Background The costs of healthcare are on the rise. With an ageing population, growing demand for health services and expensive new technologies, Australia’s annual health care bill has more than doubled in the last ten years, and is projected to increase a further 127% by 2033. As third-party provider of health care, the Government must make difficult decisions about how best to allocate limited resources to the many new and existing drugs, technologies and health services available for prevention and treatment of disease. Cost-effectiveness analysis of interventions can help identify those that should be given funding priority in order to maximise population health, but its use in allocating resources to prevention has been limited. There have been few cost-effectiveness analyses of preventive interventions, particularly for the potentially more effective strategies targeting the whole population, such as taxation, regulation and community campaigns. Current methods are poorly designed for capturing the change in population distribution of risk that can occur with these types of interventions. Use of cost-effectiveness analysis has also been limited by the use of many different (and often simplistic) modelling methods and assumptions that prevent league table comparison of results to help identify most cost-effective strategies. This thesis presents new methods for evaluating cost-effectiveness of preventive interventions, with application to interventions promoting physical activity, preventing alcohol misuse, reducing body mass, promoting fruits and vegetables and reducing dietary salt intake, from an Australian health sector perspective. Methods Proportional multi-state life table models were developed for each risk factor and for risk factor combinations, using population impact fraction (PIF) functions to quantify the potential intervention impact of a change in individual or population risk factor exposure on disease and injury. The models were used to simulate population health in disability-adjusted life years (DALYs) and costs of disease treatment, over the lifetime of the Australian population in 2003, for a range of individual- and populationtargeted interventions using intervention costs and effects derived from Australian cost data and published evaluation studies. Monte-Carlo analysis was used to derive uncertainty around all outcome measures, and sensitivity of results to key modelling choices and assumptions was also evaluated. Cost-effectiveness of six physical activity interventions, ten alcohol interventions, two body mass interventions, 23 fruit and vegetable interventions and four dietary salt interventions was evaluated in comparison to current Australian practice. In addition, where multiple mutually-exclusive interventions were evaluated, a partial null (‘no current practice intervention’) scenario was calculated and cost-effectiveness of incrementally adding each intervention to a package was evaluated, to determine the optimal intervention mix and to compare optimal outcomes with the current practice. Findings For physical activity, a package of six individual- and population-targeted interventions is cost-effective and could avert a third of disease burden attributable to physical inactivity. For reducing alcohol misuse, a package of eight individual- and population-targeted interventions could avert a third of disease burden attributable to hazardous and heavy levels of drinking. Although the current practice of random breath testing is cost-effective, if the expenditure on random breath testing had been distributed to more cost-effective interventions, around ten times the improvement in population health could have been achieved. The individually-targeted interventions for body mass, fruits and vegetables and salt intake are not cost-effective. Providing incentives for food industry to reduce salt in processed foods, on the other hand, is far more effective in improving population health and can lead to cost-saving for the health sector in the long term. if (moderate) reductions in salt were made mandatory for food manufacturers, around 20 times the health gains achieved by the current voluntary program could be achieved. Overall, eight interventions are potentially cost-saving for the health sector: voluntary and mandatory limits on salt in processed foods; mass media- and pedometer-based community campaigns to promote physical activity; a community program to promote fruits and vegetables; and volumetric taxation, advertising bans and an increase of the minimum legal drinking age to 21 years to address alcohol misuse. A further 12 interventions for reducing alcohol misuse, and promoting physical activity and fruit and vegetable consumption, are under a $50,000 per DALY threshold of costeffectiveness, and are also recommended for health sector investment. Implications The integration of a proportional multi-state life table model with PIF function in this research has proved to have a number of advantages over previous modelling methods. The PIF function enables better simulation of the true continuous distribution of risk in the population, and facilitates analysis of population-targeted interventions that shift the whole distribution of risk. It also substantially simplifies the integration of multiple risk factors into the one model, which was previously constrained by the need to create separate states for every risk factor category (e.g. active and inactive) and risk factor categories in combination (e.g. obese and active, obese and inactive, etc.). This not only makes for easier and more accurate analyses of interventions targeting multiple risk factors, but enables evaluation of packages of many different risk factor interventions. Further investment in preventive interventions is highly recommended. The population-targeted approaches hold most promise for improving population health. Although there is potential for opposition from industry stakeholders and public concern around Government paternalism, these interventions have most potential to generate cost-savings for the health sector in the long-term. Given the weaker evidence around effectiveness of these interventions, however, it is recommended that programs are implemented with sufficient funding for monitoring and evaluation of outcomes.

A blood transfusion is one of the most common hospital procedures, yet there is a lack of reliable information on the costs of administering blood. This thesis aims to fill this information gap, and considers the impact on total costs of alternative transfusion management strategies in the National Health Service (NHS) in the United Kingdom. A high user of blood transfusion, cardiac surgery, acts as a clinical exemplar. Comprehensive estimates of the costs of administering blood are first produced. The costs of administering blood add substantially to the costs of the blood products themselves, costs for red blood cells are 40% higher when the costs of administration are added to red blood cell costs. These cost estimates were used to more accurately cost blood products transfused (compared to the costs of blood products only) in two economic evaluations assessing firstly, the cost-effectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery, and secondly, the cost-effectiveness of introducing bedside tests of haemostatic function in cardiac surgery. Both economic evaluations showed little difference in costs or outcomes between the groups and uncertainty around the cost-effectiveness results. While a restrictive threshold reduces costs associated with transfusion compared to a liberal threshold, there is no evidence based on detailed and comprehensive costings, to suggest that a restrictive threshold saves the NHS money overall. Reliable resource use data are vital for economic evaluations, and a subgroup of patients in both economic evaluations enabled resource use data collected from alternative sources to be compared. There was strong agreement between primary (clinical trial) data and routine datasets for data available from both sources, however, primary data captured post-operative complications more comprehensively than routine datasets. This thesis provides hospital managers and health economists with accurate information on the costs of administering blood for budget impact assessments and economic evaluations.

Orientador: Silvia Maria Almeida Lima Costa / Resumo: A cultura da seringueira vem crescendo no Brasil como uma atividade promissora, que ainda importa a maior parte da sua demanda de borracha natural. Existe uma grande expectativa para o crescimento de borracha no Estado de Mato Grosso do Sul, pois possui terras propícias para plantio de seringueira. Com isso, o presente trabalho tem como objetivo central avaliar questões técnicas e socioeconômicas na produção de heveicultura na Mesorregião do Estado de Mato Grosso do Sul. A abrangência do estudo tem como referencia as microrregiões de Cassilândia e Paranaíba, segundo a classificação do IBGE. A metodologia proposta foi realizada com a obtenção de dados secundários do processo produtivo da heveicultura e de dados primários com aplicação de questionários e entrevistas. Foram entrevistados 8 produtores de coágulo dos municípios de Aparecida do Taboado, Cassilândia e Paranaíba. Também foram entrevistados responsáveis por associações e pelas empresas compradoras da matéria prima na região e de outras regiões. No Estado de Mato Grosso do Sul, a área colhida com látex coagulado cresceu 47% no período de 2005 a 2015. Verificou-se que o valor investido nos primeiros anos é alto e no custo de produção a despesa com mão de obra na sangria, corresponde cerca de 66% do Custo Operacional Efetivo (COE) e 57% do Custo Operacional Total (COT). A receita só é maior que o custo para o preço do coágulo maior que R$2,26/kg. A análise de investimentos mostrou VPL negativo, TIR de 2,70% e no 18º ano... (Resumo completo, clicar acesso eletrônico abaixo) / Doutor

Background: Presenteeism is an economic concept that is difficult to identify, measure, and value. Rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are three chronic auto-immune conditions that increase levels of presenteeism. Workplace interventions (WPIs) help individuals to manage their health condition at work. Existing methods used to quantify the impact of presenteeism are unable to adequately inform the employer of the productive benefits of WPIs. The overall aim of this thesis was to appraise current methods used to quantify presenteeism and to develop methods to value the impact of presenteeism suitable for use in economic evaluations (EE) of WPIs. Methods: Two systematic reviews were conducted: 1) to assess the extent to which self-report measure of presenteeism were underpinned by economic theory; and 2) to explore if, and how, productivity was quantified and included in EE of WPIs for musculoskeletal conditions (MSDs). Thematic analysis methods were used to analyse qualitative data collected from working individuals with RA, AS or PsA (n=22) that explored the extent to which measures of health status (EQ5D; SF6D) and capability (ICECAP-A) capture the impact on ability to work caused by RA, AS or PsA. Econometric methods were used to specify prediction models that included measures of health status, capability and presenteeism, using a sample of 542 working people with RA and AS. Results The first systematic review identified 24 self-report measures of presenteeism; all, except one measure were not underpinned by economic theory. The second systematic review identified 20 EE of WPIs for MSDs. Absenteeism was included in all studies (n=20); however, presenteeism was included in only four. The qualitative data confirmed measures of health status and capability had the ability to capture those aspects of RA, AS and PsA that impact an individual’s ability to work. The best performing prediction model used an OLS specification including SF6D, age and gender to predict presenteeism measured by the WPAI. Conclusion: The results suggest that HRQoL measures, specifically the SF6D, can be used to capture and predict levels of presenteeism caused by RA, AS and PsA.

Submitted by STELLA TOSTA LEAL null (stellatostaleal@gmail.com) on 2017-10-17T01:42:15Z No. of bitstreams: 1 LEAL, S. T., 2017.pdf: 2258370 bytes, checksum: b71ae01183b3aa1336185c93a9217879 (MD5) / Approved for entry into archive by Monique Sasaki (sayumi_sasaki@hotmail.com) on 2017-10-18T19:28:04Z (GMT) No. of bitstreams: 1 leal_st_dr_ilha.pdf: 2258370 bytes, checksum: b71ae01183b3aa1336185c93a9217879 (MD5) / Made available in DSpace on 2017-10-18T19:28:04Z (GMT). No. of bitstreams: 1 leal_st_dr_ilha.pdf: 2258370 bytes, checksum: b71ae01183b3aa1336185c93a9217879 (MD5) Previous issue date: 2017-08-14 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / A cultura da seringueira vem crescendo no Brasil como uma atividade promissora, que ainda importa a maior parte da sua demanda de borracha natural. Existe uma grande expectativa para o crescimento de borracha no Estado de Mato Grosso do Sul, pois possui terras propícias para plantio de seringueira. Com isso, o presente trabalho tem como objetivo central avaliar questões técnicas e socioeconômicas na produção de heveicultura na Mesorregião do Estado de Mato Grosso do Sul. A abrangência do estudo tem como referencia as microrregiões de Cassilândia e Paranaíba, segundo a classificação do IBGE. A metodologia proposta foi realizada com a obtenção de dados secundários do processo produtivo da heveicultura e de dados primários com aplicação de questionários e entrevistas. Foram entrevistados 8 produtores de coágulo dos municípios de Aparecida do Taboado, Cassilândia e Paranaíba. Também foram entrevistados responsáveis por associações e pelas empresas compradoras da matéria prima na região e de outras regiões. No Estado de Mato Grosso do Sul, a área colhida com látex coagulado cresceu 47% no período de 2005 a 2015. Verificou-se que o valor investido nos primeiros anos é alto e no custo de produção a despesa com mão de obra na sangria, corresponde cerca de 66% do Custo Operacional Efetivo (COE) e 57% do Custo Operacional Total (COT). A receita só é maior que o custo para o preço do coágulo maior que R$2,26/kg. A análise de investimentos mostrou VPL negativo, TIR de 2,70% e no 18º ano de produção o produtor recupera o capital investido na atividade. Algumas questões devem ser levantadas para não perder competitividade, como investimentos na capacitação de produtores e sangradores e utilização de tecnologias mais adequadas à região. Os desafios são muitos, mas o cultivo da seringueira no Brasil mostra ser uma atividade lucrativa e sustentável, e as perspectivas de crescimento da produção de borracha natural no país são positivas, esperando-se que atenda pelo menos a demanda interna. / The rubber culture has been growing in Brazil and is considered a promising activity, which still imports most of its natural rubber demand. There is great expectation for the rubber growth in the State of Mato Grosso do Sul, because it has propitious lands for planting of rubber tree, with this present work has as its central objective to evaluate technical and socioeconomic issues in the production of heveculture in the Meso-region of the State of Mato Grosso The scope of the study is based on the microregions of Cassilândia and Paranaíba, according to the IBGE classification. The proposed methodology was performed with secondary data from the production process of the heveculture and primary data with application of questionnaires and interviews. Eight clot producers from the municipalities of Aparecida do Taboado, Cassilândia and Paranaíba were interviewed. Also interviewed were responsible for associations and companies buying the raw material in the region and other regions. In the State of Mato Grosso do Sul, the area harvested with coagulated latex increased 47% in the period from 2005 to 2015. It was verified that the amount invested in the first years is high and in the cost of production the labor expense in the sangria and Treatment, correspond to about 66% of COE and 57% of TOC. The revenue is only greater than the cost for the clot price greater than R$ 2.26/kg. The analysis of investments showed negative NPV, IRR of 2.70% and in the 18 year of production the producer recovers the capital invested in the activity. Some issues must be raised so as not to lose competitiveness as investments in the training of producers and bleeders, to use technologies more appropriate to the region. There are many challenges, but rubber cultivation in Brazil is proving to be a profitable and sustainable activity, and the country's natural rubber production growth prospects are positive and expected to meet at least domestic demand.

Animal feeding rations have long included carbohydrates as a primary constituent. Grains are included in most animal fattening rations, and the by-products of sugar beets have been used f or many years in livestock feeding (Kutish 1950 b). The use of molasses in commercial feed mixes in 1899 made possible its extended use in animal feeding practices (Hall 1950).

Reservoir sedimentation is a serious problem that threatens the water storage capacities across the world. Extending a dam's life requires adopting a new design and operational paradigm that focuses on managing the reservoir and watershed system to bring sediment inflow and outflow into balance by including reservoir sediment management facilities in dam and reservoir. However, the cost of methods that remove the sediment from reservoirs is usually prohibitive and is a serious factor preventing sustainable sediment management. This thesis considered a case study, Paonia Reservoir in Colorado, to investigate two aspects of reservoir operation, sediment management and economic assessment. The purpose is to determine how sediment management (sluicing using a low-level gate) effectively reduces sedimentation and whether this management is economically viable. The SRH-1D will be implemented to model the reservoir sedimentation, and RSEM evaluate it economically. The result comparison of current Paonia operation with hypothetical Paonia (added low-level gate) proved sluicing incoming sediment-laden flow effectively reduces sedimentation without interruption in the reservoir targeted functions like irrigating downstream. The deposited sediment volume could decrease more by monitoring the possible peak flow time and keeping the low-level gate open to pass high incoming flow downstream. This thesis applied RSEM to evaluate and compare the benefits and costs of continued sedimentation and eventual dam decommissioning (the existing Reservoir condition) to sediment management costs and benefits (hypothetical Paonia Reservoir). The results illustrated that sediment removal is advantageous because it contributed to decrease rate of decline of reservoir capacity, which made this capacity, and the associated instantaneous net benefits exceed those in the without sediment management alternative. The preserved benefits from sustainable sediment management offset the additional costs of incorporating sediment management. One of the key messages of this thesis is that incorporating sediment management into the planning and design phases of dam projects is essential for ensuring that the benefits of reservoir storage are sustained over the long term. This means fairness between current and future generations to enjoy the benefits of the facility while spreading the cost of ownership, operations, and maintenance over generations.

To fill a gap in the literature and to better inform decision making in oncology, this doctoral thesis investigates the role and impact of analytical methods in the economic evaluation of oncology medications through three main chapters which have been recently published. Chapter 2 presents a systematic literature survey of published economic evaluations in oncology over a 10-year period in order to identify, examine, and describe analytical methods that have been utilized (published in Pharmacoeconomics Open in 2021). This chapter demonstrated that greater detail in reporting of extrapolation methods, statistical techniques, and validation procedures is needed in order to conform with best practices outlined in existing economic evaluation guidelines. Chapter 3 complements the work of chapter 2 but takes a different perspective through an examination of the methods reported in economic evaluations published by HTA agencies in Canada, the UK, and Australia (published in Current Oncology in 2022). This chapter revealed significant reporting discrepancies across the agencies and concluded that common standards for reporting the results of HTAs should be implemented. Building on chapters 2 and 3, chapter 4 provides a model-based health technology re-assessment of an oncology drug approved on the basis of interim trial data using recently published long-term follow up data (published in Current Oncology in 2023). The findings from this chapter highlight the importance of transparency in the reporting of methods, the impact of using a life-cycle approach to HTA, and demonstrate the existence of a tradeoff between clinical/economic uncertainty and the value of the incremental cost-effectiveness ratio (ICER). The final chapter provides the overall conclusions of the research and presents avenues for future research. / Thesis / Doctor of Philosophy (PhD)

Yes / Background and objective: Health and social care may affect family carers’ health and wellbeing in addition to patients’ lives. It is recommended that such impacts (carer effects) are considered in decision-making. However, the scope of carer effects and range of decisions where carer effects should be considered is uncertain. This study aimed to identify (i) how different categories of healthcare and social care were perceived to impact on family carers and (ii) whether there was consensus about when carer effects should be formally considered in decision-making contexts. Methods: A Delphi study was conducted with 65 UK-based participants with expertise in dementia, mental health, and stroke. Participants considered two broad forms of ‘interventions’ (patient treatment and replacement care) and two broad forms of ‘organisational change’ (staffing and changes in timing/location of care). Participants assessed the likely impacts of health and social care on family carers and whether impacts should be considered in decision-making. The survey was conducted remotely at two time points. Results: Participants predicted widespread impacts from interventions and organisational changes on different domains of family carers’ lives, with ‘emotional health’ the most likely outcome to be affected. Patient treatment and replacement care services (‘interventions’) were associated with positive impacts across all domains. Conversely, timing/location changes and staffing changes (‘organisational changes’) were perceived to have mixed and negative impacts. There was widespread support (80-81%) for considering carer effects in research studies, funding decisions, and patient decision-making. Conclusion: This study highlights a perception that carer effects are widespread and important to consider in economic evaluation and decision-making. It highlights the particular need to measure and value effects on carers’ emotional health and the need to use a societal perspective to avoid cost shifting to family carers when introducing interventions and making organisational changes. / This work was funded by a National Institute for Health Research (NIHR) Career Development Fellowship (CDF-2015-08-025) awarded to HA for this research project.

<p><strong>Objective</strong>: To estimate the cost-effectiveness of an influenza immunization strategy directed at healthy children 36 months to 15 years on the herd immunity of entire communities, versus not implementing this strategy.</p> <p><strong>Design</strong>: An economic evaluation, cost-effectiveness analysis (CEA). Costs and effects were estimated jointly with a two-stage bootstrap with shrinkage correction. Uncertainties around input parameters were tested with one-way and multi-way sensitivity analysis.</p> <p><strong>Data Sources</strong>: Effect and resource consumption data were from the Hutterite Influenza Prevention Study. Unit costs were collected from multiple sources including, government reports and schedules, local suppliers, peer-reviewed articles and systematic reviews, Internet searches and study data on file.</p> <p><strong>Outcomes</strong>: Mean costs and effects, incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB) statistic and cost effectiveness acceptability curves (CEAC).</p> <p><strong>Results</strong>: The average cost per patient in the treatment arm was $69.08 and $32.66 in the control arm. The average number of influenza-free cases was of 0.96 in the treatment arm and 0.73 in the control arm. ICER was $164.19 per case of influenza averted, 95% confidence interval $28.38, $2,767.75. CEAC showed that at a willingness to pay of $177, the probability of the treatment strategy being cost effective compared to the control was 0.50. Results from sensitivity analyses were slightly different compared to base case results, supporting the robustness of base case estimates.</p> <p><strong>Conclusion</strong>: This strategy is likely to be cost effective relative to the comparator as the ICER estimate is low and because the estimate is conservative given that the study population was very healthy and the influenza season was mild. A more virulent season and a less healthy population would have produced a lower ICER or seen the treatment arm dominate the control.</p> / Master of Science (MSc)