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An economic evaluation of the three interventions to conceive without the sexual transmission of HIV between heterosexual, HIV-discordant couples with positive male partners can inform policy decisions to subsidize pregnancy planning in this setting, as there is currently no coverage as such in Ontario. A decision tree and Markov model were designed to determine the short and long-term outcomes of unprotected intercourse restricted to timed ovulation (UIRTO), sperm washing with intrauterine insemination (SWIUI), and unprotected intercourse restricted to timed ovulation with pre-exposure prophylaxis (UIRTO-PrEP). In the short-term, UIRTO was the most cost-effective strategy. In the long-term, cases of negligible HIV transmission risk determined UIRTO-PrEP as the preferred option, while SWIUI was the choice method when this risk was high. There remains a viable risk of HIV transmission between discordant couples during attempts to conceive that require the concurrent and subsidized use of UIRTO-PrEP or SWIUI to protect against HIV infection.

An economic evaluation of the three interventions to conceive without the sexual transmission of HIV between heterosexual, HIV-discordant couples with positive male partners can inform policy decisions to subsidize pregnancy planning in this setting, as there is currently no coverage as such in Ontario. A decision tree and Markov model were designed to determine the short and long-term outcomes of unprotected intercourse restricted to timed ovulation (UIRTO), sperm washing with intrauterine insemination (SWIUI), and unprotected intercourse restricted to timed ovulation with pre-exposure prophylaxis (UIRTO-PrEP). In the short-term, UIRTO was the most cost-effective strategy. In the long-term, cases of negligible HIV transmission risk determined UIRTO-PrEP as the preferred option, while SWIUI was the choice method when this risk was high. There remains a viable risk of HIV transmission between discordant couples during attempts to conceive that require the concurrent and subsidized use of UIRTO-PrEP or SWIUI to protect against HIV infection.

No mundo, as hepatites decorrentes de infecções virais têm sido uma das grandes preocupações em saúde pública devido a seu caráter crônico, curso assintomático e pela sua capacidade de determinar a perda da função hepática. Com o uso em larga escala de medicamentos antirretrovirais, a doença hepática relacionada à infecção pelo vírus da hepatite C (VHC) contribuiu para uma mudança radical na história natural da infecção pelo vírus da imunodeficiência humana (HIV). Não se sabe ao certo o peso da coinfecção VHC/HIV no Brasil, mas evidências apontam que independentemente da região geográfica, esses indivíduos apresentam maiores dificuldades em eliminar o VHC após o tratamento farmacológico, quando comparados a monoinfectados. No âmbito do SUS, o tratamento antiviral padrão para portadores do genótipo 1 do VHC e do HIV é a administração de peguinterferon associado à Ribavirina. Quanto ao período de tratamento e aos indivíduos que devem ser incluídos, os dois protocolos terapêuticos mais recentes possuem divergências. A diretriz mais atual preconiza o tratamento de indivíduos respondedores precoces somados a respondedores virológicos lentos, enquanto a diretriz imediatamente anterior exclui na 12 semana indivíduos que não respondem completamente. Com base nessa divergência, esse estudo objetivou avaliar o custo-efetividade do tratamento contra o VHC em indivíduos portadores do genótipo 1, coinfectados com o HIV, virgens de tratamento antiviral, não cirróticos e imunologicamente estabilizados, submetidos às regras de tratamento antiviral estabelecidos pelas duas mais recentes diretrizes terapêuticas direcionadas ao atendimento pelo SUS. Para tal, foi elaborado um modelo matemático de decisão, baseado em cadeias de Markov, que simulou a progressão da doença hepática mediante o tratamento e não tratamento. Foi acompanhada uma coorte hipotética de mil indivíduos homens, maiores de 40 anos. Adotou-se a perspectiva do Sistema Único de Saúde, horizonte temporal de 30 anos e taxa de desconto de 5% para os custos e consequências clínicas. A extensão do tratamento para respondedores lentos proporcionou incremento de 0,28 anos de vida ajustados por qualidade (QALY), de 7% de sobrevida e aumento de 60% no número de indivíduos que eliminaram o VHC. Além dos esperados benefícios em eficácia, a inclusão de respondedores virológicos lentos mostrou-se uma estratégia custo-efetiva ao alcançar um incremental de custo efetividade de R$ 44.171/QALY, valor abaixo do limiar de aceitabilidade proposto pela Organização Mundial da Saúde OMS - (R$ 63.756,00/QALY). A análise de sensibilidade demonstrou que as possíveis incertezas contidas no modelo são incapazes de alterar o resultado final, evidenciando, assim, a robustez da análise. A inclusão de indivíduos coinfectados VHC/HIV respondedores virológicos lentos no protocolo de tratamento apresenta-se, do ponto de vista fármaco-econômico, como uma estratégia com relação de custoefetividade favorável para o Sistema Único de Saúde. Sua adoção é perfeitamente compatível com a perspectiva do sistema, ao retornar melhores resultados em saúdeassociados a custos abaixo de um teto orçamentário aceitável, e com o da sociedade, ao evitar em maior grau, complicações e internações quando comparado à não inclusão. / Worldwide, hepatitis caused by viral infections has been a major concern for public health because of its chronicity, asymptomatic course and its ability to determine the loss of liver function. With the widespread use of antiretroviral drugs, liver disease related to infection with hepatitis C virus (HCV) contributed to a radical change in the natural history of infection with human immunodeficiency virus (HIV). No one knows for sure the weight of coinfection HCV/HIV in Brazil, but evidence suggests that, regardless of geographic region, these individuals have greater difficulty in eliminating HCV compared to monoinfected. In the Brazilian Unified Health System (SUS), the standard antiviral treatment for patients infected with genotype 1 HCV and HIV is the association of pegylated interferon with ribavirin. Regarding the treatment period and which individuals should treat the two most recent protocols have disagreements. The most current protocol calls for treatment of early responders individuals added to slow responders. Since the guideline immediately preceding the 12th week excludes individuals who do not respond completely. Based on this difference, this study aimed to evaluate the costeffectiveness of HCV treatment in individuals with the genotype 1 coinfected with HIV, antiviral-naïve, non-cirrhotic and immunologically stable, undergoing antiviral treatment rules established by two most recent therapeutic guidelines directed to attend by SUS. To this evaluation, was developed a mathematical model of decision, based on Markov chains, simulating the progression of liver disease under treatment and no treatment. It was accompanied by a hypothetical cohort of thousand men individuals, more than 40 years. Was adopted the perspective of the Brazilian Unified Health System, time horizon of 30 years and a discount rate of 5% for the costs and for clinical consequences. The extension of treatment to slow responders provided an increase of 0.28 years of quality-adjusted life (QALY), 7% survival rate and an increase of 60% in the number of individuals who eliminated HCV. Besides the expected benefits in efficacy, the slow viral responders inclusion proved to be a costeffective strategy to achieve an incremental cost-effectiveness of BRL 44,171.00/QALY, value below of acceptability threshold proposed by the World Health Organization (BRL 63,756.00/QALY). Sensitivity analysis demonstrated that the potentials uncertainties in the model are unable to alter the final result, thus demonstrating the robustness of the analysis. The Inclusion of HCV/HIV co-infected individuals slow virologic responders to treatment protocol, is presented from the point of pharmacoeconomic view, as a strategy to cost-effectiveness favorable for the Brazilian Health System. Its adoption is perfectly compatible with the system perspective, returning better health outcomes with costs below an acceptable budget cap, and the society, to avoid a greater extent, complications and hospitalizations when compared to non-inclusion.

No mundo, as hepatites decorrentes de infecções virais têm sido uma das grandes preocupações em saúde pública devido a seu caráter crônico, curso assintomático e pela sua capacidade de determinar a perda da função hepática. Com o uso em larga escala de medicamentos antirretrovirais, a doença hepática relacionada à infecção pelo vírus da hepatite C (VHC) contribuiu para uma mudança radical na história natural da infecção pelo vírus da imunodeficiência humana (HIV). Não se sabe ao certo o peso da coinfecção VHC/HIV no Brasil, mas evidências apontam que independentemente da região geográfica, esses indivíduos apresentam maiores dificuldades em eliminar o VHC após o tratamento farmacológico, quando comparados a monoinfectados. No âmbito do SUS, o tratamento antiviral padrão para portadores do genótipo 1 do VHC e do HIV é a administração de peguinterferon associado à Ribavirina. Quanto ao período de tratamento e aos indivíduos que devem ser incluídos, os dois protocolos terapêuticos mais recentes possuem divergências. A diretriz mais atual preconiza o tratamento de indivíduos respondedores precoces somados a respondedores virológicos lentos, enquanto a diretriz imediatamente anterior exclui na 12 semana indivíduos que não respondem completamente. Com base nessa divergência, esse estudo objetivou avaliar o custo-efetividade do tratamento contra o VHC em indivíduos portadores do genótipo 1, coinfectados com o HIV, virgens de tratamento antiviral, não cirróticos e imunologicamente estabilizados, submetidos às regras de tratamento antiviral estabelecidos pelas duas mais recentes diretrizes terapêuticas direcionadas ao atendimento pelo SUS. Para tal, foi elaborado um modelo matemático de decisão, baseado em cadeias de Markov, que simulou a progressão da doença hepática mediante o tratamento e não tratamento. Foi acompanhada uma coorte hipotética de mil indivíduos homens, maiores de 40 anos. Adotou-se a perspectiva do Sistema Único de Saúde, horizonte temporal de 30 anos e taxa de desconto de 5% para os custos e consequências clínicas. A extensão do tratamento para respondedores lentos proporcionou incremento de 0,28 anos de vida ajustados por qualidade (QALY), de 7% de sobrevida e aumento de 60% no número de indivíduos que eliminaram o VHC. Além dos esperados benefícios em eficácia, a inclusão de respondedores virológicos lentos mostrou-se uma estratégia custo-efetiva ao alcançar um incremental de custo efetividade de R$ 44.171/QALY, valor abaixo do limiar de aceitabilidade proposto pela Organização Mundial da Saúde OMS - (R$ 63.756,00/QALY). A análise de sensibilidade demonstrou que as possíveis incertezas contidas no modelo são incapazes de alterar o resultado final, evidenciando, assim, a robustez da análise. A inclusão de indivíduos coinfectados VHC/HIV respondedores virológicos lentos no protocolo de tratamento apresenta-se, do ponto de vista fármaco-econômico, como uma estratégia com relação de custoefetividade favorável para o Sistema Único de Saúde. Sua adoção é perfeitamente compatível com a perspectiva do sistema, ao retornar melhores resultados em saúdeassociados a custos abaixo de um teto orçamentário aceitável, e com o da sociedade, ao evitar em maior grau, complicações e internações quando comparado à não inclusão. / Worldwide, hepatitis caused by viral infections has been a major concern for public health because of its chronicity, asymptomatic course and its ability to determine the loss of liver function. With the widespread use of antiretroviral drugs, liver disease related to infection with hepatitis C virus (HCV) contributed to a radical change in the natural history of infection with human immunodeficiency virus (HIV). No one knows for sure the weight of coinfection HCV/HIV in Brazil, but evidence suggests that, regardless of geographic region, these individuals have greater difficulty in eliminating HCV compared to monoinfected. In the Brazilian Unified Health System (SUS), the standard antiviral treatment for patients infected with genotype 1 HCV and HIV is the association of pegylated interferon with ribavirin. Regarding the treatment period and which individuals should treat the two most recent protocols have disagreements. The most current protocol calls for treatment of early responders individuals added to slow responders. Since the guideline immediately preceding the 12th week excludes individuals who do not respond completely. Based on this difference, this study aimed to evaluate the costeffectiveness of HCV treatment in individuals with the genotype 1 coinfected with HIV, antiviral-naïve, non-cirrhotic and immunologically stable, undergoing antiviral treatment rules established by two most recent therapeutic guidelines directed to attend by SUS. To this evaluation, was developed a mathematical model of decision, based on Markov chains, simulating the progression of liver disease under treatment and no treatment. It was accompanied by a hypothetical cohort of thousand men individuals, more than 40 years. Was adopted the perspective of the Brazilian Unified Health System, time horizon of 30 years and a discount rate of 5% for the costs and for clinical consequences. The extension of treatment to slow responders provided an increase of 0.28 years of quality-adjusted life (QALY), 7% survival rate and an increase of 60% in the number of individuals who eliminated HCV. Besides the expected benefits in efficacy, the slow viral responders inclusion proved to be a costeffective strategy to achieve an incremental cost-effectiveness of BRL 44,171.00/QALY, value below of acceptability threshold proposed by the World Health Organization (BRL 63,756.00/QALY). Sensitivity analysis demonstrated that the potentials uncertainties in the model are unable to alter the final result, thus demonstrating the robustness of the analysis. The Inclusion of HCV/HIV co-infected individuals slow virologic responders to treatment protocol, is presented from the point of pharmacoeconomic view, as a strategy to cost-effectiveness favorable for the Brazilian Health System. Its adoption is perfectly compatible with the system perspective, returning better health outcomes with costs below an acceptable budget cap, and the society, to avoid a greater extent, complications and hospitalizations when compared to non-inclusion.

Abstract The purpose of this study was to compare the effectiveness, costs and benefits of screening for diabetic retinopathy with retinal photography and with ophthalmoscopic examination in health care centres by primary care physicians, and also to study the quality of life and mortality of visually impaired diabetics. There are about 150 000 diabetics in Finland. There were 881 visually impaired persons due to diabetic retinopathy in the Finnish Register of Visually Impaired Patients in 1994 (1122 in 1997). Laser photocoagulation has proved to be an effective treatment in diabetic retinopathy preventing visual loss. The screening methods are ophthalmoscopic examination and retinal photography. The incidence of retinopathy was calculated from the photogaphy screening in the Oulu Health Care Centre in 1987 (N = 1015), in 1991–92 (N = 1844) and in 1993–94 (N = 1484). The ophthalmoscopy screening was studied from patients' records (N = 242) in the Raahe Health Care Centre. Out of 120 visually impaired persons with diabetic retinopathy in the province of Pohjois-Pohjanmaa, 50 were interviewed by the health care secretary. The study included cost-benefit analysis for the costs of screening and treatment of diabetic retinopathy compared with the costs of visual impairment. Furthermore the quality of life of patients with visual impairment due to diabetic retinopathy was studied using the Nottingham Health Profile questionaire (NHP) and compared with diabetic patients without visual impairment. The mortality rate of visually impaired patients was compared to that of diabetic retinopathy patients who had been treated with laser photocoagulation. The incidence of all diabetic retinopathy was 9.4 per cent per year and 2.8 per cent per year for moderate to severe retinopathy, and in patients with no insulin in their treatment the incidence of all retinopathy was 3.0 and 1.2 per cent per year respectively. The screening costs per diabetic person screened were 148 Finnish marks (FIM) in the photographic method and 68 FIM in the ophthalmoscopic method. It was calculated that 156 visual impairment cases could be prevented per year in Finland with the photographic method. The screening and treating costs in finding one preventable case of visual impairment were 185 000 FIM. The costs of visual impairment were 594 000 FIM per patient. So retinal photography screening and treatment of diabetic retinopathy could lead to savings of 63.9 million FIM per yearly screening in Finland. The quality of life of visually impaired persons was worse than that of other diabetics in two dimensions of the NHP, Energy and Mobility. In the second part of the NHP, the quality of life of visually impaired persons was worse than that of other diabetics in all questions except working. The mortality rate of visually impaired persons, 14.5 per cent per year was twice as high as that of diabetic patients treated with laser photocoagulation. The incidence of diabetic retinopathy in Finland was about the same as in other industrialized countries. Retinal photography seemed to be a cost-effective screening method for preventing visual impairment and the cost benefit ratio of screening and treating diabetic retinopathy was 3.2. The quality of life of visually impaired patients was worse and mortality risk higher than that of other diabetics. / Tiivistelmä Tarkoituksena oli tutkia perusterveydenhuollossa silmänpohjakuvauksella tai oftalmoskopialla tehdyn diabeettisen retinopatian seulonnan vaikuttavuutta, kustannuksia ja hyötyjä näkövammaisuuden ehkäisyssä sekä diabeettisen retinopatian ilmaantuvuutta, ja sen vuoksi näkövammaisten elämänlaatua ja kuolleisuutta. Suomessa on noin 150 000 diabeetikkoa. Diabeettisen retinopatian aiheuttama näkövamma oli Näkövammarekisterin mukaan vuoden 1994 alussa 881:lla suomalaisella (vuoden 1997 lopussa 1122:lla suomalaisella). Diabeettisen retinopatian aiheuttamaa näkövammaisuutta voidaan ehkäistä ajoissa toteutetulla silmänpohjan laser-fotokoagulaatiohoidolla. Uusien tautitapausten löytämiseksi käytetään oftalmoskopiaa ja silmänpohjakuvausta. Diabeettisen retinopatian ilmaantuvuus laskettiin Oulussa vuosina 1987 (N = 1015), 1991–92 (N = 1844) ja 1993–95 (N = 1484) toteutettujen silmänpohjakuvausten perusteella. Diabeettisen retinopatian oftalmoskooppista toteamista tutkittiin Raahen seudun terveyskeskuksen diabetesvastaanoton potilaiden sairauskertomuksista (N = 242). Seulontamenetelmien tehokkuutta arvioitiin kustannusvaikuttavuusanalyysillä ja diabeettisen retinopatian seulonnan ja hoidon hyötyä näkövammaisuuden ehkäisyssä kustannus-hyötyanalyysillä. Pohjois-Pohjanmaalta diabeettisen retinopatian johdosta näkövammarekisteriin ilmoitetuista (N = 120) haastateltiin tavoitetut 50 henkilöä. Haastatelluilla näkövammaisille sekä Oulussa vuosina 1991–92 silmänpohjakuvaukseen osallistuneille tehtiin elämänlaatukysely NHP-mittarilla. Elämänlaatua ja kuolleisuutta tutkittiin tapaus-verrokki asetelmalla. Tutkimuksen mukaan Diabeettisen retinopatian koko ilmaantuvuus oli 9,4 % vuodessa ja diabeetikoilla, joiden hoidossa ei käytetty insuliinia, ilmaantuvuus oli 3,0 % vuodessa. Vaikean tausta- ja proliferatiivisen retinopatian ilmaantuvuus oli vastaavasti 2,8 % ja 1,2 % vuodessa. Silmänpohjakuvaukseen perustuvan seulonnan ja laserhoidon kustannukset olivat 192 mk seulottua kohti. Silmänpohjakuvausseulonnalla olisi tämän tutkimuksen mukaan mahdollista estää Suomessa vuosittain 156 näkövammaa kustannusten ollessa noin 185 000 mk estettyä näkövammaa kohti. Yhden näkövamman kustannukset olivat yhteensä 594 000 mk. Silmänpohjakuvaukseen perustuvalla seulonnalla olisi mahdollista säästää noin 63,9 milj. mk vuodessa edellyttäen, että tulokset ovat yleistettävissä koko maahan. Diabeettisen retinopatian johdosta näkövammaisten elämänlaatu oli selvästi muita diabeetikkoja huonompi NHP-mittarin ulottuvuuksilla tarmokkuus ja liikkuminen sekä useilla keskeisillä elämänalueilla. Näkövammaisten diabeetikkojen kuolemanriski oli yli kaksinkertainen laserhoidettuhin näkönsä säilyttäneiisiin diabeettista retinopatiaa sairastaviin verrattuna. Tutkimuksen mukaan diabeettisen retinopatian ilmaantuvuus oli Suomessa samalla tasolla kuin muissa teollistuneissa maissa. Silmänpohjakuvaussseulonta osoittautui taloudellisesti kannattavaksinäkövammojen ehkäisyssä. Näkövammaisuus heikensi diabeetikkojen elämänlaatua ja lisäsi kuolemanriskiä.

Abstract Each year approximately 11,000 induced abortions are performed in Finland, the majority of these women being younger than 25 years of age. Medical abortion with the antiprogestin mifepristone and the prostaglandin analogue misoprostol is increasingly being used instead of surgical method (dilatation of cervix and uterine evacuation with instruments). Similarly, miscarriages can be treated with medical or surgical management. Still, clinical outcomes of the medical treatment of miscarriage are not well established, and various different regimens exist. The aim of this study was to investigate the frequency and risk factors of repeat abortions and immediate post-abortal complications, focusing especially on the impact of the method of abortion. National health registries were used as a data source. Another part of the study was aimed at comparing the efficacy, acceptability and cost-effectiveness of the medical and surgical treatment of miscarriage. In national cohort, the risk of repeat abortion was associated with sociodemographic characteristics (parity, previous abortion, low socioeconomic status, being unmarried but cohabiting or single), but not with the method of abortion. The risk of repeat termination of pregnancy decreased with age, among women living in rural area, and when intrauterine devices or sterilization were planned for future contraception. The overall incidence of adverse events was 4-fold greater in the medical compared to the surgical abortion cohort. Hemorrhage and incomplete abortion were more common following medical abortion, but the incidence of infections did not differ. Medical and surgical treatment of miscarriage were compared in a randomized setting; the efficacy of the treatment did not differ. Medically treated patients were less satisfied with the treatment and had experienced more pain. In the cost analysis, the primary costs of the surgical treatment were higher, but more unexpected events and complications increased the secondary costs in the medical group. In summary, medical abortion offered a good alternative to surgical method without increasing the risk of repeat abortions, but with an increased risk of short-term adverse events. The medical method was efficient in treating miscarriages, and the majority of women were satisfied with the treatment. Neither of the methods was economically superior in treating miscarriage.

Background: Despite proven efficacy, Manual Vacuum Aspiration (MVA) use for incomplete abortions is low in the Swaziland setting, including Raleigh Fitkin Memorial (RFM) Hospital. Uncertainty in the costs implications of introducing MVA to replace Dilatation and Curettage (D&C) is the major hindrance to change. This study aimed to evaluate the cost-effectiveness of introducing MVA as an evacuation method for first trimester incomplete miscarriages as well as assess the implications of the introduction of MVA to the entire post-abortion care budget at RFM Hospital. Methods: The methods comprised cost-effectiveness and budget impact analyses from a healthcare perspective based on a theoretical cohort. Clinical outcomes data for procedures were obtained from relevant literature. Costs were collated from prospective suppliers and then compared for the two treatment modalities. Future numbers of annual evacuations were extrapolated from previous annual figures. First trimester miscarriages were in turn extrapolated from proportions found in previous studies. Total budgets were calculated under the current scenario, as well as if MVA had to be introduced. Results: With initial capital costs of ZAR11 093.00, introduction of MVA for first trimester incomplete abortions will cut post-abortion care costs by 34.7%. MVA would cost ZAR819.86 per procedure while D&C costs ZAR1 255.40 per procedure. An estimated 26 MVA procedures done instead of D&C will compensate for the initial capital investment. Introduction of MVA into the post-abortion care programme will save the hospital about ZAR516 115.30 annually, with at least similar clinical outcomes compared to D&C. Conclusions: MVA should be considered as the first option in first trimester post abortion care. / Dissertation (MSc)--University of Pretoria, 2013. / gm2014 / Clinical Epidemiology / unrestricted

After many years of research have been developed, and then in January 2013 approved by the European Medicines Agency new multicomponent vaccine against meningococcal disease Group B Bexsero from Novartis. Meningococcal disease, because of its rapid progression and tragic consequences, a very dangerous disease. The aim of my thesis was to try to quantify the impact on the costs and benefits of the introduction of vaccination for the most vulnerable groups, namely children after birth to 4 years of age, by comparing the hypothetical vaccinated and unvaccinated cohorts. The work itself has not demonstrated at today's prices and epidemiological data Bexsero vaccines, cost efficiency. However, at a reduced cost or increased incidence of cases appear to vaccination Bexsero as well utilized resources.

This diploma thesis is focused on cost analysis of cataract treatment.The aim of the diploma thesis is to evaluate the effectiveness and efficiency of cataract surgery and treatment in terms of the costs and benefits of treatment in two possible ways from the perspective of the patient and the health care facility.