Thesis (M.S. in Systems Engineering)--Naval Postgraduate School, March 2007. / Thesis Advisor(s): Thomas D. Fiorino, Tom Huynh. "March 2007." Includes bibliographical references (p. 87-90). Also available in print.

In an attempt to manage scarce health care resources and keep drug expenditure low, health care administrators worldwide have to make careful considerations regarding the choice of drugs to be provided to patients within their systems. One of the key strategies that is being employed to achieve this goal is the use of formularies. A major challenge in the formulary development process is to use pharmacoeconomics and outcomes research effectively to arrive at formularies that simultaneously provide patients with effective pharmacotherapy whilst maintaining financial stability. The extent to which this can be successfully achieved depends to a large extent on the availability of appropriate pharmacoeconomic data. The primary objectives of this study were to describe the availability and quality of literature pertaining to South African based pharmacoeconomic research, and to establish the manner in and extent to which pharmacoeconomic data is used in drug formulary decision-making processes, in both the private and public health care sectors in South Africa. A structured bibliographic search for South African pharmacoeconomic studies was conducted and a qualitative assessment of the identified studies which met the predetermined inclusion criteria was completed, using a pre-validated quality evaluation tool. In order to determine the use of pharmacoeconomic data in the formulary decisionmaking processes, by various stake holders in both the public and private of health care sectors in South Africa, a cross-sectional, descriptive study using a self-administered questionnaire was conducted. The results suggest that there is a limited availability of pharmacoeconomic research data in South Africa. Only 16 full pharmacoeconomic studies could be identified as having been published between 01 January 1995 and 30 June 2007. The quality of 3 of these studies was considered to be ‘dubious’, one study was found to be of high standard whilst the other 12 (74.95%) were of acceptable quality and thus could be considered as suitable to be used in formulary decision-making. The results of the national survey indicated that pharmacoeconomics is considered to be of importance and is used in formulary decision-making processes in both the public and private sectors. The primary source of pharmacoeconomic data used in formulary decisions appears to be international peer-reviewed publications. Of concern however, is the finding that this data, mostly from studies conducted outside of South Africa, is applied directly without sensitivity analysis or modelling. The results of the literature search and the subsequent quality appraisal suggest that pharmacoeconomic research and the use of pharmacoeconomic data in formulary decisions is at its infancy in South Africa. Thus efforts are needed to develop and grow the discipline of pharmacoeconomics in South Africa.

Control of groundwater plays an important part in operations at many open pit mines. Selection of an efficient and cost effective dewatering program that will improve slope stability of the pit walls is frequently complicated by the complex and somewhat uncertain hydrogeologic environment found at most mine sites. This dissertation describes a risk-cost-benefit (RCB) framework that can be used to identify the most effective dewatering strategy under such conditions, because the stochastic framework explicitly accounts for uncertainty in hydrogeologic and shear strength parameters in the groundwater flow, slope stability and economic analyses. In the framework, the monetary worth of each design alternative is measured in terms of an economic objective function. This function is defined in terms of a discounted stream of benefits, costs and risks over the operational life of the mine. Benefits consist of revenue generated from the sale of mineral concentrate. Costs include normal operating and dewatering expenses. Monetary risks are defined as the economic consequences associated with slope failure of the pit wall, multiplied by the probability of such a failure occurring. Selection of the best design strategy from a specified set of alternatives is achieved by determining the economic objective function for each design and then selecting the alternative that yields the highest value of the objective function. Estimation of the probability of slope failure requires an accurate assessment of the level of uncertainty associated with each input parameter, a forecast of how dewatering efforts are expected to affect pore pressures in the pit wall in light of the uncertain hydrogeologic environment, and an evaluation of the effect that the pore pressure reductions will have on improving stability of the pit wall. Prediction of the pore pressure response to dewatering efforts is achieved with SG-FLOW, a steady state, saturated-unsaturated finite element model of groundwater flow. Slope stability is evaluated with SG-SLOPE, a two dimensional, limit equilibrium stability model based on the versatile Sarma method of stability analysis. To account for input parameter uncertainty, both the groundwater flow stability models are invoked in a conditional Monte-Carlo simulation that is based on a geostatistical description of the level of uncertainty inherent in the available hydrogeological and geotechnical data. Besides documenting the methodology implemented in the framework to conduct the geostatistical groundwater flow and economic analyses of the objective function, this dissertation also presents a sensitivity analysis and a case history study that demonstrate the application of the RCB framework to design problems typically encountered in operating mines. The sensitivity study explores how each set of input parameters, including hydrologic data, shear strength parameters, slope angles of the pit wall and dewatering system specifications impact on the profitability of the mining operation. The study utilized a base case scenario that is based on overburden conditions at Highland Valley Copper; therefore, the conclusions cannot be applied blindly at other sites. However, the framework can be used to formulate site specific conclusions for other large base-metal open pit mines. After the objective function was calculated for the base case, the aforementioned input parameters were systematically perturbed in turn to study how each parameter impacts on profitability of the mine. The sensitivity study showed that in the particular case analyzed changes in the slope angle and dewatering efforts can improve profitability by many millions of dollars. In particular, steep slope angles can be utilized in the early stages of mine development while the pit walls are relatively low, and then flattened as the pit wall height increases and the monetary consequences of slope failure become more pronounced. Furthermore, the sensitivity results indicated that pit dewatering is likely to be effective over a range of hydraulic conductivities from lxlO"8 m/s to lxlO'5 m/s and that accurate estimation of the mean hydraulic conductivity is much more important than estimating other statistics that describe the hydraulic conductivity field, including the variance and the range of correlation. Results of the sensitivity study clearly demonstrate that the RCB framework can be used effectively to identify the most effective dewatering strategy given a limited amount of geologic and hydrologic information. Also, it is shown that the framework can be used to identify the most important input parameters for each specific dewatering problem and to establish the approximate monetary worth of data collection. The case history study documents how the RCB framework was applied at Highland Valley Copper (HVC). Groundwater control is recognized as an important component of mining operations at this mine site; dewatering measures utilized on the property involve both high capacity dewatering wells and horizontal drains. The benefits of pit dewatering include improved slope stability, drier operating conditions in the pit, and a convenient production water supply. These benefits do not come cheaply, HVC is expecting to spend in excess of six million dollars on groundwater control in the next ten years. Before investing such large sums in groundwater control, mine management should be confident that the capital investment is justified, i.e. that the resulting economic benefits will significantly exceed the costs of the dewatering effort. Using historical data provided by HVC, the case history study documented in this dissertation shows how the RCB framework is used to identify the most profitable combination of slope geometry and groundwater control in design sector R3 of HVC's Valley Pit. By considering three possible slope angle and groundwater control options it is shown that by continuing to implement an aggressive dewatering program, HVC can expect to reduce operating costs by as much as nine million dollars in this design sector. / Science, Faculty of / Earth, Ocean and Atmospheric Sciences, Department of / Graduate

The Expanded Food and Nutrition Education Program (EFNEP) is one of the largest efforts of the US Department of Agriculture (USDA) to promote healthy dietary behavior practices among the low income adults and youths in the US. Although the program is shown to be effective in achieving its stated goals, the cost effectiveness of the money spent on EFNEP remains largely unknown. This dissertation analyzes the costs and effectiveness of the EFNEP, and is organized in three essays. The first essay investigates the effectiveness of the adult EFNEP and evaluates the returns to scale on the money spent in this program by utilizing an indirect production function approach. Results indicate that the program has increasing returns to scale at the National level, although a significant variation exists across the states. The second essay develops a framework for conducting the cost effectiveness analysis (CEA) for the youth EFNEP. The CEA framework is then applied to the data from Virginia youth EFNEP to estimate the cost effectiveness ratio (CER). The CER is estimated to be about $75 per behavior improvement. The third essay examines the outcomes and the attributes of the youth EFNEP program using the Rasch model type measurement model.  Findings suggest that the youth EFNEP is effective in achieving its stated program goals. In addition, the program related characteristics are found to be important attributes of effective programs. Overall, this dissertation has important policy implications for improving the (cost) effectiveness of nutrition education programs. " / Ph. D.

Ser dueño de un negocio puede ser por momentos agobiante. ASAC es una excelente opción que no sólo acompaña, sino que permite encontrar la solución a los problemas diarios desarrollando en nuestros clientes capacidades internas de gestión y ventajas competitivas fundamentadas en el conocimiento y el uso de la tecnología optimizando el tiempo dedicado a sus actividades. ASAC asesora a personas que trabajan desde casa permitiéndoles desarrollar estrategias que les permitirán reducir costos alcanzando la rentabilidad esperada, mejorando procesos y resultados, preparando a los emprendedores para ser dueños de su tiempo y no un empleado de su propia empresa; los ayudará a reencontrarse con los sueños que los llevaron a emprender y abrir su propio negocio. / Owning a business can be overwhelming at times. ASAC is an excellent option that not only accompanies, but also allows us to find the solution to daily problems by developing in our clients internal management skills and competitive advantages based on knowledge and the use of technology, optimizing the time dedicated to their activities. ASAC advises people who work from home, allowing them to develop strategies that will allow them to reduce costs, achieving the expected profitability, improving processes and results, preparing entrepreneurs to be owners of their time and not an employee of their own company; will help them to rediscover the dreams that led them to start and open their own business. / Trabajo de investigación

Objective/Hypothesis: This study aimed to determine the clinical and cost-effectiveness of endoscopes during cholesteatoma surgery. More specifically, this study hypothesized that endoscope use would reduce cholesteatoma recurrence rates and cost. Study Design: Case series involving the prospective enrollment of 110 consecutive cholesteatoma patients over a 2-year period. Methods: Patients underwent cholesteatoma surgery with microscopy. During dissection, the location of the cholesteatoma was assessed. At the end of dissection and before reconstruction, the same subunits were visualized with straight and angled endoscopes for residual cholesteatoma. Hearing was analyzed before surgery and at the last possible examination. Costs were analyzed using Medicare reimbursement rates from the Centers for Medicare and Medicaid Services. Results: Intraoperative endoscopic surveillance was able to detect residual cholesteatoma in 18 patients. With a 0° endoscope, residual cholesteatoma was noted in the epitympanum (two patients), sinus tympani (one patient), and the supratubal air cells (one patient). With a 45° endoscope, residual cholesteatoma was noted in the epitympanum (three patients), sinus tympani (nine patients), the supratubal air cells (two patients), and the mesotympanum (two patients). From a cost analysis, endoscopic surveillance ($6110.36 per patient) are less expensive than second look surgeries ($11,829.83 per patient), observation ($7097.20 per patient), and observation with annual magnetic resonance imaging studies ($9891.95 per patient). The patients hearing improved after surgery, consistent with previous studies. No complications were noted from the use of endoscopes. Conclusions: Intraoperative endoscopic surveillance reduced recurrence in our series of 110 patients. Endoscopes are particularly useful in evaluating the epitympanum, mesotympanum, sinus tympani, and supratubal air cells. Moreover, endoscopic surveillance is cost-effective. Level of Evidence: 4 Laryngoscope, 128:2867–2871, 2018.

The nitrogen reduction goals for the Chesapeake Bay are proving particularly difficult achieve. One of the contributing sources of N loading to the Bay is legacy N from groundwater springs. Denitrifying spring bioreactors are a best management practice that offers an opportunity to abate N from groundwater springs. The objective of this research is to estimate the regional abatement costs to remove legacy N using bioreactors. We identified 196 candidate springs for bioreactor installation that had a median spring flow of greater or equal to 100 m3 d-1 and greater or equal to 3 mg L-1. Under assumptions that 25% of the spring flow can be diverted to the bioreactor and a bioreactor N removal efficiency of 20%, we estimate that it would cost $3,325,400 yr-1 to abate 106,911 kg N yr-1. The driving factor of driving the unit costs of N removal is the amount of spring flow treated by the bioreactor. Further research is needed to understand how to optimize bioreactor performance and the benefits of increasing the percentage of spring flow treated given the impact these two factors on the cost-effectiveness of spring bioreactors in removing N. / Master of Science / There is a Chesapeake Bay Watershed total maximum daily load (TMDL) to reduce pollutants from going into the Bay. The reduction measures to achieve the TMDL goals must be in place by 2025. The nitrogen reduction goal for the Bay is proving particularly difficult to achieve. One of the contributing sources of N loading to the Bay is legacy N from groundwater springs. Denitrifying spring bioreactors are a best management practice that offers an opportunity to abate N from groundwater springs. One form of a denitrifying bioreactor is a hole in the ground filled with carbon substrate (i.e. woodchips) that is used to treat N rich water. Due to the conditions created in the spring bioreactor, the process of denitrification occurs, and N is removed from the water treated. The objective of this research is to estimate the regional abatement costs to remove legacy N using bioreactors. We identified 196 candidate springs for bioreactor installation that had a median spring flow of greater or equal to 100 m3 d-1 and greater or equal to 3 mg L-1. Under assumptions that 25% of the spring flow can be diverted to the bioreactor and a bioreactor N removal efficiency of 20%, we estimate that it would cost $3,325,400 yr-1 to abate 106,911 kg N yr-1. The driving factor of driving the unit costs of N removal is the amount of spring flow treated by the bioreactor. Further research is needed to understand how to optimize bioreactor performance and the benefits of increasing the percentage of spring flow treated given the impact these two factors on the cost-effectiveness of spring bioreactors in removing N.

A simulation model analyzes cost effectiveness of remote facility monitoring for risk reduction in rural water supply systems by performing a break-even analysis that compares operating costs with manual and remote monitoring. Water system operating cost includes the value of water loss (i.e., realized risk) resulting from operating excursions which are inversely related to mechanical reliability. Reliability is controlled by facility monitoring that identifies excursions enabling operators to implement mitigating measures. Cost effectiveness refers to the cost relationship among operating alternatives that reveals changed economic conditions at different operating rates inherent in the inverse relationship between fixed and variable costs. Break-even analysis describes cost effectiveness by identifying the operating rate above which the more capital intensive alternative will result in lower operating cost. Evidence indicates that increased monitoring frequency associated with remote monitoring can reduce water system operating cost by improving reliability, but whether remote monitoring is cost effective depends upon system-specific factors. The lack of a documented tool for evaluating this type of cost effectiveness led to the project objective of developing a model that performs break-even analysis by simulating water system operating costs as functions of system size (delivery rate). When the spreadsheet-based static deterministic parametric simulation model is run for the Tazewell County, Virginia water system based upon 1998 data, break even is predicted at approximately fifty-five percent of annual capacity (116,338,000 gallons) with operating cost of $1,043,400. Maximum annual operating cost reduction from a $317,600 investment provides payback in nine years. / Master of Science

Yes / The key questions to be addressed in this study are: with the benefit of hindsight, what conflict prevention 'packages' could the international community have designed in order to minimise the probability of the conflicts that actually took place? How much would have been saved if these packages had been implemented, given reasonable estimates about their costs, compared with the actual cost of conflict and post-conflict intervention. The first section provides a background to the conflicts. This is followed by an assessment of the levels of resources that the international community has committed to the Western Balkans since 1991. The third part of the study provides two hypothetical scenarios for CP interventions that might have restrained conflict from breaking out. These CP packages are then costed and an assessment of their probability of success is made.

The Supplemental Nutrition Assistance Program Education (SNAP-Ed) is an extension of the Supplemental Nutrition Assistance Program (SNAP) that aims to promote living healthier lifestyles for low-income participants of SNAP with limited resources. This thesis aims to investigate the effectiveness of Virginia's adult SNAP-Ed program through a cost-effective analysis (CEA) for fiscal year 2013 which requires the separation of the into the costs and the effects of the program. The costs for the program are categories as the labor, capital, material, and utility costs that are required to implement the adult SNAP-Ed program. The effects are measured as the number of participants who start, graduate, and improve from the start to the end of the program. The effects were measured on a retrospective self-assessment that measured both if a participant graduated and their magnitude of improvement. The analysis showed that as the state of Virginia the adult SNAP-Ed program incurred a cost of $2,488,170.07 with 6,759 participants starting the program and 3,704 of those that graduated in fiscal year 2013. Participants that improved on at least one of the questions by a score of one were 3,609 of the 3,704 that graduated. For the state of Virginia the cost effective ratio (CER) for starting a participant was $368 and CER of $672 for each graduated participant. An improvement on at least one question saw a CER value of $689. These findings show patterns that can be used for future policy implementation and the focus of the program. / Master of Science