Environmental, health and safety cost benefit analysis in the United States chemical industry

The purpose of this research project is to determine whether there is a cost/benefit to allocating financial and other company-related resources to improve environmental, health and safety performance beyond that which is required by law. The issue of whether a company benefits from spending dollars to achieve environmental, health and safety performance beyond legal compliance is an important issue to the chemical manufacturing industry in the United States because of the voluminous and complex legal requirements impacting environmental, health and safety expenditures. The cost/benefit issue has practical significance because many U.S. chemical manufacturing companies base their environmental, health and safety management strategies on just achieving and maintaining compliance with legal requirements when in reality this strategy may actually be a higher cost way of managing environmental, health and safety practices. This difference in environmental, health and safety management strategy is being investigated to determine if managing environmental, health and safety to achieve performance beyond that which is required by law results in a greater benefit to companies in the U.S. chemical manufacturing sector.

Cost-benefit analysis: The ``gold standard'' re-examined

The dissertation reviews the recommendations of the Panel on Cost Effectiveness in Health and Medicine (Panel) convened by the US Public Health Service in 1993 in four areas: aggregation of costs and benefits, methods of estimating resources used, definition of population impacted and perspective used in cost benefit analysis. Financial data from a clinical trial was used to test whether different approaches in each of the above four areas would change the net benefit resulting from a cost benefit analysis. Differences in aggregation of cost and benefit resulted in the same net benefit, but not the same cost/benefit ratios. Differences in resource use estimation methods, population subgroups definitions and perspectives all produced different net benefits. Difference in perspective resulted in different and often opposing decisions as to whether the proposed intervention from the clinical trial should be implemented. ^

Policy analysis of iron micronutrient programs at USAID: The FANTA program in East Africa and the micronutrient initiative in Bihar region of India, using comparative cost effective and cost benefit analysis

It is the aim of this paper to examine iron supplementation programs which receive funding from United States Agency for International Development (USAID) but approach combating iron deficiency anemia in two vastly different ways. A brief literature review and background information on iron deficiencies and the differences between supplementation programs and micronutrient fortification were reviewed. Two non-governmental organizations (NGO's) were examined for this paper: the Food and Nutrition Technical Assistance II (FANTA) and the MicroNutrient Initiative. The FANTA program included an educational component to their supplementation program while the MicroNutrient Initiative solely used supplementation of micronutrients to their population. Methods used were cost-benefit analysis and cost-effectiveness analysis to determine the overall effectiveness of each program in reducing iron deficiency anemia in each population, if the added costs of the incentives in the FANTA program changed the cost-effectiveness of the program compared to the MicroNutrient Initiative program and to determine which program imparted the greatest benefit to each population by reducing the disease burden in Disability Adjusted Life Years (DALY). Results showed that the unit cost of the FANTA program per person was higher than the MicroNutrient Initiative program due to the educational component. The FANTA program reduced iron deficiency anemia less overall but cost less for each percentage point of anemia decreased in their respective populations. The MicroNutrient Initiative program had a better benefit cost ratio for the populations it served. The MicroNutrient Initiative's large scale program imparted many advantages by reducing unit cost per person and decreasing iron deficiency anemia. The FANTA program was more effective at decreasing iron deficiency anemia with less money: $5,660 per 1% decrease in iron deficiency anemia versus $18,450 per 1% decrease in iron deficiency anemia for the MicroNutrient Initiative program. ^ In conclusion, economic analysis cannot measure all of the benefits associated with programs that contain an educational component or large scale supplementation. More information needs to be gathered by NGOs and reported to USAID, such as detailed prevalence rates of iron deficiency anemia among the populations served. Further research is needed to determine the effects an educational supplementation program has on compliance rates of participants and motivation to participate in supplementation programs whose aim is to decrease iron deficiency anemia in a targeted population.^

The evolution and assessment of pharmaceutical care: Structure, processes, and outcomes

The evolution of pharmaceutical care is identified through a complete review of the literature published in the American Journal of Health-System Pharmacy, the sole comprehensive publication of institutional pharmacy practice. The evolution is categorized according to characteristics of structure (organizational structure, the role of the pharmacist), process (drug delivery systems, formulary management, acquiring drug products, methods to impact drug therapy decisions), and outcomes (cost of drug delivery, cost of drug acquisition and use, improved safety, improved health outcomes) recorded from the 1950s through the 1990s. While significant progress has been made in implementing basic drug distribution systems, levels of pharmacy involvement with direct patient care is still limited.^ A new practice framework suggests enhanced direct patient care involvement through increase in the efficiency and effectiveness of traditional pharmacy services. Recommendations advance internal and external organizational structure relationships that position pharmacists to fully use their unique skills and knowledge to impact drug therapy decisions and outcomes. Specific strategies facilitate expansion of the breadth and scope of each process component in order to expand the depth of integration of pharmacy and pharmaceutical care within the broad healthcare environment. Economic evaluation methods formally evaluate the impact of both operational and clinical interventions.^ Outcome measurements include specific recommendations and methods to increase efficiency of drug acquisition, emphasizing pharmacists' roles that impact physician prescribing decisions. Effectiveness measures include those that improve safety of drug distribution systems, decrease the potential of adverse drug therapy events, and demonstrate that pharmaceutical care can significantly contribute to improvement in overall health status.^ The implementation of the new framework is modeled on a case study at the M.D. Anderson Cancer Center. The implementation of several new drug distribution methods facilitated the redeployment of personnel from distributive functions to direct patient care activities with significant personnel and drug cost reduction. A cost-benefit analysis illustrates that framework process enhancements produced a benefit-to-cost ratio of 7.9. In addition, measures of effectiveness demonstrated significant levels of safety and enhanced drug therapy outcomes. ^

A MANAGEMENT INFORMATION SYSTEM AND EVALUATION SCHEME FOR THE UNIVERSITY OF TEXAS EMPLOYEE ASSISTANCE PROGRAMS

Early Employee Assistance Programs (EAPs) had their origin in humanitarian motives, and there was little concern for their cost/benefit ratios; however, as some programs began accumulating data and analyzing it over time, even with single variables such as absenteeism, it became apparent that the humanitarian reasons for a program could be reinforced by cost savings particularly when the existence of the program was subject to justification.^ Today there is general agreement that cost/benefit analyses of EAPs are desirable, but the specific models for such analyses, particularly those making use of sophisticated but simple computer based data management systems, are few.^ The purpose of this research and development project was to develop a method, a design, and a prototype for gathering managing and presenting information about EAPS. This scheme provides information retrieval and analyses relevant to such aspects of EAP operations as: (1) EAP personnel activities, (2) Supervisory training effectiveness, (3) Client population demographics, (4) Assessment and Referral Effectiveness, (5) Treatment network efficacy, (6) Economic worth of the EAP.^ This scheme has been implemented and made operational at The University of Texas Employee Assistance Programs for more than three years.^ Application of the scheme in the various programs has defined certain variables which remained necessary in all programs. Depending on the degree of aggressiveness for data acquisition maintained by program personnel, other program specific variables are also defined. ^

Should Texas use public funding for bariatric surgery?

Background. Obesity in America has increased exponentially since the 1970s with no sign of slowing down. It is a major public health problem, and is currently the second leading cause of preventable deaths in America (Flegal et al., 2010). Bariatric surgery is currently the only approved therapy that has shown to have a lasting impact on obese patients. While the initial cost of the surgery remains high, numerous cost-benefit analyses have demonstrated an overall cost saving within two to five years (McEwen et al., 2010). Only three states, including Texas, do not currently fund bariatric surgery through Medicare and Medicaid. ^ Objectives. To determine whether the current data on the cost-benefit analysis of bariatric surgery supports Texas' decision to not publicly fund bariatric surgery through its Medicare and Medicaid programs. ^ Methods. We conducted literature reviews to determine the current cost of obesity in Texas as well as the methods being employed to treat obesity currently. We then analyzed the history of bariatric surgery and its current implementation, looking at safety and the future benefits of bariatric surgery. We then looked at key cost-benefit analyses and meta-analyses to determine the cost effectiveness of bariatric surgery. We then analyzed both direct medical expenditures and indirect benefits of bariatric surgery. ^ Conclusions. If the obesity epidemic continues unabated, it will become one of the leading health expenditures in Texas within decades. Given that surgery is currently the only approved therapy for obesity that has been shown to be effective in the majority of patients, Texas' decision not to publicly fund bariatric surgery is short sighted.^

The Colic Clinic---a comprehensive program evaluation

Child abuse correlated with excessive infant crying affects millions of families each year, with consequences of the abuse lasting a lifetime. The University Of Texas School Of Medicine's Colic Clinic is currently in the early stages of testing Dr. Harvey Karp's combinatorial soothing technique for infants called "The Happiest Baby on the Block". In order to gauge the program's potential effectiveness, the Colic Clinic Protocol was examined in order to assess the applicability of the intervention to known causal factors of child abuse associated with excessive infant crying. ^ This evaluation also carried out an anticipated cost-benefit breakout analysis for the implementation of the intervention for 100 children and compared the cost of the program implementation to the cost associated with a single instance of child abuse. The analysis revealed that while accounting for materials, advertising, salaried personnel and other overhead expenses, the cost to implement the intervention was less than half the cost of the medical treatment associated with a single victim of whiplash-shaken infant syndrome. ^ Although the program is still in its early evaluative phase, the future implications of this work are extensive. If this intervention is revealed to be relevant and cost effective, it will precipitate sweeping changes in medical education and training, public health detection and prevention programs, and law enforcement.^

Indigent care and infant mortality in Texas

Infant Mortality has been made a point of emphasis by the Department of Health and Human Services in the Healthy People 2000, 2010, and 2020 priorities. This study used the Behavioral Model for Vulnerable Populations to consider a number of factors which impact infant mortality in the indigent populations in the State of Texas. The primary focus of this study was the enabling factor of community resources, specifically the program used by each county to provide care to their indigent population. The Legislature of the State of Texas requires that each state have a program set up within a Hospital District, Public Hospital or develop a County Indigent Health Care Program (CIHCP) in order to provide the basic health care needs of their most vulnerable residents. We sought to determine whether the development of a CICHP without an appointed hospital to provide the care would have an adverse effect on residents seeking care and increase infant mortality. A Poisson Regression Analysis was used to analyze incidence rate ratios adjusting for race/ethnicity and wealth/poverty variables. Our study showed that counties using a CIHCP had significantly lower infant mortality rates when compared to counties using a hospital district and were statistically equivalent to counties using a public hospital program or a combination of service programs. This relationship was maintained when adjusted incidence rate ratios were calculated. This may give evidence that counties struggling to fund a public hospital or hospital district may be able to find a more cost-effective alternative in the CIHCP without adversely affecting the health status of their residents. More cost-benefit analysis and controlling analysis must be done to further characterize this relationship. ^

Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

Improving the Quality of Life of spousal caregivers of stroke survivors: A cost effectiveness analysis

Back ground and Purpose. There is a growing consensus among health care researchers that Quality of Life (QoL) is an important outcome and, within the field of family caregiving, cost effectiveness research is needed to determine which programs have the greatest benefit for family members. This study uses a multidimensional approach to measure the cost effectiveness of a multicomponent intervention designed to improve the quality of life of spousal caregivers of stroke survivors. Methods. The CAReS study (Committed to Assisting with Recovery after Stroke) was a 5-year prospective, longitudinal intervention study for 159 stroke survivors and their spousal caregivers upon discharge of the stroke survivor from inpatient rehabilitation to their home. CAReS cost data were analyzed to determine the incremental cost of the intervention per caregiver. The mean values of the quality-of-life predictor variables of the intervention group of caregivers were compared to the mean values of usual care groups found in the literature. Significant differences were then divided into the cost of the intervention per caregiver to calculate the incremental cost effectiveness ratio for each predictor variable. Results. The cost of the intervention per caregiver was approximately $2,500. Statistically significant differences were found between the mean scores for the Perceived Stress and Satisfaction with Life scales. Statistically significant differences were not found between the mean scores for the Self Reported Health Status, Mutuality, and Preparedness scales. Conclusions. This study provides a prototype cost effectiveness analysis on which researchers can build. Using a multidimensional approach to measure QoL, as used in this analysis, incorporates both the subjective and objective components of QoL. Some of the QoL predictor variable scores were significantly different between the intervention and comparison groups, indicating a significant impact of the intervention. The estimated cost of the impact was also examined. In future studies, a scale that takes into account both the dimensions and the weighting each person places on the dimensions of QoL should be used to provide a single QoL score per participant. With participant level cost and outcome data, uncertainty around each cost-effectiveness ratio can be calculated using the bias-corrected percentile bootstrapping method and plotted to calculate the cost-effectiveness acceptability curves.^