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Chapter 2 examines how and why the United States chose to deliver the EITC in one annual payment as a tax refund, and how this is a stark contrast to how other social benefits are administered. One reason is administrative cost – it is relatively inexpensive to allow taxpayers to self-declare eligibility and receive benefits as a tax refund. Because other social benefit programs have direct contact with their recipients prior to payment, those programs have far higher administrative costs and far smaller overpayment rates. Delivery of social benefits through the tax system also avoids the stigma associated with applying for benefits through social welfare workers. This chapter cites empirical studies about taxpayer preferences as to delivery method and timing of refund and evidence as to how EITC recipients spend their refund. It also describes experiments with periodic payment, including the Advance Earned Income Tax Credit.
Equitable access to mental healthcare is a priority for many countries. The National Health Service in England uses a weighted capitation formula to ensure that the geographical distribution of resources reflects need.
To produce a revised formula for estimating local need for secondary mental health, learning disability (intellectual disability) and psychological therapies services for adults in England.
We used demographic records for 43 751 535 adults registered with a primary care practitioner in England linked with service use, ethnicity, physical health diagnoses and type of household, from multiple data-sets. Using linear regression, we estimated the individual cost of care in 2015 as a function of individual- and area-level need and supply variables in 2013 and 2014. We sterilised the effects of the supply variables to obtain individual-need estimates. We aggregated these by general practitioner practice, age and gender to derive weights for the national capitation formula.
Higher costs were associated with: being 30–50 years old, compared with 20–24; being Irish, Black African, Black Caribbean or of mixed ethnicity, compared with White British; having been admitted for specific physical health conditions, including drug poisoning; living alone, in a care home or in a communal environment; and living in areas with a higher percentage of out-of-work benefit recipients and higher prevalence of severe mental illness. Longer distance from a provider was associated with lower cost.
The resulting needs weights were higher in more deprived areas and informed the distribution of some 12% (£9 bn in 2019/20) of the health budget allocated to local organisations for 2019/20 to 2023/24.
The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective.
To assess the clinical effectiveness over 6 years and the impact on costs and care home admission.
We conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission.
In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference −2.00 points, 95% CI −3.38 to −0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58–1.35).
START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers.
Declarations of interest
G.L., Z.W. and C.C. are supported by the UCLH National Institute for Health Research (NIHR) Biomedical Research Centre. G.L. and P.R. were in part supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Z.W. reports during the conduct of the study; personal fees from GE Healthcare, grants from GE Healthcare, grants from Lundbeck, other from GE Healthcare, outside the submitted work.
Individuals may perceive personalised dietary advice as more relevant and motivational than national guidelines. Personal preference and food cost are factors that can affect consumer decisions. The objective of this study was to present a method for modelling and analysing the trade-off between deviation from preference and food cost for optimised personalised dietary recommendations. Quadratic programming was applied to minimise deviation from fish preference and cost simultaneously with different weights on the cost for 3016 Danish adults (whose dietary intake and body weight were recorded in a national dietary survey). Model constraints included recommendations for EPA, DHA and vitamin D and tolerable levels for methyl mercury, dioxins and dioxin-like polychlorinated biphenyls. When only minimising deviation from preference, 50 % of the study population should be recommended to increase fish intake, 48 % should be suggested to maintain current consumption and 2 % should be suggested to decrease fish consumption. When only minimising cost, the vast majority (99 %) should be recommended to only consume herring, which is the least-expensive fish species. By minimising deviation from preference and cost simultaneously with different weights on the cost, personalised optimal trade-off curves between deviation from fish intake preference and fish cost could be generated for each individual in our study population, except for twenty-two individuals (0·7 %) whose contaminant background exposure was too high. In the future, the method of this paper could be applied in the personal communication of healthy and safe food recommendations that fit the preferences of individual consumers.
The aim of this study was to describe patient level costing methods and develop a database of healthcare resource use and cost in patients with AHF receiving ventricular assist device (VAD) therapy.
Patient level micro-costing was used to identify documented activity in the years preceding and following VAD implantation, and preceding heart transplant for a cohort of seventy-seven consecutive patients listed for heart transplantation (2009–12). Clinician interviews verified activity, established time resource required for each activity, and added additional undocumented activities. Costs were sourced from the general ledger, salary, stock price, pharmacy formulary data, and from national medical benefits and prostheses lists. Linked administrative data analyses of activity external to the implanting institution, used National Weighted Activity Units (NWAU), 2014 efficient price, and admission complexity cost weights and were compared with micro-costed data for the implanting admission.
The database produced includes patient level activity and costs associated with the seventy-seven patients across thirteen resource areas including hospital activity external to the implanting center. The median cost of the implanting admission using linked administrative data was $246,839 (interquartile range [IQR] $246,839–$271,743), versus $270,716 (IQR $211,740–$378,482) for the institutional micro-costing (p = .08).
Linked administrative data provides a useful alternative for imputing costs external to the implanting center, and combined with institutional data can illuminate both the pathways to transplant referral and the hospital activity generated by patients experiencing the terminal phases of heart failure in the year before transplant, cf-VAD implant, or death.
Crime is an important outcome in many social policy evaluations. Benefits to society from preventing crime are based on avoiding victimization and freeing criminal justice system resources. For the latter, analysts need information about the marginal cost of policing for different types of crime across jurisdictions; however, this information is not readily available. This paper details key economic concepts relevant to law enforcement services, and then combines publicly available police expenditure data with insights from observational and time-diary studies to generate state-level, crime-specific, average variable cost estimates for crime-response services conducted by police by crime type. Since there is considerable uncertainty concerning various parameters underpinning these calculations, we use Monte Carlo simulation methods to incorporate the uncertainty into our estimates. This study finds that the U.S. population-weighted average variable cost of law enforcement response per police-reported Part 1 violent crime is $10,900, ranging from $6900 to $15,400 at the 10th and 90th percentiles, respectively. For a Part 1 property crime, the equivalent figure is $1300, with a range from $700 to $1700.
The patient portal may be an effective method for administering surveys regarding participant research experiences but has not been systematically studied.
We evaluated 4 methods of delivering a research participant perception survey: mailing, phone, email, and patient portal. Participants of research studies were identified (n=4013) and 800 were randomly selected to receive a survey, 200 for each method. Outcomes included response rate, survey completeness, and cost.
Among those aged <65 years, response rates did not differ between mail, phone, and patient portal (22%, 29%, 30%, p>0.07). Among these methods, the patient portal was the lowest-cost option. Response rates were significantly lower using email (10%, p<0.01), the lowest-cost option. In contrast, among those aged 65+ years, mail was superior to the electronic methods (p<0.02).
The patient portal was among the most effective ways to reach research participants, and was less expensive than surveys administered by mail or telephone.
Objectives: Our study addresses the important issue of estimating treatment costs from historical data. It is a problem frequently faced by health technology assessment analysts. We compared four approaches used to estimate current costs when good quality contemporary data are not available using liver transplantation as an example.
Methods: First, the total cost estimates extracted for patients from a cohort study, conducted in the 1990s, were inflated using a published inflation multiplier. Second, resource use estimates from the cohort study were extracted for hepatitis C patients and updated using current unit costs. Third, expert elicitation was carried out to identify changes in clinical practice over time and quantify current resource use. Fourth, routine data on resource use were obtained from National Health Service Blood and Transplant (NHSBT).
Results: The first two methods did not account for changes in clinical practice. Also the first was not specific to hepatitis patients. The use of experts confirmed significant changes in clinical practice. However, the quantification of resource use using experts is challenging as clinical specialists may not have a complete overview of clinical pathway. The NHSBT data are the most accurate reflection of transplantation and posttransplantation phase; however, data were not available for the whole pathway of care. The best estimate of total cost, combining NHSBT data and expert elicitation, is £121,211.
Discussion: Observational data from routine care are potentially the most reliable reflection of current resource use. Efforts should be made to make such data readily available and accessible to researchers. Expert elicitation provided reasonable estimates.
This study evaluates the morbidity, mortality, and cost differences between patients who underwent either a simple or a complex arterial switch operation.
A retrospective study of patients undergoing an arterial switch operation at a single institution was performed. Simple cases were defined as patients with d-transposition of the great arteries with usual coronary anatomy or circumflex artery originating from the right with either intact ventricular septum or ventricular septal defect. Complex cases included all other forms of coronary anatomy, aortic coarctation or arch hypoplasia, and Taussig–Bing anomalies. Costs were acquired using an institutional activity-based accounting system.
A total of 98 patients were identified, 68 patients in the simple group and 30 in the complex group. The mortality rate was 2% for the simple and 7% for the complex group, p=0.23. Major morbidities including cardiac arrest, extracorporeal membrane oxygenation, a major coronary event, surgical or catheter-based re-intervention, stroke, or permanent pacemaker placement, non-cardiac surgical procedures, mediastinitis, and sepsis did not differ between the simple and complex groups (16 versus 27%, p=0.16). The complex group had increased bleeding requiring re-exploration (0 versus 10%, p=0.04). Hospital and ICU length of stay did not differ. Complex patients had higher overall hospital costs (simple $80,749 versus complex $97,387, p=0.01) and higher postoperative costs (simple $60,192 versus complex $70,132, p=0.02). The operating room and supplies accounted for the majority of the cost difference.
Complex arterial switches can be safely performed with low rates of morbidity and mortality but at an increased cost.
Objectives: To compare the recently used phacoemulsification systems using a health technology assessment (HTA) model.
Methods: A self-administered questionnaire, which included questions to gauge on the opinions of the recently used phacoemulsification systems, was distributed to the chief cataract surgeons in the departments of ophthalmology of eighteen tertiary hospitals in Shanghai, China. A series of senile cataract patients undergoing phacoemulsification surgery were enrolled in the study. The surgical results and the average costs related to their surgeries were all recorded and compared for the recently used phacoemulsification systems.
Results: The four phacoemulsification systems currently used in Shanghai are the Infiniti Vision, Centurion Vision, WhiteStar Signature, and Stellaris Vision Enhancement systems. All of the doctors confirmed that the systems they used would help cataract patients recover vision. A total of 150 cataract patients who underwent phacoemulsification surgery were enrolled in the present study. A significant difference was found among the four groups in cumulative dissipated energy, with the lowest value found in the Centurion group. No serious complications were observed and a positive trend in visual acuity was found in all four groups after cataract surgery. The highest total cost of surgery was associated with procedures conducted using the Centurion Vision system, and significant differences between systems were mainly because of the cost of the consumables used in the different surgeries.
Conclusions: This HTA comparison of four recently used phacoemulsification systems found that each of system offers a satisfactory vision recovery outcome, but differs in surgical efficacy and costs.
The objective of this study was to estimate the economic impact of subclinical ketosis (SCK) in dairy cows. This metabolic disorder occurs in the period around calving and is associated with an increased risk of other diseases. Therefore, SCK affects farm productivity and profitability. Estimating the economic impact of SCK may make farmers more aware of this problem, and can improve their decision-making regarding interventions to reduce SCK. We developed a dynamic stochastic simulation model that enables estimating the economic impact of SCK and related diseases (i.e. mastitis, metritis, displaced abomasum, lameness and clinical ketosis) occurring during the first 30 days after calving. This model, which was applied to a typical Dutch dairy herd, groups cows according to their parity (1 to 5+), and simulates the dynamics of SCK and related diseases, and milk production per cow during one lactation. The economic impact of SCK and related diseases resulted from a reduced milk production, discarded milk, treatment costs, costs from a prolonged calving interval and removal (culling or dying) of cows. The total costs of SCK were €130 per case per year, with a range between €39 and €348 (5 to 95 percentiles). The total costs of SCK per case per year, moreover, increased from €83 per year in parity 1 to €175 in parity 3. Most cows with SCK, however, had SCK only (61%), and costs were €58 per case per year. Total costs of SCK per case per year resulted for 36% from a prolonged calving interval, 24% from reduced milk production, 19% from treatment, 14% from discarded milk and 6% from removal. Results of the sensitivity analysis showed that the disease incidence, removal risk, relations of SCK with other diseases and prices of milk resulted in a high variation of costs of SCK. The costs of SCK, therefore, might differ per farm because of farm-specific circumstances. Improving data collection on the incidence of SCK and related diseases, and on consequences of diseases can further improve economic estimations.
The aim of this paper is to highlight the neglected role of archaeological archives in Cultural Resource Management in particular and in the discipline of archaeology in general. Through reference to a major recent survey of the size, condition, usage and future prospects of archaeological archives in England, it is argued that the neglect of archives leads to fundamental questions regarding the purpose of archaeology in general. Why are archaeological archives generated and kept ‘for posterity’? If they are worthy of retention, how can they be better used and integrated into the discipline? It is argued that there is a need to recognize the ‘ex situ’ archaeological resource as a concept and that archaeology should recognize that the study of this resource should be a major area of activity alongside the generation of new information through fieldwork.
This review provides a comparative analysis on the unenriched and alternative cage systems used in commercial egg production as required by the directive (99/74/EC) of the EU Council on animal welfare in terms of technical performance indicators, distribution of cost items, egg sales revenue, and profitability. Unenriched (conventional) cages are commonly used in Turkey. However these cages don't provide for the laying hens natural needs. The comparison was taken from data regarding Lohmann Brown Classic and Lohmann LSL Classic laying hybrids kept in two caging systems. The rearing period was composed of 399 days starting when 16-week-old commercial pullets were put into unenriched and alternative cage systems and ending at the end of their 73rd weeks of age when laying hens were removed from production. The average shares of the some important cost items in the total cost in the production period were calculated to be as follows for unenriched and alternative cage systems, respectively: pullet 22.17% and 21.17%; feed 61.31% and 58.29%; labour 2.67% and 2.55%; veterinary and health 0.74% and 0.98%; egg packaging 3.23% and 3.48%; maintenance and repair expenses 1.50% and 2.29%; and depreciation costs 5.48% and 8.35%. The average cost of producing one egg was found to be 0.094 US$ and 0.097 US$, respectively. It was determined that investment costs in alternative cage systems was 14.93% higher and the production cost per hen was 2.03% higher than that in unenriched cage systems. In Turkey, on January 1, 2023, all systems will be converted to alternative cages. Investment amounts and production costs for the alternative cage systems are very important in this transformation process. Therefore the present review is to examine the available information on the production data of laying hens reared in the unenriched and alternative cages and to make economic feasibility conclusions under Turkey conditions.
Despite reported benefits of Telecare use for older adults, uptake of Telecare in the United Kingdom remains relatively low. Non-users of Telecare are an under-researched group in the Telecare field. We conducted 22 qualitative individual semi-structured interviews to explore the views and opinions of current non-users of Telecare regarding barriers and facilitators to its use, and explored considerations which may precede their decision to accept, or reject, Telecare. Framework analysis identified a number of themes which influence the outcome and timing of this decision, including peace of mind (for the individual and their family), the strength and composition of an individual's support network, the impact of changing personal and health circumstances, and lack of communication about Telecare (e.g. advertising). A cost–benefit decision process appears to take place for the potential user, whereby the benefit of peace of mind is weighed against perceived ‘costs’ of using Telecare. Telecare is often perceived as a last resort rather than a preventative measure. A number of barriers to Telecare use need to be addressed if individuals are to make fully informed decisions regarding their Telecare use, and to begin using Telecare at a time when it could provide them with optimal benefit. Although the study was set in England, the findings may be relevant for other countries where Telecare is used.
For the past 10 years, in long-term care systems, we have witnessed the accelerated deployment of casemix management systems. A casemix is formed by clusters, defined by individual characteristics that explain similar resource use. However, certain questions regarding the development of these systems must be raised. Moreover, none of these systems was developed in the context of an integrated care organization that can track the progress of a dependent elderly person through every kind of care arrangement available—from own home, through intermediate facility, to long-term care institution. This article emphasizes the necessity of being well informed about the features of existing systems, in order to choose or develop the system that best answers the goals of a particular health care system. Finally, it underlines important elements that should be considered in each step of the development of a casemix system in this context.
Introduction: Diabetes mellitus (DM) is a common chronic disease. The Canadian Diabetes Association (CDA) estimated that the national direct cost of DM accounts for approximately 3.5% of public healthcare spending. The economic burden has been estimated to be $12.2 billion in 2010 and projected to increase by $4.7 billion (38%) by 2020. For the province of Alberta, the estimated cost was $1.3 billion in 2015 and $1.7 billion for 2025. The cost of lesser complications of DM like hypoglycemia is not as well understood. The objective of this study was to estimate the health system cost of presentations by adults to Alberta emergency departments (ED) for hypoglycemia associated with type 1 (T1DM) or type 2 (T2DM) diabetes. Methods: A retrospective cohort study was conducted using administrative data for Alberta for a five-year period (fiscal years 2010/11-2014/15). Data were sourced from an administrative database: National Ambulatory Care Reporting System (NACRS). Records of interest were those for ED patients with an ICD-10-CA diagnosis of DM-associated hypoglycemia. A top-down approach was used to estimate costs, excluding physician and ambulance fees. This involved resource intensity weight (RIW), cost of a standard hospital stay (CSHS), and adjustment for inflation (to average value of Canadian dollar for Alberta for January-September 2015). A descriptive analysis was conducted. Results: Data extraction yielded 7,835 presentations by 5,884 patients. The median RIW was 0.0547. RIWs are centered at 1, thus the resource-use/cost of these presentations is well below that of the “average” case. Estimated costs per episode ranged from $108.63 to $4,136.59 with median of $431.11 (IQR: 369.40-639.50). Median episodic subgrouped costs were as follows: sex: $427.72 for males, $439.20 for females; DM type: $411.61 for T1DM, $511.63 for T2DM; date period: $835,862.09/year, $69,655.17/month, $16,030.23/week, and $2,288.78/day. Conclusion: Using population-based administrative data, we identified median costs for DM-associated hypoglycemia of approximately $430/case. Given the frequency, this condition incurs significant healthcare resource use and costs; continued efforts to reduce these ED visits seem worthwhile.
Introduction: Diabetes mellitus (DM) is a major chronic disease. Many patients with DM suffer hypoglycemic episodes that may be mild, moderate or severe, requiring ambulance and emergency department (ED) services. The cost of these DM-associated hypoglycemic episodes in the ED is not well understood. This study identified literature on DM-associated hypoglycemia costs that were incurred in acute care settings, with particular interest in the ED setting. Methods: The methods of this systematic review were based on an a priori protocol. The literature searches involved 12 databases. Study selection and quality assessment were conducted independently by two reviewers. Costs from included studies were standardized to year 2014 Canadian dollars. Mean with standard deviation (SD) and median costs with interquartile range (IQR) were calculated whenever possible. Results: The systematic search yielded 1,164 studies and 62 were included. The largest proportion of studies (45%) originated from USA data. Quality of included studies varied widely. Although none of the studies were purely a cost analysis of DM-associated hypoglycemia in the ED, 15 studies reported some ED costs. Median DM-associated hypoglycemic episode costs were $1,187.15 in the ED and $1,288.92 irrespective of setting. More severe episodes were more costly; costs were 8.5 times higher in the inpatient setting than in the ED. Episode costs were 18-45% higher for patients with Type 2 DM than Type 1. Direct costs comprised 80% of total costs. Conclusion: Acute episodes of DM-associated hypoglycemia are costly. These episodes also often require hospitalization; the highest costs are incurred by admitted patients with Type 2 DM. More studies are needed to better understand the costs associated with ED use by patients with DM-associated hypoglycemia.
According to the deformation and movement requirements of the FAST reflector, a multipurpose analysis, including the load-bearing behavior, deformation, construction costs of the reflector supporting structure and its model, is presented in this paper. The advantages and disadvantages of steel and aluminum alloy structures are also discussed and compared through detailed design calculations under load-bearing capacity and normal working conditions.