Class of 2004 Abstract / Objective: To develop and populate a decision-analytic model comparing the cost and efficacy of imatinib versus allogenic bone marrow transplantation (BMT) with a matched unrelated donor in the treatment of newly-diagnosed, Philadelphia positive (Ph (+)), chronic phase, chronic myelogenous leukemia (CML). Design: Markov cohort analysis and Monte Carlo microsimulation. Measurements and Main Results: Direct medical costs were measured from the perspective of a third-party payer. Efficacy data and probabilities were obtained from survivability findings emanating primarily from randomized controlled trials (RCTs). A two-year time horizon was employed with three month treatment cycles. BMT was established as the baseline comparator and the base case was defined as a 35 year old, Ph(+) male patient with newly-diagnosed CML. Results from the Monte Carlo trial found that the incremental cost-efficacy ratio was −$5,000 for imatinib (95th % Confidence Interval: −$70,000, $84,000). Analysis of the cost-efficacy plane indicated that imatinib dominated BMT in 84.69 percent of cases, while BMT was dominant in 0.76 percent of cases. Sensitivity analyses of costs and discount rates found results to be robust. Conclusion: Imatinib was observed in a majority of cases to be both less costly and more efficacious relative to BMT in the treatment of CML, suggesting that this pharmaceutical agent is a dominant therapeutic strategy. When available, the incorporation of long-term clinical data are required to assess cost-efficacy beyond the two-year time horizon of this study.

The goal of this dissertation was to examine the realized value of targeted therapies in routine care and to identify opportunities for improving the return on medical spending for these technologies. Chapter 1 investigated the value of targeted therapies in lung cancer patients who were treated in routine care. This observational, claims-based analysis used propensity score, and instrumental variable methods, combined with a Kaplan Meier Sample Average estimator to calculate lifetime costs and life expectancy. An incremental comparison showed that the realized value of targeted therapies in routine care was unfavorable relative to chemotherapy treatment. Subgroup analyses revealed that initial erlotinib therapy yielded effectiveness results that are substantially lower than efficacy survival outcomes in molecularly guided trials. Our results indicated that in routine care, chemotherapy was the most cost effective strategy. The unexpectedly low outcomes with first-line erlotinib suggested that some of the value of this treatment was not being realized in practice. Chapter 2 examined the practice patterns of targeted therapies and utilization of predictive biomarker testing in routine care to better understand the observed gaps between trial-based and `real-world' outcomes with these agents. In our nationally representative cohort of lung cancer patients, we found that the vast majority of patients did not undergo molecular testing to inform first-line therapy. Our prediction models for biomarker screening and first-line treatment suggested that phenotypic enrichment criteria guided selection for testing and initiation of erlotinib therapy. Since clinical characteristics do not adequately discriminate between mutation positive and wild type tumors, these practices signal the need for wider dissemination of biomarker screening to accurately target patients towards improving therapeutic gains with erlotinib. Chapter 3 assessed the cost-effectiveness of multiplexed predictive biomarker screening to inform treatment decisions in lung cancer patients. Using a micro-simulation model to evaluate the incremental value of molecularly guided therapy compared to chemotherapy in unselected patients, we found that personalized therapy is a cost effective strategy. Our results indicated that better value of targeted therapies in lung cancer is achievable through molecularly guided treatment.

The study was looking at achieving more cost-effective implementation of the Eastern Cape Thicket Rehabilitation Project. Project management has been identified as a key for a proper implementation of any kind of work. For project management to be effective, individual learning and development of project managers is of paramount importance. An improved communication process is vital, that clearly specifies objectives if any success will be achieved. A proper and structural way of addressing change is a need, so that no unnecessary delays are experienced. A need is there for processes to be streamlined to avoid duplications as they are unnecessary costs. Employees need to be given an opportunity to have their ideas looked at, a way of testing if they really have been empowered. The important thing is that their views must speak to the standards of the project. Reductions in costs are a must for more communities to benefit in the project. Continuous improvement is the way forward.

This thesis investigated the cost-effectiveness of a 12-month supervised aerobic walking program with or without a behavioural intervention and an educational pamphlet, compared to an unsupervised/self-directed educational pamphlet intervention, among individuals with moderate osteoarthritis (OA) of the knee. Analyses included an economic evaluation to assess the cost effectiveness of the two walking interventions from both the societal and Canadian provincial/territorial health care payer perspectives. A value of information analysis exploring the potential value of future research was also performed. Results revealed that the unsupervised/self-directed intervention was the most cost-effective approach given that it cost the least to implement and participants had higher quality-adjusted life years (QALYs). Walking, either supervised in a community setting, or unsupervised in a setting such as the home, may be a favourable non-pharmacological option for the management of OA of the knee. The thesis concludes with a policy discussion relating to the funding of non-pharmacological therapies.

This work includes a series of studies that examines the health and economic impacts of screening mammography from international and Canadian perspectives. This work is a compendium of several researched chapters that include an introduction, four body chapters, and a discussion. The body chapters include a systematic review of the health economic literature on screening mammography, a review of quantitative models used to examine the consequences of breast cancer screening, and cost-effectiveness analyses of screening mammography programs in Canada for the general female population and for subgroups of the population at high-risk for breast cancer. There are three analytic chapters that will be submitted as manuscripts for peer-reviewed publication. The main results of this research show that current screening mammography practices in Canada may extend life at an acceptable cost to the health care system. Due to the outlined methodological limitations of this research the results should be interpreted with caution.

The capital-output ratio has been widely used by economists and econometricians in model building for policy purposes in both developed and developing countries. Particularly in the developing economies, where planning has been an important feature of economic policy, the projection of output and investment requirements in different sectors is often based on the capital-output ratio. In the First Five-Year Plan of the United Arab Republic (U.A.R.), planners have basically used the incremental capital-output ratio for broad general sectors to derive investment requirements therein. The plan's realizations fell short of the target. This was natural and to be expected in a first effort to plan economic development. However, this raises many important questions. Was the discrepancy between the realization and the target in the First Five-Year Plan due to the very nature of the capital-output ratio technique itself? To what extent did changing external conditions lead to such discrepancy? In order to attempt an answer to these questions, it is necessary to be aware of the meaning, limitations and problems of measuring the capital-output ratio. This is the subject matter of Chapter II. Chapter III is devoted to searching the answers to the question raised in the previous paragraph. The trend of the capital-output ratio is vitally important for the developing countries with scarce capital. This is because the higher is that ratio, the more investment will be needed to achieve a certain rate of growth. In our case: What is the likely trend of the capital-output ratio for U.A.R., and what are its implications for the future development of the country? Specifically, will the country face increasing, or diminishing, problems in the future as far as capital financing is concerned? Chapter IV will attempt to frame an answer to these questions based on both, theoretical argument and empirical evidence. / Arts, Faculty of / Vancouver School of Economics / Graduate

Class of 2017 Abstract / Objectives: To assess the cost-effectiveness of vancomycin, daptomycin, linezolid, oritavancin, and telavancin as empiric treatment for MRSA skin and soft tissue infections in an inpatient setting from a third party perspective. Methods: A decision analytic tree model was constructed using TreeAge Pro and utilizing efficacy data from published clinical trials and costs estimates using HCUPnet.gov and Micromedex’s RedBook. Sensitivity analyses were run on linezolid costs, as well as oritavancin’s costs and efficacy data. Results: Linezolid was the most cost effective medication, dominating all other therapies. In a sensitivity analysis, increasing linezolid’s cost to include 7 days of inpatient therapy did not result in other therapies no longer being dominated. In two other sensitivity analyses, oritavancin was no longer dominated at 91.8% efficacy, but was still dominated with only 3 days of inpatient therapy. Conclusions: Linezolid was the most cost effective therapy for empiric treatment of suspected MRSA skin and soft tissue infections requiring hospitalization from a third party perspective.

Class of 2008 Abstract / Objectives: To determine the cost-effectiveness of adding a thiazolidinedione (TZD) versus insulin glargine (glargine) as a triple regimen for treatment of Type 2 diabetes mellitus for patients not controlled with metformin and a sulfonylurea. Methods: A decision analytic model was developed to compare the clinical outcomes and costs of triple therapy with either a TZD or glargine. Published literature was used to determine treatment efficacy and the frequency of clinically important adverse effects. Cost data were obtained from the 2007 Physician Fee Reference and North Carolina Industrial Commission website. The decision tree was built using TreeAge software. Clinical outcome measures included HgA1c (A1C) control, hypoglycemia frequency, and the development of edema associated with the use of these medications. A Monte Carlo probabilistic sensitivity analysis was conducted to determine the mean and 95% CIs for both treatment efficacy and costs. Results: There was no statistically significant difference in the efficacy of adding either a TZD or glargine in achieving a goal A1C ≤ 7%. However, glargine triple therapy was estimated to be significantly less costly than TZD triple therapy ($3,161/yr; 95% CI $3,116 to $3,356 versus $3,769/yr; 95% CI $3,667 to $3,902, respectively). Conclusions: Most patients requiring triple therapy for the management of T2DM should receive glargine rather than a TZD due to the significantly lower cost producing similar clinical efficacy.

This thesis examines the problems with social cost-benefit analysis in three areas -- economics, ethics and politics -- and suggests how these problems might be addressed in government project review processes. Problems in economics are empirical, methodological or theoretical dilemmas that make a social cost-benefit analysis difficult to prepare and interpret. Problems in ethics stem from the value judgments implicit in a social cost-benefit analysis that may be in conflict with the ethical beliefs of some individuals in society. Problems in politics stem from the various powers of individuals in a political process and challenge the relevancy of analysis. A literature survey, primarily of welfare economics but also of environmental ethics and political theory, is used to determine the various problems with social cost-benefit analysis, while a case study is used to illustrate how these problems are reflected in practice. Similarly, ideas for improvement are drawn from the literature of environmental impact assessment and these ideas are illustrated by applying them to the case study. The problems are discussed according to the stage of analysis at which they occur: problem definition, specification of objectives, selection of alternatives, prediction of consequences, and evaluation of alternatives. The case study is of the social cost-benefit analysis of B.C. Hydro's proposed Site C hydroelectric development and the associated project review process of the B.C. Utilities Commission Act. Empirical problems in economics range from: defining "wicked problems"; measuring interpersonal utility; defining and measuring consequences; obtaining adequate data; and evaluating or recognizing intangibles. Methodological problems in economics include: predicting consequences; elements of bias in evaluation techniques; the neglect of non-users in evaluation techniques for non-market resources; option values for environmental resources; and evaluating irreversible project consequences. Theoretical problems in economics stem from: narrow problem definitions and incomplete specification of alternatives which hinder achievement of optimal decisions; the theory of "second best"; the Scitovsky reversal paradox; the need for actual compensation to take place under certain situations; the use of willingness-to-pay or willingness-to-be-compensated measures of consumer surplus; the selection of a discount rate; and the effect of risk and uncertainty on evaluation. Ethical problems in social cost-benefit analysis arise from: the existence of multiple and conflicting problem definitions and sets of alternatives; Arrow's Impossibility Theorem which precludes the specification of a social welfare function; value judgments made implicitly in the methods of inquiry in both economics and the science needed for impact prediction; the existence of non-utilitarian frameworks that conflict with the utilitarian emphasis of social cost-benefit analysis; the reductionist nature of valuing environmental resources; the judgments made about individual rights in the selection of willingness-to-pay and willingness-to-be-compensated measures; and the judgments made about future generations in the selection of a discount rate. Political problems in social cost-benefit analysis are evident in: the hidden agendas and political goals of politicians, bureaucrats and interest groups; incentives to bias problem definition and alternative selection in order to justify a politically but not necessarily economically justified project; incentives to restrict the boundaries of analysis to provincial boundaries; and incentives to overstate benefits, understate costs and neglect qualitative project effects. Some of the economic, ethical and political problems can be resolved by changing the way that government project review processes operate. Three broad changes are recommended: a two-tier review process which clearly separates evaluation from the preceding stages of analysis; an increased use of public and interdepartmental review in the early stages of analysis; and a flexible and experimental approach to evaluation. / Business, Sauder School of / Graduate

acase@tulane.edu / Background It is estimated 3 to 5 million individuals in the U.S. are chronically infected with the Hepatitis C virus (HCV). (Durham DP, 2016) More than 12,000 deaths occur annually in the U.S. as a result of HCV-related liver disease. (Wieland A, 2015) The cost of treatment medication for an individual with HCV genotype-1 is approximately $100,000 for 12 weeks of therapy. (Reau N, 2014) The exorbitant cost of HCV treatment has led to fears that many who could benefit from treatment will not receive it considering many with HCV are uninsured or have Medicaid. Purpose The purpose of this study is to quantify the cost, cost-effectiveness, and adverse outcomes associated with denying or delaying HCV treatment among the Louisiana Medicaid (LA-Medicaid) HCV GT-1 population. Methodology This project evaluates the cost and cost-effectiveness of treating HCV compared to not treating; initiating early treatment compared to late treatment and HCV-related health outcomes. A decision tree and Markov model simulates progression through the various states of health involved in progressive HCV disease, including death (hepatic and other causes). Results Don’t Treat/Treat Comparison Treatment was generally cost-effective, exhibiting an incremental cost-effectiveness ratio (ICER) of $21,670/life-year and $37,067/QALY (Quality-Adjusted Life-Years) gained. Optimal Treatment Stage Comparison Treatment of a person at F0 was cost effective, exhibiting an ICER of $6,482/QALY and $6,194/year of life compared to not treating at all and treating at F1, F2, F3, F4 or after LT. Conclusion Treatment of HCV-infected patients without liver fibrosis or in early stages of liver fibrosis appear to be more cost-effective than treating in advance stages of liver fibrosis or denying treatment. / 1 / Dwana Green