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1.  Age-26 Cost-Benefit Analysis of the Child-Parent Center Early Education Program 
Child development  2011;82(1):10.1111/j.1467-8624.2010.01563.x.
We conducted a cost-benefit analysis of the Child-Parent Center (CPC) early childhood intervention. Using data collected up to age 26 on health and well-being, the study is the first adult economic analysis of a sustained large-scale and publicly-funded intervention. As part of the Chicago Longitudinal Study, a complete cohort of 900 low-income children who enrolled in 20 CPCs beginning at age 3 were compared to 500 well-matched low-income children who participated in the usual educational interventions for the economically disadvantaged in Chicago schools. School-age services were provided up to age 9 (third grade). Findings indicated that the three components of CPC had economic benefits in 2007 dollars that exceeded costs. The preschool program provided a total return to society of $10.83 per dollar invested (net benefits per participant of $83,708). Benefits to the public (other than program participants and families) were $7.20 per dollar invested. The primary sources of benefits were increased earnings and tax revenues, averted criminal justice system and victim costs, and savings for child welfare, special education, and grade retention. The school-age program had a societal return of $3.97 per dollar invested and a $2.11 public return. The extended intervention program (4 to 6 years of participation) had a societal return of $8.24 and public return of $5.21. Estimates were robust across a wide range of discount rates and alternative assumptions, and were consistent with the results of Monte Carlo simulations. Males, 1-year preschool participants, and children from higher risk families had greater economic benefits. Findings provide strong evidence that sustained early childhood programs can contribute to well-being for individuals and society.
doi:10.1111/j.1467-8624.2010.01563.x
PMCID: PMC3817956  PMID: 21291448
2.  Patented Drug Extension Strategies on Healthcare Spending: A Cost-Evaluation Analysis 
PLoS Medicine  2013;10(6):e1001460.
In a cost-evaluation analysis of pharmacy invoice data in one Canton in Switzerland, Nathalie Vernaz and colleagues find that “evergreening” strategies pursued by drug manufacturers have been successful in maintaining market share and contribute to increased overall healthcare costs.
Please see later in the article for the Editors' Summary
Background
Drug manufacturers have developed “evergreening” strategies to compete with generic medication after patent termination. These include marketing of slightly modified follow-on drugs. We aimed to estimate the financial impact of these drugs on overall healthcare costs and also to examine the impact of listing these drugs in hospital restrictive drug formularies (RDFs) on the healthcare system as a whole (“spillover effect”).
Methods and Findings
We used hospital and community pharmacy invoice office data in the Swiss canton of Geneva to calculate utilisation of eight follow-on drugs in defined daily doses between 2000 and 2008. “Extra costs” were calculated for three different scenarios assuming replacement with the corresponding generic equivalent for prescriptions of (1) all brand (i.e., initially patented) drugs, (2) all follow-on drugs, or (3) brand and follow-on drugs. To examine the financial spillover effect we calculated a monthly follow-on drug market share in defined daily doses for medications prescribed by hospital physicians but dispensed in community pharmacies, in comparison to drugs prescribed by non-hospital physicians in the community.
Estimated “extra costs” over the study period were €15.9 (95% CI 15.5; 16.2) million for scenario 1, €14.4 (95% CI 14.1; 14.7) million for scenario 2, and €30.3 (95% CI 29.8; 30.8) million for scenario 3. The impact of strictly switching all patients using proton-pump inhibitors to esomeprazole at admission resulted in a spillover “extra cost” of €330,300 (95% CI 276,100; 383,800), whereas strictly switching to generic cetirizine resulted in savings of €7,700 (95% CI 4,100; 11,100). Overall we estimated that the RDF resulted in “extra costs” of €503,600 (95% CI 444,500; 563,100).
Conclusions
Evergreening strategies have been successful in maintaining market share in Geneva, offsetting competition by generics and cost containment policies. Hospitals may be contributing to increased overall healthcare costs by listing follow-on drugs in their RDF. Therefore, healthcare providers and policy makers should be aware of the impact of evergreening strategies.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The development of a new medical drug—from discovery of a new compound to regulatory approval for its use—can take many years and cost millions of dollars. In 1995 the World Trade Organization adopted an international law (Trade-Related Aspects of Intellectual Property Rights—TRIPS) by which pharmaceutical companies can protect their intellectual property through patents. Under TRIPS, pharmaceutical companies are granted exclusive manufacturing rights for up to 20 years for each new drug, generating large revenues that often exceed initial investments costs, thus providing an incentive for pharmaceutical companies to continue to invest in the research and development of new drugs. However, recent stricter regulatory procedures for drug approval, national price control policies, and increased competition from generic manufacturers (that produce drugs similar to the brand drug once the patent has expired) have meant that pharmaceutical company profits have increasingly come under pressure.
Why Was This Study Done?
One of the tactics that pharmaceutical companies currently use in response to this situation is to extend their market monopoly. This practice is known as “evergreening” and refers to the situation in which pharmaceutical companies slightly change the formulation of their brand drug into “follow on” drugs, for example, by combining formulations or producing slow-release forms, so that they can extend the patent. The impact of such follow-on drugs on overall healthcare costs in high-resource settings is unclear and has received little attention. In this study, the researchers assessed the overall costs associated with the prescribing of follow-on drugs in the Swiss canton of Geneva.
What Did the Researchers Do and Find?
The researchers identified prescriptions of eight follow-on drugs issued by hospital and community pharmacists in Geneva between 2000 and 2008. To analyze the impact of evergreening strategies on healthcare spending, they calculated the market share score (an indicator of market competitiveness) for all prescriptions of the originally patented (brand) drug, the follow-on drug, and generic versions of the drug. The researchers then used hospital and community databases to analyze the costs of replacing brand and/or follow-on drugs with a corresponding generic drug (when available) under three scenarios (1) replacing all brand drug prescriptions, (2) replacing all follow-on drug prescriptions, and (3) replacing both follow-on and brand prescriptions.
Using these methods, the researchers found that over the study period, the number of patients receiving either a brand or follow-on drug increased from 56,686 patients in 2001 to 131,193 patients in 2008. The total cost for all studied drugs was €171.5 million, of which €103.2 million was for brand drugs, €41.1 million was for follow-on drugs, and €27.2 million was for generic drugs. Based on scenario 1 (all brand drugs being replaced by generics) and scenario 2 (all follow-on drugs being replaced by generics), over the study period, the healthcare system could have saved €15.9 million and €14.4 million in extra costs, respectively. The researchers also found some evidence that hospital prescribing patterns (through a restrictive drug formulary) influenced prescribing in the community: over the study period, the influence of hospital prescription patterns on the community resulted in an extra cost of €503,600 (mainly attributable to two drugs, esomeprazole and escitalopram). However, this influence also resulted in some savings because of a generic drug listed in the hospital formulary: use of the generic version of the drug cetirizine resulted in savings of €7,700.
What Do These Findings Mean?
These findings show that in a high-income setting, evergreening strategies developed by pharmaceutical companies for follow-on drugs substantially contributed to an increase in overall healthcare costs. These findings also provide further evidence that policies encouraging prescribing of generic medicines could have substantial savings on healthcare expenditure and, if implemented in hospital formularies, could also influence prescribing outside of the hospital setting, resulting in further savings. However, in their analysis, the researchers assumed that the health outcomes of patients would be the same whatever type of drug they used (brand, generic, or follow-on), as they had no information on health outcomes. Nevertheless, this study provides useful information for healthcare providers and policy makers about the cost implications of the evergreening strategies used by the pharmaceutical industry, particularly for follow-on drugs.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001460.
This study is further discussed in a PLOS Medicine Perspective by Aaron Kesselheim
Wikipedia provides an explanation of evergreening (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Trade Organization has detailed information on TRIPS
doi:10.1371/journal.pmed.1001460
PMCID: PMC3672218  PMID: 23750120
3.  Childhood Lead Poisoning: Conservative Estimates of the Social and Economic Benefits of Lead Hazard Control 
Environmental Health Perspectives  2009;117(7):1162-1167.
Background
This study is a cost–benefit analysis that quantifies the social and economic benefits to household lead paint hazard control compared with the investments needed to minimize exposure to these hazards.
Objectives
This research updates estimates of elevated blood lead levels among a cohort of children ≤ 6 years of age and compiles recent research to determine a range of the costs of lead paint hazard control ($1–$11 billion) and the benefits of reduction attributed to each cohort for health care ($11–$53 billion), lifetime earnings ($165–$233 billion), tax revenue ($25–$35 billion), special education ($30–$146 million), attention deficit–hyperactivity disorder ($267 million), and the direct costs of crime ($1.7 billion).
Results
Each dollar invested in lead paint hazard control results in a return of $17–$221 or a net savings of $181–269 billion.
Conclusions
There are substantial returns to investing in lead hazard control, particularly targeted at early intervention in communities most likely at risk. Given the high societal costs of inaction, lead hazard control appears to be well worth the price.
doi:10.1289/ehp.0800408
PMCID: PMC2717145  PMID: 19654928
cost-benefit; economics; housing; lead poisoning
4.  The Economic Benefits Resulting from the First 8 Years of the Global Programme to Eliminate Lymphatic Filariasis (2000–2007) 
Background
Between 2000–2007, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) delivered more than 1.9 billion treatments to nearly 600 million individuals via annual mass drug administration (MDA) of anti-filarial drugs (albendazole, ivermectin, diethylcarbamazine) to all at-risk for 4–6 years. Quantifying the resulting economic benefits of this significant achievement is important not only to justify the resources invested in the GPELF but also to more fully understand the Programme's overall impact on some of the poorest endemic populations.
Methodology
To calculate the economic benefits, the number of clinical manifestations averted was first quantified and the savings associated with this disease prevention then analyzed in the context of direct treatment costs, indirect costs of lost-labor, and costs to the health system to care for affected individuals. Multiple data sources were reviewed, including published literature and databases from the World Health Organization, International Monetary Fund, and International Labour Organization
Principal Findings
An estimated US$21.8 billion of direct economic benefits will be gained over the lifetime of 31.4 million individuals treated during the first 8 years of the GPELF. Of this total, over US$2.3 billion is realized by the protection of nearly 3 million newborns and other individuals from acquiring lymphatic filariasis as a result of their being born into areas freed of LF transmission. Similarly, more than 28 million individuals already infected with LF benefit from GPELF's halting the progression of their disease, which results in an associated lifetime economic benefit of approximately US$19.5 billion. In addition to these economic benefits to at-risk individuals, decreased patient services associated with reduced LF morbidity saves the health systems of endemic countries approximately US$2.2 billion.
Conclusions/Significance
MDA for LF offers significant economic benefits. Moreover, with favorable program implementation costs (largely a result of the sustained commitments of donated drugs from the pharmaceutical industry) it is clear that the economic rate of return of the GPELF is extremely high and that this Programme continues to prove itself an excellent investment in global health.
Author Summary
Lymphatic filariasis (LF), commonly known as ‘elephantiasis’, is one of the world's most debilitating infectious diseases. In 83 countries worldwide, more than 1.3 billion people are at risk of infection with an estimated 120 million individuals already infected. A recent publication reviewing the health impact of the first 8 years of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) demonstrated the enormous health benefits achieved in populations receiving annual mass drug administration (MDA), as a result of infection prevented, disease progression halted, and ancillary treatment of co-infections. To date, however, no studies have estimated the economic value of these health benefits, either to the individuals or the societies afflicted with LF. Our study estimates that US$21.8 billion will be gained among individuals benefitting from just the first 8 years of the Global Programme, and an additional US$2.2 billion will be saved by the health systems of endemic countries. Treating endemic populations is possible at very low cost – particularly because of the generous drug donations from two pharmaceutical companies – but results in enormous economic benefits. Findings from this study yield a much clearer understanding the GPELF's full economic impact and strengthen the conviction that it is a ‘best buy’ in global health.
doi:10.1371/journal.pntd.0000708
PMCID: PMC2879371  PMID: 20532228
5.  Economic Impact of Pharmacy Graduates on a Regional Economy 
Objectives
To analyze the impact of recent pharmacy graduates on a local economy.
Methods
Input-output analysis was applied to data from Spokane County, Washington, in 2006 and the findings were reviewed and conclusions were drawn.
Results
The local college of pharmacy added nearly $1 million (in 2006) directly to the local economy. New pharmacists added nearly $400,000 in direct value. However, because the graduates alleviated a shortage of pharmacists in the area, thereby avoiding both the tangible and intangible (eg, human health) economic costs of a continued shortage, the true economic impact may have been even greater.
Conclusions
Doctor of pharmacy (PharmD) graduates entering the workforce add substantial value, both to the local retail pharmacy industry specifically and the local economy in general. Thus, the economic impact of the pharmacy practice program training these students is also substantial.
PMCID: PMC2701241  PMID: 19564989
economic impact; input-output modeling; program assessment
6.  The impact of diabetes prevention on labour force participation and income of older Australians: an economic study 
BMC Public Health  2012;12:16.
Background
Globally, diabetes is estimated to affect 246 million people and is increasing. In Australia diabetes has been made a national health priority. While the direct costs of treating diabetes are substantial, and rising, the indirect costs are considered greater. There is evidence that interventions to prevent diabetes are effective, and cost-effective, but the impact on labour force participation and income has not been assessed. In this study we quantify the potential impact of implementing a diabetes prevention program, using screening and either metformin or a lifestyle intervention on individual economic outcomes of pre-diabetic Australians aged 45-64.
Methods
The output of an epidemiological microsimulation model of the reduction in prevalence of diabetes from a lifestyle or metformin intervention, and another microsimulation model, Health&WealthMOD, of health and the associated impacts on labour force participation, personal income, savings, government revenue and expenditure were used to quantify the estimated outcomes of the two interventions.
Results
An additional 753 person years in the labour force would have been achieved from 1993 to 2003 for the male cohort aged 60-64 years in 2003, if a lifestyle intervention had been introduced in 1983; with 890 person years for the equivalent female group. The impact on labour force participation was lower for the metformin intervention, and increased with age for both interventions. The male cohort aged 60-64 years in 2003 would have earned an additional $30 million in income with the metformin intervention, and the equivalent female cohort would have earned an additional $25 million. If the lifestyle intervention was introduced, the same male and female cohorts would have earned an additional $34 million and $28 million respectively from 1993 to 2003. For the individuals involved, on average, males would have earned an additional $44,600 per year and females an additional $31,800 per year, if they had continued to work as a result of preventing diabetes.
Conclusions
In addition to improved health and wellbeing, considerable benefits to individuals, in terms of both additional working years and increased personal income, could be made by introducing either a lifestyle or metformin intervention to prevent diabetes.
doi:10.1186/1471-2458-12-16
PMCID: PMC3295674  PMID: 22225701
7.  Economic Return From the Women’s Health Initiative Estrogen Plus Progestin Clinical Trial 
Annals of internal medicine  2014;160(9):594-602.
Background
The findings of the Women’s Health Initiative (WHI) estrogen plus progestin (E+P) trial led to a substantial reduction in use of combined hormone therapy (cHT) among postmenopausal women in the United States. The economic effect of this shift has not been evaluated relative to the trial’s $260 million cost (2012 U.S. dollars).
Objective
To estimate the economic return from the WHI E+P trial.
Design
Decision model to simulate health outcomes for a “WHI scenario” with observed cHT use and a “no-WHI scenario” with cHT use extrapolated from the pretrial period.
Data Sources
Primary analyses of WHI outcomes, peer-reviewed literature, and government sources.
Target Population
Postmenopausal women in the United States, aged 50 to 79 years, who did not have a hysterectomy.
Time Horizon
2003 to 2012.
Perspective
Payer.
Intervention
Combined hormone therapy.
Outcome Measures
Disease incidence, expenditure, quality-adjusted life-years, and net economic return.
Results of Base-Case Analysis
The WHI scenario resulted in 4.3 million fewer cHT users, 126 000 fewer breast cancer cases, 76 000 fewer cardiovascular disease cases, 263 000 more fractures, 145 000 more quality-adjusted life-years, and expenditure savings of $35.2 billion. The corresponding net economic return of the trial was $37.1 billion ($140 per dollar invested in the trial) at a willingness-to-pay level of $100 000 per quality-adjusted life-year.
Results of Sensitivity Analysis
The 95% CI for the net economic return of the trial was $23.1 to $51.2 billion.
Limitation
No evaluation of indirect costs or outcomes beyond 2012.
Conclusion
The WHI E+P trial made high-value use of public funds with a substantial return on investment. These results can contribute to discussions about the role of public funding for large, prospective trials with high potential for public health effects.
Primary Funding Source
National Heart, Lung, and Blood Institute.
doi:10.7326/M13-2348
PMCID: PMC4157355  PMID: 24798522
8.  Estimating the payoffs from cardiovascular disease research in Canada: an economic analysis 
CMAJ Open  2013;1(2):E83-E90.
Background
Investments in medical research can result in health improvements, reductions in health expenditures and secondary economic benefits. These “returns” have not been quantified in Canada. Our objective was to estimate the return on cardiovascular disease research funded by public or charitable organizations.
Methods
Our primary outcome was the internal rate of return on cardiovascular disease research funded by public or charitable sources. The internal rate of return is the annual monetary benefit to the economy for each dollar invested in cardiovascular disease research. Calculation of the internal rate of return involved the following: measuring expenditures on cardiovascular disease research, estimating the health gains accrued from new treatments for cardiovascular disease, determining the proportion of health gains attributable to cardiovascular disease research and the time lag between research expenditures and health gains, and estimating the spillovers from public- or charitable-sector investments to other sectors of the economy.
Results
Expenditures by public or charitable organizations on cardiovascular disease research from 1981 to 1992 amounted to $392 million (2005 dollars). Health gains associated with new treatments from 1994 to 2005 (13-yr lag) amounted to 2.2 million quality-adjusted life-years. We calculated an internal rate of return of 20.6%.
Conclusion
Canadians obtain relatively high health and economic gains from investments in cardiovascular disease research. Every $1 invested in cardiovascular disease research by public or charitable sources yields a stream of benefits of roughly $0.21 to the Canadian economy per year, in perpetuity.
doi:10.9778/cmajo.20130003
PMCID: PMC3986018  PMID: 25077108
9.  The economic impact of diabetes through lost labour force participation on individuals and government: evidence from a microsimulation model 
BMC Public Health  2014;14:220.
Background
Diabetes is a costly and debilitating disease. The aim of the study is to quantify the individual and national costs of diabetes resulting from people retiring early because of this disease, including lost income; lost income taxation, increased government welfare payments; and reductions in GDP.
Methods
A purpose-built microsimulation model, Health&WealthMOD2030, was used to estimate the economic costs of early retirement due to diabetes. The study included all Australians aged 45–64 years in 2010 based on Australian Bureau of Statistics’ Surveys of Disability, Ageing and Carers. A multiple regression model was used to identify significant differences in income, government welfare payments and taxation liabilities between people out of the labour force because of their diabetes and those employed full time with no chronic health condition.
Results
The median annual income of people who retired early because of their diabetes was significantly lower (AU$11 784) compared to those employed full time without a chronic health condition who received almost five times more income. At the national level, there was a loss of AU$384 million in individual earnings by those with diabetes, an extra AU$4 million spent in government welfare payments, a loss of AU$56 million in taxation revenue, and a loss of AU$1 324 million in GDP in 2010: all attributable to diabetes through its impact on labour force participation. Sensitivity analysis was used to assess the impact of different diabetes prevalence rates on estimates of lost income, lost income taxation, increased government welfare payments, and reduced GDP.
Conclusions
Individuals bear the cost of lost income in addition to the burden of the disease. The Government endures the impacts of lost productivity and income taxation revenue, as well as spending more in welfare payments. These national costs are in addition to the Government’s direct healthcare costs.
doi:10.1186/1471-2458-14-220
PMCID: PMC3975899  PMID: 24592931
Diabetes; Chronic disease; Labour force participation; Economic costs; Microsimulation modelling; Income; Taxation; Government welfare payments; GDP
10.  Emerging Trends in Cancer Care: Health Plans’ and Pharmacy Benefit Managers’ Perspectives on Changing Care Models 
American Health & Drug Benefits  2012;5(4):242-253.
Background
Cancer care in the United States is being transformed by a number of medical and economic trends, including rising drug costs, increasing availability of targeted therapies and oral oncolytic agents, healthcare reform legislation, changing reimbursement practices, a growing emphasis on comparative effectiveness research (CER), the emerging role of accountable care organizations (ACOs), and the increased role of personalization of cancer care.
Objective
To examine the attitudes of health plan payers and pharmacy benefit managers (PBMs) toward recent changes in cancer care, current cost-management strategies, and anticipated changes in oncology practice during the next 5 years.
Methods
An online survey with approximately 200 questions was conducted by Reimbursement Intelligence in 2011. The survey was completed by 24 medical directors and 31 pharmacy directors from US national and regional health plans and 8 PBMs. All respondents are part of a proprietary panel of managed care decision makers and are members of the Pharmacy and Therapeutics Committees of their respective plans, which together manage more than 150 million lives. Survey respondents received an honorarium for completing the survey. The survey included quantitative and qualitative questions about recent developments in oncology management, such as the impact on their plans or PBMs of healthcare reform, quality improvement initiatives, changes in reimbursement and financial incentives, use of targeted and oral oncolytics, and personalized medicine. Respondents were treated as 1 group, because there were no evident differences in responses between medical and pharmacy directors or PBMs.
Results
Overall, survey respondents expressed interest in monitoring and controlling the costs of cancer therapy, and they anticipated increased use of specialty pharmacy for oncology drugs. When clinical outcomes are similar for oral oncolytics and injectable treatments, 93% prefer the oral agents, which are covered under the specialty tier by 59% of the plans. The use of the National Comprehensive Cancer Network practice guidelines for coverage and reimbursement of oncologic agents is reported as “very frequent” by 10% of survey respondents, “frequent” by 21%, and “moderately frequent” by 7%. Most (66%) respondents believe that it is probable and 3% believe it is highly probable that healthcare reform will help to control oncology treatment costs, although 59% also predict an increase in utilization restrictions and 48% predict more stringent comparative effectiveness evidence requirements. The survey reveals a considerable uncertainty among health plans and PBMs about the eventual impact of ACOs on oncology care. Although 82% of those surveyed believe that measures such as increasing adherence to evidence-based treatments will achieve cost-savings, nearly half (48%) had no plans to use such measures.
Conclusions
Recent trends in healthcare legislation, rising drug costs, and changing reimbursement practices are poised to significantly alter conventional models of cancer care delivery and payment. The results of this survey indicate that health plans and PBMs anticipate greater use of evidence-based management strategies, including CER, quality initiatives, and biomarker testing for appropriate cancer therapy selection. In addition, they anticipate greater focus on cost control, with a greater role for utilization management and increased patient cost-sharing. Finally, there is a high level of uncertainty among plans and PBMs about the eventual impact of ACOs and other aspects of healthcare reform on oncology practice.
PMCID: PMC4046474  PMID: 24991323
11.  Return on Investment: A Fuller Assessment of the Benefits and Cost Savings of the US Publicly Funded Family Planning Program 
The Milbank Quarterly  2014;92(4):667-720.
Context
Each year the United States’ publicly supported family planning program serves millions of low-income women. Although the health impact and public-sector savings associated with this program's services extend well beyond preventing unintended pregnancy, they never have been fully quantified.
Methods
Drawing on an array of survey data and published parameters, we estimated the direct national-level and state-level health benefits that accrued from providing contraceptives, tests for the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), Pap tests and tests for human papillomavirus (HPV), and HPV vaccinations at publicly supported family planning settings in 2010. We estimated the public cost savings attributable to these services and compared those with the cost of publicly funded family planning services in 2010 to find the net public-sector savings. We adjusted our estimates of the cost savings for unplanned births to exclude some mistimed births that would remain publicly funded if they had occurred later and to include the medical costs for births through age 5 of the child.
Findings
In 2010, care provided during publicly supported family planning visits averted an estimated 2.2 million unintended pregnancies, including 287,500 closely spaced and 164,190 preterm or low birth weight (LBW) births, 99,100 cases of chlamydia, 16,240 cases of gonorrhea, 410 cases of HIV, and 13,170 cases of pelvic inflammatory disease that would have led to 1,130 ectopic pregnancies and 2,210 cases of infertility. Pap and HPV tests and HPV vaccinations prevented an estimated 3,680 cases of cervical cancer and 2,110 cervical cancer deaths; HPV vaccination also prevented 9,000 cases of abnormal sequelae and precancerous lesions. Services provided at health centers supported by the Title X national family planning program accounted for more than half of these benefits.
The gross public savings attributed to these services totaled approximately $15.8 billion—$15.7 billion from preventing unplanned births, $123 million from STI/HIV testing, and $23 million from Pap and HPV testing and vaccines. Subtracting $2.2 billion in program costs from gross savings resulted in net public-sector savings of $13.6 billion.
Conclusions
Public expenditures for the US family planning program not only prevented unintended pregnancies but also reduced the incidence and impact of preterm and LBW births, STIs, infertility, and cervical cancer. This investment saved the government billions of public dollars, equivalent to an estimated taxpayer savings of $7.09 for every public dollar spent.
doi:10.1111/1468-0009.12080
PMCID: PMC4266172  PMID: 25314928
family planning services; cost-benefit analysis; contraception; financing
12.  Return on Investment: A Fuller Assessment of the Benefits and Cost Savings of the US Publicly Funded Family Planning Program 
The Milbank Quarterly  2014;92(4):667-720.
Context
Each year the United States’ publicly supported family planning program serves millions of low-income women. Although the health impact and public-sector savings associated with this program's services extend well beyond preventing unintended pregnancy, they never have been fully quantified.
Methods
Drawing on an array of survey data and published parameters, we estimated the direct national-level and state-level health benefits that accrued from providing contraceptives, tests for the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), Pap tests and tests for human papillomavirus (HPV), and HPV vaccinations at publicly supported family planning settings in 2010. We estimated the public cost savings attributable to these services and compared those with the cost of publicly funded family planning services in 2010 to find the net public-sector savings. We adjusted our estimates of the cost savings for unplanned births to exclude some mistimed births that would remain publicly funded if they had occurred later and to include the medical costs for births through age 5 of the child.
Findings
In 2010, care provided during publicly supported family planning visits averted an estimated 2.2 million unintended pregnancies, including 287,500 closely spaced and 164,190 preterm or low birth weight (LBW) births, 99,100 cases of chlamydia, 16,240 cases of gonorrhea, 410 cases of HIV, and 13,170 cases of pelvic inflammatory disease that would have led to 1,130 ectopic pregnancies and 2,210 cases of infertility. Pap and HPV tests and HPV vaccinations prevented an estimated 3,680 cases of cervical cancer and 2,110 cervical cancer deaths; HPV vaccination also prevented 9,000 cases of abnormal sequelae and precancerous lesions. Services provided at health centers supported by the Title X national family planning program accounted for more than half of these benefits. The gross public savings attributed to these services totaled approximately $15.8 billion—$15.7 billion from preventing unplanned births, $123 million from STI/HIV testing, and $23 million from Pap and HPV testing and vaccines. Subtracting $2.2 billion in program costs from gross savings resulted in net public-sector savings of $13.6 billion.
Conclusions
Public expenditures for the US family planning program not only prevented unintended pregnancies but also reduced the incidence and impact of preterm and LBW births, STIs, infertility, and cervical cancer. This investment saved the government billions of public dollars, equivalent to an estimated taxpayer savings of $7.09 for every public dollar spent.
doi:10.1111/1468-0009.12080
PMCID: PMC4266172  PMID: 25314928
family planning services; cost-benefit analysis; contraception; financing
13.  Assessing the health benefits of air pollution reduction for children. 
Environmental Health Perspectives  2004;112(2):226-232.
Benefit-cost analyses of environmental regulations are increasingly mandated in the United States. Evaluations of criteria air pollutants have focused on benefits and costs associated with adverse health effects. Children are significantly affected by the health benefits of improved air quality, yet key environmental health policy analyses have not previously focused specifically on children's effects. In this article we present a "meta-analysis" approach to child-specific health impacts derived from the U.S. Clean Air Act (CAA). On the basis of data from existing studies, reductions in criteria air pollutants predicted to occur by 2010 because of CAA regulations are estimated to produce the following impacts: 200 fewer expected cases of postneonatal mortality; 10,000 fewer asthma hospitalizations in children 1-16 years old, with estimated benefits ranging from 20 million U.S. dollars to 46 million U.S. dollars (1990 U.S. dollars); 40,000 fewer emergency department visits in children 1-16 years old, with estimated benefits ranging from 1.3 million U.S. dollars to 5.8 million U.S. dollars; 20 million school absences avoided by children 6-11 years old, with estimated benefits of 0.7-1.8 billion U.S. dollars; and 10,000 fewer infants of low birth weight, with estimated benefits of 230 million U.S. dollars. Inclusion of limited child-specific data on hospitalizations, emergency department visits, school absences, and low birth weight could be expected to add 1-2 billion U.S. dollars (1990 U.S. dollars) to the 8 billion U.S. dollars in health benefits currently estimated to result from decreased morbidity, and 600 million U.S. dollars to the 100 billion U.S. dollars estimated to result from decreased mortality. These estimates highlight the need for increased consideration of children's health effects. Key needs for environmental health policy analyses include improved information for children's health effects, additional life-stage-specific information, and improved health economics information specific for children.
PMCID: PMC1241833  PMID: 14754578
14.  The personal and national costs of mental health conditions: impacts on income, taxes, government support payments due to lost labour force participation 
BMC Psychiatry  2011;11:72.
Background
Mental health conditions have the ability to interrupt an individual's ability to participate in the labour force, and this can have considerable follow on impacts to both the individual and the state.
Method
Cross-sectional analysis of the base population of Health&WealthMOD, a microsimulation model built on data from the Australian Bureau of Statistics' Survey of Disability, Ageing and Carers and STINMOD, an income and savings microsimulation model was used to quantify the personal cost of lost income and the cost to the state from lost income taxation, increased benefits payments and lost GDP as a result of early retirement due to mental health conditions in Australians aged 45-64 in 2009.
Results
Individuals aged 45 to 64 years who have retired early due to depression personally have 73% lower income then their full time employed counterparts and those retired early due to other mental health conditions have 78% lower incomes. The national aggregate cost to government due to early retirement from these conditions equated to $278 million (£152.9 million) in lost income taxation revenue, $407 million (£223.9 million) in additional transfer payments and around $1.7 billion in GDP in 2009 alone.
Conclusions
The costs of mental health conditions to the individuals and the state are considerable. While individuals has to bear the economic costs of lost income in addition to the burden of the conditions itself, the impact on the state is loss of productivity from reduced workforce participation, lost income taxation revenue, and increased government support payments - in addition to direct health care costs.
doi:10.1186/1471-244X-11-72
PMCID: PMC3114713  PMID: 21526993
15.  A Revised Estimate of the Burden of Illness of Gout☆ 
Background
Gout is a chronic, inflammatory arthritis characterized by painful and debilitating acute/episodic flares. Until recently, gout has been regarded as a minor medical problem, in part because the associated economic burden has not been appreciated. Previous literature on this subject focused on the costs associated with acute episodes of gout rather than on the long-term medical and economic implications of this chronic disorder.
Objective
Our aim was to estimate the current impact of gout in the United States with respect to disability and economic costs.
Methods
The following data sources were used: published data on the incremental economic burden of gout; statistics from the US Census Bureau and the US Bureau of Labor Statistics; and recent epidemiological and clinical literature concerning the course, treatment, and outcomes of the disease. Disability is expressed as days of lost productivity. Charges for gout-related treatments were used as direct cost inputs.
Results
Gout affects an estimated 8 million Americans, among whom those working have an average of almost 5 more absence days annually than workers without gout. On average, the incremental annual cost of care for a gout patient is estimated at >$3000 compared with a nongouty individual. Even though comorbidities common in gout patients account for a portion of this increased economic burden, the total annual cost attributable to gout patients in the United States is likely in the tens of billions of dollars and comparable to those of other major chronic disorders, such as migraine and Parkinson’s disease.
Conclusions
The economic burden of gout is most readily assessable in patients whose acute arthritic flares result in emergency department visits, bedridden days, and episodic loss of productivity. Chronic progression of the disease can also result in long-term impairment of function and health-related quality of life, but the contribution of chronic gout to the economic burden is more difficult to quantitate because gout is frequently associated with serious cardiovascular, metabolic, and renal comorbidities. Recent demonstration that successful gout management can reverse functional deficits in many chronic gout patients, however, supports the views that chronic gout contributes substantially to the medical and thus economic costs of these patients and that early and aggressive efforts to improve gout outcomes are likely to reduce the associated economic burden.
doi:10.1016/j.curtheres.2013.04.003
PMCID: PMC3898191  PMID: 24465034
burden of illness; gout
16.  Can Broader Diffusion of Value-Based Insurance Design Increase Benefits from US Health Care without Increasing Costs? Evidence from a Computer Simulation Model 
PLoS Medicine  2010;7(2):e1000234.
Using a computer simulation based on US data, R. Scott Braithwaite and colleagues calculate the benefits of value-based insurance design, in which patients pay less for highly cost-effective services.
Background
Evidence suggests that cost sharing (i.e.,copayments and deductibles) decreases health expenditures but also reduces essential care. Value-based insurance design (VBID) has been proposed to encourage essential care while controlling health expenditures. Our objective was to estimate the impact of broader diffusion of VBID on US health care benefits and costs.
Methods and Findings
We used a published computer simulation of costs and life expectancy gains from US health care to estimate the impact of broader diffusion of VBID. Two scenarios were analyzed: (1) applying VBID solely to pharmacy benefits and (2) applying VBID to both pharmacy benefits and other health care services (e.g., devices). We assumed that cost sharing would be eliminated for high-value services (<$100,000 per life-year), would remain unchanged for intermediate- or unknown-value services ($100,000–$300,000 per life-year or unknown), and would be increased for low-value services (>$300,000 per life-year). All costs are provided in 2003 US dollars. Our simulation estimated that approximately 60% of health expenditures in the US are spent on low-value services, 20% are spent on intermediate-value services, and 20% are spent on high-value services. Correspondingly, the vast majority (80%) of health expenditures would have cost sharing that is impacted by VBID. With prevailing patterns of cost sharing, health care conferred 4.70 life-years at a per-capita annual expenditure of US$5,688. Broader diffusion of VBID to pharmaceuticals increased the benefit conferred by health care by 0.03 to 0.05 additional life-years, without increasing costs and without increasing out-of-pocket payments. Broader diffusion of VBID to other health care services could increase the benefit conferred by health care by 0.24 to 0.44 additional life-years, also without increasing costs and without increasing overall out-of-pocket payments. Among those without health insurance, using cost saving from VBID to subsidize insurance coverage would increase the benefit conferred by health care by 1.21 life-years, a 31% increase.
Conclusion
Broader diffusion of VBID may amplify benefits from US health care without increasing health expenditures.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
More money is spent per person on health care in the US than in any other country. US health care expenditure accounts for 16.2% of the gross domestic product and this figure is rising. Indeed, the increase in health care costs is outstripping the economy's growth rate. Consequently, US policy makers and providers of health insurance—health care in the US is largely provided by the private sector and is paid for through private health insurance or through government programs such as Medicare and Medicaid—are looking for better ways to control health expenditures. Although some health care cost reductions can be achieved by increasing efficiency, controlling the quantity of health care consumed is an essential component of strategies designed to reduce health expenditures. These strategies can target health care providers (for example, by requiring primary care physicians to provide referrals before their patients' insurance provides cover for specialist care) or can target consumers, often through cost sharing. Nowadays, most insurance plans include several tiers of cost sharing in which patients pay a larger proportion of the costs of expensive interventions than of cheap interventions.
Why Was This Study Done?
Cost sharing decreases health expenditure but it can also reduce demand for essential care and thus reduce the quality of care. Consequently, some experts have proposed value-based insurance design (VBID), an approach in which the amount of cost sharing is set according to the “value” of an intervention rather than its cost. The value of an intervention is defined as the ratio of the additional benefits to the additional costs of the intervention when compared to the next best alternative intervention. Under VBID, cost sharing could be waived for office visits necessary to control blood pressure in people with diabetes, which deliver high-value care, but could be increased for high-tech scans for dementia, which deliver low-value care. VBID has been adopted by several private health insurance schemes and its core principal is endorsed by US policy makers. However, it is unclear whether wider use of VBID is warranted. In this study, the researchers use a computer simulation of the US health care system to estimate the impact of broader diffusion of VBID on US health care benefits and costs.
What Did the Researchers Do and Find?
The researchers used their computer simulation to estimate the impact of applying VBID to cost sharing for drugs alone and to cost sharing for drugs, procedures, and other health care services for one million hypothetical US patients. In their simulation, the researchers eliminated cost sharing for services that cost less than US$100,000 per life-year gained (high-value services) and increased cost-sharing for services that cost more than US$300,000 per life-year gained (low-value services); cost-sharing remained unchanged for intermediate- or unknown-value services. With the current pattern of cost sharing, 60% of health expenditure is spent on low-value services and health care increases life expectancy by 4.70 years for an annual per person expenditure of US$5,688, the researchers report. With widespread application of VBID to cost sharing for drugs alone, health care increased life expectancy by an additional 0.03 to 0.05 years without increasing costs. With widespread application of VBID to cost sharing for other health care services, health care increased life expectancy by a further 0.24 to 0.44 years without additional costs. Finally, if the costs saved by applying VBID were used to subsidize insurance for the 15% of the US population currently without health insurance, the benefit conferred by health care among these people would increase by 1.21 life-years.
What Do These Findings Mean?
The findings of this study depend on the many assumptions included in the computer simulation, which, although complex, is a greatly simplified representation of the US health care system. Nevertheless, these findings suggest that if VBID were used more widely within the US health care system to encourage the use of high-value services, it might be possible to amplify the benefits from US health care without increasing health expenditures. Importantly, the money saved by VBID could be used to help fund universal insurance, a central aim of US health care reform. More research is needed, however, to determine the value of various health care interventions and to investigate whether other ways of linking value to cost sharing might yield even better gains in life expectancy at little or no additional cost.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000234.
Wikipedia has a page on health care in the United States (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Families USA works to promote high-quality affordable health care for all Americans and provides information about all aspects of US health care and about US health care reforms
The US Centers for Medicare and Medicaid provides information on the major government health insurance programs and on US national health expenditure statistics
doi:10.1371/journal.pmed.1000234
PMCID: PMC2821897  PMID: 20169114
17.  Avoiding a bad apple: Insect pollination enhances fruit quality and economic value☆ 
Highlights
•Insect pollination affects not only the quantity of apple production but also the quality.•The value of insect pollination to UK apple production may have previously been underestimated.•UK apple production could be significantly improved through management of insect pollination.•It is important to consider variety when valuing ecosystem services such as pollination to agricultural production.
Insect pollination is important for food production globally and apples are one of the major fruit crops which are reliant on this ecosystem service. It is fundamentally important that the full range of benefits of insect pollination to crop production are understood, if the costs of interventions aiming to enhance pollination are to be compared against the costs of the interventions themselves. Most previous studies have simply assessed the benefits of pollination to crop yield and ignored quality benefits and how these translate through to economic values. In the present study we examine the influence of insect pollination services on farmgate output of two important UK apple varieties; Gala and Cox. Using field experiments, we quantify the influence of insect pollination on yield and importantly quality and whether either may be limited by sub-optimal insect pollination. Using an expanded bioeconomic model we value insect pollination to UK apple production and establish the potential for improvement through pollination service management. We show that insects are essential in the production of both varieties of apple in the UK and contribute a total of £36.7 million per annum, over £6 million more than the value calculated using more conventional dependence ratio methods. Insect pollination not only affects the quantity of production but can also have marked impacts on the quality of apples, influencing size, shape and effecting their classification for market. These effects are variety specific however. Due to the influence of pollination on both yield and quality in Gala, there is potential for insect pollination services to improve UK output by up to £5.7 million per annum. Our research shows that continued pollinator decline could have serious financial implications for the apple industry but there is considerable scope through management of wild pollinators or using managed pollinator augmentation, to improve the quality of production. Furthermore, we show that it is critically important to consider all production parameters including quality, varietal differences and management costs when valuing the pollination service of any crop so investment in pollinator management can be proportional to its contribution.
doi:10.1016/j.agee.2013.10.032
PMCID: PMC3990452  PMID: 24748698
Apples; Pollination; Economic valuation; Pollinators; Pollination deficit; Apple quality; United Kingdom
18.  National Burden of Preventable Adverse Drug Events Associated with Inpatient Injectable Medications: Healthcare and Medical Professional Liability Costs 
Background
Harmful medication errors, or preventable adverse drug events (ADEs), are a prominent quality and cost issue in healthcare. Injectable medications are important therapeutic agents, but they are associated with a greater potential for serious harm than oral medications. The national burden of preventable ADEs associated with inpatient injectable medications and the associated medical professional liability (MPL) costs have not been previously described in the literature.
Objective
To quantify the economic burden of preventable ADEs related to inpatient injectable medications in the United States.
Methods
Medical error data (MedMarx 2009–2011) were utilized to derive the distribution of errors by injectable medication types. Hospital data (Premier 2010–2011) identified the numbers and the types of injections per hospitalization. US payer claims (2009–2010 MarketScan Commercial and Medicare 5% Sample) were used to calculate the incremental cost of ADEs by payer and by diagnosis-related group (DRG). The incremental cost of ADEs was defined as inclusive of the time of inpatient admission and the following 4 months. Actuarial calculations, assumptions based on published literature, and DRG proportions from 17 state discharge databases were used to derive the probability of preventable ADEs per hospitalization and their annual costs. MPL costs were assessed from state- and national-level industry reports, premium rates, and from closed claims databases between 1990 and 2011. The 2010 American Hospital Association database was used for hospital-level statistics. All costs were adjusted to 2013 dollars.
Results
Based on this medication-level analysis of reported harmful errors and the frequency of inpatient administrations with actuarial projections, we estimate that preventable ADEs associated with injectable medications impact 1.2 million hospitalizations annually. Using a matched cohort analysis of healthcare claims as a basis for evaluating incremental costs, we estimate that inpatient preventable ADEs associated with injectable medications increase the annual US payer costs by $2.7 billion to $5.1 billion, averaging $600,000 in extra costs per hospital. Across categories of injectable drugs, insulin had the highest risk per administration for a preventable ADE, although errors in the higher-volume categories of anti-infective, narcotic/analgesic, anticoagulant/thrombolytic and anxiolytic/sedative injectable medications harmed more patients. Our analysis of liability claims estimates that MPL associated with injectable medications totals $300 million to $610 million annually, with an average cost of $72,000 per US hospital.
Conclusion
The incremental healthcare and MPL costs of preventable ADEs resulting from inpatient injectable medications are substantial. The data in this study strongly support the clinical and business cases of investing in efforts to prevent errors related to injectable medications.
PMCID: PMC4031698  PMID: 24991335
19.  Pharmacy access to syringes among injecting drug users: follow-up findings from Hartford, Connecticut. 
Public Health Reports  1998;113(Suppl 1):81-89.
OBJECTIVE: To break the link between drug use and the human immunodeficiency virus (HIV), in 1992 the state of Connecticut rescinded a 14-year ban on pharmacy sales of syringes without a physician's prescription. In 1993, the Center for Disease Control and Prevention (CDC) evaluated the impact of the new legislation on access to syringes among injecting drug users (IDUs) and found an initial pattern of expanded access. However, it also found that some pharmacies, after negative experiences with IDU customers, reverted to requiring a prescription. This chapter reports findings from a four-year follow-up study of current IDU access to over-the-counter (OTC) pharmacy syringes in Hartford, Connecticut. METHODS: Through structured interviews, brief telephone interviews, and mailed surveys, data on nonprescription syringe sale practices were collected on 27 pharmacies, including 18 of the 21 pharmacies in Hartford and none from pharmacies in contiguous towns, during June and July 1997. Interview data on pharmacy syringe purchase from two sample of IDUs, a group of out-of-treatment injectors recruited through street outreach, and a sample of users of the Hartford Needle Exchange Program, also are reported. RESULTS: The study found that, while market trends as well as negative experiences have further limited pharmacy availability of nonprescription syringes, pharmacies remain an important source of sterile syringes for IDUs. However, the distribution of access in not even; in some areas of the city it is much easier to purchase nonprescription syringes than in other. All of the seven pharmacies located on the north end of Hartford reported that they had a policy of selling OTC syringes, whereas only six (54.5%) of the II pharmacies located on the south end have such a policy. Overt racial discrimination was not found to be a barrier to OTC access to syringes. CONCLUSIONS: To further decrease acquired immunodeficiency syndrome (AIDS) risk among IDUs, there is a need for public education to counter empirically unsupported stereotypes about IDUs that diminish their access to health care and AIDS prevention resources and services. In states or cities where pharmacy sale of nonprescription syringes is illegal, policy makers should examine the benefits of removing existing barriers to sterile syringe acquisition. In cases in which pharmacy sale of nonprescription syringes is legal, local health departments should implement educational programs to inform pharmacy staff and management about the critically important role low-cost (or cost-free), sterile syringe access can play in HIV prevention.
PMCID: PMC1307730  PMID: 9722813
20.  Obesity in the Workplace: Impact on Cardiovascular Disease, Cost, and Utilization of Care 
American Health & Drug Benefits  2011;4(5):271-278.
Background
In forecasting the future of cardiovascular disease (CVD), the American Heart Association calls for preventive strategies with particular attention to obesity. The association between obesity and CVD, including coronary artery disease (CAD) and diabetes, is well established. The rising prevalence of obesity in the workforce may have additional implications for employers and employees besides the demonstrated effects on absenteeism and workers' compensation.
Objective
This study was undertaken to determine the impact of population obesity on care utilization and cost of cardiovascular conditions such as hypertension, CAD, and cerebrovascular disease (or stroke) in a large US population of employees engaged in a major corporate wellness program.
Study sample
Using data from a single large industrial employer across 29 geographically distinct worksites in the United States, 179,708 episodes of care from 2004 to 2007 for 10,853 employees were included.
Methods
The population-based economic impact of obesity was calculated on the basis of the frequency of episodes of care per 1000 employees and on the amount eligible for payment per episode of care in US dollars. Data were obtained from a wellness program databases, episode of illness inventories, and pharmacy and medical claims. High and low prevalence rates of obesity, by obesity quartile, were used to create linear mixed models to examine associations with disease outcomes, while controlling for correlation within each worksite.
Results
Worksites with a high rate of obesity (ie, in the fourth quartile) had 348.4 more episodes of care of any kind per 1000 employees (P <.001), 38.6 more hypertension episodes of care per 1000 employees (P <.001), and 2.5 more cerebrovascular disease episodes of care per 1000 employees (P = .017) compared with worksites in the lower 3 quartiles. A worksite in the fourth obesity rate quartile had $223 greater cost per any kind of episode (P <.001), $169 greater cost per hypertension episode (P = .003), and $1620 more per CAD episode (P = .005) compared with worksites in the lower 3 quartiles. The overall economic impact per 1000 employees was calculated by combining episode frequency and eligible amount for payment per episode. For sites in the lower 3 quartiles of obesity, the eligible amount per 1000 employees for any kind of care was $4.01 million. However, for sites in the highest obesity quartile, the eligible amount for payment per 1000 employees was $5.26 million. This translates into $1250 greater cost per employee. Similar calculations were used to evaluate the effect of obesity on the amount eligible for payment per employee for hypertension, CAD, and cerebrovascular disease episodes, with an estimated $69, $89, and $8 greater cost, respectively, per employee.
Conclusion
Worksites with greater obesity prevalence rates were associated with numerically more frequent and more expensive episodes of care than worksites with low obesity prevalence.
PMCID: PMC4105722  PMID: 25126355
21.  Hospital Economics of Primary Total Knee Arthroplasty at a Teaching Hospital 
Background
The hospital cost of total knee arthroplasty (TKA) in the United States is a major growing expense for the Centers for Medicare & Medicaid Services (CMS). Many hospitals are unable to deliver TKA with profitable or breakeven economics under the current Diagnosis-Related Group (DRG) hospital reimbursement system.
Questions/purposes
The purposes of the current study were to (1) determine revenue, expenses, and profitability (loss) for TKA for all patients and for different payors; (2) define changes in utilization and unit costs associated with this operation; and (3) describe TKA cost control strategies to provide insight for hospitals to improve their economic results for TKA.
Results
From 1991 to 2009, Lahey Clinic converted a $2172 loss per case on primary TKA in 1991 to a $2986 profit per case in 2008. The improved economics was associated with decreasing revenue in inflation-adjusted dollars and implementation of hospital cost control programs that reduced hospital expenses for TKA. Reduction of hospital length of stay and reduction of knee implant costs were the major drivers of hospital expense reduction.
Conclusions
During the last 25 years, our economic experience with TKA is concerning. Hospital revenues have lagged behind inflation, hospital expenses have been reduced, and our institution is earning a profit. However, the margin for TKA is decreasing and Managed Medicare patients do not generate a profit. The erosion of hospital revenue for TKA will become a critical issue if it leads to economic losses for hospitals or reduced access to TKA.
Level of Evidence
Level III, Economic and Decision Analyses. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1486-2
PMCID: PMC3008872  PMID: 20694537
22.  Impact of clinical pharmacy services on renal transplant recipients’ adherence and outcomes 
The purpose of this article is to provide a description of a clinical pharmacy services program implemented in a renal transplant clinic to improve medication access and adherence as well as health and economic outcomes among renal transplant recipients (RTRs). Following a team-based planning process and an informal survey of RTRs, a clinical pharmacy service intervention was implemented in the Medical College of Georgia renal transplant clinic. As part of the intervention, a clinical pharmacist reviewed and optimized medication therapy, provided instructions on how to take medication, and assisted with enrollment into medication assistance programs. Significant differences were found between RTRs who did and did not receive clinical pharmacy services on measures of adherence, health, economics, and quality of life. Clinical pharmacy services, as described in this article, have a positive impact on renal transplant recipients’ medication adherence, health and economic outcomes, and health-related quality of life. The findings described here suggest that clinical pharmacy services are a viable and effective option for improving care for RTRs in an outpatient clinic setting.
PMCID: PMC2770420  PMID: 19920975
renal transplant recipients; immunosuppressant therapy adherence; health outcomes; economic outcomes
23.  The Impact of 5-HT3RA Use on Cost and Utilization in Patients with Chemotherapy-Induced Nausea and Vomiting: Systematic Review of the Literature 
American Health & Drug Benefits  2014;7(3):171-182.
Background
Individual studies have assessed the impact of standard prophylactic therapy with 5-hydroxytryptamine receptor antagonists (5-HT3RAs) for chemotherapy-induced nausea and vomiting (CINV) on cost and utilization, but no synthesis of the findings exists.
Objective
To systematically review published literature on costs and utilization associated with CINV prophylaxis with palonosetron and other 5-HT3RAs.
Methods
PubMed and the National Institute for Health Research Centre for Reviews and Dissemination databases, conferences of 4 organizations (ie, Academy of Managed Care Pharmacy, American Society of Clinical Oncology, International Society for Pharmacoeconomics and Outcomes Research, and Multinational Association of Supportive Care in Cancer), and the bibliographies of relevant articles were queried for the medical subject headings and key terms of “ondansetron,” “granisetron,” “palonosetron,” “dolasetron mesylate,” “costs,” “cost analysis,” and “economics.” We included records published (full-length articles after 1997 and conference presentations after 2010) in English and with human patients, reporting data on cost and utilization (rescue medication, outpatient and inpatient services) associated with the use of 5-HT3RAs for the treatment or prevention of CINV.
Results
Of the 434 identified studies, 32 are included in the current analysis: 7 studies report costs, 18 report utilization, and 7 studies report both. The costs are reported in US dollars (7 studies), in Euros (5 studies), and in Canadian dollars (2 studies). The studies vary in designs, patients, 5-HT3RA regimens, and the definition of outcomes. The US studies report higher drug costs for CINV prophylaxis with palonosetron compared with ondansetron, lower medical outpatient and inpatient costs for palonosetron versus other 5-HT3RAs, and higher acquisition costs for palonosetron versus ondansetron or other 5-HT3RAs. Fewer patients receiving palonosetron versus with ondansetron or other 5-HT3RAs required rescue medication or used outpatient or inpatient care. In Europe and in Canada, the total pharmacy costs and use of rescue medications reported are lower for patients receiving prophylaxis with palonosetron.
Conclusions
This analysis shows that prophylaxis with palonosetron for the treatment of CINV is associated with higher acquisition treatment costs, but also with lower use of rescue medications and outpatient and inpatient services compared with ondansetron or other 5-HT3RAs in the United States. Therefore, the use of palonosetron as a standard treatment may lead to reduced service utilization for CINV.
PMCID: PMC4070626  PMID: 24991400
24.  The cost of health professionals' brain drain in Kenya 
Background
Past attempts to estimate the cost of migration were limited to education costs only and did not include the lost returns from investment. The objectives of this study were: (i) to estimate the financial cost of emigration of Kenyan doctors to the United Kingdom (UK) and the United States of America (USA); (ii) to estimate the financial cost of emigration of nurses to seven OECD countries (Canada, Denmark, Finland, Ireland, Portugal, UK, USA); and (iii) to describe other losses from brain drain.
Methods
The costs of primary, secondary, medical and nursing schools were estimated in 2005. The cost information used in this study was obtained from one non-profit primary and secondary school and one public university in Kenya. The cost estimates represent unsubsidized cost. The loss incurred by Kenya through emigration was obtained by compounding the cost of educating a medical doctor and a nurse over the period between the average age of emigration (30 years) and the age of retirement (62 years) in recipient countries.
Results
The total cost of educating a single medical doctor from primary school to university is US$ 65,997; and for every doctor who emigrates, a country loses about US$ 517,931 worth of returns from investment. The total cost of educating one nurse from primary school to college of health sciences is US$ 43,180; and for every nurse that emigrates, a country loses about US$ 338,868 worth of returns from investment.
Conclusion
Developed countries continue to deprive Kenya of millions of dollars worth of investments embodied in her human resources for health. If the current trend of poaching of scarce human resources for health (and other professionals) from Kenya is not curtailed, the chances of achieving the Millennium Development Goals would remain bleak. Such continued plunder of investments embodied in human resources contributes to further underdevelopment of Kenya and to keeping a majority of her people in the vicious circle of ill-health and poverty. Therefore, both developed and developing countries need to urgently develop and implement strategies for addressing the health human resource crisis.
doi:10.1186/1472-6963-6-89
PMCID: PMC1538589  PMID: 16846492
25.  Partner for Promotion: An Innovative Advanced Community Pharmacy Practice Experience 
Objectives
To implement the Partner for Promotion (PFP) program which was designed to enhance the skills and confidence of students and community pharmacy preceptors to deliver and expand advanced patient care services in community pharmacies and also to assess the program's impact.
Design
A 10-month longitudinal community advanced pharmacy practice experience was implemented that included faculty mentoring of students and preceptors via formal orientation; face-to-face training sessions; online monthly meetings; feedback on service development materials; and a web site offering resources and a discussion board. Pre- and post-APPE surveys of students and preceptors were used to evaluate perceptions of knowledge and skills.
Assessment
The skills survey results for the first 2 years of the PFP program suggest positive changes occurring from pre- to post-APPE survey in most areas for both students and preceptors. Four of the 7 pharmacies in 2005-2006 and 8 of the 14 pharmacies in 2006-2007 were able to develop an advanced patient care service and begin seeing patients prior to the conclusion of the APPE. As a result of the PFP program from 2005-2007, 14 new experiential sites entered into affiliation agreements with The Ohio State University College of Pharmacy.
Conclusion
The PFP program offers an innovative method for community pharmacy faculty members to work with students and preceptors in community pharmacies in developing patient care services.
PMCID: PMC2661166  PMID: 19325954
community pharmacy; pharmaceutical services; administration; advanced pharmacy practice experience

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