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.

This is a prospective, non-randomized pilot study comparing the cost-utility of hepatic resection, radiofrequency ablation (RFA), systemic chemotherapy, and symptom control only for the treatment of colorectal liver metastases. Seven patients underwent hepatic resection, 7 underwent RFA, 20 received chemotherapy, and 6 received symptom control alone. Liver resection provided an average of 2.51 QALY’s compared to 1.99 QALY’s for RFA, and 1.18 QALY’s for chemotherapy, and 0.82 QALY’s for symptom control alone. The costs were $20,122, $ 15,845, $15,069, and $3,899, respectively. The cost-utilities of liver resection and RFA were similar at $8,027 and $7,965 per QALY, respectively, although patients receiving RFA generally had more advanced disease. The cost-utility of chemotherapy was $12,751/QALY and the cost-utility of symptom control alone was $4,788/QALY. RFA is still a relatively new. However, if long-term survival proves promising, it may prove to be a viable alternative to liver resection. / May 2006

How to allocate resources in the health care sector is academically dealt with within the subject of health economics. Economic evaluations are within this area used to compare the costs and effects of medical interventions with the purpose to help decision makers decide how to allocate resources. Oxygen deficiency in the foetus during birth can lead to severe life long injuries in the child. In high-risk deliveries, it is therefore considered necessary to use foetal surveillance with a scalp electrode and the choice is between surveillance with internal cardiotocography (CTG) and surveillance with ST analysis. The standard procedure is in most hospitals currently CTG, which records the foetal heart rate and the uterine contractions. The second strategy, in this thesis referred to as ST analysis, complements CTG with foetal electrocardiography(ECG) and ST analysis. The objective of this report is to from a societal perspective determine the cost-effectiveness of using ST analysis in complicated deliveries, compared to the use of CTG alone. A cost-utility analysis was performed based on a probabilistic decision model incorporating the relevant strategies and outcomes. The costs and effects of the two different treatment strategies were compared in a decision tree. Discounted costs and quality-adjusted life-years (QALYs) were measured and simulated over a life-time perspective. The analysis resulted in an incremental effect of 0.005 QALYs for the ST analysis strategy, when compared to the CTG strategy. ST analysis was also associated with a €30 lower cost. Thus, CTG is dominated by the ST analysis strategy. The probability that ST analysis is the cost-effective alternative is high for all values of willingness-to-pay for a QALY, which means that a decision to implement the ST analysis strategy based on the results of this thesis would be surrounded by a low degree of uncertainty.

<p>How to allocate resources in the health care sector is academically dealt with within the subject of health economics. Economic evaluations are within this area used to compare the costs and effects of medical interventions with the purpose to help decision makers decide how to allocate resources.</p><p>Oxygen deficiency in the foetus during birth can lead to severe life long injuries in the child. In high-risk deliveries, it is therefore considered necessary to use foetal surveillance with a scalp electrode and the choice is between surveillance with internal cardiotocography (CTG) and surveillance with ST analysis. The standard procedure is in most hospitals currently CTG, which records the foetal heart rate and the uterine contractions. The second strategy, in this thesis referred to as ST analysis, complements CTG with foetal electrocardiography(ECG) and ST analysis.</p><p>The objective of this report is to from a societal perspective determine the cost-effectiveness of using ST analysis in complicated deliveries, compared to the use of CTG alone. A cost-utility analysis was performed based on a probabilistic decision model incorporating the relevant strategies and outcomes. The costs and effects of the two different treatment strategies were compared in a decision tree. Discounted costs and quality-adjusted life-years (QALYs) were measured and simulated over a life-time perspective.</p><p>The analysis resulted in an incremental effect of 0.005 QALYs for the ST analysis strategy, when compared to the CTG strategy. ST analysis was also associated with a €30 lower cost. Thus, CTG is dominated by the ST analysis strategy. The probability that ST analysis is the cost-effective alternative is high for all values of willingness-to-pay for a QALY, which means that a decision to implement the ST analysis strategy based on the results of this thesis would be surrounded by a low degree of uncertainty.</p>

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.

This is a prospective, non-randomized pilot study comparing the cost-utility of hepatic resection, radiofrequency ablation (RFA), systemic chemotherapy, and symptom control only for the treatment of colorectal liver metastases. Seven patients underwent hepatic resection, 7 underwent RFA, 20 received chemotherapy, and 6 received symptom control alone. Liver resection provided an average of 2.51 QALY’s compared to 1.99 QALY’s for RFA, and 1.18 QALY’s for chemotherapy, and 0.82 QALY’s for symptom control alone. The costs were $20,122, $ 15,845, $15,069, and $3,899, respectively. The cost-utilities of liver resection and RFA were similar at $8,027 and $7,965 per QALY, respectively, although patients receiving RFA generally had more advanced disease. The cost-utility of chemotherapy was $12,751/QALY and the cost-utility of symptom control alone was $4,788/QALY. RFA is still a relatively new. However, if long-term survival proves promising, it may prove to be a viable alternative to liver resection.

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.