcome though not to the extent the provider promises. The difference of treatment duration is minimal and has no significant advantage. The foregone education for the patient is not possible to quantify in monetary terms but could have significant impact depending on different geographical areas but will small differences between the systems. Hence, in lack of unbiased studies and just focusing on average values, SLB dominates CB and should be the preferred choice of treatment until new long-term studies has been published. / Bakgrund: Alla behandlingar, särskilt de som är offentligt finansierade, borde ha genomgått kostnadseffektivitetsbedömningar för att kunna fatta bästa möjliga beslut. Inom sjukhälsovård är detta ett välutvecklat område. Inom tandvård generellt, men kanske ortodonti i synnerhet, är detta ett outforskat område och kostnadseffektivitetsstudier är sällsynta. Malocklusion kan behandlas med flera olika system. Säljargument från olika tandställningsleverantörer, som t.ex. självligerande brackets (SLB) ger löften om t.ex. kortare behandlingsperiod, kortare tid i tandläkarstolen, färre besök men till en högre inköpskostnad. I brist på resultat från oberoende RCT saknas riktlinjer. Det är upp till den enskilda tandläkaren att välja den behandlingsmetod/system som hen finner bäst. Syfte: Syftet med uppsatsen är att undersöka kostnadseffektiviteten mellan SLB jämfört med konventionella brackets (CB) för att avgöra vilket av dessa två system borde anses vara föredraget behandlingsalternativ i ett offentligt finansierat system Metod: Med kostnadseffektivitetskvoten (incremental cost-effectiveness ratio, ICER) beräkna det mest kostnadseffektiva systemet från ett samhällsperspektiv som inkluderar alla kostnader. För att uppskatta direkta behandlingskostnaden kommer Referensprislistan att användas som produktionskostnadsbas. Med hjälp av sekundära källor som undersöker de kostnadsdrivande komponenterna, uppskatta produktionskostnaden för SLB. För att mäta de indirekta behandlingskostnaderna skapas en matris för att påvisa kostnaden med ställtid från arbete och resekostnader. Resultatet av de olika behandlingsalternativen kommer att mätas från olika perspektiv, såsom generella hälsoprofiler och tillståndsspecifika. Behandlingsperiod och missad utbildnings kommer också att undersökas. Slutsats: Efter det att produktionskostnaderna har blivit justerade visas att totalkostnaden för SLB är något billigare. Färre antal besök, kortare tid i behandlingsrummet är det positiva sidorna av det högre inköpspriset för SLB. De flesta av resultaten är inte statistiskt signifikanta men det finns en tendens mot bättre effekt med SLB. SLB tycks vara det billigare och mest effektiva systemet om än inte i den utsträckning som säljargumenten hävdar. Skillnaden i behandlingsperiod är minimal och har igen avgörande betydelse. Den missade utbildningen är svårligen kvantifierbar i monetära termer men kan ha en avgörande betydelse beroende på olika geografiska platser men med små skillnader mellan systemen. Följaktligen, i brist på oberoende studier och med ett fokus på medelvärde är SLB det dominerande valet över CB och borde vara det föredragna behandlingsalternativet fram till dess att nya långsiktiga forskningsrön har blivit publicerade.

A sociedade tem se tornado cada vez mais instruída e exigente, na qual os clientes possuem grande influência nas estruturas da organização, fazendo com que as empresas busquem aumentar a satisfação dos clientes, atendendo-os de modo a superar as suas expectativas. Nesse contexto, estão inseridos os doadores de sangue. No Brasil, a lei que regulamenta o funcionamento dos serviços hemoterápicos preconiza que a doação de sangue deve ser um ato voluntário e altruísta, no qual o doador não deve receber nenhum tipo de vantagem para realizar a doação de sangue. Segundo dados da Coordenação Geral de Sangue e Hemoderivados, no ano de 2014, a região Sudeste, na qual está concentrada a maior parte da população brasileira, registrou uma das menores taxas de doação: a cada 1.000 habitantes, apenas 17,22 % doaram sangue. É fundamental para os hemocentros identificarem a maneira mais convincente e estimulante de convocar/captar doadores de sangue, de modo a manter os estoques suficientes, além de atender os doadores conforme suas expectativas. Portanto, o objetivo desse estudo foi avaliar qual a ferramenta de abordagem individual e coletiva que apresenta o melhor custoefetividade somado à preferência dos doadores, a qual será essencial para o aumento do número de doações. Para isso, os dados utilizados abrangem um período de 4 anos (2012 a 2015) e representam o número de candidatos à doação de sangue de duas instalações do Hemocentro RP, ambos localizados na cidade de Ribeirão Preto (Sede e Posto de Coleta). Valores-p para o teste de Dickey e Fuller de estacionariedade sugerem que as séries analisadas não são estacionárias, sendo então diferenciadas, passando a apresentar p<0,01. Foi observado que existe correlação (p = 0,31) entre o número de malas diretas e o retorno dos doadores seis meses após o envio das mesmas. No Posto de Coleta, não foi constatada essa correlação. Além disso, as ferramentas para captação que trabalham com os doadores de reposição apresentaram melhores resultados, tais como as ferramentas com atendimento mais personalizado (contato telefônico) juntamente com as campanhas realizadas pelo Facebook Inc. / Society has become increasingly educated and demanding, in which the customers have a strong influence on the organization\'s structures, causing companies to seek to increase the customer satisfaction, meeting them in a way that exceeds their expectations. In this context, blood donors are inserted. In Brazil, the law that regulates the operation of hemotherapy services recommends that blood donation should be a voluntary and altruistic act in which the donor should not receive any type of advantage in order to donate blood. According to data from the \"Coordenação Geral de Sangue e Hemoderivados\", in 2014, the Southeast region, where most of the Brazilian population is concentrated, had one of the lowest rates of donation: for every 1,000 inhabitants, only 17.22% donated blood. It is essential for blood centers to identify the most convincing and stimulating way to recruit and invite blood donors, to maintain sufficient stocks by serving donors according to their expectations. Therefore, the aim of this study was to evaluate which tool of individual and collective approach presents the best cost-effectiveness besides to donor preference, which will be essential for increasing the number of donations. To do so, the data cover a period of 4 years (2012 to 2015) and represent the number of candidates for blood donation from two Hemocentro RP facilities, both located in the city of Ribeirão Preto (\"Sede\" and \"Posto de Coleta\"). p-values for the test of Dickey and Fuller of stationarity suggest that the series analyzed are not stationary, being then differentiated, with p <0.01. It was observed that there is a correlation (p = 0.31) between the number of direct mailings and the donors return six months after sending them. No correlation was verified at the \"Posto de Coleta\". Moreover, recruitment tools for replacement donors present better results, such as the tools with more personalized service (telephone contact) along with the campaigns carried out by Facebook Inc.

Mesmo com o crescimento da dependência da vida humana em relação aos serviços ecossistêmicos, a taxa de perda de diversidade genética no planeta tem alcançado níveis semelhantes à de grandes eventos de extinção, evidenciando a necessidade de ações para a conservação dos recursos naturais. Em adição aos tradicionais instrumentos de comando e controle para a conservação, os instrumentos econômicos têm tido crescente atenção no mundo nos últimos anos, com especial destaque para os Pagamentos por Serviços Ambientais (PSA). A abordagem de pagamentos de incentivos tem crescido na última década e, apesar das potencialidades que o PSA apresenta, muitos programas falham em incorporar o conhecimento científico em sua execução, sendo esse um dos aspectos que podem acarretar baixo desempenho ambiental e econômico. Neste contexto, o presente projeto buscou avaliar a custo-eficácia do PSA em paisagens fragmentadas. A área de estudo é o estado de São Paulo, cuja fragmentação historicamente ocorre pela expansão agropecuária e pelos diversos impactos decorrentes do grande crescimento populacional em seu território. Foram distribuídos questionários para a obtenção das preferências dos proprietários rurais paulistas em relação aos programas de PSA para restauração de vegetação nativa. Os dados coletados foram relacionados a características socioeconômicas e ambientais e um modelo beta inflacionado de zero misto dentro da classe GAMLSS foi utilizado. Em seguida, o modelo foi utilizado para predizer os resultados para os proprietários não entrevistados e a curva de investimento para diferentes retornos para conservação foi construída. Os resultados apontaram que o PSA é uma alternativa muito custosa frente aos orçamentos ambientais paulistas e que traz poucos benefícios para a restauração no estado de São Paulo. A pesquisa possui uma vertente teórica, pois contribui para a compreensão da adequabilidade do PSA em paisagens fragmentadas, e uma vertente prática, pois explicita a quantidade de recursos necessária para a execução dos programas analisados. / Although the dependence of human activities on ecosystem services has risen in the past decades, the current rate of genetic diversity loss has substantially declined and reached alarming levels. In addition to the traditional command and control approach for the promotion of conservation, growing attention has been given to economic instruments, especially to Payments for Environmental Services (PES). Despite all potentialities of the PES instrument, many programs fail to introduce scientic knowledge in the execution. Such a lack of foundation may result in low environmental and economic performance. The present research aims at evaluating the cost-effectiveness of PES in fragmented landscapes. The study area is the state of São Paulo, which has been fragmented by the agricultural and pasture expansion, and the impacts linked to the large population growth. A survey with dierent PES programs was sent to rural landowners and responses were analyzed and linked to socioeconomic and environmental characteristics through a zero-inflated beta mixed model, within the GAMLSS framework. The model was used to predict enrollment of non-respondents in different PES programs. Finally, the relationship between total area for restoration and the amount of resources needed for each program was compared to the environmental budget of the state of São Paulo. Results show that PES is a very costly alternative that can provide only few results for restoration. The present work has a theoretical orientation, as it contributes to the comprehension of the feasibility of PES programs in fragmented landscapes, and a practical orientation, as it quantifies the amount of resources required by the programs analyzed.

A centrifugação é o principal método utilizado para fracionar o Sangue Total (ST) nos componentes sanguíneos: Concentrados de Hemácias (CH), Concentrados Plaquetas (CP), Plasma e Crioprecipitado, (também chamados de Hemocomponentes). Com intuito de prevenir ou controlar hemorragias, os CP obtidos por centrifugação tornaram-se o padrão no atendimento inicial aos pacientes com baixas contagens de plaquetas. Porém, para obter uma unidade terapêutica (UT), no Hemocentro RP, é necessário agregar seis CP, formando o Pool de CPST (PCP), o que leva a exposição do receptor a vários doadores diferentes. O CP obtido por aférese (CPAF), advindo de equipamento que permite a seleção já na coleta, fornece a dose necessária em apenas uma doação. Baseado no levantamento de dados internos do Hemocentro de RP o presente estudo analisou, através da metodologia de Custeio Baseado em Atividade (ABC), os custos atribuídos às distintas metodologias para a produção dos CP, sabendo que no Hemocentro RP, os CP são dispensados como UT independente da forma de obtenção. Os resultados obtidos foram utilizados na Análise de Custo-Efetividade, evidenciando que a coleta por Centrifugação de ST com a produção de PCP foi mais custo efetiva em 2015 do que a coleta de aférese, porém, por uma diferença relativamente pequena, devido ao grande percentual de obtenção de dupla Unidade Terapêutica (CPAF2). / Centrifugation is the main method used for fractionating Total Blood (TB) to blood components: Red Cells Concentrate (CR), Platelet Concentrates (PC), Plasma and Cryoprecipitate (also called Hemocomponents). In order to prevent or control bleeding, CPs obtained by centrifugation became the standard treatment of patients with low platelet counts. However, to obtain a therapeutic unit (TU), at Hemocentro RP, it is necessary to get together six PCs, forming a Pool of TBPC (PCP), exposing the receptor to several different donors. PC obtained by apheresis (CPAF), which is provided by a equipment that allows selective collection, achieve the dose necessary for the selection in just one donation. Based on the collection of internal data from the Hemocentro RP, the present study analyzed, through the methodology of ActivityBased Costing (ABC), the costs attributed to the different methodologies for the production of PCs knowing that in the Hemocenter RP PCs are dispensed as TU independent of the way of obtaining. The results obtained were used in the CostEffectiveness Analysis, showing collecting by TB Centrifugation producing PC is more cost-effective, however CPAF was almost as effective as in 2015, a great achievement of Dual Therapeutic Unit in a single donation (CPAF2).

Introdução: Dados de custo necessários na Análise de Custo-Efetividade (CEA) são, muitas vezes, obtidos de estudos longitudinais primários. Neste contexto, é comum a presença de censura caracterizada por não se ter os dados de custo a partir de certo momento, devido ao fato de que indivíduos saem do estudo sem esse estar finalizado. A ideia da Ponderação pela Probabilidade Inversa (IPW – do inglês, Inverse Probability Weighting) vem sendo bastante estudada na literatura relacionada a esse problema, mas é desconhecida a disponibilidade de ferramentas computacionais para esse contexto. Objetivo: Construir ferramentas computacionais em software Excel e R, para estimação de custos pelo método IPW conforme proposto por Bang e Tsiatis (2000), com o objetivo de lidar com o problema da censura em dados de custos. Métodos: Através da criação de planilhas eletrônicas em software Excel e programação em software R, e utilizando-se bancos de dados hipotéticos com situações diversas, busca-se propiciar ao pesquisador maior entendimento do uso desse estimador bem como a interpretação dos seus resultados. Resultados: As ferramentas desenvolvidas, ao proporcionarem a aplicação do método IPW de modo intuitivo, se mostraram como facilitadoras para a estimação de custos na presença de censura, possibilitando calcular a ICER a partir de dados de custo. Conclusão: As ferramentas desenvolvidas permitem ao pesquisador, além de uma compreensão prática do método, a sua aplicabilidade em maior escala, podendo ser considerada como alternativa satisfatória às dificuldades postas pelo problema da censura na CEA. / Introduction: Cost data needed in Cost-Effectiveness Analysis (CEA) are often obtained from longitudinal primary studies. In this context, it is common the presence of censoring characterized by not having cost data after a certain point, due to the fact that individuals leave the study without this being finalized. The idea of Inverse Probability Weighting (IPW) has been extensively studied in the literature related to this problem, but is unknown the availability of computational tools for this context. Objective: To develop computational tools in software Excel and software R, to estimate costs by IPW method, as proposed by Bang and Tsiatis (2000), in order to deal with the problem of censorship in cost data. Methods: By creating spreadsheets in Excel software and programming in R software, and using hypothetical database with different situations, we seek to provide to the researcher most understanding of the use of IPW estimator and the interpretation of its results. Results: The developed tools, affording the application of IPW method in an intuitive way, showed themselves as facilitators for the cost estimation in the presence of censorship, allowing to calculate the ICER from more accurate cost data. Conclusion: The developed tools allow the researcher, besides a practical understanding of the method, its applicability on a larger scale, and may be considered a satisfactory alternative to the difficulties posed by the problem of censorship in CEA.