<p> Background. Norovirus disease is of great public health significance as evidenced by the health and economic burdens each year in the United States. Although norovirus disease afflicts all ages in the general population, vulnerable segments of the population include the young and elderly. Currently there is no norovirus vaccine on the market to prevent norovirus infection nor is there prescribed medical treatment other than supportive care for self-limiting symptoms. </p><p> Methods. Surveillance data on norovirus outbreaks obtained from the Centers for Disease Control National Outbreak Reporting System, school enrollment data obtained from the National Department of Education, healthcare resource utilization data obtained from the Healthcare Cost and Utilization Project, and results from published research findings were used to estimate the health and economic burdens of norovirus disease among the school age population. Decision analysis was used to model the costs and benefits of norovirus vaccination. Cost effectiveness analysis was conducted from the societal and healthcare perspectives in order to determine the incremental cost-effectiveness ratios for the alternative health strategy compared to the current standard health strategy. Univariate and multivariate analyses were conducted in order to examine uncertainty associated with parameters and assess how the uncertainty affects the outputs of the decision model. Probabilistic sensitivity analysis was conducted in order to assess and quantify the impact of varying all parameters at the same time. </p><p> Results. Norovirus results in high numbers of illnesses and high direct medical, direct non-medical and indirect costs among school age children. In terms of health burden, there were a greater number of cases requiring supportive care than any other health outcome. The cost of supportive care is relatively inexpensive until indirect costs are factored in to the total cost of one episode of norovirus illness. </p><p> The results of the present study indicated that when comparing the standard health strategy of no norovirus vaccination to that of the alternative health strategy of norovirus vaccination, vaccination was found to be optimal. The results of probabilistic sensitivity analysis indicated that the alternative health strategy was marginally cost effective. </p><p> Conclusion. The results of the present study represent the first attempt to estimate the health and economic burdens of norovirus disease among the school age population with a focus on norovirus disease spread occurring in closed (schools) environments. The study findings will illustrate the uniqueness of closed environments in perpetuating norovirus spread and the feasibility of norovirus vaccination among school age children. The results of cost-effectiveness analysis indicated vaccination was an optimal strategy but is marginally effective. </p><p> Given the numerous limitations of using passive surveillance data, future research efforts should use higher quality and more accurate sources of data in order to estimate the health and economic burdens of norovirus disease and examine the other hidden costs of norovirus outbreaks such as environmental decontamination, school closure, student and staff absenteeism and other intangible costs. In addition, future research efforts should use the findings from this and other studies that have identified high prevalence of norovirus disease among younger age groups in order to establish priority age groups for vaccination when a vaccine becomes available on the market. Clinical trials are underway and development of a norovirus vaccine is expected within the next few years. </p>

<p> This research examines three factors &ndash; macroeconomic conditions, the Deficit Reduction Act of 2005, and <i>inter-vivos</i> transfers &ndash; that influence both the availability of long-term care services and the use of these services. The first essay explores how changes in the macroeconomy, specifically the 2007-2009 &ldquo;Great Recession,&rdquo; affect the utilization of paid and unpaid long-term care services. It is theoretically unclear how long-term care use should be affected by such downturns, as an individual&rsquo;s health status, wealth, insurance coverage and access to care are all likely to change during a significant downturn such as the &ldquo;Great Recession.&rdquo; Using data from the 1998-2012 waves of the Health and Retirement Study, a survey that follows Americans over the age of 50 as they begin to transition into retirement, we estimate the effects of changes in the unemployment rate at both the national and county levels on long-term care use. We find consistent evidence that overall care use declines significantly during downturns, with additional results suggesting that these results may be driven by reductions in individual wealth and improvements in individual health status. The second essay examines how the implementation of the Deficit Reduction Act of 2005, a policy that imposed stricter regulations about how individuals could &ldquo;spend down&rdquo; their assets to become Medicaid eligible, impacts both asset transfers and long-term care use among the elderly. Using data from the 1998-2010 waves of the Health and Retirement Study, I estimate the effects of this policy using a difference-in-difference framework. Overall, individuals seem to substitute from making inter-vivos transfers to holding assets in trusts in response to the enactment of the Deficit Reduction Act. With regard to care use, individuals seem to substitute from in-home long-term care to more visits to both doctors and adult day care facilities following the DRA, an effect primarily driven by the wealthiest and youngest individuals. The third essay investigates the relationship between parent-to-child inter-vivos asset transfers and future informal care provision by that child. Using data from the 1998 &ndash; 2010 waves of the Health and Retirement Study, I am able to use the timing of the transfers and the care use to describe this relationship. The results suggest that the receipt of an inter-vivos transfer during the previous two years is strongly positively correlated with that child&rsquo;s likelihood of providing care during the previous month. In addition, I confirm a previous finding in the literature that child&rsquo;s gender, relationship to the parent and geographical proximity to the parent all significantly influence the child&rsquo;s decision to provide care.</p>

Thesis (Ph. D.)--University of Toronto, 2008. / Includes bibliographical references.

Thesis (Ph.D.)--Aberdeen University, 2006. / Title from web page (viewed on Oct. 8, 2009). Includes bibliographical references.

Resource allocation formulae in Scotland include an adjustment for remoteness and rurality.  However, there is little empirical evidence about the precise effects of remoteness and rurality on hospital costs.  The main objective of this thesis is to identify and examine the reasons as to why hospitals in remote and rural areas incur higher costs, than comparable hospitals in urban areas.  A literature review on the principal determinants of hospital costs and methods of empirical estimation identified input prices, such as labour costs, and output related features, such as delayed discharges, as the most likely influential factors.  A new set of rurality and remoteness measures was developed, so as to perform sensitivity analysis regarding the impact of those measures on hospital costs.  A panel translog hospital cost function was estimated that showed that rurality and remoteness contribute to increased hospital costs, although the size of this effect is relatively small.  An hourly wage equation was estimated to assess how medical and dental staff pay is affected by rurality and remoteness and results confirmed compensating wage differential theory in that, staff working in urban hospitals will get higher pay in order to compensate for higher costs of living.  Finally, a delayed discharge model showed that hospitals in remote and rural areas suffer from longer delayed discharges.  A fixed-effect model was used in the estimation of these models, so as to control for unobserved factors that affect hospital costs and have been proved difficult to control for in the past.  The different measures of rurality did not yield the same results, the measure that best reflected remoteness, instead of rurality, was the most significant across all models.

Background: The adoption of the Sustainable Development Goals in 2015 has renewed interest in maternal mortality reduction. Indonesia"'s maternal mortality ratio is among the highest in Southeast Asia. While skilled birth attendance (SBA) reduces the risk of maternal death, few studies have been done on SBA utilization in Indonesia using nationally representative data. This study estimated the own-price, cross-price, and income elasticities of demand for SBA in Indonesia. The effects of community and health system factors on SBA were also explored. Methods: Data from the 2004 wave of the Indonesia Family Life Survey, were used as the primary source of information. These data were supplemented with information from reports produced by the Indonesian Ministries of Health and Finance and the World Bank. The polytomous outcome variable was choice of attendance at last birth. Three estimation strategies were used to estimate the elasticities"u2014multinomial logit, multinomial probit, and an instrumental variable multinomial probit model. Statistical significance was determined at the 5% level. Results: The own-price elasticities of the facility-based delivery alternatives were between -1 and 0, indicating that demand is own-price inelastic for those alternatives. Two cross-price elasticities"u2014price of skilled home deliveries on demand for unskilled home deliveries and price of public facility deliveries on demand for skilled home deliveries"u2014indicated that women chose lower priced alternatives as the price of an alternative is increased. Increased income reduced demand for unskilled home deliveries and increased the demand for skilled home and private facility deliveries. Community and health system-level factors had small but significant effects on delivery attendance. Increases in the percentage of women in the community with SBA were associated with higher likelihood of using skilled delivery alternatives over unskilled home deliveries. Health worker density increased likelihood of choosing public facility deliveries over unskilled home deliveries. Finally, government health expenditure was positively associated with choosing skilled home and public facility deliveries over unskilled home deliveries, but was negatively associated with choosing private facility over unskilled home deliveries. Discussion: The elasticities revealed that women substituted for lower-priced alternatives as the price of an alternative increased and that they increased utilization of skilled delivery alternatives as household income increased. These findings can be interpreted as evidence that price is still a barrier to accessing SBA in Indonesia. The findings from the community and health system-level variables suggest extra-individual characteristics also affect individual decision-making on choice of delivery attendance. / 1 / Rieza Hawarina Soelaeman

<p> Racial disparity continues to be a struggle in America. The main purpose of this project was to determine whether there is a relationship between race and the acquisition of health insurance in adult residents of California who are younger than 65 years old. Through secondary data gathering, analysis of an existing racial disparity in health care insurance acquisition was accomplished. The results of the project indicate that a relationship exists between race and health insurance acquisition, thereby promoting an opportunity to determine hindering factors and discuss recommendations that can help to alleviate them. Multiple factors that influence the acquisition of health insurance among residents in California have been cited. Some of these factors such as affordability and immigration status are more relevant in the Latino racial group compared to the others. The awareness of this relationship promotes implications towards a legislative focus on the underserved populations and a development of action plans and public policies that can aid in acquisition of health insurance for all.</p>

Several reviews have shown that health problems are the single most common adverse event experienced by households in many low- and middle-income countries. There is a great deal of research documenting household health expenditure and its impact on poverty. However, evidence on the costs incurred by households outside of the health care system is at best scattered. The objective of this present study is to document the household response to illness in China using two large-scale panel household surveys and following a 'health shocks' approach. Health shocks are used to address endogeneity concerns associated with the use of alternative traditional health measures. In this manuscript, the impact of health shocks on household socio-economic status and welfare is analysed using a framework encompassing household income, medical expenditure, consumption patterns, coping strategies, and labour force supply. We find that health shocks lead to a significant increase in medical expenditure (significant for all types of shocks), and in the case of a health shock experienced by a household head, to a decrease in income ranging around five per cent of the total household income. This decrease in income is partly explained by a statistically significant reduction in labour force supply (work hours and labour force participation) from individuals who experienced a shock (larger for women and elderly). In addition, for rural-to-urban migrant workers, health shocks are associated with a higher probability of returning. However, spouses also increase their labour force supply in response, which helps avoiding large shortfalls in income. Significant coping strategies include increase in debts and remittances; and in some cases, sale of assets. On consumption, households are mostly able to maintain consumption levels following the occurrence of a health shock (with the exception of food consumption). Nonetheless, we find a significant large negative trailing impact on consumption in subsequent years. This is in line with the literature arguing that households are risk adverse and deploy ineffective coping strategies to avoid immediate shortfalls in consumption, which generate delayed costs in the long run. The results of the analyses carried out in this thesis highlight some of the potential channels of impoverishment due to health shocks, which might be of interest for policy makers, especially in China where a large-scale health system reform is currently taking place.

<p> Investment in addressing structural stigma and discrimination against refugees in resource-poor urban areas is both needed, and possible. The large population of refugees residing in resource-poor urban areas is likely to grow, and tensions in a number of settings are now documented. Without interventions to adequately address such tensions, both the protection needs of refugee populations and the stability of hosting countries could be affected. Through qualitative analysis of an urban refugee dataset in Uganda, this dissertation identified community-level drivers of structural stigma and discrimination as safeguarding one&rsquo;s body and property, defending status, and perpetuating exploitation. The designs of potentially successful programs to address these drivers were then identified though systematic review, and included one or more of the following: 1) the utilization of multiple intervention components; 2) direct information provision (e.g., lecture, role-play, other active engagement) or direct contact with stigmatized groups; 3) cooperative work between community members and stigmatized groups to better livelihoods; 4) popular opinion leaders who have authority to make change, and 5) traditional ceremonies valued by the communities for cleansing and healing. One such design involving an agricultural livelihood program in a resource-poor urban area of the Northeast United States was costed, utilizing a primarily bottom-up approach and a societal perspective in the collection of both financial and economic costs. The unit cost per participating family was significantly lower than government services that provide comparable nutritional support, but did not include components of working with the community to reduce stigma and discrimination. Thus, the studied program provided more services for a lower cost. In addition, it empowered stigmatized refugees to advocate for and support themselves, and engendered goodwill in the community by involving community members to work alongside refugee participants, improving upon a neglected piece of land, and providing fresh produce. Further research is needed to better measure the social and financial dividends of programs to address structural stigma and discrimination, particularly against urban refugees. Such research can only come in tandem with further investment, the imperative and potential of which are compellingly clear.</p><p>

<p> <b>Objectives:</b> This research identified the potential predictors of medication adherence and studied the impact of medication adherence on healthcare utilization and costs among elderly with diabetes who were enrolled in a State Pharmaceutical Assistance Program (SPAP). </p><p> <b>Methods:</b> Pharmaceutical Assistance Contract for Elderly (PACE) programs&rsquo; database was used to identify study population and estimate medication adherence as proportion of days covered (PDC) for 12-months post-index observation period (adherent: PDC &ge; 80%; nonadherent: PDC &lt; 80%). Healthcare utilization and costs for the study period were estimated using Pennsylvania Health Care Cost Containment Council&rsquo;s hospital inpatient discharge records. Healthcare utilization measures included all-cause, diabetes-specific, diabetes-related and diabetes-specific &amp; related number of inpatient hospital admissions and length of stay (LOS). Multiple regression analyzes were performed to determine the predictors of medication adherence and to assess the association of medication adherence with risk of hospitalization, hospital service utilization and costs. </p><p> <b>Results:</b> Among 9,497 elderly PACE enrollees with diabetes, 81% were adherent and 21% were hospitalized. Race, marital status, number of unique medications and out-of-pocket payment were the significant predictors of medication adherence. The odds of being hospitalized were higher for nonadherent patients by the factor 2.030 than adherent patients (95% CI: 1.784&ndash;2.310). After controlling for covariates, non-adherent patients had significantly a greater number of all-cause (IRR 1.2727; 95% CI 1.1937&ndash;1.3569), more diabetes-related (IRR 1.2210; 95% CI 1.0492&ndash;1.4210) and more combined diabetes-specific &amp; related (IRR 1.2106; 95% CI 1.0495&ndash;1.3965) hospital visits than adherent patients. After adjusting for covariates, LOS for non-adherent patients was longer for all-cause (IRR 1.2388; 95% CI 1.1706&ndash;1.3111), diabetes-related (IRR 1.1341; 95% CI 1.0415&ndash;1.2349) and for diabetes-specific &amp; related (IRR 1.1271; 95% CI 1.0357&ndash;1.2267) hospitalization than adherent patients. GLM models showed that medication nonadherence was associated with significant increase in all-cause hospitalization costs ($22,670 vs $16,383; p &lt; 0.0001) and diabetes-related hospitalization costs ($13,518 vs $12,634; p = 0.0003). </p><p> <b>Conclusions:</b> Medication nonadherence was associated with an increased risk of hospitalization, greater number of hospital visits, longer hospital LOS and substantial hospitalization costs among elderly SPAP beneficiaries with diabetes. Utilization of our findings to develop interventions or policies to improve medication adherence would significantly impact the US healthcare system particularly while allocating limited healthcare resources.</p><p>