The extent to which economic evaluations of public health programs in Ontario are conducted and used by decision makers is currently very limited. This thesis supports public health decision-making through applied and methodological work. The applied work demonstrates different methods to evaluate the cost-effectiveness of public health interventions using the examples of seasonal and pandemic influenza immunization programs. The methodological component explores whether time horizon choice, one methodological consideration in economic evaluations, introduces bias. The economic evaluation of Ontario’s universal influenza immunization program (UIIP) uses primarily provincial health administrative databases to assess the impact of UIIP on health outcomes (quality-adjusted life years (QALYs), mortality), health care resource use (physician office visits, emergency department visits, and hospitalizations), and costs due to seasonal influenza. Ontario’s UIIP was found to be cost-effective compared to a targeted program. The economic evaluation of Ontario’s H1N1 (2009) mass immunization program uses a mathematical modeling approach to describe the pandemic as observed in Ontario. By removing immunization from the simulation, the impact of the program was evaluated. Outcome measures include health outcomes (attack rate, deaths, QALYs), resource use, and cost (physician office visits, emergency department visits, hospitalizations). The analysis found Ontario’s mass immunization program to be highly cost-effective despite high program cost. The methodological component investigates whether time horizon choice, a major methodological choice, introduces bias to economic evaluations. The existence, magnitude and direction of time horizon bias are demonstrated using a formal model. This work supports current guidelines in recommending a lifetime time horizon and provides a framework to discuss bias in economic evaluations. This thesis demonstrates different approaches to evaluate the cost-effectiveness of public health interventions, informs decision-making, and establishes the groundwork to guide future economic evaluations of public health interventions.

Background: Health economic evaluations are becoming an increasingly important means of analysing which care alternative resource utilisation is the most cost effective. It is a new topic in the medical device industry that causes much uncertainty and unstructured use of the actors involved. Study questions: Why is it difficult to develop, implement and disseminate this standardized health economic evaluation models in medical technology? Is there a possibility to standardize health economic evaluations within the medical device industry? Purpose: The purpose of this study is to investigate the standardization issues for health economic evaluations within the medical device industry. Method: A qualitative approach was used in the form of interviews with five actors that are active or have a connection to the medical device industry. The data collection consists of journals, reports, Internet searches and literature among other things. Conclusion: It is possible to standardize, but with certain restrictions such as the county council's budget, influence of industry-specific factors, lack of knowledge and the important interaction between actors.

Chronic diseases place a substantial economic burden on the health care system. Physical inactivity, poor diet and smoking are considered to be the main causes of high rates of chronic disease. Evidence clearly supports the positive influence of physical activity on health determinants, other health outcomes and quality of life. This implies that an increase in physical activity improves general health status and has the potential to reduce utilization of expensive healthcare services and disability days. Earlier studies show that physical activity programs would be an effective way of providing preventive care for people with chronic conditions. However studies that relate physical activity programs to health care utilization are limited in economics literature.<p>The aim of this paper is to examine the impact of physical activity programs on healthcare utilization. From 2002 to 2003, adults over the age of 50 years, in a mid-size Canadian city, presenting with excess weight, type 2 diabetes, hypertension, hyperlipidemia or osteoarthritis were recruited. Following a screening process, eligible participants were randomly assigned to one of two programs: a class-based structured program or a home-based unstructured program. Validated questionnaires related to health status and quality of life were completed and physical tests were carried out at baseline, 3, 6, 12 months and 24 months after the program initiation. In addition participants use of physician and hospital services and pharmaceutical expenditures were accessed through their administrative data files for three years, one year before and two years after the intervention. Using administrative data from Sask Health and individual level survey data the effects of physical activity programs on health care utilization were estimated. The results showed that structured physical activity program can reduce annual physician costs significantly. The exponential effect of aging was found to be significant on hospital utilization, and the number of comorbidities was found to be significant on prescription drug utilization.

Behovet av högkvalitativ vård i relation med begränsade resurser har lett till en utveckling av disciplinen hälsoekonomi, vars syfte är att uppnå en effektiv resursfördelning inom sjukvården. Då sjuksköterskan utgör en av sjukvårdens största resurser finns det forskning som visar att sjuksköterskor kan göra påverkan inom hälsoekonomi och uppmuntras samtidigt till en större ekonomisk medvetenhet. Syftet var att beskriva faktorer som kan ge hälsoekonomisk påverkan utifrån sjuksköterskans omvårdnadsåtgärder. En litteraturöversikt gjordes genom en systematisk sammanställning och analys av vetenskapliga artiklar. Resultatet visade att faktorer som patientcentrerat omvårdnadsarbete, patientsäker omvårdnad, bra samordning, personalsäkerhet i samband med omvårdnadsåtgärder samt eftersträvan av bra kompetens och kritiskt förhållningssätt, kan ge en hälsoekonomisk påverkan utifrån sjuksköterskans omvårdnadsåtgärder. Sjuksköterskan kan också bidra genom att tillämpa de förutsättningar som sjukvården som organisation bidrar med i form av att följa riktlinjer. Därmed kan hälsoekonomiska förutsättningar uppnås genom sjuksköterskans omvårdnadsåtgärder, utan att det försummar vårdkvaliteten, vilket innebär att sjuksköterskor bör uppmuntras till en större hälsoekonomisk medvetenhet. Då hälsoekonomi kan påverkas utifrån omvårdnadsåtgärder bör mer forskning inom detta område eftersträvas. / The need for high quality care in relation to limited resources led to development of the discipline of health economics, which aims to achieve an efficient allocation of resources in health care. Nurses are one of the largest health care resources and there is research showing that nurses can make impact in health economics and encouraged simultaneously to a greater financial awareness. The aim was to describe factors that may cause health economic influences from nursing interventions. A literature review was done by a systematic compilation and analysis of scientific articles. The results showed that factors such as patient-centered care, ensuring good and safe care, good coordination, personnel safety associated with nursing intervention and striving for good skills and critical approach, can provide health economics influences based on nursing intervention. The nurse can also help by applying the conditions that health care organization is contributing in terms of following the guidelines. Health economic conditions can be achieved by the nursing intervention without neglecting her care quality, which means that nurses should be encouraged to greater health economic awareness. Health economics can be influenced by nursing interventions; therefore more research in this field would be required.

In the first chapter, I investigate the welfare effect of the government subsidizing medical insurance. To that extent, I construct and simulate a partial equilibrium computational model of medical care consumption and choice of insurance contracts. I use the overall utility of agents as a welfare measure and find that it is not welfare improving to subsidize uninsured agents by taxing insured ones. In addition I use the framework to verify the insurance contract choice effect and find a strong insurance contract choice effect. In Chapter 2, I investigate the effect of the price setting process under managed health care plans, such as HMOs and PPOs, on prices, profits of insurance companies and medical care providers, and household’s welfare compared to the indemnity plans prevalent before the advent of managed care. I construct a simple game played between a representative insurance company and a medical care provider to determine the price of medical care paid by insured and uninsured households. In addition, insurance companies set premiums not through solving the usual principal-agent problem which forces a zero profit condition, but rather and more realistically by optimizing profits. The outcome of this game is compared to the outcome of the indemnity plans where no price negotiations would occur. In Chapter 3, I investigate the effect of the suggested reform to the United States’ tax code in treatment of housing assets. In particular, I study the effect of the abolishment of the preferential tax treatment of housing assets (tax deductible mortgage interest payments and tax-free imputed rents) on the ownership and foreclosure rates in the housing market. I construct a model where heterogeneous agents decide on housing tenure in which default on housing mortgages occurs in equilibrium. I use this model to quantify the effect of this preferential tax treatment. I find that the elimination of the preferential tax treatment of housing assets results in a 33.4% reduction in foreclosures. Specifically, only eliminating the tax deductibility of interest on mortgage payments leads to a 12.4% reduction in foreclosure rates, while only taxing imputed rents generates a 32.5% reduction in foreclosure rates. / text

This dissertation examines methods used to evaluate the cost-effectiveness of childhood obesity interventions in order to help decision-makers prioritize among competing health programs using standardized outcomes. Chapter 1 generates inputs for use in cost-effectiveness analyses (CEAs) of childhood obesity interventions. In Chapter 1.1, I use data from the Medical Expenditure Panel Survey to predict expenditures associated with obesity in childhood and adolescence. I found that obese children and adolescents have significantly different expenditures than their normal weight counterparts. I conclude that exclusion of obesity-related medical expenditures can potentially undervalue the cost-effectiveness of interventions. In Chapter 1.2, I use data from the Study of Early Child Care and Youth Development to examine the longitudinal trajectory of child weight. I derived probabilities of transitioning between weight classes that can be used in a decision-analytic model to extrapolate the effectiveness of childhood obesity interventions beyond childhood. I found that deviating from CDC BMI reference categories can more accurately capture the risk of future obesity. In Chapter 2, I evaluate the cost-effectiveness of a primary care-based obesity prevention program, High Five for Kids. Over two years, High Five for Kids was low-cost, but only marginally effective in reducing BMI. I used a decision analytic simulation model to extrapolate trial outcomes over a 10-year horizon, and found that in the long-term, primary care based obesity prevention was likely to be cost-effective relative to usual care. I also found that key methodological considerations can meaningfully influence the cost-effectiveness of childhood obesity interventions. In Chapter 3, I develop an agent-based model to explore the dynamics of the potential spread of obesity within families. I found that the “contagion” of obesity could result in significant collateral weight loss in family members not targeted in an intervention. As a result, CEAs may underestimate the benefits of obesity interventions. Moreover, I found that unless interventions are targeted toward all obese children in a family, the contagion of obesity can hinder weight loss in intervention targets. This model can be leveraged as a tool to optimize family-based obesity intervention strategies and inform randomized controlled obesity prevention trials.

Chapter 1 investigates whether physicians' financial incentives influence health care supply, technology diffusion, and resulting patient outcomes. In 1997, Medicare consolidated the geographic regions across which it adjusts payments for physician services, generating area-specific price shocks that are plausibly exogenous with respect to health care demand. Areas with higher payment shocks experience significant increases in health care supply. On average, a 2 percent increase in payment rates leads to a 5 percent increase in care provision per patient. Elective procedures such as cataract surgery respond twice as strongly as less discretionary services like dialysis. Higher reimbursements also increase the pace of technology diffusion, as non-radiologists acquire magnetic resonance imaging scanners more readily when prices increase. The magnitudes of our empirical findings imply that changing provider incentives explain up to one third of recent growth in spending on physician services. The incremental care has no significant impacts on mortality, hospitalizations, or heart attacks. In chapter 2, we analyze bargaining between health care providers and private insurers in the shadow of large public insurance programs. Using several distinct sources of variation in Medicares payment rates, we find robust evidence that private insurers adapt to Medicare pricing. The relationship between private and public prices is both significantly positive and significantly less than one-for-one. The results reject both the strong view that private insurers mimic Medicare and views that emphasize cost-shifting as the predominant feature of these markets. Private responses to Medicare payments are larger in states with more competitive insurance markets. The evidence is consistent with models in which Medicares payment rates serve as a basis for negotiations between insurers and provider networks. Chapter 3 revisits the standard user cost model of housing prices and concludes that the predicted impact of interest rates on prices is much lower once the model is generalized to include mean-reverting interest rates, mobility, prepayment, elastic housing supply, and credit-constrained home buyers. The modest predicted impact of interest rates on prices is in line with empirical estimates, and suggests that lower real rates can explain only one-fifth of the rise in prices from 1996 to 2006. / Economics

This dissertation presents three papers applying health economics to the study of risky behaviors. The first uses data from the 1979 National Longitudinal Survey of Youth to examine the relationship between adverse events and risky behaviors among adolescents. Substance use responses to experiencing either of two adverse events--violent crime victimization or death of a non-family member one felt close to--explain 6.7 percent of first cigarette use, and 14.3 percent of first use of illegal drugs other than marijuana. Analyses of exercise, a positive coping mechanism, find shock-responses consistent with a coping-response, but not with rational, time-inconsistent, or non-rational drivers considered here. I conclude that distressing events lead to risky behaviors, with a coping response contributing to this effect.

Defining health and economic burden of Invasive Meningococcal Disease (IMD) in Canada is critical to inform Public Health Policy around immunization programs. A comprehensive literature review was conducted to assess available studies, a lack of comprehensive Canadian data to allow evaluation of total economic burden of IMD was identified in Canada. Thus, this dissertation proposes a prospective cost collection methodology tailored to Canadian data and healthcare utilization (HCU). All patient-related HCU is considered and outlined. HCU is then categorized as direct or indirect and relevant direct and indirect healthcare costs are detailed. Intangible costs are described and methodology for capturing these costs using validated quality of life instruments is proposed. As all published economic evaluations of this disease lack prospective collection of data, this study proposes the use of a patient diary to serve as a memory aid during patient cost-collection interviews.

This paper examines the correlates of seasonal flu vaccination in Canada between 2000 and 2011. In terms of the socio-economic characteristics of the population that relate to higher take-up, my findings are consistent with the previous literature. Specifically, the most important predictors of vaccination are the risk factors: age and chronic conditions. My results also suggest that both novel respiratory disease outbreaks and provincial immunization program design are important determinants of the seasonal flu vaccine take-up. The absence of a separate vaccine intended to protect from a novel virus during its epidemic could increase the seasonal flu vaccine take-up. In cases when a separate vaccine is offered, the seasonal flu vaccine take-up depends on the timing of vaccines’ delivery and the extent of prior influenza immunization coverage for a specific population subgroup in a province.