Background: Lung cancer was the fifth leading cause of mortality globally in 2010, and the leading cause of cancer mortality in Canada, representing 26% of all cancer deaths for both men and women in 2017. Radon is a very modifiable environmental exposure that is the second most important cause of lung cancer. Objectives: The objectives of this thesis are to quantify the lung cancer burden associated with residential radon and to identify the most cost effective mitigation options to reduce residential radon in Canada. Methods: The global burden of lung cancer mortality attributable to radon in 2012 was estimated from the 66 countries for which a representative national radon survey was available, using several different models for excess relative risk (ERR) of lung cancer from radon studies. Cost-utility analyses are conducted for 20 practical radon interventions scenarios to reduce residential radon exposures in new and existing housing in Canada, each province/territory and 17 census metropolitan areas. A societal perspective and a lifetime horizon are adopted. A Markov cohort model and a discrete event simulation are used to model residents by household, based on a period-life table analysis, at a discount rate of 1.5%. Results: The estimates of the global median PAR were consistent, ranging from 16.5% to 13.6% for the three ERR models based on miners, and the mean estimates of PAR for Canada ranged from 16.3% to 14.6%. It is very cost effective to install radon preventive measures in new construction compared to no radon control in all regions across Canada. At a radon mitigation threshold of 100 Bq/m3, the sequential analysis recommends the combination of the activation of preventive measures in new housing with the mitigation of existing housing at current testing and mitigation rates for cost effectiveness thresholds between 51,889 and 92,072 $/QALY for Canada, between 27,558 and 85,965 $/QALY for Manitoba, and between 15,801 and 36,547 $/QALY for the Yukon. The discounted ICER for screening and mitigation of existing housing at current rates relative to no radon control measures is 62,451 (66,421) $/QALY using a Markov cohort model (discrete event simulation model) for mitigation of housing above a threshold of 200 Bq/m3, and is 58,866 (59,556) $/QALY using a Markov cohort model (discrete event simulation model) for mitigation of housing above a threshold of 100 Bq/m3. Conclusions: Cost effective residential radon interventions should be implemented across Canada to reduce exposures to this very modifiable cause of lung cancer and to help reduce the increasing lung cancer burden in an ageing Canadian population.

This paper analysis the cost-utility, measured in cost per QALY gained, of impact absorbent flooring that reduce hip fractures among institutionalized elderly in comparison to standard flooring. The study is based on experimental data from an elderly institution, where the absorbing floor was installed in 2010. Using a decision tree, the costs and benefits related to the new flooring are calculated on a one year basis, resulting in an incremental cost per QALY of 713327 SEK for the base case. Although the experimental data shows that there is an impact of the new flooring in reducing hip fractures a conclusion whether the policy is cost-effective or not can hardly be drawn. Sensitivity analysis based on a simulation of 5000 cases suggests that the result is robust. / Effektsamband i Samhället

Introduction: Facial lipoatrophy is a stigmatizing hallmark for HIV-positive status, and can lead to poor social functioning. Information gleaned from an economic evaluation of facial lipoatrophy treatments would inform policy decision making concerning potential public insurance coverage. Methods: A decision-analytic model was used to estimate the lifetime costs and Quality Adjusted Life Years (QALYs) gained from treatments using either poly-l-lactic or and polyalkylimide gel for HIV positive patients. Disease progression probabilities and utilities were derived from the literature. Costs were obtained from interviews with physicians and product distributors. Findings: Incremental costs per QALY were $66,409 CAD/$57,352 CAD for poly-l-lactic acid, and $48,715 CAD/$45,457 CAD for polyalkylimide gel® (Societal perspective/Ministry of Health perspective). Sensitivity analysis did not have a significant effect on the lower incremental costs per QALY reported for polyalkylimide gel. Conclusion: Our base-case analysis revealed that treatments using polyalkylimide gel offers lower ICUR than treatments using poly-l-lactic acid.

Introduction: Facial lipoatrophy is a stigmatizing hallmark for HIV-positive status, and can lead to poor social functioning. Information gleaned from an economic evaluation of facial lipoatrophy treatments would inform policy decision making concerning potential public insurance coverage. Methods: A decision-analytic model was used to estimate the lifetime costs and Quality Adjusted Life Years (QALYs) gained from treatments using either poly-l-lactic or and polyalkylimide gel for HIV positive patients. Disease progression probabilities and utilities were derived from the literature. Costs were obtained from interviews with physicians and product distributors. Findings: Incremental costs per QALY were $66,409 CAD/$57,352 CAD for poly-l-lactic acid, and $48,715 CAD/$45,457 CAD for polyalkylimide gel® (Societal perspective/Ministry of Health perspective). Sensitivity analysis did not have a significant effect on the lower incremental costs per QALY reported for polyalkylimide gel. Conclusion: Our base-case analysis revealed that treatments using polyalkylimide gel offers lower ICUR than treatments using poly-l-lactic acid.

A principal purpose of this thesis is to present an economic evaluation of ecosystems. The concept of ecosystem health is adopted to ascertain the status of ecosystems. Ecosystem health is considered in part an economic concept and defined as a function of utility through the ecosystem services that satisfy various needs, subject to preserving the integrity of the adaptive cycle. In order to quantify the utility supplied by ecosystem services the novel utility index Ecosystem Outcome Protection Year (ECOPY) is developed. By forming this index, an evaluation can be performed using cost utility analysis, which avoids monetizing these benefits. An attempt is made to ascertain an appropriate approach for ecosystem management. It is reasoned that expert intuition can determine some kind of macro-regularities in ecosystems despite their complex dynamics. Hence, these inferences could be used for ecosystem management. Adaptive co-management is introduced as a means to bring about the collaboration of experts as resource co-managers. The concept of informed intuition is developed to bring about a systematic approach to learning and evaluation where the mental models of experts are transcribed using fuzzy cognitive mapping. However, it is argued that ecosystems as complex adaptive systems are non-ergodic and full of surprises. Accordingly, abduction, the logic of creative conjecture is systematically developed, for the purposes of maintaining mental model flexibility. This systematic application of abduction with an informed intuition forms the proposed abductive process of research, which is grounded in Shacklean potential surprise, a non-probabilistic function. To demonstrate this novel research process, a post-classical economic evaluation of Te Waihora lake ecosystem is undertaken, which employs the ECOPY index and potential surprise method. This empirical case study reveals various cost-effective management actions for improving lake health, which went beyond the intuitions of resource co-managers. This indicated the potential of the approach, which is considered a significant contribution for the methodological development of ecosystem management.

Preventative interventions often demand that resources be consumed in the present in exchange for future benefits. Understanding these trade-offs, in a context of resource constraints, is essential for policy makers. Cost-effectiveness analysis is one tool to inform decision-making. Targeted testing and treatment (TTT) for latent tuberculosis infection (LTBI) consists in identifying people at high risk for LTBI for preventive treatment to decrease the risk that they will develop active tuberculosis disease (ATBD). The state of Tennessee began conducting TTT statewide in 2001. This study uses a decision tree to evaluate the cost and outcomes of TTT for LTBI in Tennessee, compared to passive ATBD case finding (PACF). Key event probabilities were obtained from the Tennessee TTT program and from the literature. Outcomes are measured in terms of Quality Adjusted Life Years (QALY). The cost-effectiveness threshold was set at $100,000/QALY saved. One-way sensitivity analyses around factors related to study design (exclusion of patient costs, secondary transmission, discount rate and analytical horizon), the program’s environment (prevalence of LTBI and drug resistance, ATBD treatment costs) and program performance (program maturity, treatment initiation and completion rate, testing in low-risk group, test characteristics, screening costs) were conducted, as was probabilistic sensitivity analysis (PSA) which takes into account the uncertainty in multiple parameters simultaneously. The base case, with a 25-year time horizon and 3% discount rate, shows that TTT prevents 47 ATBD cases, and saves 31 QALYs per 100,000 patients screened for LTBI at a societal cost of $12,579 (2011 US$) per QALY saved. Sensitivity analyses identified value thresholds that would trigger a change in preferred policy. PSA shows that the likelihood that TTT would be cost-effective is low. Decision makers interested in implementing TTT should carefully assess the characteristics of the local TB epidemic and expected program performance to determine whether TTT is preferable over PACF from a cost-effectiveness viewpoint.

<p>Diss. (sammanfattning) Umeå : Umeå universitet, 1992, härtill 6 uppsatser.</p> / digitalisering@umu

Preventative interventions often demand that resources be consumed in the present in exchange for future benefits. Cost-effectiveness analysis is a tool to understand these trade-offs, and inform decision-making under resource constraints. Targeted testing and treatment (TTT) for latent tuberculosis infection (LTBI) consists in identifying people at high risk for LTBI for preventive treatment to decrease the risk of active tuberculosis disease (ATBD). The state of Tennessee began conducting TTT statewide in 2001. This study uses a decision tree to evaluate the cost and outcomes of TTT for LTBI in Tennessee, compared to passive ATBD case finding (PACF). Key probabilities were obtained from the Tennessee TTT program and the literature. Outcomes are measured in terms of Quality Adjusted Life Years (QALY). The cost-effectiveness threshold was $100,000/QALY saved. One-way sensitivity analyses around factors related to study design, the program’s environment, and program performance were conducted, as was probabilistic sensitivity analysis (PSA) which takes into account the uncertainty in multiple parameters simultaneously. The base case, with a 25-year analytic horizon and 3% discount rate, shows that TTT prevents 47 ATBD cases, and saves 31 QALYs per 100,000 patients screened at a societal cost of $12,579 per QALY saved. Sensitivity analyses identified value thresholds that would trigger a change in preferred policy. PSA shows that the likelihood that TTT would be cost-effective is low. Decision makers should carefully assess the characteristics of the local TB epidemic and expected program performance to determine whether TTT is preferable over PACF from a cost-effectiveness viewpoint.

An economic evaluation of the three interventions to conceive without the sexual transmission of HIV between heterosexual, HIV-discordant couples with positive male partners can inform policy decisions to subsidize pregnancy planning in this setting, as there is currently no coverage as such in Ontario. A decision tree and Markov model were designed to determine the short and long-term outcomes of unprotected intercourse restricted to timed ovulation (UIRTO), sperm washing with intrauterine insemination (SWIUI), and unprotected intercourse restricted to timed ovulation with pre-exposure prophylaxis (UIRTO-PrEP). In the short-term, UIRTO was the most cost-effective strategy. In the long-term, cases of negligible HIV transmission risk determined UIRTO-PrEP as the preferred option, while SWIUI was the choice method when this risk was high. There remains a viable risk of HIV transmission between discordant couples during attempts to conceive that require the concurrent and subsidized use of UIRTO-PrEP or SWIUI to protect against HIV infection.

An economic evaluation of the three interventions to conceive without the sexual transmission of HIV between heterosexual, HIV-discordant couples with positive male partners can inform policy decisions to subsidize pregnancy planning in this setting, as there is currently no coverage as such in Ontario. A decision tree and Markov model were designed to determine the short and long-term outcomes of unprotected intercourse restricted to timed ovulation (UIRTO), sperm washing with intrauterine insemination (SWIUI), and unprotected intercourse restricted to timed ovulation with pre-exposure prophylaxis (UIRTO-PrEP). In the short-term, UIRTO was the most cost-effective strategy. In the long-term, cases of negligible HIV transmission risk determined UIRTO-PrEP as the preferred option, while SWIUI was the choice method when this risk was high. There remains a viable risk of HIV transmission between discordant couples during attempts to conceive that require the concurrent and subsidized use of UIRTO-PrEP or SWIUI to protect against HIV infection.