Cost-benefit evaluation of routine influenza immunisation in people 65-74 years of age

OBJECTIVES: To determine the cost-effectiveness of influenza vaccination in people aged 65-74 years in the absence of co-morbidity. DESIGN: Primary research: randomised controlled trial. SETTING: Primary care. PARTICIPANTS: People without risk factors for influenza or contraindications to vaccination were identified from 20 general practitioner (GP) practices in Liverpool in September 1999 and invited to participate in the study. There were 5875/9727 (60.4%) people aged 65-74 years identified as potentially eligible and, of these, 729 (12%) were randomised. INTERVENTION: Participants were randomised to receive either influenza vaccine or placebo (ratio 3:1), with all individuals receiving pneumococcal vaccine unless administered in the previous 10 years. Of the 729 people randomised, 552 received vaccine and 177 received placebo; 726 individuals were administered pneumococcal vaccine. MAIN OUTCOME MEASURES AND METHODOLOGY OF ECONOMIC EVALUATION: GP attendance with influenza-like illness (ILI) or pneumonia (primary outcome measure); or any respiratory symptoms; hospitalisation with a respiratory illness; death; participant self-reported ILI; quality of life (QoL) measures at 2, 4 and 6 months post-study vaccination; adverse reactions 3 days after vaccination. A cost-effectiveness analysis was undertaken to identify the incremental cost associated with the avoidance of episodes of influenza in the vaccination population and an impact model was used to extrapolate the cost-effectiveness results obtained from the trial to assess their generalisability throughout the NHS. RESULTS: In England and Wales, weekly consultations for influenza and ILI remained at baseline levels (less than 50 per 100,000 population) until week 50/1999 and then increased rapidly, peaking during week 2/2000 with a rate of 231/100,000. This rate fell within the range of 'higher than expected seasonal activity' of 200-400/100,000. Rates then quickly declined, returning to baseline levels by week 5/2000. The predominant circulating strain during this period was influenza A (H3N2). Five (0.9%) people in the vaccine group were diagnosed by their GP with an ILI compared to two (1.1%) in the placebo group [relative risk (RR), 0.8; 95% confidence interval (CI) = 0.16 to 4.1]. No participants were diagnosed with pneumonia by their GP and there were no hospitalisations for respiratory illness in either group. Significantly fewer vaccinated individuals self-reported a single ILI (4.6% vs 8.9%, RR, 0.51; 95% CI for RR, 0.28 to 0.96). There was no significant difference in any of the QoL measurements over time between the two groups. Reported systemic side-effects showed no significant differences between groups. Local side-effects occurred with a significantly increased incidence in the vaccine group (11.3% vs 5.1%, p = 0.02). Each GP consultation avoided by vaccination was estimated from trial data to generate a net NHS cost of 174 pounds. CONCLUSIONS: No difference was seen between groups for the primary outcome measure, although the trial was underpowered to demonstrate a true difference. Vaccination had no significant effect on any of the QoL measures used, although vaccinated individuals were less likely to self-report ILI. The analysis did not suggest that influenza vaccination in healthy people aged 65-74 years would lead to lower NHS costs. Future research should look at ways to maximise vaccine uptake in people at greatest risk from influenza and also the level of vaccine protection afforded to people from different age and socio-economic populations.

Evaluation of field wetlands for mitigation of diffuse pollution from agriculture: sediment retention, cost and effectiveness

Diffuse pollution, and the contribution from agriculture in particular, has become increasingly important as pollution from point sources has been addressed by wastewater treatment. Land management approaches, such as construction of field wetlands, provide one group of mitigation options available to farmers. Although field wetlands are widely used for diffuse pollution control in temperate environments worldwide, there is a shortage of evidence for the effectiveness and viability of these mitigation options in the UK. The Mitigation Options for Phosphorus and Sediment Project aims to make recommendations regarding the design and effectiveness of field wetlands for diffuse pollution control in UK landscapes. Ten wetlands have been built on four farms in Cumbria and Leicestershire. This paper focuses on sediment retention within the wetlands, estimated from annual sediment surveys in the first two years, and discusses establishment costs. It is clear that the wetlands are effective in trapping a substantial amount of sediment. Estimates of annual sediment retention suggest higher trapping rates at sandy sites (0.5–6 t ha�1 yr�1), compared to silty sites (0.02–0.4 t ha�1 yr�1) and clay sites (0.01–0.07 t ha�1 yr�1). Establishment costs for the wetlands ranged from £280 to £3100 and depended more on site specific factors, such as fencing and gateways on livestock farms, rather than on wetland size or design. Wetlands with lower trapping rates would also have lower maintenance costs, as dredging would be required less frequently. The results indicate that field wetlands show promise for inclusion in agri-environment schemes, particularly if capital payments can be provided for establishment, to encourage uptake of these multi-functional features.

A low-cost wireless temperature sensor: evaluation for use in environmental applications

With a wide range of applications benefiting from dense network air temperature observations but with limitations of costs, existing siting guidelines and risk of damage to sensors, new methods are required to gain a high resolution understanding of the spatio-temporal patterns of urban meteorological phenomena such as the urban heat island or precision farming needs. With the launch of a new generation of low cost sensors it is possible to deploy a network to monitor air temperature at finer spatial resolutions. Here we investigate the Aginova Sentinel Micro (ASM) sensor with a bespoke radiation shield (together < US$150) which can provide secure near-real-time air temperature data to a server utilising existing (or user deployed) Wireless Fidelity (Wi-Fi) networks. This makes it ideally suited for deployment where wireless communications readily exist, notably urban areas. Assessment of the performance of the ASM relative to traceable standards in a water bath and atmospheric chamber show it to have good measurement accuracy with mean errors < ± 0.22 °C between -25 and 30 °C, with a time constant in ambient air of 110 ± 15 s. Subsequent field tests of it within the bespoke shield also had excellent performance (root-mean-square error = 0.13 °C) over a range of meteorological conditions relative to a traceable operational UK Met Office platinum resistance thermometer. These results indicate that the ASM and bespoke shield are more than fit-for-purpose for dense network deployment in urban areas at relatively low cost compared to existing observation techniques.

Efficient evaluation of highly oscillatory acoustic scattering surface integrals

We consider the approximation of some highly oscillatory weakly singular surface integrals, arising from boundary integral methods with smooth global basis functions for solving problems of high frequency acoustic scattering by three-dimensional convex obstacles, described globally in spherical coordinates. As the frequency of the incident wave increases, the performance of standard quadrature schemes deteriorates. Naive application of asymptotic schemes also fails due to the weak singularity. We propose here a new scheme based on a combination of an asymptotic approach and exact treatment of singularities in an appropriate coordinate system. For the case of a spherical scatterer we demonstrate via error analysis and numerical results that, provided the observation point is sufficiently far from the shadow boundary, a high level of accuracy can be achieved with a minimal computational cost.

An evaluation of the use of Cottonseed cake in the diet of growing pigs

An experiment was conducted to determine the effects of including cottonseed cake in rations for weaned growing pigs. Thirty-two Landrace x Large White pigs, weighing 20-24 kg, were included in four blocks formed on the basis of initial weight within sex in an otherwise completely randomized block design. The pigs were killed when they reached a live weight of 75.0 +/- 2.0 kg and the half careases were analysed into cuts and the weights of the organs were recorded. An estimate of the productivity of the pigs on each diet was calculated. Cottonseed cake reduced the voluntary feed intake (p < 0.001) and live weight gains (p < 0.001) and increased the heart, kidney and liver weights (p < 0.01). The pigs on the soya bean-based control diet took the shortest time to reach slaughter weight. The result was probably in part due to lysine deficiency and in part to the effect of free gossypol. It was found that it is at present cost-effective to include cottonseed cake in pig weaner grower diets up to 300 g/kg in Cameroon.

Predicting feed quality - chemical analysis and in vitro evaluation

As the ideal method of assessing the nutritive value of a feedstuff, namely offering it to the appropriate class of animal and recording the production response obtained, is neither practical nor cost effective a range of feed evaluation techniques have been developed. Each of these balances some degree of compromise with the practical situation against data generation. However, due to the impact of animal-feed interactions over and above that of feed composition, the target animal remains the ultimate arbitrator of nutritional value. In this review current in vitro feed evaluation techniques are examined according to the degree of animal-feed interaction. Chemical analysis provides absolute values and therefore differs from the majority of in vitro methods that simply rank feeds. However, with no host animal involvement, estimates of nutritional value are inferred by statistical association. In addition given the costs involved, the practical value of many analyses conducted should be reviewed. The in sacco technique has made a substantial contribution to both understanding rumen microbial degradative processes and the rapid evaluation of feeds, especially in developing countries. However, the numerous shortfalls of the technique, common to many in vitro methods, the desire to eliminate the use of surgically modified animals for routine feed evaluation, paralleled with improvements in in vitro techniques, will see this technique increasingly replaced. The majority of in vitro systems use substrate disappearance to assess degradation, however, this provides no information regarding the quantity of derived end-products available to the host animal. As measurement of volatile fatty acids or microbial biomass production greatly increases analytical costs, fermentation gas release, a simple and non-destructive measurement, has been used as an alternative. However, as gas release alone is of little use, gas-based systems, where both degradation and fermentation gas release are measured simultaneously, are attracting considerable interest. Alternative microbial inocula are being considered, as is the potential of using multi-enzyme systems to examine degradation dynamics. It is concluded that while chemical analysis will continue to form an indispensable part of feed evaluation, enhanced use will be made of increasingly complex in vitro systems. It is vital, however, the function and limitations of each methodology are fully understood and that the temptation to over-interpret the data is avoided so as to draw the appropriate conclusions. With careful selection and correct application in vitro systems offer powerful research tools with which to evaluate feedstuffs. (C) 2003 Elsevier B.V. All rights reserved.

An illustration of the modelling of cost and efficacy data from a clinical trial

Health care providers, purchasers and policy makers need to make informed decisions regarding the provision of cost-effective care. When a new health care intervention is to be compared with the current standard, an economic evaluation alongside an evaluation of health benefits provides useful information for the decision making process. We consider the information on cost-effectiveness which arises from an individual clinical trial comparing the two interventions. Recent methods for conducting a cost-effectiveness analysis for a clinical trial have focused on the net benefit parameter. The net benefit parameter, a function of costs and health benefits, is positive if the new intervention is cost-effective compared with the standard. In this paper we describe frequentist and Bayesian approaches to cost-effectiveness analysis which have been suggested in the literature and apply them to data from a clinical trial comparing laparoscopic surgery with open mesh surgery for the repair of inguinal hernias. We extend the Bayesian model to allow the total cost to be divided into a number of different components. The advantages and disadvantages of the different approaches are discussed. In January 2001, NICE issued guidance on the type of surgery to be used for inguinal hernia repair. We discuss our example in the light of this information. Copyright © 2003 John Wiley & Sons, Ltd.

An evaluation of the costs of making specific secondary metabolites: does the yield penalty incurred by host plant resistance to insects due to competition for resources?

The presumption that the synthesis of 'defence' compounds in plants must incur some 'trade-off' or penalty in terms of annual crop yields has been used to explain observed inverse correlations between resistance to herbivores and rates of growth or photosynthesis. An analysis of the cost of making secondary compounds suggests that this accounts for only a small part of the overall carbon budget of annual crop plants. Even the highest reported amounts of secondary metabolites found in different crop species (flavonoids, allylisothiocyanates, hydroxamic acids, 2-tridecanone) represent a carbon demand that can be satisfied by less than an hour's photosynthesis. Similar considerations apply to secondary compounds containing nitrogen or sulphur, which are unlikely to represent a major investment compared to the cost of making proteins, the major demand for these elements. Decreases in growth and photosynthesis in response to stress are more likely the result of programmed down-regulation. Observed correlations between yield and low contents of unpalatable or toxic compounds may be the result of parallel selection during the refinement of crop species by humans.

A system's model for maintenance support and decision making in building services systems

Modern buildings are designed to enhance the match between environment, spaces and the people carrying out work, so that the well-being and the performance of the occupants are all in harmony. Building services are systems that facilitate a healthy working environment within which workers productivity can be optimised in the buildings. However, the maintenance of these services is fraught with problems that may contribute to up to 50% of the total life cycle cost of the building. Maintenance support is one area which is not usually designed into the system as this is not common practice in the services industry. The other areas of shortfall for future designs are; client requirements, commissioning, facilities management data and post occupancy evaluation feedback which needs to be adequately planned to capture and document this information for use in future designs. At the University of Reading an integrated approach has been developed to assemble the multitude of aspects inherent in this field. The means records required and measured achievements for the benefit of both building owners and practitioners. This integrated approach can be represented in a Through Life Business Model (TLBM) format using the concept of Integrated Logistic Support (ILS). The prototype TLBM developed utilises the tailored tools and techniques of ILS for building services. This TLBM approach will facilitate the successful development of a databank that would be invaluable in capturing essential data (e.g. reliability of components) for enhancing future building services designs, life cycle costing and decision making by practitioners, in particular facilities managers.

Critical reliability issues for building services systems

This paper addresses two critical issues associated with reliability and maintenance of building services systems. The first is the ratio of operating and/or maintenance costs to initial costs for building services systems. It is an important parameter for life cycle costing and maintenance policy development. The second is the proportion of items among building services systems that need preventive maintenance. In this paper, we estimate the ratios based on a cost dataset. It suggests that correctly estimating the ratio be important but using a constant ratio in life cycle costing may result in wrong decisions. It also estimates the proportion of preventive maintenance for building services systems on the basis of the distribution of failure patterns.

Cost-effectiveness of a preventive counseling and support package for postnatal depression

Objectives: This study reports the cost-effectiveness of a preventive intervention, consisting of counseling and specific support for the mother-infant relationship, targeted at women at high risk of developing postnatal depression. Methods: A prospective economic evaluation was conducted alongside a pragmatic randomized controlled trial in which women considered at high risk of developing postnatal depression were allocated randomly to the preventive intervention (n = 74) or to routine primary care (n = 77). The primary outcome measure was the duration of postnatal depression experienced during the first 18 months postpartum. Data on health and social care use by women and their infants up to 18 months postpartum were collected, using a combination of prospective diaries and face-to-face interviews, and then were combined with unit costs ( pound, year 2000 prices) to obtain a net cost per mother-infant dyad. The nonparametric bootstrap method was used to present cost-effectiveness acceptability curves and net benefit statistics at alternative willingness to pay thresholds held by decision makers for preventing 1 month of postnatal depression. Results: Women in the preventive intervention group were depressed for an average of 2.21 months (9.57 weeks) during the study period, whereas women in the routine primary care group were depressed for an average of 2.70 months (11.71 weeks). The mean health and social care costs were estimated at 2,396.9 pound per mother-infant dyad in the preventive intervention group and 2,277.5 pound per mother-infant dyad in the routine primary care group, providing a mean cost difference of 119.5 pound (bootstrap 95 percent confidence interval [Cl], -535.4, 784.9). At a willingness to pay threshold of 1,000 pound per month of postnatal depression avoided, the probability that the preventive intervention is cost-effective is .71 and the mean net benefit is 383.4 pound (bootstrap 95 percent Cl, -863.3- pound 1,581.5) pound. Conclusions: The preventive intervention is likely to be cost-effective even at relatively low willingness to pay thresholds for preventing 1 month of postnatal depression during the first 18 months postpartum. Given the negative impact of postnatal depression on later child development, further research is required that investigates the longer-term cost-effectiveness of the preventive intervention in high risk women.

Predicting fault inflow in iterative software development processes: an industrial evaluation

This paper addresses the need for accurate predictions on the fault inflow, i.e. the number of faults found in the consecutive project weeks, in highly iterative processes. In such processes, in contrast to waterfall-like processes, fault repair and development of new features run almost in parallel. Given accurate predictions on fault inflow, managers could dynamically re-allocate resources between these different tasks in a more adequate way. Furthermore, managers could react with process improvements when the expected fault inflow is higher than desired. This study suggests software reliability growth models (SRGMs) for predicting fault inflow. Originally developed for traditional processes, the performance of these models in highly iterative processes is investigated. Additionally, a simple linear model is developed and compared to the SRGMs. The paper provides results from applying these models on fault data from three different industrial projects. One of the key findings of this study is that some SRGMs are applicable for predicting fault inflow in highly iterative processes. Moreover, the results show that the simple linear model represents a valid alternative to the SRGMs, as it provides reasonably accurate predictions and performs better in many cases.

Interventions to promote healthy eating habits: evaluation and recommendations

Although in several EU Member States many public interventions have been running for the prevention and/or management of obesity and other nutrition-related health conditions, few have yet been formally evaluated. The multidisciplinary team of the EATWELL project will gather benchmark data on healthy eating interventions in EU Member States and review existing information on the effectiveness of interventions using a three-stage procedure (i) Assessment of the intervention's impact on consumer attitudes, consumer behaviour and diets; (ii) The impact of the change in diets on obesity and health and (iii) The value attached by society to these changes, measured in life years gained, cost savings and quality-adjusted life years. Where evaluations have been inadequate, EATWELL will gather secondary data and analyse them with a multidisciplinary approach incorporating models from the psychology and economics disciplines. Particular attention will be paid to lessons that can be learned from private sector that are transferable to the healthy eating campaigns in the public sector. Through consumer surveys and workshops with other stakeholders, EATWELL will assess the acceptability of the range of potential interventions. Armed with scientific quantitative evaluations of policy interventions and their acceptability to stakeholders, EATWELL expects to recommend more appropriate interventions for Member States and the EU, providing a one-stop guide to methods and measures in interventions evaluation, and outline data collection priorities for the future.

PINCER trial: a cluster randomised trial comparing the effectiveness and cost-effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors in general practice are an important source of potentially preventable morbidity and mortality. Building on previous descriptive, qualitative and pilot work, we sought to investigate the effectiveness, cost-effectiveness and likely generalisability of a complex pharm acist-led IT-based intervention aiming to improve prescribing safety in general practice. Objectives: We sought to: • Test the hypothesis that a pharmacist-led IT-based complex intervention using educational outreach and practical support is more effective than simple feedback in reducing the proportion of patients at risk from errors in prescribing and medicines management in general practice. • Conduct an economic evaluation of the cost per error avoided, from the perspective of the National Health Service (NHS). • Analyse data recorded by pharmacists, summarising the proportions of patients judged to be at clinical risk, the actions recommended by pharmacists, and actions completed in the practices. • Explore the views and experiences of healthcare professionals and NHS managers concerning the intervention; investigate potential explanations for the observed effects, and inform decisions on the future roll-out of the pharmacist-led intervention • Examine secular trends in the outcome measures of interest allowing for informal comparison between trial practices and practices that did not participate in the trial contributing to the QRESEARCH database. Methods Two-arm cluster randomised controlled trial of 72 English general practices with embedded economic analysis and longitudinal descriptive and qualitative analysis. Informal comparison of the trial findings with a national descriptive study investigating secular trends undertaken using data from practices contributing to the QRESEARCH database. The main outcomes of interest were prescribing errors and medication monitoring errors at six- and 12-months following the intervention. Results: Participants in the pharmacist intervention arm practices were significantly less likely to have been prescribed a non-selective NSAID without a proton pump inhibitor (PPI) if they had a history of peptic ulcer (OR 0.58, 95%CI 0.38, 0.89), to have been prescribed a beta-blocker if they had asthma (OR 0.73, 95% CI 0.58, 0.91) or (in those aged 75 years and older) to have been prescribed an ACE inhibitor or diuretic without a measurement of urea and electrolytes in the last 15 months (OR 0.51, 95% CI 0.34, 0.78). The economic analysis suggests that the PINCER pharmacist intervention has 95% probability of being cost effective if the decision-maker’s ceiling willingness to pay reaches £75 (6 months) or £85 (12 months) per error avoided. The intervention addressed an issue that was important to professionals and their teams and was delivered in a way that was acceptable to practices with minimum disruption of normal work processes. Comparison of the trial findings with changes seen in QRESEARCH practices indicated that any reductions achieved in the simple feedback arm were likely, in the main, to have been related to secular trends rather than the intervention. Conclusions Compared with simple feedback, the pharmacist-led intervention resulted in reductions in proportions of patients at risk of prescribing and monitoring errors for the primary outcome measures and the composite secondary outcome measures at six-months and (with the exception of the NSAID/peptic ulcer outcome measure) 12-months post-intervention. The intervention is acceptable to pharmacists and practices, and is likely to be seen as costeffective by decision makers.