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1.  Diabetic retinopathy screening with pharmacy-based teleophthalmology in a semiurban setting: a cost-effectiveness analysis 
CMAJ Open  2016;4(1):E95-E102.
Diabetic eye complications are the leading cause of visual loss among working-aged people. Pharmacy-based teleophthalmology has emerged as a possible alternative to in-person examination that may facilitate compliance with evidence-based recommendations and reduce barriers to specialized eye care. The objective of this study was to estimate the cost-effectiveness of mobile teleophthalmology screening compared with in-person examination (primary care) for the diabetic population residing in semiurban areas of southwestern Ontario.
A decision tree was constructed to compare in-person examination (comparator program) versus pharmacy-based teleophthalmology (intervention program). The economic model was designed to identify patients with more than minimal diabetic retinopathy, manifested by at least 1 microaneurysm at examination (modified Airlie House classification grade of ≥ 20). Cost-effectiveness was assessed as cost per case detected (true-positive result) and cost per case correctly diagnosed (including true-positive and true-negative results).
The cost per case detected was $510 with in-person examination and $478 with teleophthalmology, and the cost per case correctly diagnosed was $107 and $102 respectively. The incremental cost-effectiveness ratio was $314 per additional case detected and $73 per additional case correctly diagnosed. Use of pharmacologic dilation and health care specialists' fees were the most important cost drivers.
The study showed that a compound teleophthalmology program in a semiurban community would be more effective but more costly than in-person examination. The findings raise the question of whether the benefits of pharmacy-based teleophthalmology in semiurban areas, where in-person examination is still available, are equivalent to those observed in remote communities. Further study is needed to investigate the impact of this program on the prevention of severe vision loss and quality of life in a semiurban setting.
PMCID: PMC4866927  PMID: 27280120
2.  The cost of providing methadone maintenance treatment in Ontario, Canada 
To estimate the cost of providing methadone maintenance treatment in Ontario, Canada, from the perspective of the public payer.
We analyzed a database of all patient clinic visits, laboratory tests for urine toxicology screening, and methadone scripts from a group of methadone clinics in Ontario. The database consisted of patient visits and visit information from January 1, 2003 to December 31, 2009. We estimated the cost of providing methadone maintenance treatment as the sum of physician costs, laboratory costs for urine samples (toxicology screens), methadone costs and pharmacy costs. Pharmacy costs include dispensing fees and markups. All costs are expressed in 2010 CAD.
The database consisted of 9479 unique patients. The average age on the date of the first recorded visit was 34.3 and 62.3% were male. There were 6,425,937 patient-days of treatment and the total cost of all treatment-related services was approximately $99,491,000. The total cost was comprised of physician billing (9.8%), pharmacy costs (39.8%), methadone (3.8%), and performing urine toxicology screens (46.7%). The average cost per day in treatment was $15.48, corresponding to $5651 per year if patients were to remain in treatment continuously.
The cost of providing methadone maintenance treatment in Ontario is comparable to estimates from the United States and Australia.
Scientific Significance
This information is important to policy makers for planning and budgeting purposes and as part of a full cost-benefit or cost-effectiveness analysis of methadone treatment.
PMCID: PMC3626407  PMID: 22783917
methadone; cost; electronic medical record
3.  Reducing Ambulance Diversion at Hospital and Regional Levels: Systemic Review of Insights from Simulation Models 
Optimal solutions for reducing diversion without worsening emergency department (ED) crowding are unclear. We performed a systematic review of published simulation studies to identify: 1) the tradeoff between ambulance diversion and ED wait times; 2) the predicted impact of patient flow interventions on reducing diversion; and 3) the optimal regional strategy for reducing diversion.
Data Sources: Systematic review of articles using MEDLINE, Inspec, Scopus. Additional studies identified through bibliography review, Google Scholar, and scientific conference proceedings. Study Selection: Only simulations modeling ambulance diversion as a result of ED crowding or inpatient capacity problems were included. Data extraction: Independent extraction by two authors using predefined data fields.
We identified 5,116 potentially relevant records; 10 studies met inclusion criteria. In models that quantified the relationship between ED throughput times and diversion, diversion was found to only minimally improve ED waiting room times. Adding holding units for inpatient boarders and ED-based fast tracks, improving lab turnaround times, and smoothing elective surgery caseloads were found to reduce diversion considerably. While two models found a cooperative agreement between hospitals is necessary to prevent defensive diversion behavior by a hospital when a nearby hospital goes on diversion, one model found there may be more optimal solutions for reducing region wide wait times than a regional ban on diversion.
Smoothing elective surgery caseloads, adding ED fast tracks as well as holding units for inpatient boarders, improving ED lab turnaround times, and implementing regional cooperative agreements among hospitals are promising avenues for reducing diversion.
PMCID: PMC3789914  PMID: 24106548
4.  Incentives for Optimal Multi-level Allocation of HIV Prevention Resources 
INFOR  2012;49(4):241-246.
HIV/AIDS prevention funds are often allocated at multiple levels of decision-making. Optimal allocation of HIV prevention funds maximizes the number of HIV infections averted. However, decision makers often allocate using simple heuristics such as proportional allocation. We evaluate the impact of using incentives to encourage optimal allocation in a two-level decision-making process. We model an incentive based decision-making process consisting of an upper-level decision maker allocating funds to a single lower-level decision maker who then distributes funds to local programs. We assume that the lower-level utility function is linear in the amount of the budget received from the upper-level, the fraction of funds reserved for proportional allocation, and the number of infections averted. We assume that the upper level objective is to maximize the number of infections averted. We illustrate with an example using data from California, U.S.
PMCID: PMC3678845  PMID: 23766551
HIV; AIDS; resource allocation; public policy
5.  Cost-effectiveness of a 21-gene recurrence score assay versus Canadian clinical practice in women with early-stage estrogen- or progesterone-receptor-positive, axillary lymph-node negative breast cancer 
BMC Cancer  2012;12:447.
A 21-gene recurrence score (RS) assay may inform adjuvant systematic treatment decisions in women with early stage breast cancer. We sought to investigate the cost effectiveness of using the RS-assay versus current clinical practice (CCP) in women with early-stage estrogen- or progesterone-receptor-positive, axilliary lymph-node negative breast cancer (ER+/ PR + LN- ESBC) from the perspective of the Canadian public healthcare system.
We developed a Markov model to project the lifetime clinical and economic consequences of ESBC. We evaluated adjuvant therapy separately in post- and pre-menopausal women with ER+/ PR + LN- ESBC. We assumed that the RS-assay would reclassify pre- and post-menopausal women among risk levels (low, intermediate and high) and guide adjuvant systematic treatment decisions. The model was parameterized using 7 year follow up data from the Manitoba Cancer Registry, cost data from Manitoba administrative databases, and secondary sources. Costs are presented in 2010 CAD. Future costs and benefits were discounted at 5%.
The RS-assay compared to CCP generated cost-savings in pre-menopausal women and had an ICER of $60,000 per QALY gained in post-menopausal women. The cost effectiveness was most sensitive to the proportion of women classified as intermediate risk by the RS-assay who receive adjuvant chemotherapy and the risk of relapse in the RS-assay model.
The RS-assay is likely to be cost effective in the Canadian healthcare system and should be considered for adoption in women with ER+/ PR + LN- ESBC. However, ongoing assessment and validation of the assay in real-world clinical practice is warranted.
PMCID: PMC3488327  PMID: 23031196
Breast cancer; Chemotherapy; Cost-effectiveness; 21-gene recurrence score assay
6.  Cost Effectiveness of Screening Strategies for Early Identification of HIV and HCV Infection in Injection Drug Users 
PLoS ONE  2012;7(9):e45176.
To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).
Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15–59).
We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).
Adding HIV and HCV viral RNA testing to antibody testing averts 14.8–30.3 HIV and 3.7–7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.
Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3–6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.
PMCID: PMC3445468  PMID: 23028828
7.  Randomized trial of distance-based treatment for young children with discipline problems seen in primary health care 
Family Practice  2012;30(1):14-24.
Many parents of preschool-age children have concerns about how to discipline their child but few receive help. We examined the effects of a brief treatment along with usual care, compared with receiving usual care alone.
Parents (N = 178) with concerns about their 2- to 5-year olds’ discipline were recruited when they visited their family physician at 1 of 24 practices.
After completing mailed baseline measures, parents were randomly assigned to receive usual care or the Parenting Matters intervention along with usual care. Parenting Matters combined a self-help booklet with two calls from a telephone coach during a 6-week treatment period. Follow-up assessments were completed at 7 weeks post-randomization, and 3 and 6 months later.
Behaviour problems (Eyberg Child Behaviour Inventory) decreased significantly more in the Parenting Matters condition compared with Usual Care alone, based on a significant time by treatment group effect in intent-to-treat, growth curve analyses (P = 0.033). The Parenting Matters group also demonstrated greater and more rapid improvement than in usual care alone in terms of overall psychopathology (Child Behaviour Checklist, P = 0.02), but there were no group differences in parenting. The overall magnitude of group differences was small (d = 0.15 or less).
A brief early intervention combining a self-help booklet and telephone coaching is an effective way to treat mild behaviour problems among young children. This minimal-contact approach addresses the need for interventions in primary health care settings and may be a useful component in step-care models of mental health.
PMCID: PMC3552315  PMID: 22948337
Behaviour problems; brief intervention; distance treatment; preschool-age children
8.  Cost-Effectiveness of Adding Cetuximab to Platinum-Based Chemotherapy for First-Line Treatment of Recurrent or Metastatic Head and Neck Cancer 
PLoS ONE  2012;7(6):e38557.
To assess the cost effectiveness of adding cetuximab to platinum-based chemotherapy in first-line treatment of patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) from the perspective of the Canadian public healthcare system.
We developed a Markov state transition model to project the lifetime clinical and economic consequences of recurrent or metastatic HNSCC. Transition probabilities were derived from a phase III trial of cetuximab in patients with recurrent or metastatic HNSCC. Cost estimates were obtained from London Health Sciences Centre and the Ontario Case Costing Initiative, and expressed in 2011 CAD. A three year time horizon was used. Future costs and health benefits were discounted at 5%.
In the base case, cetuximab plus platinum-based chemotherapy compared to platinum-based chemotherapy alone led to an increase of 0.093 QALY and an increase in cost of $36,000 per person, resulting in an incremental cost effectiveness ratio (ICER) of $386,000 per QALY gained. The cost effectiveness ratio was most sensitive to the cost per mg of cetuximab and the absolute risk of progression among patients receiving cetuximab.
The addition of cetuximab to standard platinum-based chemotherapy in first-line treatment of patients with recurrent or metastatic HNSCC has an ICER that exceeds $100,000 per QALY gained. Cetuximab can only be economically attractive in this patient population if the cost of cetuximab is substantially reduced or if future research can identify predictive markers to select patients most likely to benefit from the addition of cetuximab to chemotherapy.
PMCID: PMC3379991  PMID: 22745668
9.  Allocating funds for HIV/AIDS: a descriptive study of KwaDukuza, South Africa 
Health Policy and Planning  2010;26(1):33-42.
Objective Through a descriptive study, we determined the factors that influence the decision-making process for allocating funds to HIV/AIDS prevention and treatment programmes, and the extent to which formal decision tools are used in the municipality of KwaDukuza, South Africa.
Methods We conducted 35 key informant interviews in KwaDukuza. The interview questions addressed specific resource allocation issues while allowing respondents to speak openly about the complexities of the HIV/AIDS resource allocation process.
Results Donors have a large influence on the decision-making process for HIV/AIDS resource allocation. However, advocacy groups, governmental bodies and local communities also play an important role. Political power, culture and ethics are among a set of intangible factors that have a strong influence on HIV/AIDS resource allocation. Formal methods, including needs assessment, best practice approaches, epidemiologic modelling and cost-effectiveness analysis are sometimes used to support the HIV/AIDS resource allocation process. Historical spending patterns are an important consideration in future HIV/AIDS allocation strategies.
Conclusions Several factors and groups influence resource allocation in KwaDukuza. Although formal economic and epidemiologic information is sometimes used, in most cases other factors are more important for resource allocation decision-making. These other factors should be considered in any attempts to improve the resource allocation processes.
PMCID: PMC3119385  PMID: 20551138
Resource allocation; decision-making; priority setting; HIV/AIDS; South Africa
10.  The Cost Effectiveness of Counseling Strategies to Improve Adherence to Highly Active Antiretroviral Therapy (HAART) Among Men Who Have Sex with Men 
Inadequate adherence to highly active antiretroviral therapy (HAART) may lead to poor health outcomes and the development of HIV strains that are resistant to HAART. We developed a model to evaluate the cost effectiveness of counseling interventions to improve adherence to HAART among men who have sex with men (MSM).
We developed a dynamic compartmental model that incorporates HIV treatment, adherence to treatment, and infection transmission and progression. All data estimates were obtained from secondary sources. We evaluated a counseling intervention given prior to initiation of HAART and before all changes in drug regimens, combined with phone-in support while on HAART. We considered a moderate-prevalence and a high-prevalence population of MSM.
If the impact of HIV transmission is ignored, the counseling intervention has a cost-effectiveness ratio of $25,500 per QALY gained. When HIV transmission is included, the cost-effectiveness ratio is much lower: $7,400 and $8,700 per QALY gained in the moderate- and high-prevalence populations, respectively. When the intervention is twice as costly per counseling session and half as effective as we estimated (in terms of the number of individuals who become highly adherent, and who remain highly adherent), then the intervention costs $17,100 and $19,600 per QALY gained in the two populations, respectively.
Counseling to improve adherence to HAART increased length of life, modestly reduced HIV transmission, and cost substantially less than $50,000 per QALY gained over a wide range of assumptions, but did not reduce the proportion of drug-resistant strains. Such counseling provides only modest benefit as a tool for HIV prevention, but can provide significant benefit for individual patients at an affordable cost.
PMCID: PMC3243050  PMID: 18349433
Cost Effectiveness; Adherence; HIV; Counseling; Computer Simulation
11.  The impact of delays to admission from the emergency department on inpatient outcomes 
We sought to determine the impact of delays to admission from the Emergency Department (ED) on inpatient length of stay (LOS), and IP cost.
We conducted a retrospective analysis of 13,460 adult (≥ 18 yrs) ED visits between April 1 2006 and March 30 2007 at a tertiary care teaching hospital with two ED sites in which the mode of disposition was admission to ICU, surgery or inpatient wards. We defined ED Admission Delay as ED time to decision to admit > 12 hours. The primary outcomes were IP LOS, and total IP cost.
Approximately 11.6% (n = 1558) of admitted patients experienced admission delay. In multivariate analysis we found that admission delay was associated with 12.4% longer IP LOS (95% CI 6.6% - 18.5%) and 11.0% greater total IP cost (6.0% - 16.4%). We estimated the cumulative impact of delay on all delayed patients as an additional 2,183 inpatient days and an increase in IP cost of $2,109,173 at the study institution.
Delays to admission from the ED are associated with increased IP LOS and IP cost. Improving patient flow through the ED may reduce hospital costs and improve quality of care. There may be a business case for investments to reduce emergency department admission delays.
PMCID: PMC2912828  PMID: 20618934
12.  Optimal Investment in HIV Prevention Programs: More Is Not Always Better 
Health care management science  2009;12(1):27-37.
This paper develops a mathematical/economic framework to address the following question: Given a particular population, a specific HIV prevention program, and a fixed amount of funds that could be invested in the program, how much money should be invested? We consider the impact of investment in a prevention program on the HIV sufficient contact rate (defined via production functions that describe the change in the sufficient contact rate as a function of expenditure on a prevention program), and the impact of changes in the sufficient contact rate on the spread of HIV (via an epidemic model). In general, the cost per HIV infection averted is not constant as the level of investment changes, so the fact that some investment in a program is cost effective does not mean that more investment in the program is cost effective. Our framework provides a formal means for determining how the cost per infection averted changes with the level of expenditure. We can use this information as follows: When the program has decreasing marginal cost per infection averted (which occurs, for example, with a growing epidemic and a prevention program with increasing returns to scale), it is optimal either to spend nothing on the program or to spend the entire budget. When the program has increasing marginal cost per infection averted (which occurs, for example, with a shrinking epidemic and a prevention program with decreasing returns to scale), it may be optimal to spend some but not all of the budget. The amount that should be spent depends on both the rate of disease spread and the production function for the prevention program. We illustrate our ideas with two examples: that of a needle exchange program, and that of a methadone maintenance program.
PMCID: PMC2786080  PMID: 19938440
HIV/AIDS; Resource Allocation; HIV Prevention; Cost-Effectiveness Analysis
13.  The cost-effectiveness of Vancouver's supervised injection facility 
The cost-effectiveness of Canada's only supervised injection facility has not been rigorously evaluated. We estimated the impact of the facility on survival, rates of HIV and hepatitis C virus infection, referral to methadone maintenance treatment and associated costs.
We simulated the population of Vancouver, British Columbia, including injection drug users and persons infected with HIV and hepatitis C virus. The model used a time horizon of 10 years and the perspective of the health care system. We compared the situation of the supervised injection facility with one that had no facility but that had other interventions, such as needle-exchange programs. The effects considered were decreased needle sharing, increased use of safe injection practices and increased referral to methadone maintenance treatment. Outcomes included life-years gained, costs, and incremental cost-effectiveness ratios discounted at 5% per year.
Focusing on the base assumption of decreased needle sharing as the only effect of the supervised injection facility, we found that the facility was associated with an incremental net savings of almost $14 million and 920 life-years gained over 10 years. When we also considered the health effect of increased use of safe injection practices, the incremental net savings increased to more than $20 million and the number of life-years gained to 1070. Further increases were estimated when we considered all 3 health benefits: the incremental net savings was more than $18 million and the number of life-years gained 1175. Results were sensitive to assumptions related to injection frequency, the risk of HIV transmission through needle sharing, the frequency of safe injection practices among users of the facility, the costs of HIV-related care and of operating the facility, and the proportion of users who inject in the facility.
Vancouver's supervised injection site is associated with improved health and cost savings, even with conservative estimates of efficacy.
PMCID: PMC2582765  PMID: 19015565
14.  S4HARA: System for HIV/AIDS resource allocation 
HIV/AIDS resource allocation decisions are influenced by political, social, ethical and other factors that are difficult to quantify. Consequently, quantitative models of HIV/AIDS resource allocation have had limited impact on actual spending decisions. We propose a decision-support System for HIV/AIDS Resource Allocation (S4HARA) that takes into consideration both principles of efficient resource allocation and the role of non-quantifiable influences on the decision-making process for resource allocation.
S4HARA is a four-step spreadsheet-based model. The first step serves to identify the factors currently influencing HIV/AIDS allocation decisions. The second step consists of prioritizing HIV/AIDS interventions. The third step involves allocating the budget to the HIV/AIDS interventions using a rational approach. Decision-makers can select from several rational models of resource allocation depending on availability of data and level of complexity. The last step combines the results of the first and third steps to highlight the influencing factors that act as barriers or facilitators to the results suggested by the rational resource allocation approach. Actionable recommendations are then made to improve the allocation. We illustrate S4HARA in the context of a primary healthcare clinic in South Africa.
The clinic offers six types of HIV/AIDS interventions and spends US$750,000 annually on these programs. Current allocation decisions are influenced by donors, NGOs and the government as well as by ethical and religious factors. Without additional funding, an optimal allocation of the total budget suggests that the portion allotted to condom distribution be increased from 1% to 15% and the portion allotted to prevention and treatment of opportunistic infections be increased from 43% to 71%, while allocation to other interventions should decrease.
Condom uptake at the clinic should be increased by changing the condom distribution policy from a pull system to a push system. NGOs and donors promoting antiretroviral programs at the clinic should be sensitized to the results of the model and urged to invest in wellness programs aimed at the prevention and treatment of opportunistic infections. S4HARA differentiates itself from other decision support tools by providing rational HIV/AIDS resource allocation capabilities as well as consideration of the realities facing authorities in their decision-making process.
PMCID: PMC2386442  PMID: 18366800

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