Study objectives and significance Generally, patients go to hospitals or clinical offices for seeking health care service. However, some studies reveal that old patient or those who have disability would get hurt and expose in some dangerous situation, such as falls and infection. As the reasons, the rehabilitation delivery model, which sends the service to patients¡¦ community, is needed. The community delivering-rehabilitation model that this study focuses on integrates hospital center and retirement home. This study is to compare the community delivering-rehabilitation model and general delivery model that patients go to hospital for rehabilitation service. Data and methods In one-year study duration from Nov. 1, 2002 to Oct. 31, 2003, the Barthel Index score from two delivery models were collected every 3 months. On the other hand, patients¡¦ rehabilitation costs were collected once 3 months, too. The study unit is individual unit. Cost-effectiveness analysis (CEA) was used here to be a standard comparing tool. CEA was computed by dividing the cost that patient spent in 3 months into the Barthel Index score which patient improved his functional status. Independent variables include environmental factors and structural factors The Environment factors include rehabilitation delivery model and the patient-therapist ratio. Structural factors include chain-affiliation status, instrumental volume and status. The General Estimating Equation was used here for comparing longitudinal dependent data. Results The study reveals that environmental factors and structural factors affect the performance of rehabilitation units. Environmental factors positively affect the rehabilitation effect. Structural factors negatively affect the rehabilitation effect. On the other hand, Environmental factors positively affect the rehabilitation efficiency. Structural factors negatively affect the rehabilitation efficiency. Conclusion and the project¡¦s relevance to public health The community delivering-rehabilitation model has better rehabilitation effect, but on the aspect of efficiency, is not as good as general delivery model. However, the community delivering-rehabilitation model has good accessibility to patient. It also concerns patient safety. If the model can improve its efficiency, the promotion of health can be further implied in community delivering-rehabilitation model.

This thesis employed methods used in health care decision making to evaluate strategies for prevention and treatment of febrile neutropenia (FN) in non-Hodgkin lymphoma (NHL) patients. The objectives of this thesis were to quantify the cost-effectiveness of filgrastim and pegfilgrastim as primary prophylaxis against FN in NHL patients, to develop an algorithm for converting health-related quality of life data collected in non-Hodgkin lymphoma patients into preference-based health utility values, and to evaluate NHL patients’ preferences for outpatient treatment of FN. The cost-effectiveness analysis demonstrated that neither filgrastim, nor pegfilgrastim are cost-effective, with respective incremental cost-effectiveness ratios [95% confidence interval] of $4,599,000/QALY [$597,045, dominated] and $6,272,000/QALY [$730,692, dominated], well above the normally accepted threshold of $50,000/QALY. The algorithm for deriving health utility values was based on a regression model that used health utility values obtained from the EQ-5D instrument as the outcome variable and the four subscales of the Functional Assessment of Cancer Therapy – General (FACT-G) questionnaire as the predictor variables. The model final model included three of the FACT-G subscales, and had an R-squared value of 0.502 and a mean squared error of 0.013. A discrete choice experiment was used to examine patients’ preferences for out patient treatment of FN, and demonstrated that out-of-pocket costs, unpaid caregiver time required daily, and probability of return to hospital are all significant attributes when considering outpatient therapy for FN. Adjusted odds ratios [95% confidence intervals] of accepting outpatient treatment for FN were 0.84 [0.75 to 0.95] for each $10 increase in out-of-pocket cost; 0.82 [0.68 to 0.99] for each 1 hour increase in daily unpaid caregiver time; and 0.53 [0.50 to 0.57] for each 5% increase in probability of return to hospital. These results provide important information for clinicians and health care decision makers involved in implementing programs for NHL patients with FN.

This thesis employed methods used in health care decision making to evaluate strategies for prevention and treatment of febrile neutropenia (FN) in non-Hodgkin lymphoma (NHL) patients. The objectives of this thesis were to quantify the cost-effectiveness of filgrastim and pegfilgrastim as primary prophylaxis against FN in NHL patients, to develop an algorithm for converting health-related quality of life data collected in non-Hodgkin lymphoma patients into preference-based health utility values, and to evaluate NHL patients’ preferences for outpatient treatment of FN. The cost-effectiveness analysis demonstrated that neither filgrastim, nor pegfilgrastim are cost-effective, with respective incremental cost-effectiveness ratios [95% confidence interval] of $4,599,000/QALY [$597,045, dominated] and $6,272,000/QALY [$730,692, dominated], well above the normally accepted threshold of $50,000/QALY. The algorithm for deriving health utility values was based on a regression model that used health utility values obtained from the EQ-5D instrument as the outcome variable and the four subscales of the Functional Assessment of Cancer Therapy – General (FACT-G) questionnaire as the predictor variables. The model final model included three of the FACT-G subscales, and had an R-squared value of 0.502 and a mean squared error of 0.013. A discrete choice experiment was used to examine patients’ preferences for out patient treatment of FN, and demonstrated that out-of-pocket costs, unpaid caregiver time required daily, and probability of return to hospital are all significant attributes when considering outpatient therapy for FN. Adjusted odds ratios [95% confidence intervals] of accepting outpatient treatment for FN were 0.84 [0.75 to 0.95] for each $10 increase in out-of-pocket cost; 0.82 [0.68 to 0.99] for each 1 hour increase in daily unpaid caregiver time; and 0.53 [0.50 to 0.57] for each 5% increase in probability of return to hospital. These results provide important information for clinicians and health care decision makers involved in implementing programs for NHL patients with FN.

Background Equity is rarely included in health economic evaluations, partly because the techniques for addressing equity have been inadequate. Since 2013 health economists have developed two competing health economic technologies: distributional costeffectiveness analysis (DCEA) and extended cost-effectiveness analysis (ECEA). Both technologies represent a significant advance, and each provides a framework to address equity considerations in cost-effectiveness analysis. Methods A scoping literature review was used to identify and synthesise the relevant literature on incorporating equity concerns into economic evaluations. A second focused review identified literature which discussed or applied DCEA and ECEA. Key themes in the literature were identified using NVivo qualitative data analysis software. Results The review revealed three key areas of difference between DCEA and ECEA: First, the analysis of trade-offs between improving health and reducing inequity; second, the analysis of financial impacts of health policies; and third, the incorporation of opportunity costs. ECEA can analyse financial risk protection while DCEA can analyse opportunity costs and trade-offs between improving equity and reducing health. ECEA is designed for low- and middle-income countries, whereas DCEA is better suited to developed health systems such as the National Health Service in the United Kingdom. To date, there have been 27 studies using ECEA and five studies using DCEA. Future developments for DCEA and ECEA include incorporating alternative methods to simplify the data requirements for the techniques, providing methods to assist decision makers to clarify their equity concerns, and improving the presentation of outcomes to make them accessible to non-specialists. Conclusions DCEA and ECEA are both economic frameworks which address equity considerations in cost-effectiveness analysis. This study examines and compares these two techniques in order to assist policymakers and decision makers to determine which of the two methods is best able to address their specific needs for their particular circumstances.

Background There is an increasing rate of cesarean section globally. Both low and high cesarean section rates are associated with maternal and neonatal mortality and morbidities. In Nicaragua, the rate of cesarean section is beyond the WHO recommendation of 10% to 15%. Aim The aim of this study was to evaluate the costs-effectiveness of elective caesarean section when compared with vaginal delivery in hospital in Nicaragua, a lower-middle income setting. Methods A 3 months prospective cohort study was conducted in a hospital in León, Nicaragua, from 1st May 2010 to 31st July 2010. Two questionnaires were used to obtain data, one on costs and maternal complications after delivery, and the other on postpartum complications. A descriptive analysis regarding maternal and neonatal outcomes, and a cost-effectiveness analysis were conducted comparing elective cesarean section with vaginal delivery, followed by a sensitivity analysis regarding change on rates of elective cesarean section. Results The cesarean section rate was 37.9%, and the elective cesarean section rate was 21%. The percentage of live births was 99.6% in elective cesarean section group and 98.9% in vaginal delivery group. Cesarean section had both positive and negative influences on maternal complications and postpartum complications. The costs of elective cesarean section was higher than vaginal delivery ($66 compared to $39.36). For one more live birth, 3805.71 US dollars were needed. Conclusion The maternal outcomes of cesarean section need to be improved. With the increasing cesarean section rates, more medical resources are needed in the future.

Adenoviruses, particularly types 4 and 7, are associated with febrile respiratory illness (FRI) outbreaks in US military basic trainees. Vaccines against these two serotypes controlled FRI in basic trainees until production ceased in the mid-1990s. After contracting a new manufacturer, adenovirus vaccination of military basic trainees resumed in 2011. The purpose of this dissertation was to assess the cost-effectiveness of using the new adenovirus type 4 and type 7 vaccines for the prevention of FRI in US military basic trainees from the perspective of each military branch. Two decision tree models comparing adenovirus vaccination to no adenovirus vaccination were used for this dissertation. The first model is similar to previous models used to assess the cost-effectiveness of the adenovirus vaccine in the military, where the outcome is number of FRI hospitalizations prevented. The second model created for this dissertation used information gathered from published literature and conversations with experts on the adenovirus vaccine. The outcome for the second model was number of training days lost (TDL) averted. Results from part I indicated that adenovirus vaccination of basic trainees was cost-effective as measured by FRI hospitalizations prevented in all US military service branches but the Coast Guard. The model showed that reintroducing the adenovirus vaccine to basic trainees saved the Army $5.8 million, the Navy, $1 million, the Marine Corps, $238,000, and the Air Force, $5.2 million, annually. In addition, adenovirus vaccination prevented 1,221, 543, 317, 677 cases of FRI hospitalization annually in the Army, Navy, Marine Corps, and Air Force respectively. In part II of this study, adenovirus vaccination of basic trainees was the dominant strategy as measured by TDL averted in all US military service branches but the Marine Corps and the Coast Guard. Results indicate that it would cost approximately $37.63 and $563.78 per TDL averted for the Marine Corps and Coast Guard respectively. Both models used for this dissertation provide evidence supporting the cost-effectiveness of using the adenovirus vaccine in US basic trainees in all services but the Coast Guard. / text

Objectives: The objectives of the research were to determine which intravenous (IV) antibiotics were cost-effective in Diabetic Foot Infections (DFIs) and to assess the impact of MRSA prevalence on clinical outcome. Methods: A Cost-effectiveness analysis (CEA) was performed on IV antibiotics used to treat moderate to severe DFIs in hospitalized patients. MRSA prevalence was taken into account by calculating an ‘Adjusted cure rate’ and re-analysing the CEA. Results: In the original CEA, imipenem/cilastatin was the cost-effective agent. When MRSA prevalence was taken into account imipenem/cilastatin, moxifloxacin, cefoxitin and ertapenem were cost-effective antibiotics. Conclusion: MRSA prevalence adjustments changed the results of the CEA and included classes of IV antibiotics that are seen being using in practice, such as fluoroquinolones and cephalosporins. These methods could potentially have an impact on the evaluation of clinical cure rates and resistance when evaluating the literature.

Objectives: The objectives of the research were to determine which intravenous (IV) antibiotics were cost-effective in Diabetic Foot Infections (DFIs) and to assess the impact of MRSA prevalence on clinical outcome. Methods: A Cost-effectiveness analysis (CEA) was performed on IV antibiotics used to treat moderate to severe DFIs in hospitalized patients. MRSA prevalence was taken into account by calculating an ‘Adjusted cure rate’ and re-analysing the CEA. Results: In the original CEA, imipenem/cilastatin was the cost-effective agent. When MRSA prevalence was taken into account imipenem/cilastatin, moxifloxacin, cefoxitin and ertapenem were cost-effective antibiotics. Conclusion: MRSA prevalence adjustments changed the results of the CEA and included classes of IV antibiotics that are seen being using in practice, such as fluoroquinolones and cephalosporins. These methods could potentially have an impact on the evaluation of clinical cure rates and resistance when evaluating the literature.

Magister Scientiae - MSc (Pharmacy Administration and Policy Regulation) / Aim: The purpose of this research was to assess the validity of pharmacoeconomic evaluation in Egypt three years after the guideline was issued and analyse challenges and opportunities for improvement. Objectives: To conduct a literature review of pricing, medicine reimbursement, and pharmacoeconomic evaluation. Examine, in conjunction with relevant stakeholders, the progress of the pharmacoeconomic evaluation. To present examples of pharmacoeconomic evaluation deployment. To propose recommendations on how to optimize the pharmacoeconomic implementation. Methods: A literature review and a qualitative research method that was conducted using a semi-structured interview with stakeholders of the reimbursement process in Egypt. In addition, examples were analysed to determine the impact of pharmacoeconomic methods on medicine reimbursement in Egypt. Results: The Egyptian Pharmacoeconomic Evaluation Unit was established in 2013, it supports various reimbursement decisions, especially for new technologies. The unit evaluations depended mainly on the available international data. However, fragmentation of the health care system in Egypt is a major obstacle to progress. The guidelines are still non-compulsory for implementation, and accordingly some reimbursement committees do not consider its evaluation in its decision making. Conclusion and Recommendations: The pharmacoeconomic evaluation has demonstrated a good start in Egypt. To gain the full benefit of pharmacoeconomic evaluation, authorities need to consider reducing the complexity of health care system, setting clear strategies, building capabilities to improve pharmacoeconomic awareness; endorsing risk sharing strategy and building a proper health related information system along with creation of full Health Technology Assessment program. The above-mentioned recommendations could be associated together under the Universal Health Coverage road map that Egypt committed to achieve by 2030.

<p><strong>Objective</strong>: To estimate the cost-effectiveness of an influenza immunization strategy directed at healthy children 36 months to 15 years on the herd immunity of entire communities, versus not implementing this strategy.</p> <p><strong>Design</strong>: An economic evaluation, cost-effectiveness analysis (CEA). Costs and effects were estimated jointly with a two-stage bootstrap with shrinkage correction. Uncertainties around input parameters were tested with one-way and multi-way sensitivity analysis.</p> <p><strong>Data Sources</strong>: Effect and resource consumption data were from the Hutterite Influenza Prevention Study. Unit costs were collected from multiple sources including, government reports and schedules, local suppliers, peer-reviewed articles and systematic reviews, Internet searches and study data on file.</p> <p><strong>Outcomes</strong>: Mean costs and effects, incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB) statistic and cost effectiveness acceptability curves (CEAC).</p> <p><strong>Results</strong>: The average cost per patient in the treatment arm was $69.08 and $32.66 in the control arm. The average number of influenza-free cases was of 0.96 in the treatment arm and 0.73 in the control arm. ICER was $164.19 per case of influenza averted, 95% confidence interval $28.38, $2,767.75. CEAC showed that at a willingness to pay of $177, the probability of the treatment strategy being cost effective compared to the control was 0.50. Results from sensitivity analyses were slightly different compared to base case results, supporting the robustness of base case estimates.</p> <p><strong>Conclusion</strong>: This strategy is likely to be cost effective relative to the comparator as the ICER estimate is low and because the estimate is conservative given that the study population was very healthy and the influenza season was mild. A more virulent season and a less healthy population would have produced a lower ICER or seen the treatment arm dominate the control.</p> / Master of Science (MSc)