A cost-effectiveness analysis of fluvastatin in patients with diabetes after successful percutaneous coronary intervention

Background: The Lescol Intervention Prevention Study (LIPS) was a multinational randomized controlled trial that showed a 47% reduction in the relative risk of cardiac death and a 22% reduction in major adverse cardiac events (MACEs) from the routine use of fluvastatin, compared with controls, in patients undergoing percutaneous coronary intervention (PCI, defined as angioplasty with or without stents). In this study, MACEs included cardiac death, nonfatal myocardial infarction, and subsequent PCI and coronary artery bypass graft. Diabetes was the greatest risk factor for MACEs. Objective: This study estimated the cost-effectiveness of fluvastatin when used for secondary prevention of MACEs after PCI in people with diabetes. Methods: A post hoc subgroup analysis of patients with diabetes from the LIPS was used to estimate the effectiveness of fluvastatin in reducing myocardial infarction, revascularization, and cardiac death. A probabilistic Markov model was developed using United Kingdom resource and cost data to estimate the additional costs and quality-adjusted life-years (QALYs) gained over 10 years from the perspective of the British National Health Service. The model contained 6 health states, and the transition probabilities were derived from the LIPS data. Crossover from fluvastatin to other lipid-lowering drugs, withdrawal from fluvastatin, and the use of lipid-lowering drugs in the control group were included. Results: In the subgroup of 202 patients with diabetes in the LIPS trial, 18 (15.0%) of 120 fluvastatin patients and 21 (25.6%) of 82 control participants were insulin dependent (P = NS). Compared with the control group, patients treated with fluvastatin can expect to gain an additional mean (SD) of 0.196 (0.139) QALY per patient over 10 years (P < 0.001) and will cost the health service an additional mean (SD) of 10 (E448) (P = NS) (mean [SD] US $16 [$689]). The additional cost per QALY gained was;(51 (US $78). The key determinants of cost-effectiveness included the probabilities of repeat interventions, cardiac death, the cost of fluvastatin, and the time horizon used for the evaluation. Conclusion: Fluvastatin was an economically efficient treatment to prevent MACEs in these patients with diabetes undergoing PCI.

Assessing cost-effectiveness of drug interventions for schizophrenia

Objective: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia. Method: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered. Results: Replacing oral typicals with risperidone or olanzapine has an incremental cost-effectiveness ratio (ICER) of A$48 000 and A$92 000/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of A$80 000. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at A$20 000. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at A$42 000 or A$23 000/DALY respectively. The least cost-effective intervention is to replace risperidone with olanzapine at A$160 000/DALY. Conclusions: Based on an A$50 000/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

Development of an intelligent quality management system using fuzzy association rules

In order to survive in the increasingly customer-oriented marketplace, continuous quality improvement marks the fastest growing quality organization’s success. In recent years, attention has been focused on intelligent systems which have shown great promise in supporting quality control. However, only a small number of the currently used systems are reported to be operating effectively because they are designed to maintain a quality level within the specified process, rather than to focus on cooperation within the production workflow. This paper proposes an intelligent system with a newly designed algorithm and the universal process data exchange standard to overcome the challenges of demanding customers who seek high-quality and low-cost products. The intelligent quality management system is equipped with the ‘‘distributed process mining” feature to provide all levels of employees with the ability to understand the relationships between processes, especially when any aspect of the process is going to degrade or fail. An example of generalized fuzzy association rules are applied in manufacturing sector to demonstrate how the proposed iterative process mining algorithm finds the relationships between distributed process parameters and the presence of quality problems.

Prioritizing tropical habitats for long-distance migratory songbirds: an assessment of habitat quality at a stopover site in Colombia

Long-distance migratory birds are declining globally and migration has been identified as the primary source of mortality in this group. Despite this, our lack of knowledge of habitat use and quality at stopovers, i.e., sites where the energy for migration is accumulated, remains a barrier to designing appropriate conservation measures, especially in tropical regions. There is therefore an urgent need to assess stopover habitat quality and concurrently identify efficient and cost-effective methods for doing so. Given that fuel deposition rates directly influence stopover duration, departure fuel load, and subsequent speed of migration, they are expected to provide a direct measure of habitat quality and have the advantage of being measurable through body-mass changes. Here, we examined seven potential indicators of quality, including body-mass change, for two ecologically distinct Neotropical migratory landbirds on stopover in shade-coffee plantations and tropical humid premontane forest during spring migration in Colombia: (1) rate of body-mass change; (2) foraging rate; (3) recapture rate; (4) density; (5) flock size; (6) age and sex ratios; and (7) body-mass distribution. We found higher rates of mass change in premontane forest than in shade-coffee in Tennessee Warbler Oreothlypis peregrina, a difference that was mirrored in higher densities and body masses in forest. In Gray-cheeked Thrush Catharus minimus, a lack of recaptures in shade-coffee and higher densities in forest, also suggested that forest provided superior fueling conditions. For a reliable assessment of habitat quality, we therefore recommend using a suite of indicators, taking into account each species’ ecology and methodological considerations. Our results also imply that birds stopping over in lower quality habitats may spend a longer time migrating and require more stopovers, potentially leading to important carryover effects on reproductive fitness. Evaluating habitat quality is therefore imperative prior to defining the conservation value of newly identified stopover regions.

Cost-effectiveness of zoledronic acid and strontium-89 as bone protecting treatments in addition to chemotherapy in patients with metastatic castrate-refractory prostate cancer: results from the TRAPEZE trial (ISRCTN 12808747)

OBJECTIVE: To evaluate the cost-effectiveness of adding zoledronic acid or strontium-89 to standard docetaxel chemotherapy for patients with castrate-refractory prostate cancer (CRPC).

PATIENTS AND METHODS: Data on resource use and quality of life for 707 patients collected prospectively in the TRAPEZE 2 × 2 factorial randomised trial (ISRCTN 12808747) were used to assess the cost-effectiveness of i) zoledronic acid versus no zoledronic acid (ZA vs. no ZA), and ii) strontium-89 versus no strontium-89 (Sr89 vs. no Sr89). Costs were estimated from the perspective of the National Health Service in the UK and included expenditures for trial treatments, concomitant medications, and use of related hospital and primary care services. Quality-adjusted life-years (QALYs) were calculated according to patients' responses to the generic EuroQol EQ-5D-3L instrument, which evaluates health status. Results are expressed as incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves.

RESULTS: The per-patient cost for ZA was £12 667, £251 higher than the equivalent cost in the no ZA group. Patients in the ZA group had on average 0.03 QALYs more than their counterparts in no ZA group. The ICER for this comparison was £8 005. Sr89 was associated with a cost of £13 230, £1365 higher than no Sr89, and a gain of 0.08 QALYs compared to no Sr89. The ICER for Sr89 was £16 884. The probabilities of ZA and Sr89 being cost-effective were 0.64 and 0.60, respectively.

CONCLUSIONS: The addition of bone-targeting treatments to standard chemotherapy led to a small improvement in QALYs for a modest increase in cost (or cost-savings). ZA and Sr89 resulted in ICERs below conventional willingness-to-pay per QALY thresholds, suggesting that their addition to chemotherapy may represent a cost-effective use of resources.

Effectiveness and Cost-effectiveness of Outpatient Physiotherapy After Knee Replacement for Osteoarthritis: Study Protocol for a Randomised Controlled Trial

Background: Primary total knee replacement is a common operation that is performed to provide pain relief and restore functional ability. Inpatient physiotherapy is routinely provided after surgery to enhance recovery prior to hospital discharge. However, international variation exists in the provision of outpatient physiotherapy after hospital discharge. While evidence indicates that outpatient physiotherapy can improve short-term function, the longer term benefits are unknown. The aim of this randomised controlled trial is to evaluate the long-term clinical effectiveness and cost-effectiveness of a 6-week group-based outpatient physiotherapy intervention following knee replacement. Methods/design: Two hundred and fifty-six patients waiting for knee replacement because of osteoarthritis will be recruited from two orthopaedic centres. Participants randomised to the usual-care group (n = 128) will be given a booklet about exercise and referred for physiotherapy if deemed appropriate by the clinical care team. The intervention group (n = 128) will receive the same usual care and additionally be invited to attend a group-based outpatient physiotherapy class starting 6 weeks after surgery. The 1-hour class will be run on a weekly basis over 6 weeks and will involve task-orientated and individualised exercises. The primary outcome will be the Lower Extremity Functional Scale at 12 months post-operative. Secondary outcomes include: quality of life, knee pain and function, depression, anxiety and satisfaction. Data collection will be by questionnaire prior to surgery and 3, 6 and 12 months after surgery and will include a resource-use questionnaire to enable a trial-based economic evaluation. Trial participation and satisfaction with the classes will be evaluated through structured telephone interviews. The primary statistical and economic analyses will be conducted on an intention-to-treat basis with and without imputation of missing data. The primary economic result will estimate the incremental cost per quality-adjusted life year gained from this intervention from a National Health Services (NHS) and personal social services perspective. Discussion: This research aims to benefit patients and the NHS by providing evidence on the long-term effectiveness and cost-effectiveness of outpatient physiotherapy after knee replacement. If the intervention is found to be effective and cost-effective, implementation into clinical practice could lead to improvement in patients’ outcomes and improved health care resource efficiency.

An Empirical Analysis of Manufacturing Overhead Cost Drivers

Empirical validity of the claim that overhead costs are driven not by production volume but by transactions resulting from production complexity is examined using data from 32 manufacturing plants from the electronics, machinery, and automobile components industries. Transactions are measured using number of engineering change orders, number of purchasing and production planning personnel, shop- floor area per part, and number of quality control and improvement personnel. Results indicate a strong positive relation between manufacturing overhead costs and both manufacturing transactions and production volume. Most of the variation in overhead costs, however, is explained by measures of manufacturing transactions, not volume.

Preparation of environmental monitoring plan pattern for surface water quality in Iran (Case study: Gharehsou River)

Using water quality management programs is a necessary and inevitable way for preservation and sustainable use of water resources. One of the important issues in determining the quality of water in rivers is designing effective quality control networks, so that the measured quality variables in these stations are, as far as possible, indicative of overall changes in water quality. One of the methods to achieve this goal is increasing the number of quality monitoring stations and sampling instances. Since this will dramatically increase the annual cost of monitoring, deciding on which stations and parameters are the most important ones, along with increasing the instances of sampling, in a way that shows maximum change in the system under study can affect the future decision-making processes for optimizing the efficacy of extant monitoring network, removing or adding new stations or parameters and decreasing or increasing sampling instances. This end, the efficiency of multivariate statistical procedures was studied in this thesis. Multivariate statistical procedure, with regard to its features, can be used as a practical and useful method in recognizing and analyzing rivers’ pollution and consequently in understanding, reasoning, controlling, and correct decision-making in water quality management. This research was carried out using multivariate statistical techniques for analyzing the quality of water and monitoring the variables affecting its quality in Gharasou river, in Ardabil province in northwest of Iran. During a year, 28 physical and chemical parameters were sampled in 11 stations. The results of these measurements were analyzed by multivariate procedures such as: Cluster Analysis (CA), Principal Component Analysis (PCA), Factor Analysis (FA), and Discriminant Analysis (DA). Based on the findings from cluster analysis, principal component analysis, and factor analysis the stations were divided into three groups of highly polluted (HP), moderately polluted (MP), and less polluted (LP) stations Thus, this study illustrates the usefulness of multivariate statistical techniques for analysis and interpretation of complex data sets, and in water quality assessment, identification of pollution sources/factors and understanding spatial variations in water quality for effective river water quality management. This study also shows the effectiveness of these techniques for getting better information about the water quality and design of monitoring network for effective management of water resources. Therefore, based on the results, Gharasou river water quality monitoring program was developed and presented.

Social/economic costs and health-related quality of life in patients with epidermolysis bullosa in Europe

BACKGROUND: The aim of this study was to determine the social/economic costs and health-related quality of life (HRQOL) of patients with epidermolysis bullosa (EB) in eight EU member states. METHODS: We conducted a cross-sectional study of patients with EB from Bulgaria, France, Germany, Hungary, Italy, Spain, Sweden and the United Kingdom. Data on demographic characteristics, health resource utilisation, informal care, labour productivity losses, and HRQOL were collected from the questionnaires completed by patients or their caregivers. HRQOL was measured with the EuroQol 5-domain (EQ-5D) questionnaire. RESULTS: A total of 204 patients completed the questionnaire. Average annual costs varied from country to country, and ranged from euro9509 to euro49,233 (reference year 2012). Estimated direct healthcare costs ranged from euro419 to euro10,688; direct non-healthcare costs ranged from euro7449 to euro37,451 and labour productivity losses ranged from euro0 to euro7259. The average annual cost per patient across all countries was estimated at euro31,390, out of which euro5646 accounted for direct health costs (18.0 %), euro23,483 accounted for direct non-healthcare costs (74.8 %), and euro2261 accounted for indirect costs (7.2 %). Costs were shown to vary across patients with different disability but also between children and adults. The mean EQ-5D score for adult EB patients was estimated at between 0.49 and 0.71 and the mean EQ-5D visual analogue scale score was estimated at between 62 and 77. CONCLUSION: In addition to its negative impact on patient HRQOL, our study indicates the substantial social/economic burden of EB in Europe, attributable mostly to high direct non-healthcare costs.

Design of a new laboratory for quality control of mussel produced in Sagres

Dissertação de mestrado, Qualidade em Análises, Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2014

Framework for measuring success of construction projects

The construction industry is dynamic in nature. The concept of project success has remained ambiguously defined in the construction industry. Project success means different things to different people. While some authors consider time, cost and quality as the predominant targets, others suggest that success is something more complex. The aim of this report is to develop a framework for measuring success of construction projects. A range of Key Performance Indicators (KPIs), measured both objectively and subjectively is developed. The identification of KPIs helps set a benchmark for measuring the performance of a construction project and provides significant insights into developing a general and comprehensive base for further research.

Traps for the unwary : reform stories of private sector managers entering public service

The purpose of this research is to capture and interpret the stories of “outsider” managers who make the transition to the public sector. These experiences are considered in the context of efforts to shift public management culture in a direction consistent with meeting contemporary demands placed on public sector organisations. It is often noted that an important strategy for changing culture is the infusion of outsiders. Outsiders are thought to bring new perspectives that, through a dialectical process (Van de Ven 1995), create the potential for change. While there have been cross-sector comparisons (Broussine 1990; Silfvast 1994; Redman 1997), little attention has been given to the experience of those who make the transition in the context of efforts to reform public sector management culture. Not only is the infusion of private sector managers into the public sector a potential culture change strategy, it is also a personal experience for those who make the transition. Boundary crossing is typically an anxiety provoking experience (Van Maanen & Schein 1979) and the quality of this experience influences decisions to commit, engage, disengage or exit. The quality of the experience is likely to be affected by how the public organisation responds to people making this transition, that is, their investment in people processing (Saks 2007). The cost of recruitment and selection processes at middle and senior management levels warrants a greater research focus on this transition. In this paper we argue that the experiences of those who make the transition from private to public sectors has much to tell us about the traps that transition managers experience in making this change, the implications for injecting outsider managers as a strategy for achieving public management culture change, and how reform-oriented public organisations can manage the transitions of outsider managers into the public sector in order that best value might be achieved for both the individual and organisational change goals.

High quality indoor environments for office buildings

The quality of office indoor environments is considered to consist of those factors that impact the occupants according to their health and well-being and (by consequence) their productivity. Indoor Environment Quality (IEQ) can be characterized by four indicators: • Indoor air quality indicators • Thermal comfort indicators • Lighting indicators • Noise indicators. Within each indicator, there are specific metrics that can be utilized in determining an acceptable quality of an indoor environment based on existing knowledge and best practice. Examples of these metrics are: indoor air levels of pollutants or odorants; operative temperature and its control; radiant asymmetry; task lighting; glare; ambient noise. The way in which these metrics impact occupants is not fully understood, especially when multiple metrics may interact in their impacts. It can be estimated that the potential cost of lost productivity from poor IEQ may be much in excess of other operating costs of a building. However, the relative productivity impacts of each of the four indicators is largely unknown. The CRC Project ‘Regenerating Construction to Enhance Sustainability’ has a focus on IEQ impacts before and after building refurbishment. This paper provides an overview of IEQ impacts and criteria and the implementation of a CRC project that is currently researching these factors during the refurbishment of a Melbourne office building. IEQ measurements and their impacts will be reported in a future paper

High quality indoor environments for sustainable office buildings

The quality of office indoor environments is considered to consist of those factors that impact occupants according to their health and well-being and (by consequence) their productivity. Indoor Environment Quality (IEQ) can be characterized by four indicators: • Indoor air quality indicators • Thermal comfort indicators • Lighting indicators • Noise indicators. Within each indicator, there are specific metrics that can be utilized in determining an acceptable quality of an indoor environment based on existing knowledge and best practice. Examples of these metrics are: indoor air levels of pollutants or odorants; operative temperature and its control; radiant asymmetry; task lighting; glare; ambient noise. The way in which these metrics impact occupants is not fully understood, especially when multiple metrics may interact in their impacts. While the potential cost of lost productivity from poor IEQ has been estimated to exceed building operation costs, the level of impact and the relative significance of the above four indicators are largely unknown. However, they are key factors in the sustainable operation or refurbishment of office buildings. This paper presents a methodology for assessing indoor environment quality (IEQ) in office buildings, and indicators with related metrics for high performance and occupant comfort. These are intended for integration into the specification of sustainable office buildings as key factors to ensure a high degree of occupant habitability, without this being impaired by other sustainability factors. The assessment methodology was applied in a case study on IEQ in Australia’s first ‘six star’ sustainable office building, Council House 2 (CH2), located in the centre of Melbourne. The CH2 building was designed and built with specific focus on sustainability and the provision of a high quality indoor environment for occupants. Actual IEQ performance was assessed in this study by field assessment after construction and occupancy. For comparison, the methodology was applied to a 30 year old conventional building adjacent to CH2 which housed the same or similar occupants and activities. The impact of IEQ on occupant productivity will be reported in a separate future paper

Measuring and supporting quality of life

It is widely acknowledged that “quality of life” (QoL) is an imprecise concept, which is difficult to define (Arnold, 1991; Ball et al., 2000; Bury & Holme, 1993; Byrne & MacLean, 1997; Guse & Masesar, 1999; McDowell & Newell, 1996). McDowell and Newell (1996) described the term as “intuitively familiar” (p.382), suggesting that everyone believes that they know what it means; while, in reality its meaning differs from person to person. Recent years, have seen steadily increasing interest in the study and measurement of QoL related to human services, which reflects greater importance being attached to accountability in its widest sense. Anecdotally, many care staff will indicate that ensuring good QoL for their clients is important to them, but how can we ascertain whether we are achieving positive QoL outcomes, and given the complexities of the concept and its measurement, how can we best incorporate QoL assessment into everyday practice? This chapter will explore the issues of QoL definition and measurement, particularly as they pertain to aged care. It will consider many measurement tool options, and provide advice on how to choose an appropriate instrument for your circumstances. Issues of quality of care and their relationship to QoL will also be considered, and the chapter will conclude with a discussion on the integration of QoL assessment into practice. Because residential aged care constitutes a living environment as well as a care environment, QoL is considered particularly pertinent in this context, and as such, it will provide much of the focus for the chapter