Estimation de l'impact économique de l'introduction d'un test diagnostique rapide pour le dépistage des MRSA au CHUV

Contexte : Parmi les infections nosocomiales, le Staphylocoque méticilline résistant (MRSA) est le germe pathogène le plus couramment identifié dans les hôpitaux du monde entier. La stratégie de contrôle des MRSA au CHUV implique le dépistage des patients à risque. Avec la méthode de dépistage par culture, le temps d'attente est de plusieurs jours. Ceci occasionne des problèmes dans la gestion des flux des patients, principalement à cause des mesures d'isolement. Pour réduire le temps d'attente, l'hôpital envisage d'utiliser une méthode de diagnostic rapide par "polymerase chain reaction" (PCR). Méthodologie : Les données concernant les dépistages réalisés, dans trois services durant l'année 2007, ont été utilisées. Le nombre de jours d'isolement a d'abord été déterminé par patient et par service. Ensuite une analyse des coûts a été effectuée afin d'évaluer la différence des coûts entre les deux méthodes pour chaque service. Résultats : Le principal impact économique de la méthode par PCR dépend principalement du nombre de jours d'isolements évités par rapport à la méthode de culture. Aux services de soins, l'analyse a été menée sur 192 dépistages. Quand la différence de jours d'isolement est de deux jours, le coût des dépistages diminue de plus de 12kCHF et le nombre de jours d'isolement diminue de 384 jours. Au centre interdisciplinaire des urgences, sur 96 dépistages, le gain potentiel avec la méthode PCR est de 6kCHF avec une diminution de 192 jours d'isolement. Aux soins intensifs adultes, la méthode de dépistage par PCR est la méthode la plus rentable avec une diminution des coûts entre 4KCHF et 20K CHF et une diminution des jours d'isolement entre 170 et 310. Pour les trois services analysés, les résultats montrent un rapport coût-efficacité favorable pour la méthode PCR lorsque la diminution des jours d'isolement est supérieure à 1.3 jour. Quand la différence de jours d'isolement est inférieure à 1.3, il faut tenir compte d'autres paramètres, comme le coût de matériel qui doit être supérieur à 45.5 CHF, et du nombre d'analyses par dépistage, qui doit être inférieur à 3, pour que la PCR reste l'alternative la plus intéressante. Conclusions : La méthode par PCR montre des avantages potentiels importants, tant économiques qu'organisationnels qui limitent ou diminuent les contraintes liées à la stratégie de contrôle des MRSA au CHUV. [Auteure, p. 3]

Estimation des coûts engendrés par l'occupation inappropriée des lits de soins aigus du CHUV par des patients en attente de placement

[Table des matières] 1. Pourquoi s'intéresser à l'occupation inappropriée des lits de soins aigus au CHUV ?. - 1.1. Etat des lieux. - 1.1.1. Les chiffres du CHUV. - 1.1.2. La cellule de gestion des flux de patients. - 1.1.3. L'unité de patients en attente de placement. - 1.1.4. La pénurie de lits dans les EMS vaudois. - 1.1.5. Le vieillissement de la population vaudoise. - 1.2. Evidences nationales et internationales. - - 2. Estimation des coûts. - 2.1. Coûts chiffrables. - 2.1.1. Perte financière directe. - 2.1.2. Coûts des transferts pour engorgement. - 2.1.3. Coût d'opportunité. - 2.2. Coûts non chiffrables. - 2.2.1. Patients. - 2.2.2. Personnel médical. - 2.2.3. CHUV. - - 3. Propositions. - 3.1. Prises en charge alternatives. - 3.1.1. Les réseaux intégrés de services aux personnes âgées. - 3.1.2. Les courts séjours gériatriques. - 3.1.3. Autres solutions. - 3.2. Prévention. - 3.2.1. Prévention des chutes. - 3.2.2. La prévention par l'information aux personnes âgées. - 3.2.3. La prévention par l'information à l'ensemble de la population

Risk Management or Uncertainty Governance? The Challenge of an Interdiscplinary Approach

Peer-reviewed

Quantitative market and sales forecast accuracy analysis

The main objective of this master’s thesis was to quantitatively study the reliability of market and sales forecasts of a certain company by measuring bias, precision and accuracy of these forecasts by comparing forecasts against actual values. Secondly, the differences of bias, precision and accuracy between markets were explained by various macroeconomic variables and market characteristics. Accuracy and precision of the forecasts seems to vary significantly depending on the market that is being forecasted, the variable that is being forecasted, the estimation period, the length of the estimated period, the forecast horizon and the granularity of the data. High inflation, low income level and high year-on-year market volatility seems to be related with higher annual market forecast uncertainty and high year-on-year sales volatility with higher sales forecast uncertainty. When quarterly market size is forecasted, correlation between macroeconomic variables and forecast errors reduces. Uncertainty of the sales forecasts cannot be explained with macroeconomic variables. Longer forecasts are more uncertain, shorter estimated period leads to higher uncertainty, and usually more recent market forecasts are less uncertain. Sales forecasts seem to be more uncertain than market forecasts, because they incorporate both market size and market share risks. When lead time is more than one year, forecast risk seems to grow as a function of root forecast horizon. When lead time is less than year, sequential error terms are typically correlated, and therefore forecast errors are trending or mean-reverting. The bias of forecasts seems to change in cycles, and therefore the future forecasts cannot be systematically adjusted with it. The MASE cannot be used to measure whether the forecast can anticipate year-on-year volatility. Instead, we constructed a new relative accuracy measure to cope with this particular situation.

A correlation sensitivity analysis of non-life underwriting risk in solvency capital requirement estimation

This paper analyses the impact of using different correlation assumptions between lines of business when estimating the risk-based capital reserve, the Solvency Capital Requirement -SCR-, under Solvency II regulations. A case study is presented and the SCR is calculated according to the Standard Model approach. Alternatively, the requirement is then calculated using an Internal Model based on a Monte Carlo simulation of the net underwriting result at a one-year horizon, with copulas being used to model the dependence between lines of business. To address the impact of these model assumptions on the SCR we conduct a sensitivity analysis. We examine changes in the correlation matrix between lines of business and address the choice of copulas. Drawing on aggregate historical data from the Spanish non-life insurance market between 2000 and 2009, we conclude that modifications of the correlation and dependence assumptions have a significant impact on SCR estimation.

The permanence of the client under uncertain estimations

Marketing has studied the permanence of a client within an enterprise because it is a key element in the study of the value (economic) of the client (CLV). The research that they have developed is based in deterministic or random models, which allowed estimating the permanence of the client, and the CLV. However, when it is not possible to apply these schemes for not having the panel data that this model requires, the period of time of a client with the enterprise is uncertain data. We consider that the value of the current work is to have an alternative way to estimate the period of time with subjective information proper of the theory of uncertainty.

Models for the estimation of thermodynamic properties of layered double hydroxides: application to the study of their anion exchange characteristics

Several models for the estimation of thermodynamic properties of layered double hydroxides (LDHs) are presented. The predicted thermodynamic quantities calculated by the proposed models agree with experimental thermodynamic data. A thermodynamic study of the anion exchange process on LDHs is also made using the described models. Tables for the prediction of monovalent anion exchange selectivities on LDHs are provided. Reasonable agreement is found between the predicted and the experimental monovalent anion exchange selectivities.

Estimation of Water Circulation in a Mediterranean Salt Marsh and its Relationship with Flooding Causes

Variations in water volume in small depressions in Mediterranean salt marshes in Girona (Spain) are described and the potential causes for these variations analysed. Although the basins appear to be endorrheic, groundwater circulation is intense, as estimated from the difference between water volume observed and that expected from the balance precipitation / evaporation. The rate of variation in volume (VR = AV / VAt) may be used to estimate groundwater supply ('circulation'), since direct measurements of this parameter are impossible. Volume.conductivity figures can also be used to estimate the quantity of circulation, and to investigate the origin of water supplied to the system. The relationships between variations in the volume of water in the basins and the main causes of flooding are also analysed. Sea storms, rainfall levels and strong, dry northerly winds are suggested as the main causes of the variations in the volumes of basins. The relative importance assigned to these factors has changed, following the recent regulation of freshwater flows entering the system

Estimation of age- and stage-specific Catalan breast cancer survival functions using US and Catalan survival data

During the last part of the 1990s the chance of surviving breast cancer increased. Changes in survival functions reflect a mixture of effects. Both, the introduction of adjuvant treatments and early screening with mammography played a role in the decline in mortality. Evaluating the contribution of these interventions using mathematical models requires survival functions before and after their introduction. Furthermore, required survival functions may be different by age groups and are related to disease stage at diagnosis. Sometimes detailed information is not available, as was the case for the region of Catalonia (Spain). Then one may derive the functions using information from other geographical areas. This work presents the methodology used to estimate age- and stage-specific Catalan breast cancer survival functions from scarce Catalan survival data by adapting the age- and stage-specific US functions. Methods: Cubic splines were used to smooth data and obtain continuous hazard rate functions. After, we fitted a Poisson model to derive hazard ratios. The model included time as a covariate. Then the hazard ratios were applied to US survival functions detailed by age and stage to obtain Catalan estimations. Results: We started estimating the hazard ratios for Catalonia versus the USA before and after the introduction of screening. The hazard ratios were then multiplied by the age- and stage-specific breast cancer hazard rates from the USA to obtain the Catalan hazard rates. We also compared breast cancer survival in Catalonia and the USA in two time periods, before cancer control interventions (USA 1975–79, Catalonia 1980–89) and after (USA and Catalonia 1990–2001). Survival in Catalonia in the 1980–89 period was worse than in the USA during 1975–79, but the differences disappeared in 1990–2001. Conclusion: Our results suggest that access to better treatments and quality of care contributed to large improvements in survival in Catalonia. On the other hand, we obtained detailed breast cancer survival functions that will be used for modeling the effect of screening and adjuvant treatments in Catalonia

Cost estimation framework for modular product

Cost estimation is an important, but challenging process when designing a new product or a feature of it, verifying the product prices given by suppliers or planning a cost saving actions of existing products. It is even more challenging when the product is highly modular, not a bulk product. In general, cost estimation techniques can be divided into two main groups - qualitative and quantitative techniques - which can further be classified into more detailed methods. Generally, qualitative techniques are preferable when comparing alternatives and quantitative techniques when cost relationships can be found. The main objective of this thesis was to develop a method on how to estimate costs of internally manufactured and commercial elevator landing doors. Because of the challenging product structure, the proposed cost estimation framework is developed under three different levels based on past cost information available. The framework consists of features from both qualitative and quantitative cost estimation techniques. The starting point for the whole cost estimation process is an unambiguous, hierarchical product structure so that the product can be classified into controllable parts and is then easier to handle. Those controllable parts can then be compared to existing past cost knowledge of similar parts and create as accurate cost estimates as possible by that way.

Sampling in chemical analysis

The uncertainty of any analytical determination depends on analysis and sampling. Uncertainty arising from sampling is usually not controlled and methods for its evaluation are still little known. Pierre Gy’s sampling theory is currently the most complete theory about samplingwhich also takes the design of the sampling equipment into account. Guides dealing with the practical issues of sampling also exist, published by international organizations such as EURACHEM, IUPAC (International Union of Pure and Applied Chemistry) and ISO (International Organization for Standardization). In this work Gy’s sampling theory was applied to several cases, including the analysis of chromite concentration estimated on SEM (Scanning Electron Microscope) images and estimation of the total uncertainty of a drug dissolution procedure. The results clearly show that Gy’s sampling theory can be utilized in both of the above-mentioned cases and that the uncertainties achieved are reliable. Variographic experiments introduced in Gy’s sampling theory are beneficially applied in analyzing the uncertainty of auto-correlated data sets such as industrial process data and environmental discharges. The periodic behaviour of these kinds of processes can be observed by variographic analysis as well as with fast Fourier transformation and auto-correlation functions. With variographic analysis, the uncertainties are estimated as a function of the sampling interval. This is advantageous when environmental data or process data are analyzed as it can be easily estimated how the sampling interval is affecting the overall uncertainty. If the sampling frequency is too high, unnecessary resources will be used. On the other hand, if a frequency is too low, the uncertainty of the determination may be unacceptably high. Variographic methods can also be utilized to estimate the uncertainty of spectral data produced by modern instruments. Since spectral data are multivariate, methods such as Principal Component Analysis (PCA) are needed when the data are analyzed. Optimization of a sampling plan increases the reliability of the analytical process which might at the end have beneficial effects on the economics of chemical analysis,

Estimation of lung cancer diagnosis and treatment costs based on a patient-level analysis in Catalonia (Spain)

Background: Assessing of the costs of treating disease is necessary to demonstrate cost-effectiveness and to estimate the budget impact of new interventions and therapeutic innovations. However, there are few comprehensive studies on resource use and costs associated with lung cancer patients in clinical practice in Spain or internationally. The aim of this paper was to assess the hospital cost associated with lung cancer diagnosis and treatment by histology, type of cost and stage at diagnosis in the Spanish National Health Service. Methods: A retrospective, descriptive analysis on resource use and a direct medical cost analysis were performed. Resource utilisation data were collected by means of patient files from nine teaching hospitals. From a hospital budget impact perspective, the aggregate and mean costs per patient were calculated over the first three years following diagnosis or up to death. Both aggregate and mean costs per patient were analysed by histology, stage at diagnosis and cost type. Results: A total of 232 cases of lung cancer were analysed, of which 74.1% corresponded to non-small cell lung cancer (NSCLC) and 11.2% to small cell lung cancer (SCLC); 14.7% had no cytohistologic confirmation. The mean cost per patient in NSCLC ranged from 13,218 Euros in Stage III to 16,120 Euros in Stage II. The main cost components were chemotherapy (29.5%) and surgery (22.8%). Advanced disease stages were associated with a decrease in the relative weight of surgical and inpatient care costs but an increase in chemotherapy costs. In SCLC patients, the mean cost per patient was 15,418 Euros for limited disease and 12,482 Euros for extensive disease. The main cost components were chemotherapy (36.1%) and other inpatient costs (28.7%). In both groups, the Kruskall-Wallis test did not show statistically significant differences in mean cost per patient between stages. Conclusions: This study provides the costs of lung cancer treatment based on patient file reviews, with chemotherapy and surgery accounting for the major components of costs. This cost analysis is a baseline study that will provide a useful source of information for future studies on cost-effectiveness and on the budget impact of different therapeutic innovations in Spain.