Thesis (D.P.H.)--University of Michigan.

Zugl.: Berlin, Humboldt-University, Diss., 2008. / Includes bibliographical references.

Health and public health services in England are under increasing financial pressure. At the same time, nearly 40% of the total disease burden is potentially amenable to known causes with two of the leading behavioural risk factors being unhealthy diets and physical inactivity. To better inform decision makers and improve health in England, this thesis aims to develop a cost-effectiveness model that can directly compare diet and physical activity interventions. Published public health economic models were reviewed and the strengths and weaknesses of the modelling structures were explored. A pre-existing multistate life table model, PRIMEtime, was developed into PRIMEtime Cost Effectiveness (PRIMEtime CE). Disease specific NHS England costs were derived from NHS England Programme Budgeting Data and unrelated disease costs from NHS cost curves. Social care costs were quantified using a Department of Health tool for estimating wider societal costs. Disease specific utility decrements were adopted from a catalogue of EuroQoL five dimensions questionnaire scores. The cost effectiveness of reformulating food to have less salt and of expanding access to leisure centres in England were modelled from an NHS and social care perspective over a 10 year time horizon, including government and industry costs. Salt reformulation was dominant with an estimated cost per quality adjusted life year (QALY) of -£17,000 (95% uncertainty interval, -£40,000 to £39,000), compared with £727,000 (£514,000 to £1,064,000) for increasing access to leisure centres. Sensitivity analyses and cross validation testing of outcomes demonstrated how cost per QALY estimates were sensitive to the choice of model scope, parameters, and structure. PRIMEtime CE is a tool for decision makers to compare interventions affecting diet and physical activity, enabling them to make better informed choices about how to spend finite resources. Future work will focus on making the model freely available and expanding its risk factors to enable comparisons of other public health interventions.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-05-31T19:11:52Z No. of bitstreams: 1 charlenedyanemacedoferreira.pdf: 2081734 bytes, checksum: 74a54ac62bbcc69476767a7be92fd850 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-02T12:48:45Z (GMT) No. of bitstreams: 1 charlenedyanemacedoferreira.pdf: 2081734 bytes, checksum: 74a54ac62bbcc69476767a7be92fd850 (MD5) / Made available in DSpace on 2016-07-02T12:48:45Z (GMT). No. of bitstreams: 1 charlenedyanemacedoferreira.pdf: 2081734 bytes, checksum: 74a54ac62bbcc69476767a7be92fd850 (MD5) Previous issue date: 2012-03-26 / Introdução: Em um mundo ideal as palavras economia e saúde poucas vezes seriam encontradas na mesma frase, uma vez que saúde muitas vezes é referida como um bem no qual não é possível atribuir um preço. Baseado nos números elevados de prevalência e incidência da doença renal crônica, principalmente em seus estágios pré-dialíticos, a doença renal crônica com todas suas implicações econômicas e sociais, tornou-se um dos maiores desafios à saúde pública. Os dados disponíveis sobre custos da DRC estão concentrados principalmente nas modalidades de diálise. Atualmente, percebe-se devido à relevância da DRC para a sociedade e para sistema de saúde, que há uma necessidade de mudança de foco para as consequências da DRC antes da DRCT. Material e Métodos: A pesquisa é um estudo coorte retrospectivo de custos diretos médicos da DRC em seus estágios 3 a 5 pré-dialítico em uma população de pacientes atendidos no ambulatório de Nefrologia Geral do Centro Atenção a Saúde do Hospital Universitário (CAS/HU) da Universidade Federal de Juiz de Fora por um período de 6 meses ou mais de acompanhamento. O horizonte temporal do estudo foi de 3 anos e 6 meses, pacientes admitidos em janeiro de 2008 até julho de 2011. A população do estudo foi uma coorte aberta. A perspectiva adotada é a do Sistema Único de Saúde como órgão prestador de serviços. Os valores estimados estão atualizados para 2012. Resultados: A base de dados possui 68 pacientes, 50 % dos pacientes do sexo masculino e50% do sexo feminino. A média de idade dos pacientes na primeira consulta é de 61,44 anos. A média do tempo de acompanhamento dos pacientes é de 15 meses. A média ponderada de custo da consulta médica é de R$ 4,41 paciente/mês, com uma média de 0,44 consultas por paciente/mês. A média ponderada de custo de medicamento é R$ 12,02 paciente/mês, com uma média 1,21 medicamentos por paciente/mês. A média ponderada de custo de exame é7,53 paciente/mês, com uma média de 0,35 exames de sangue paciente/mês e 0,18 exames de urina paciente/mês. O custo total do paciente com DRC estágios 3 a 5 pré-dialítico é de R$ 23,96 paciente/mês e R$ 287,52 paciente/ano. Conclusão: O custo da DRC aumenta com sua progressão ao longo dos estágios. O custo do tratamento da DRC estágios 3 a 5 pré-dialítico é bem inferior aos custos do tratamento da DRCT quando comparado as duas principais modalidades de diálise. Dos custos médicos diretos estimados, a medicação foi a que representou maior custo, sendo a eritripoetina de maior custo devido ao valor unitário e posologia do medicamento. O segundo custo de maior representatividade foi o exame, sendo o de maior custo o exame ultrassonografia renal, devido à média de valores dos exames ultrassonografia de aparelho urinário e ultrassonografia de abdômen total. E a consulta médica foi o terceiro maior custo. Este estudo, na medida em que permite a identificação e o mapeamento de custos, pode auxiliar na escolha de intervenções mais efetivas por um menor custo e agregar elementos para alterações e aprimoramento das políticas de saúde da DRC, aumentando a eficiência e a efetividade dos serviços e a qualidade do cuidado em saúde prestado ao paciente renal. / Introduction: In an ideal world, economics and health are words that would hardly ever be found in the same sentence, since health is often referred as a good which is impossible to atribute price. Based on the high number of prevalence and incidence of the Chronic Kidney Disease, mainly its pre-dialysis stage, the disease with all its social and economic implications has become one of the biggest challenges for public health. Avaiable data about the CKD are concentrated mainly on the dialysis modality. Today, due to the relevance of CKD to the society and the health system, it can be seen that there is a great need of changing the focus into the consequences of CKD before the End-stage Kidney Disease (ESRD). Materials and methods: The research is a retrospective cohorte study of direct medical costs of CKD from stage 3 to 5 pre-dialysis in a population of patients attended by the general nephrology clinic of the Centro de Atenção a Saúde do Hospital Universitário (CAS/HU) of the Universidade Federal de Juiz de Fora over a follow-up period of 6 months or more. The period of study was 3 years and 6 months, including patients admimitted from January 2008 to July 2011. The population was an open cohorte. The perspective adopted is the one from the Sistema Único de Saúde as a purchasing agency of services. The estimated values are up to date to 2012. Results: The database includes 68 patients, being 50% male and 50% female. The average age of the patients in the first consultation is between 44 and 61 years old. The mean follow-up time of the patients is 15 months. The weighted average cost of medical consultation is R$4,41 patient/month with an average of 0.44 visits patient/month. The weighted average cost of medication is R$ 12,00 patient/month, with an average of 1.21 drugs patient/month. The weighted average cost of examination is 7.53 patients/month with an average of 0.35 blood tests patient/month and 0.18 urinalyses patient/month. The total cost of patients with CKD stages 3 to 5 pre-dialysis is R$ 23.96 patient/month and R$ 287,52 patient/year.Conclusion: The cost of CKD increases with its progression through the stages. The cost of treatment of CKD stages 3 to 5 pre-dialysis is well below the costs of treating ESRD when compared with the two main types of dialysis. Among the estimated direct medical costs, medication represented the largest cost, being erythropoietin the higher cost due to unit value and dosage of the drug. The second most representative cost was the examination, being the renal ultrasound examination the more expensive, because due to the average values of ultrasound examinations of the urinary tract and total abdominal ultrasonography. Medical consultation was the third largest cost. This study, as it allows the identification and mapping of costs, can assist in choosing the most effective interventions for a lower cost and add elements to change and improve the health policies of CKD as well, increasing the efficiency and the effectiveness of services and quality of health care provided to renal patients.

In this thesis I apply the concepts of Behavioral Economics to the analysis of the individual health care behavior. In the first chapter I provide a theoretical explanation of the link between loss aversion and health anxiety leading to infrequent preventive testing. In the second chapter I analyze this link empirically based on the general population questionnaire study. In the third chapter I theoretically explore the effects of motivational crowding-in and crowding-out induced by external or self-rewards for the self-control involving tasks such as weight loss or smoking cessation.<p><p>Understanding psychological factors behind the reluctance to use preventive testing is a significant step towards a more efficient health care policy. Some people visit doctors very rarely because of a fear to receive negative results of medical inspection, others prefer to resort to medical services in order to prevent any diseases. Recent research in the field of Behavioral Economics suggests that human's preferences may be significantly influenced by the choice of a reference point. In the first chapter I study the link between loss aversion and the frequently observed tendency to avoid useful but negative information (the ostrich effect) in the context of preventive health care choices. I consider a model with reference-dependent utility that allows to characterize how people choose their health care strategy, namely, the frequency of preventive checkups. In this model an individual lives for two periods and faces a trade-off. She makes a choice between delaying testing until the second period with the risk of a more costly treatment in the future, or learning a possibly unpleasant diagnosis today, that implies an emotional loss but prevents an illness from further development. The model shows that high loss aversion decreases the frequency of preventive testing due to the fear of a bad diagnosis. Moreover, I show that under certain conditions increasing risk of illness discourages testing.<p><p>In the second chapter I provide empirical support for the model predictions. I use a questionnaire study of a representative sample of the Dutch population to measure variables such as loss aversion, testing frequency and subjective risk. I consider the undiagnosed non-symptomatic population and concentrate on medical tests for four illnesses that include hypertension, diabetes, chronic lung disease and cancer. To measure loss aversion I employ a sequence of lottery questions formulated in terms of gains and losses of life years with respect to the current subjective life expectancy. To relate this measure of loss aversion to the testing frequency I use a two-part modeling approach. This approach distinguishes between the likelihood of participation in testing and the frequency of tests for those who decided to participate. The main findings confirm that loss aversion, as measured by lottery choices in terms of life expectancy, is significantly and negatively associated with the decision to participate in preventive testing for hypertension, diabetes and lung disease. Higher loss aversion also leads to lower frequency of self-tests for cancer among women. The effect is more pronounced in magnitude for people with higher subjective risk of illness.<p><p>In the third chapter I explore the phenomena of crowding-out and crowding-in of motivation to exercise self-control. Various health care choices, such as keeping a diet, reducing sugar consumption (e.g. in case of diabetes) or abstaining from smoking, require costly self-control efforts. I study the long-run and short-run influence of external and self-rewards offered to stimulate self-control. In particular, I develop a theoretical model based on the combination of the dual-self approach to the analysis of the time-inconsistency problem with the principal-agent framework. I show that the psychological property of disappointment aversion (represented as loss aversion with respect to the expected outcome) helps to explain the differences in the effects of rewards when a person does not perfectly know her self-control costs. The model is based on two main assumptions. First, a person learns her abstention costs only if she exerts effort. Second, observing high abstention costs brings disutility due to disappointment (loss) aversion. The model shows that in the absence of external reward an individual will exercise self-control only when her confidence in successful abstention is high enough. However, observing high abstention costs will discourage the individual from exerting effort in the second period, i.e. will lead to the crowding-out of motivation. On the contrary, choosing zero effort in period 1 does not reveal the self-control costs. Hence, this preserves the person's self-confidence helping her to abstain in the second period. Such crowding-in of motivation is observed for the intermediate level of self-confidence. I compare this situation to the case when an external reward is offered in the first period. The model shows that given a sufficiently low self-confidence external reward may lead to abstention in both periods. At the same time, without it a person would not abstain in any period. However, for an intermediate self-confidence, external reward may lead to the crowding-out of motivation. For the same level of self-confidence, the absence of such reward may cause crowding-in. Overall, the model generates testable predictions and helps to explain contradictory empirical findings on the motivational effects of different types of rewards. / Doctorat en Sciences économiques et de gestion / info:eu-repo/semantics/nonPublished

No description available.

This dissertation consists of three essays in health economics concerned with measuring the determinants of health care resource utilization and health. In the first chapter, I study entry barriers in healthcare provider markets. In the U.S., proponents of regulatory entry barriers called CON programs claim that they reduce waste by limiting "unnecessary" entry. I examine CON programs in the dialysis industry, where their effects on market structure, access, health, costs, and welfare are poorly understood, and where patients are sensitive to access and quality. I combine quasi-experimental policy variation in low population areas with a structural model of patient preferences to find that marginal entrants improved access significantly, reduced hospitalization rates, and generated for patients the utility value of traveling 275-344 fewer miles per month; but there is evidence that they contributed even more to fixed costs. Using policy variation throughout North Carolina, I also find evidence that the NC dialysis CON program created a mechanism through which incumbents could block potential entrants by expanding in tandem with their local patient populations. Taken together, my findings suggest that stronger regulatory entry barriers in low population areas may raise total welfare at patients' expense---but they also amplify concerns that CON programs dampen competition statewide. In the second chapter, I study an empirical framework commonly used in health economics research to measure the impact of an event over time using observational data: the event study. Dating back to at least Snow (1855), event studies have been used in health economics research to study mortality, health care utilization, health insurance enrollment, provider competition, and much more. Under no anticipation and parallel trends assumptions, difference-in-differences are known to identify the event's average treatment effect on the treated when units experience one event at most. In this paper, I introduce a new event study framework to accommodate settings where units may experience multiple events. I introduce a matching estimator which consistently and transparently estimates the average treatment effect on the treated of a single event under generalizations of the conventional no anticipation and parallel trends assumptions. I show that the matching estimator is equivalent to a weighted least squares estimator for a particular set of weights. I also introduce a parallel pre-trends test which can be used to scrutinize these assumptions in the usual sense. Finally, I demonstrate in a series of Monte Carlo simulations that the estimator and parallel pre-trends test work well for a wide range of treatment effects, including dynamic, non-stationary, and history-dependent treatment effects. In the third chapter, I study when and why emergency departments initiate ambulance diversions, and what happens to diverted patients. Efficiently distributing scarce healthcare resources among patients with time sensitive healthcare needs and uncertain arrival rates is a hard problem. When an emergency department gets too full, ED managers sometimes request that incoming ambulances reroute their patients to alternative destinations. While such ambulance diversions can sometimes help an overcrowded ED manage its caseload, it can also harm incoming patients and reduce systemwide EMS responsiveness. In detailed administrative records cataloging when, where, and why diversions occur, as well as who got diverted, I document that diversions commonly last exactly 1 hour, approximately 4 hours, and exactly 8 hours (indicating that managerial frictions may directly affect ED availability); that diverted patients have different characteristics than non-diverted patients (including potentially more severe symptoms); and that diverted patients spend 65% longer on the road to the hospital than non-diverted patients. I also find that diversions often occur not only because of crowdedness, but also because of hospital systems failures. I identify directions for future research.

This dissertation consists of three essays in the field of health economics. The first essay provides the first causal evidence that bargaining power in a relationship shapes pregnancy outcomes and health disparities in the US. A key driver of bargaining power is the availability of potential non incarcerated male partners in the local dating market, which I define at the race by cohort by county level. Because these sex ratios are endogenous, I use a novel instrument that leverages the randomness in sex at birth and the persistence of local demographics to isolate exogenous variation in the relative availability of men. Greater female bargaining power causes better outcomes: fewer out-of-wedlock births, less chlamydia and hypertension among mothers, and fewer infants with APGAR score below the normal level. The marriage market makes a significant contribution to racial disparities in pregnancy health. Specifically, Black women face relatively poor prospects when looking for a partner compared to White women: while there are 102 White men per 100 White women, only 89 Black men are available per 100 Black women. According to my estimates, Black women’s disadvantage accounts for 5-10% of the large racial gap in maternal and neonatal health. The racial difference in male availability is mostly policy-driven, as incarceration accounts for 45% of the gap. A counterfactual policy equalizing county-level incarceration rates for non-violent offenses between Black and White people would prevent 200-700 adverse pregnancy outcomes per year among Black mothers through the bargaining power channel alone. The second essay investigates how reopening hotels and ski facilities in Poland impacted tourism spending, mobility, and COVID-19 outcomes. We used administrative data from a government program that subsidizes travel to show that the policy increased the consumption of tourism services in ski resorts. By leveraging geolocation data from Facebook, we showed that ski resorts experienced a significant influx of tourists, increasing the number of local users by up to 50%. Furthermore, we confirmed an increase in the probability of meetings between pairs of users from distanced locations and users from tourist and non-tourist areas. As the policy impacted travel and gatherings, we then analyzed its effect on the diffusion of COVID-19. We found that counties with ski facilities experienced more infections after the reopening. Moreover, counties strongly connected to the ski resorts during the reopening had more subsequent cases than weakly connected counties. The third essay studies the diffusion of influenza-like illnesses (ILI) through social and economic networks. Using almost two decades of weekly, county-level infection and mortality data from Poland, it studies within and across-counties ILI transmission. Firstly, it evaluates the causal effect of school closures on viral transmission. The results show that closing schools for two weeks decreases the number of within county cases by 30-40%. The decline in infections extends to elderly and pre-school children. In addition, flu-related hospitalizations drop by 7.5%, and mortality related to respiratory diseases among the elderly drops by 3%. Secondly, the paper demonstrates the significant contribution of economic links to diffusion across counties. The disease follows the paths of workers commuting between home and workplace. Together with the structure of the labor mobility networks, these results highlight the central role of regional capitals in sustaining and spreading the virus.

Thesis (MBA)--University of Stellenbosch, 2010. / The aim of this research report is to identify and quantify the cost drivers of three district hospitals in the Western Cape, namely Knysna Hospital, Oudtshoorn Hospital and Mossel Bay Hospital, and to simultaneously measure value-driven performance indicators. An environmental scan identified various driving forces that would significantly affect change in the healthcare industry such as the brain drain of health professionals, consumerism and cost containment and efficiency initiatives. The Department of Health’s understanding of the eighth Batho Pele principle of value for money is generally understood as providing quality health care within prescribed cost limits. An attempt is made to establish the effect of the quadruple burden of disease (the HIV/AIDS pandemic, persistent infectious diseases, injury arising from violence and road traffic collisions and emerging chronic conditions) on hospital expenditure in the Eden District. Research identified Mossel Bay as a high TB burden area known as a TB “hotspot” and it is a recognized immigration transit point en route to Cape Town. The population analyses revealed that Mossel Bay is the growth point of the Eden District, showing extraordinary growth of 25% between 2007 and 2009. Personnel costs: This study revealed that personnel costs are responsible for the overwhelming majority of the total expenditure of the district hospitals.Staff numbers, occupation specific dispensation (OSD) implementation and annual wage negotiations are the cost drivers of personnel costs. This study also found a clear correlation between an over-expenditure in personnel expenses and over-expenditure in the total expenditure of all three hospitals. Health care costs: Expenditure on blood products is considered a major cost driver of clinical expenses. Laboratory expenditure is clearly the largest cost driver for clinical expenses at all three hospitals. Together with laboratory expenses, medicine and medical supplies are the cost drivers for clinical expenses. Costs not related to health care: The three most significant administrative expenses are communication, stationery and printing as well as travel and subsistence allowances. The cost driver for subsistence and travel expenses is the number of vehicles followed by the preference of vehicle, which in turn determines the daily tariff and the kilometre tariff. This study revealed that Knysna Municipality has the cheapest electricity cost of the three towns. It is clear that cost and consumption of electricity and water are the two variables that affect municipal service expenditure the most. Equity: When the district hospital expenditure is combined with the primary health care expenditure in the three sub-districts, the figures show that Oudtshoorn is spending 3% more than its equitable share of the total budget at a higher cost of R978 per capita, in excess of R100 above the district average. Efficiency: The cost per patient day equivalent (PDE) per economic classification for all three hospitals is less than the average cost per PDE of the district hospitals in the Western Cape. The cost/PDE of Oudtshoorn Hospital is considerably higher than that of Knysna and Mossel Bay in all economic classifications, with the single exception of the agency cost of Mossel Bay Hospital. The cost of health care always reflects a combination of price, quantity and value, and it is impossible to consider individual cost drivers in isolation. Several cost-saving initiatives and managerial control measures are recommended.

The central hypothesis of this study was that the allocation system for NHS hospital and community health services between 1997 and 2003 was not meeting key principles of compensating for differences in the need for services and unavoidable costs. The review and analyses in this study indicate that the underpinning assumptions used when formulating the need adjustment were not robust and that this led to the selection of inappropriate proxies for need. In addition it is concluded that the age adjustment underestimated the costs of elderly care. This study has concluded that the pay adjustment, which was the largest in the formula, did not reflect actual unavoidable differences in cost because the Warwick studies that were used to set the adjustment ignored the monopsonistic nature of the NHS. As a consequence the pay adjustment was based on the assumption that NHS salaries should be related to local salaries. This study identified unavoidable additional costs of providing healthcare in rural areas. These findings were consistent with other comprehensive studies on healthcare costs in Scotland, Wales and Northern Ireland. This study concludes that the exclusion of a market forces adjustment for rurality was inconsistent with all other comparable allocation formulae in the Home Countries. The absence of a rurality adjustment resulted in rural areas receiving a lower proportion of NHS funding than was justified and this is referred to as the Inverse Share Law. This study concludes that the central hypothesis was correct and that a rurality adjustment was justified, but that the principal determinant of service quality was an adequate focus on efficiency.