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Papers by Pierre Alexandre

OF THE DISSERTATION ON THE ACCURACY OF NONSURVEY REGIONAL INPUT-OUTPUT MULTIPLIERS: AN EMPIRICAL ... more OF THE DISSERTATION ON THE ACCURACY OF NONSURVEY REGIONAL INPUT-OUTPUT MULTIPLIERS: AN EMPIRICAL STUDY by Pierre Kebreau Alexandre Florida International University, 1998 Miami, Florida Professor Maria Willumsen, Major Professor Correct specification of the simple location quotients in regionalizing the national direct requirements table is essential to the accuracy of regional input-output multipliers. The purpose of this research is to examine the relative accuracy of these multipliers when earnings, employment, number of establishments, and payroll data specify the simple location quotients. For each specification type, I derive a column of total output multipliers and a column of total income multipliers. These multipliers are based on the 1987 benchmark input-output accounts of the U.S. economy and 1988-1992 state of Florida data. Error sign tests, and Standardized Mean Absolute Deviation (SMAD) statistics indicate that the output multiplier estimates overestimate the output mul...

Value in Health, 2002

METHODS: M-NCAS data were collected from nursing staff ratings of nursing home patients diagnosed... more METHODS: M-NCAS data were collected from nursing staff ratings of nursing home patients diagnosed with dementia (N = 281), in a randomized double-blind clinical trial comparing risperidone to placebo (RIS-AUS-5 trial). For each item nurses rated the extent to which they agree the target patient exhibits the behavior (agree, partially agree, doubtful/unsure, don't agree) and the extent to which the behavior is difficult to cope with (very easy, easy, difficult, very difficult). Exploratory factor analyses were performed separately for "agree" and "cope" scales to determine if empirically and conceptually valid subscales exist. Internal consistency reliability was assessed via Cronbach's alpha. Correlations with the BEHAVE-AD and Cohen-Mansfield Agitation Inventory were examined to evaluate construct validity. RESULTS: Factor analysis resulted in identification of 3 agree subscales (difficulty, attention seeking, autonomy) and 5 cope subscales (predictability, self direction, neediness, job satisfaction, affect). Total scores were internally consistent, with alphas of 0.74 for the agree scale and 0.95 for the cope scale. Internal consistency reliability was also acceptable for the 3 agree subscales (0.69, 0.77, 0.57) and for the 5 cope subscales (0.89, 0.86, 0.83, 0.86, 0.79). The M-NCAS agree and cope total scale scores correlated most highly with the BEHAVE-AD aggressiveness and anxiety/phobia subscales (r = 0.36, r = 0.35; r = 0.43, r = 0.35 respectively: p < 0.001) and the CMAI verbal/non-aggression and aggression subscales (r = 0.45, r = 0.32; r = 0.34, r = 0.31, p < 0.001), indicating adequate construct validity. CONCLUSIONS: The 32-item M-NCAS is an internally consistent and valid scale for capturing both dementiaspecific behaviors and nursing perception of job burden associated with those behaviors. The M-NCAS provides detailed item-level as well as subscale-level data.

Value in Health, 2013

Objectives: Little information exists on the acute treatment provided for rhinosinusitis and its ... more Objectives: Little information exists on the acute treatment provided for rhinosinusitis and its associated costs. We hypothesize that introducing the administration of mometasone furoate (MFNS) as a treatment for rhinosinusitis will have a substantial impact on medical resource costs, outcomes and possibly cost-effectiveness. The goal of this paper is to estimate the cost-effectiveness of treating patients with rhinosinusitis with MFNS versus amoxicillin. MethOds: A decision-analytic model was developed to estimate lifetime costs and outcomes associated with MFNS 200µg twice daily and amoxicillin 500mg three times daily in treating rhinosinusitis from the Mexican health care perspective. This study further do not included MFNS 200µg once daily as a treatment arm because it was not found to be superior to amoxicillin. Data sources included published literature, clinical trials, official price/tariff lists, and Delphi panel data. The time horizon was 2 weeks. The effectiveness outcomes of the study were modeled as changes in the Major Symptom Score (MSS). MSS consists of five questions concerning rhinorrhoea, post-nasal drip, nasal congestion, sinus headache, and facial pain. Costs were valued in US dollar, year 2012 values. Multiple 1-way sensitivity analyses and a probabilistic sensitivity analysis using Monte Carlo simulation were performed to handle uncertainty. Results: The projected costs were US$ 258 with MFNS and US272with.Thebenefits(changesintheMSS)were0.52withMFNS0.45withAmoxicilin.MFNSwasassociatedwithacostsavingsperpatientofUSUS 272 with. The benefits (changes in the MSS) were 0.52 with MFNS 0.45 with Amoxicilin. MFNS was associated with a cost savings per patient of USUS272with.Thebenefits(changesintheMSS)were0.52withMFNS0.45withAmoxicilin.MFNSwasassociatedwithacostsavingsperpatientofUS 14 versus amoxicillin over a period of 2 weeks from a health care perspective. The incremental cost-effectiveness ratio for MFNS dominated Amoxicilin. Sensitivity analysis confirmed the overall cost savings and gains in effectiveness. cOnclusiOns: Our analysis suggests MFNS improves health outcomes in a cost-effective manner compared with Amoxicilin. The economic value of Amoxicillin is influenced by difficulties involved in diagnosing the condition, effectiveness, resistance, patient compliance with treatment, and treatment failure associated with antibiotics. RespiRatoRy-Related disoRdeRs-Health Care Use & policy studies pRs12 tHe impaCt of pUbliC foRmUlaRies & GUidelines on CommUnity aCqUiRed pneUmonia (Cap) dRUGs in mexiCo

Southern Economic Journal, 2001

Social Science Research, 2004

PLoS ONE, 2010

Background: Large HIV care programs frequently subsidize antiretroviral (ARV) drugs and CD4 tests... more Background: Large HIV care programs frequently subsidize antiretroviral (ARV) drugs and CD4 tests, but patients must often pay for other health-related drugs and services. We estimated the financial burden of health care for households with HIVinfected adults taking antiretroviral therapy (ART) in Cô te d'Ivoire. Methodology/Principal Findings: We conducted a cross-sectional survey. After obtaining informed consent, we interviewed HIV-infected adults taking ART who had consecutively attended one of 18 HIV care facilities in Abidjan. We collected information on socioeconomic and medical characteristics. The main economic indicators were household capacity-to-pay (overall expenses minus food expenses), and health care expenditures. The primary outcome was the percentage of households confronted with catastrophic health expenditures (health expenditures were defined as catastrophic if they were greater than or equal to 40% of the capacity-to-pay). We recruited 1,190 adults. Median CD4 count was 187/mm 3 , median time on ART was 14 months, and 72% of subjects were women. Mean household capacity-to-pay was 213.7/month,meanhealthexpenditureswere213.7/month, mean health expenditures were 213.7/month,meanhealthexpenditureswere24.3/month, and 12.3% of households faced catastrophic health expenditures. Of the health expenditures, 75.3% were for the study subject (ARV drugs and CD4 tests, 24.6%; morbidity events diagnosis and treatment, 50.1%; transportation to HIV care centres, 25.3%) and 24.7% were for other household members. When we stratified by most recent CD4 count, morbidity events related expenses were significantly lower when subjects had higher CD4 counts. Conclusions/Significance: Many households in Cô te d'Ivoire face catastrophic health expenditures that are not attributable to ARV drugs or routine follow-up tests. Innovative schemes should be developed to help HIV-infected patients on ART face the cost of morbidity events.

Revista Panamericana de Salud Pública, 2005

Objectives. This study is based on the 2000 Demographic and Health Survey (DHS) conducted in Hait... more Objectives. This study is based on the 2000 Demographic and Health Survey (DHS) conducted in Haiti. Using the DHS information on women aged 15 to 49 who had given birth during the three years preceding the survey interview, this study was intended to: (1) examine the determinants of the likelihood of the women using prenatal care in the rural areas and in the urban areas of the country and (2) for the women who made at least one prenatal care visit, examine the determinants of the number of prenatal visits in the rural areas and the urban areas. Methods. The multivariate analysis used logistic models to identify which factors explained the decision to seek prenatal care, and negative binomial models were used to determine how many prenatal visits were conducted by the subgroup of women who did make prenatal care visits. Results. Estimated at the mean values of the control variables, the expected probability of using prenatal care services in rural Haiti was 77.16%, compared to 85.83% in urban Haiti. Among users of prenatal care services, mothers in rural areas made an expected number of 3.78 prenatal care visits, compared to 5.06 visits for the women in urban areas. Conclusions. A substantial percentage of pregnant women have access to prenatal care services in Haiti, but mothers in rural areas who decided to seek care still fell slightly below the four visits recommended by the World Health Organization. The education levels of both mothers and their partners is a dominant predictor of prenatal care use. Longer travel times and greater distances to health centers in rural areas constituted barriers to repeated visits. Policymakers and health care providers need to take these findings into consideration as they decide on the delivery and management of health care services in Haiti. Prenatal care, rural health services, urban health services, Haiti.

The American Journal of Drug and Alcohol Abuse, 2010

Background-Among adolescents, peers are an important source of drug procurement. However, little ... more Background-Among adolescents, peers are an important source of drug procurement. However, little is known about factors associated with youths' involvement in drug trade. Objectives-The aim of the study is to identify substance use behaviors and contextual factors related to drug dealing among Black and White adolescents. Methods-The sample consisted of 13,706 White and Black youths who completed the National Survey on Drug Use and Health. Separate backward logistic regression was used to identify substance use behaviors and contextual factors associated with drug dealing among Black and White youths. Results-Among White youths, drug dealing was associated with use of marijuana, hallucinogens, cocaine, prescription drug misuse, availability of cocaine, and socioeconomic status (SES). Among Black youths, marijuana use and availability of crack and marijuana were associated with drug dealing. Conclusions and Scientific Significance-For White youths, substance use seems to be more relevant to drug dealing. Consequently, preventing and treating substance abuse may reduce involvement in the illegal distribution of drugs among White youths. More research is needed to identify risk and protective factors for drug dealing among Black adolescents.

Mental Health Services Research, 2004

This study examined the relationship between placement change and outpatient mental health servic... more This study examined the relationship between placement change and outpatient mental health service use. It is based on (1) conceptual propositions about the impact of the foster care living context on mental health service use, and (2) empirical knowledge about the adverse consequences of placement change. Results of the study, which were based on a cohort of 570 children in foster care in San Diego County, suggest an association between placement changes in child welfare and use of outpatient mental health services. Specifically, an increase in the number of placement changes predicted a greater rate of outpatient mental health visits. The study further found that children who experienced behavior-related placement changes received more outpatient mental health visits than children who experienced placement changes for other reasons. Follow-up analyses of the 144 children who experienced any behavior-related placement changes further indicated that the rate of outpatient mental health service use almost doubled in the 90 days following the first behavior-related placement change. Findings from this study have implications for the practice, policy and research fields in child welfare as well as mental health. Keywords foster care; placement change; mental health services; pathways to mental health services Children and adolescents in out-of-home care are a population at high risk for a range of adverse mental health outcomes. Research during the last two decades has consistently established that foster children exhibit significantly higher rates of mental health problems than children in community samples (for conceptual and summary reviews of the empirical literature on children's mental health needs see Combs-Orme, Chernoff,

Addictive Behaviors, 2009

The objective of this study was to identify long term factors associated with substance use probl... more The objective of this study was to identify long term factors associated with substance use problem among individuals affected by severe mental illness. Prospective data come from the 1994, 1998, and 2000 waves of the Maryland Mental Health Outcomes Survey conducted among a sub-cohort of adult Medicaid recipients affected by serious mental illness. We estimated factors associated with alcohol and drug problem, as well as a hierarchy of substance use problem severity constructed from the alcohol and drug problem outcomes. Drug problem was the strongest factor associated with alcohol problem, and vice versa. Conceptualizing alcohol and drug problem separately, and as a hierarchy of severity, revealed distinct profiles of significant factors. Further research is warranted to explore the utility of modeling substance use problem in terms of a hierarchy of severity.

Journal of Substance Abuse Treatment, 2014

A benefit-cost analysis was conducted as part of a clinical trial in which newly-admitted methado... more A benefit-cost analysis was conducted as part of a clinical trial in which newly-admitted methadone patients were randomly assigned to interim methadone (IM; methadone without counseling) for the first 4 months of 12 months of methadone treatment or 12 months of methadone with one of two counseling conditions. Health, residential drug treatment, criminal justice costs, and income data in 2010 dollars were obtained at treatment entry, and 4-and 12month follow-up from 200 participants and program costs were obtained. The net benefits of treatment were greater for the IM condition but controlling for the baseline variables noted above, the difference between conditions in net monetary benefits was not significant.

Value in Health, 2011

Chronic obstructive pulmonary disease(COPD) is a highly prevalent disease and the sixth cause of ... more Chronic obstructive pulmonary disease(COPD) is a highly prevalent disease and the sixth cause of death in Korea. This study examined the national epidemiology and economic impact of COPD in Korea. METHODS: This study used the societal cost of illness framework, consisting of epidemiology of COPD, direct medical costs, direct non-medical costs, and indirect costs. National-level health survey results and insurance claim databases were used to analyze annual healthcare utilization, hospitalization costs and outpatient costs of the total Korean population (48 million people). Using a data mining technique, we identified medical claims with international classification of disease 10 codes for COPD and estimated the costs by a macrocosting method. RESULTS: The prevalence rate of COPD based on the Global Initiative for chronic obstructive lung disease(GOLD) criteria was estimated at 13.1% and its mortality rate was 14.9 persons per 1,000 population in 2008. According to the classification of the GOLD, for the population over 45 years, the stage 1 group accounted for the largest proportion(55.2%), followed by the stage 2(37.2%), stage 3(6.4%), and stage 4(1.2%).

Value in Health, 2011

eligible persons aged 2-59 years of age. The study objectives were to determine the cost-effectiv... more eligible persons aged 2-59 years of age. The study objectives were to determine the cost-effectiveness of LAIV compared to TIV in Canadian children and adolescents from a Ministry of Health (MoH) perspective and a societal perspective. METHODS: A previously published US cost-effectiveness model using patient-level data to compare LAIV and TIV was supplemented by secondary (e.g. literature) and primary data (i.e. survey of 144 Canadian physicians). To compare the costs and benefits of LAIV and TIV, a cost-utility analysis was conducted. Parameter uncertainty was addressed through probability sensitivity analysis (PSA). RESULTS: Although LAIV increased vaccination costs compared to TIV, LAIV reduced the number of influenza illness cases and lowered the number of hospitalizations, ER visits, outpatient visits and parents' days lost from work. The estimated offsets in direct costs saved were 4.19pervaccinatedchildaged2−17years.Societalsavingswere4.19 per vaccinated child aged 2-17 years. Societal savings were 4.19pervaccinatedchildaged2−17years.Societalsavingswere35.33 per vaccinated child. When costs and outcomes were considered, LAIV was the dominant strategy when compared to TIV. At a willingness to pay of $50,000 per QALY gained, the results of the PSA indicated that the probability of LAIV being cost-effective was almost 1. CONCLUSIONS: LAIV reduces the burden of influenza in children and adolescents. Consistent with US results, vaccinating children with LAIV instead of TIV is the dominant strategy from a societal and MoH perspective.

Value in Health, 2011

BACKGROUND: Clinical practice guidelines (CPG) are useful tools for clinical decision making, pro... more BACKGROUND: Clinical practice guidelines (CPG) are useful tools for clinical decision making, processes standardization and quality of care improvements. The current General Social Security and Health System (GSSHS) in Colombia is promoting the initiative of developing and implementing CPG based on evidence in order to improve efficiency and quality of care. The reduction of inequalities in health should be an objective of the GSSHS. OBJECTIVES: The main propose of this analysis is to argue why it is necessary to consider the incorporation of equity considerations in the development and implementation of clinical practice guidelines based on the evidence. METHODS: A series of reflections were made. Narrative description was used for showing the arguments that support the main findings. RESULTS: Among the main findings are: 1) Differential effectiveness by social groups of interventions could diminish final effectiveness of CPG in the GSSHS; 2) To not consider geographical, ethnic, socioeconomic, cultural and access diversity issues within the CPG could have a potential negative impacts of the CPG; 3) Overall effectiveness of GPC could be better if equity issues are included in the quality verification checklist of the guideline questions; and 4) Incorporating equity issues in the process of developing CPG could be cost effective, because improve overall effectiveness of CPG. CONCLUSIONS: To include equity issues in CPG and can help in achieving more equitable health outcomes. From this point of view CPG could be key tools to promote equity in care and health outcomes.

Value in Health, 2011

To assess the incremental cost-effectiveness of SFC compared with MON for the control of persiste... more To assess the incremental cost-effectiveness of SFC compared with MON for the control of persistent asthma in children. Methods: We conducted an economic evaluation on a 12-week prospective randomized open-label parallel-group comparison of SFC versus MON in children with symptomatic asthma receiving inhaled corticosteroids and short-acting ␤2-agonists. Asthma-related medication, unscheduled physician contacts and hospitalizations were collected prospectively. The main effectiveness measure was percentage of asthma-controlled week with no short-acting ␤2-agonist use during the study period. The analysis was conducted from the Mexican healthcare perspective using 2010 unit cost prices, and only direct costs were considered, all costs are reported in US dollar.. The model was made fully probabilistic to reflect the joint uncertainty in the model parameters. Results: Over the whole treatment period, the median percentages of asthma-controlled weeks were 83.3% in the SFC group and 66.7% in the MON group (SFC-MON difference, 16.7%; 95% CI, 8.3-16.7; P Ͻ 0.001 in favor of SFC). The mean total cost of the SFC regimen was $ 2,323 compared with $ 3,230 for the MON regimen. The SFC was the dominant strategy (both more effective and less expensive) using the SFC was associated with an incremental cost per additional asthmacontrolled of $ (5,467). Probabilistic sensitivity analysis tested numerous assumptions about the model cost and efficacy parameters and found that the results were robust to most changes. Conclusions: This analysis demonstrates that, compared with MON, SFC may be cost saving from the Mexican health care perspective for the treatment of pediatric patients with asthma. SFC provided a reduction in the number of severe exacerbations, frequent asthma symptoms and rescue medication use. Incremental cost-effectiveness analysis indicated the dominance of SFC because of both lower costs and greater efficacy.

Value in Health, 2012

with pharmacist-managed ESA clinics (nϭ314) and at six sites with usual care only (nϭ167); outpat... more with pharmacist-managed ESA clinics (nϭ314) and at six sites with usual care only (nϭ167); outpatients were followed for 6 months in 2009. We took a VA perspective with projections over a five-year time horizon; costs and effectiveness values were discounted at 3%/yr. Strategy-specific likelihoods of target range hemoglobin values (10-12 g/dl) were based on study results. Utilities for ND-CKD and ESA-related adverse events and their likelihood were obtained from the literature. ESA costs were based on average monthly epoetin and darbepoetin doses per patient during the study and VA ESA cost data. RESULTS: In the base case analysis, cost and effectiveness were 12,500and2.096quality−adjustedlife−years(QALYs)inthepharmacistmanagedESAclinicsand12,500 and 2.096 quality-adjusted life-years (QALYs) in the pharmacistmanaged ESA clinics and 12,500and2.096quality−adjustedlife−years(QALYs)inthepharmacistmanagedESAclinicsand15,500 and 2.093 QALYs in usual care; ESA clinics dominated usual care. In one-way sensitivity analyses, ESA clinics no longer dominated if their patients' probability of being in the target range fell to 0.54 (base case 0.

Value in Health, 2010

A323 ous abstinence rate and intervention costs were estimated. a dynamic population model for CO... more A323 ous abstinence rate and intervention costs were estimated. a dynamic population model for COPD was used to project the long-term (cost-)effectiveness of one year implementation of minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy for 50% of the smoking COPD patients compared to usual care. Time horizon was 25 years. Uncertainty and one-way sensitivity analyses were performed for variations in (the calculation of) the abstinence rates, the type of projection, intervention costs and discount rates. RESULTS: Nine studies were selected. The average 12 months continuous abstinence rates were estimated to be 1.4% for usual care, 2.6% for minimal counseling, 6.0% for intensive counseling and 12.3% for pharmacotherapy. Compared to usual care, the costs per QALY gained for minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy were c16,900, c8,200 and c2,400, respectively. Results were most sensitive to variations in abstinence rates and discount rates. CONCLUSIONS: Compared to usual care intensive counseling and pharmacotherapy resulted in low costs per QALY gained with ratios comparable to results presented for smoking cessation in the general population. Compared to intensive counseling alone, intensive counseling plus pharmacotherapy was cost saving and dominated the other interventions.

Value in Health, 2010

A323 ous abstinence rate and intervention costs were estimated. a dynamic population model for CO... more A323 ous abstinence rate and intervention costs were estimated. a dynamic population model for COPD was used to project the long-term (cost-)effectiveness of one year implementation of minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy for 50% of the smoking COPD patients compared to usual care. Time horizon was 25 years. Uncertainty and one-way sensitivity analyses were performed for variations in (the calculation of) the abstinence rates, the type of projection, intervention costs and discount rates. RESULTS: Nine studies were selected. The average 12 months continuous abstinence rates were estimated to be 1.4% for usual care, 2.6% for minimal counseling, 6.0% for intensive counseling and 12.3% for pharmacotherapy. Compared to usual care, the costs per QALY gained for minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy were c16,900, c8,200 and c2,400, respectively. Results were most sensitive to variations in abstinence rates and discount rates. CONCLUSIONS: Compared to usual care intensive counseling and pharmacotherapy resulted in low costs per QALY gained with ratios comparable to results presented for smoking cessation in the general population. Compared to intensive counseling alone, intensive counseling plus pharmacotherapy was cost saving and dominated the other interventions.

OF THE DISSERTATION ON THE ACCURACY OF NONSURVEY REGIONAL INPUT-OUTPUT MULTIPLIERS: AN EMPIRICAL ... more OF THE DISSERTATION ON THE ACCURACY OF NONSURVEY REGIONAL INPUT-OUTPUT MULTIPLIERS: AN EMPIRICAL STUDY by Pierre Kebreau Alexandre Florida International University, 1998 Miami, Florida Professor Maria Willumsen, Major Professor Correct specification of the simple location quotients in regionalizing the national direct requirements table is essential to the accuracy of regional input-output multipliers. The purpose of this research is to examine the relative accuracy of these multipliers when earnings, employment, number of establishments, and payroll data specify the simple location quotients. For each specification type, I derive a column of total output multipliers and a column of total income multipliers. These multipliers are based on the 1987 benchmark input-output accounts of the U.S. economy and 1988-1992 state of Florida data. Error sign tests, and Standardized Mean Absolute Deviation (SMAD) statistics indicate that the output multiplier estimates overestimate the output mul...

Value in Health, 2002

METHODS: M-NCAS data were collected from nursing staff ratings of nursing home patients diagnosed... more METHODS: M-NCAS data were collected from nursing staff ratings of nursing home patients diagnosed with dementia (N = 281), in a randomized double-blind clinical trial comparing risperidone to placebo (RIS-AUS-5 trial). For each item nurses rated the extent to which they agree the target patient exhibits the behavior (agree, partially agree, doubtful/unsure, don't agree) and the extent to which the behavior is difficult to cope with (very easy, easy, difficult, very difficult). Exploratory factor analyses were performed separately for "agree" and "cope" scales to determine if empirically and conceptually valid subscales exist. Internal consistency reliability was assessed via Cronbach's alpha. Correlations with the BEHAVE-AD and Cohen-Mansfield Agitation Inventory were examined to evaluate construct validity. RESULTS: Factor analysis resulted in identification of 3 agree subscales (difficulty, attention seeking, autonomy) and 5 cope subscales (predictability, self direction, neediness, job satisfaction, affect). Total scores were internally consistent, with alphas of 0.74 for the agree scale and 0.95 for the cope scale. Internal consistency reliability was also acceptable for the 3 agree subscales (0.69, 0.77, 0.57) and for the 5 cope subscales (0.89, 0.86, 0.83, 0.86, 0.79). The M-NCAS agree and cope total scale scores correlated most highly with the BEHAVE-AD aggressiveness and anxiety/phobia subscales (r = 0.36, r = 0.35; r = 0.43, r = 0.35 respectively: p < 0.001) and the CMAI verbal/non-aggression and aggression subscales (r = 0.45, r = 0.32; r = 0.34, r = 0.31, p < 0.001), indicating adequate construct validity. CONCLUSIONS: The 32-item M-NCAS is an internally consistent and valid scale for capturing both dementiaspecific behaviors and nursing perception of job burden associated with those behaviors. The M-NCAS provides detailed item-level as well as subscale-level data.

Value in Health, 2013

Objectives: Little information exists on the acute treatment provided for rhinosinusitis and its ... more Objectives: Little information exists on the acute treatment provided for rhinosinusitis and its associated costs. We hypothesize that introducing the administration of mometasone furoate (MFNS) as a treatment for rhinosinusitis will have a substantial impact on medical resource costs, outcomes and possibly cost-effectiveness. The goal of this paper is to estimate the cost-effectiveness of treating patients with rhinosinusitis with MFNS versus amoxicillin. MethOds: A decision-analytic model was developed to estimate lifetime costs and outcomes associated with MFNS 200µg twice daily and amoxicillin 500mg three times daily in treating rhinosinusitis from the Mexican health care perspective. This study further do not included MFNS 200µg once daily as a treatment arm because it was not found to be superior to amoxicillin. Data sources included published literature, clinical trials, official price/tariff lists, and Delphi panel data. The time horizon was 2 weeks. The effectiveness outcomes of the study were modeled as changes in the Major Symptom Score (MSS). MSS consists of five questions concerning rhinorrhoea, post-nasal drip, nasal congestion, sinus headache, and facial pain. Costs were valued in US dollar, year 2012 values. Multiple 1-way sensitivity analyses and a probabilistic sensitivity analysis using Monte Carlo simulation were performed to handle uncertainty. Results: The projected costs were US$ 258 with MFNS and US272with.Thebenefits(changesintheMSS)were0.52withMFNS0.45withAmoxicilin.MFNSwasassociatedwithacostsavingsperpatientofUSUS 272 with. The benefits (changes in the MSS) were 0.52 with MFNS 0.45 with Amoxicilin. MFNS was associated with a cost savings per patient of USUS272with.Thebenefits(changesintheMSS)were0.52withMFNS0.45withAmoxicilin.MFNSwasassociatedwithacostsavingsperpatientofUS 14 versus amoxicillin over a period of 2 weeks from a health care perspective. The incremental cost-effectiveness ratio for MFNS dominated Amoxicilin. Sensitivity analysis confirmed the overall cost savings and gains in effectiveness. cOnclusiOns: Our analysis suggests MFNS improves health outcomes in a cost-effective manner compared with Amoxicilin. The economic value of Amoxicillin is influenced by difficulties involved in diagnosing the condition, effectiveness, resistance, patient compliance with treatment, and treatment failure associated with antibiotics. RespiRatoRy-Related disoRdeRs-Health Care Use & policy studies pRs12 tHe impaCt of pUbliC foRmUlaRies & GUidelines on CommUnity aCqUiRed pneUmonia (Cap) dRUGs in mexiCo

Southern Economic Journal, 2001

Social Science Research, 2004

PLoS ONE, 2010

Background: Large HIV care programs frequently subsidize antiretroviral (ARV) drugs and CD4 tests... more Background: Large HIV care programs frequently subsidize antiretroviral (ARV) drugs and CD4 tests, but patients must often pay for other health-related drugs and services. We estimated the financial burden of health care for households with HIVinfected adults taking antiretroviral therapy (ART) in Cô te d'Ivoire. Methodology/Principal Findings: We conducted a cross-sectional survey. After obtaining informed consent, we interviewed HIV-infected adults taking ART who had consecutively attended one of 18 HIV care facilities in Abidjan. We collected information on socioeconomic and medical characteristics. The main economic indicators were household capacity-to-pay (overall expenses minus food expenses), and health care expenditures. The primary outcome was the percentage of households confronted with catastrophic health expenditures (health expenditures were defined as catastrophic if they were greater than or equal to 40% of the capacity-to-pay). We recruited 1,190 adults. Median CD4 count was 187/mm 3 , median time on ART was 14 months, and 72% of subjects were women. Mean household capacity-to-pay was 213.7/month,meanhealthexpenditureswere213.7/month, mean health expenditures were 213.7/month,meanhealthexpenditureswere24.3/month, and 12.3% of households faced catastrophic health expenditures. Of the health expenditures, 75.3% were for the study subject (ARV drugs and CD4 tests, 24.6%; morbidity events diagnosis and treatment, 50.1%; transportation to HIV care centres, 25.3%) and 24.7% were for other household members. When we stratified by most recent CD4 count, morbidity events related expenses were significantly lower when subjects had higher CD4 counts. Conclusions/Significance: Many households in Cô te d'Ivoire face catastrophic health expenditures that are not attributable to ARV drugs or routine follow-up tests. Innovative schemes should be developed to help HIV-infected patients on ART face the cost of morbidity events.

Revista Panamericana de Salud Pública, 2005

Objectives. This study is based on the 2000 Demographic and Health Survey (DHS) conducted in Hait... more Objectives. This study is based on the 2000 Demographic and Health Survey (DHS) conducted in Haiti. Using the DHS information on women aged 15 to 49 who had given birth during the three years preceding the survey interview, this study was intended to: (1) examine the determinants of the likelihood of the women using prenatal care in the rural areas and in the urban areas of the country and (2) for the women who made at least one prenatal care visit, examine the determinants of the number of prenatal visits in the rural areas and the urban areas. Methods. The multivariate analysis used logistic models to identify which factors explained the decision to seek prenatal care, and negative binomial models were used to determine how many prenatal visits were conducted by the subgroup of women who did make prenatal care visits. Results. Estimated at the mean values of the control variables, the expected probability of using prenatal care services in rural Haiti was 77.16%, compared to 85.83% in urban Haiti. Among users of prenatal care services, mothers in rural areas made an expected number of 3.78 prenatal care visits, compared to 5.06 visits for the women in urban areas. Conclusions. A substantial percentage of pregnant women have access to prenatal care services in Haiti, but mothers in rural areas who decided to seek care still fell slightly below the four visits recommended by the World Health Organization. The education levels of both mothers and their partners is a dominant predictor of prenatal care use. Longer travel times and greater distances to health centers in rural areas constituted barriers to repeated visits. Policymakers and health care providers need to take these findings into consideration as they decide on the delivery and management of health care services in Haiti. Prenatal care, rural health services, urban health services, Haiti.

The American Journal of Drug and Alcohol Abuse, 2010

Background-Among adolescents, peers are an important source of drug procurement. However, little ... more Background-Among adolescents, peers are an important source of drug procurement. However, little is known about factors associated with youths' involvement in drug trade. Objectives-The aim of the study is to identify substance use behaviors and contextual factors related to drug dealing among Black and White adolescents. Methods-The sample consisted of 13,706 White and Black youths who completed the National Survey on Drug Use and Health. Separate backward logistic regression was used to identify substance use behaviors and contextual factors associated with drug dealing among Black and White youths. Results-Among White youths, drug dealing was associated with use of marijuana, hallucinogens, cocaine, prescription drug misuse, availability of cocaine, and socioeconomic status (SES). Among Black youths, marijuana use and availability of crack and marijuana were associated with drug dealing. Conclusions and Scientific Significance-For White youths, substance use seems to be more relevant to drug dealing. Consequently, preventing and treating substance abuse may reduce involvement in the illegal distribution of drugs among White youths. More research is needed to identify risk and protective factors for drug dealing among Black adolescents.

Mental Health Services Research, 2004

This study examined the relationship between placement change and outpatient mental health servic... more This study examined the relationship between placement change and outpatient mental health service use. It is based on (1) conceptual propositions about the impact of the foster care living context on mental health service use, and (2) empirical knowledge about the adverse consequences of placement change. Results of the study, which were based on a cohort of 570 children in foster care in San Diego County, suggest an association between placement changes in child welfare and use of outpatient mental health services. Specifically, an increase in the number of placement changes predicted a greater rate of outpatient mental health visits. The study further found that children who experienced behavior-related placement changes received more outpatient mental health visits than children who experienced placement changes for other reasons. Follow-up analyses of the 144 children who experienced any behavior-related placement changes further indicated that the rate of outpatient mental health service use almost doubled in the 90 days following the first behavior-related placement change. Findings from this study have implications for the practice, policy and research fields in child welfare as well as mental health. Keywords foster care; placement change; mental health services; pathways to mental health services Children and adolescents in out-of-home care are a population at high risk for a range of adverse mental health outcomes. Research during the last two decades has consistently established that foster children exhibit significantly higher rates of mental health problems than children in community samples (for conceptual and summary reviews of the empirical literature on children's mental health needs see Combs-Orme, Chernoff,

Addictive Behaviors, 2009

The objective of this study was to identify long term factors associated with substance use probl... more The objective of this study was to identify long term factors associated with substance use problem among individuals affected by severe mental illness. Prospective data come from the 1994, 1998, and 2000 waves of the Maryland Mental Health Outcomes Survey conducted among a sub-cohort of adult Medicaid recipients affected by serious mental illness. We estimated factors associated with alcohol and drug problem, as well as a hierarchy of substance use problem severity constructed from the alcohol and drug problem outcomes. Drug problem was the strongest factor associated with alcohol problem, and vice versa. Conceptualizing alcohol and drug problem separately, and as a hierarchy of severity, revealed distinct profiles of significant factors. Further research is warranted to explore the utility of modeling substance use problem in terms of a hierarchy of severity.

Journal of Substance Abuse Treatment, 2014

A benefit-cost analysis was conducted as part of a clinical trial in which newly-admitted methado... more A benefit-cost analysis was conducted as part of a clinical trial in which newly-admitted methadone patients were randomly assigned to interim methadone (IM; methadone without counseling) for the first 4 months of 12 months of methadone treatment or 12 months of methadone with one of two counseling conditions. Health, residential drug treatment, criminal justice costs, and income data in 2010 dollars were obtained at treatment entry, and 4-and 12month follow-up from 200 participants and program costs were obtained. The net benefits of treatment were greater for the IM condition but controlling for the baseline variables noted above, the difference between conditions in net monetary benefits was not significant.

Value in Health, 2011

Chronic obstructive pulmonary disease(COPD) is a highly prevalent disease and the sixth cause of ... more Chronic obstructive pulmonary disease(COPD) is a highly prevalent disease and the sixth cause of death in Korea. This study examined the national epidemiology and economic impact of COPD in Korea. METHODS: This study used the societal cost of illness framework, consisting of epidemiology of COPD, direct medical costs, direct non-medical costs, and indirect costs. National-level health survey results and insurance claim databases were used to analyze annual healthcare utilization, hospitalization costs and outpatient costs of the total Korean population (48 million people). Using a data mining technique, we identified medical claims with international classification of disease 10 codes for COPD and estimated the costs by a macrocosting method. RESULTS: The prevalence rate of COPD based on the Global Initiative for chronic obstructive lung disease(GOLD) criteria was estimated at 13.1% and its mortality rate was 14.9 persons per 1,000 population in 2008. According to the classification of the GOLD, for the population over 45 years, the stage 1 group accounted for the largest proportion(55.2%), followed by the stage 2(37.2%), stage 3(6.4%), and stage 4(1.2%).

Value in Health, 2011

eligible persons aged 2-59 years of age. The study objectives were to determine the cost-effectiv... more eligible persons aged 2-59 years of age. The study objectives were to determine the cost-effectiveness of LAIV compared to TIV in Canadian children and adolescents from a Ministry of Health (MoH) perspective and a societal perspective. METHODS: A previously published US cost-effectiveness model using patient-level data to compare LAIV and TIV was supplemented by secondary (e.g. literature) and primary data (i.e. survey of 144 Canadian physicians). To compare the costs and benefits of LAIV and TIV, a cost-utility analysis was conducted. Parameter uncertainty was addressed through probability sensitivity analysis (PSA). RESULTS: Although LAIV increased vaccination costs compared to TIV, LAIV reduced the number of influenza illness cases and lowered the number of hospitalizations, ER visits, outpatient visits and parents' days lost from work. The estimated offsets in direct costs saved were 4.19pervaccinatedchildaged2−17years.Societalsavingswere4.19 per vaccinated child aged 2-17 years. Societal savings were 4.19pervaccinatedchildaged2−17years.Societalsavingswere35.33 per vaccinated child. When costs and outcomes were considered, LAIV was the dominant strategy when compared to TIV. At a willingness to pay of $50,000 per QALY gained, the results of the PSA indicated that the probability of LAIV being cost-effective was almost 1. CONCLUSIONS: LAIV reduces the burden of influenza in children and adolescents. Consistent with US results, vaccinating children with LAIV instead of TIV is the dominant strategy from a societal and MoH perspective.

Value in Health, 2011

BACKGROUND: Clinical practice guidelines (CPG) are useful tools for clinical decision making, pro... more BACKGROUND: Clinical practice guidelines (CPG) are useful tools for clinical decision making, processes standardization and quality of care improvements. The current General Social Security and Health System (GSSHS) in Colombia is promoting the initiative of developing and implementing CPG based on evidence in order to improve efficiency and quality of care. The reduction of inequalities in health should be an objective of the GSSHS. OBJECTIVES: The main propose of this analysis is to argue why it is necessary to consider the incorporation of equity considerations in the development and implementation of clinical practice guidelines based on the evidence. METHODS: A series of reflections were made. Narrative description was used for showing the arguments that support the main findings. RESULTS: Among the main findings are: 1) Differential effectiveness by social groups of interventions could diminish final effectiveness of CPG in the GSSHS; 2) To not consider geographical, ethnic, socioeconomic, cultural and access diversity issues within the CPG could have a potential negative impacts of the CPG; 3) Overall effectiveness of GPC could be better if equity issues are included in the quality verification checklist of the guideline questions; and 4) Incorporating equity issues in the process of developing CPG could be cost effective, because improve overall effectiveness of CPG. CONCLUSIONS: To include equity issues in CPG and can help in achieving more equitable health outcomes. From this point of view CPG could be key tools to promote equity in care and health outcomes.

Value in Health, 2011

To assess the incremental cost-effectiveness of SFC compared with MON for the control of persiste... more To assess the incremental cost-effectiveness of SFC compared with MON for the control of persistent asthma in children. Methods: We conducted an economic evaluation on a 12-week prospective randomized open-label parallel-group comparison of SFC versus MON in children with symptomatic asthma receiving inhaled corticosteroids and short-acting ␤2-agonists. Asthma-related medication, unscheduled physician contacts and hospitalizations were collected prospectively. The main effectiveness measure was percentage of asthma-controlled week with no short-acting ␤2-agonist use during the study period. The analysis was conducted from the Mexican healthcare perspective using 2010 unit cost prices, and only direct costs were considered, all costs are reported in US dollar.. The model was made fully probabilistic to reflect the joint uncertainty in the model parameters. Results: Over the whole treatment period, the median percentages of asthma-controlled weeks were 83.3% in the SFC group and 66.7% in the MON group (SFC-MON difference, 16.7%; 95% CI, 8.3-16.7; P Ͻ 0.001 in favor of SFC). The mean total cost of the SFC regimen was $ 2,323 compared with $ 3,230 for the MON regimen. The SFC was the dominant strategy (both more effective and less expensive) using the SFC was associated with an incremental cost per additional asthmacontrolled of $ (5,467). Probabilistic sensitivity analysis tested numerous assumptions about the model cost and efficacy parameters and found that the results were robust to most changes. Conclusions: This analysis demonstrates that, compared with MON, SFC may be cost saving from the Mexican health care perspective for the treatment of pediatric patients with asthma. SFC provided a reduction in the number of severe exacerbations, frequent asthma symptoms and rescue medication use. Incremental cost-effectiveness analysis indicated the dominance of SFC because of both lower costs and greater efficacy.

Value in Health, 2012

with pharmacist-managed ESA clinics (nϭ314) and at six sites with usual care only (nϭ167); outpat... more with pharmacist-managed ESA clinics (nϭ314) and at six sites with usual care only (nϭ167); outpatients were followed for 6 months in 2009. We took a VA perspective with projections over a five-year time horizon; costs and effectiveness values were discounted at 3%/yr. Strategy-specific likelihoods of target range hemoglobin values (10-12 g/dl) were based on study results. Utilities for ND-CKD and ESA-related adverse events and their likelihood were obtained from the literature. ESA costs were based on average monthly epoetin and darbepoetin doses per patient during the study and VA ESA cost data. RESULTS: In the base case analysis, cost and effectiveness were 12,500and2.096quality−adjustedlife−years(QALYs)inthepharmacistmanagedESAclinicsand12,500 and 2.096 quality-adjusted life-years (QALYs) in the pharmacistmanaged ESA clinics and 12,500and2.096quality−adjustedlife−years(QALYs)inthepharmacistmanagedESAclinicsand15,500 and 2.093 QALYs in usual care; ESA clinics dominated usual care. In one-way sensitivity analyses, ESA clinics no longer dominated if their patients' probability of being in the target range fell to 0.54 (base case 0.

Value in Health, 2010

A323 ous abstinence rate and intervention costs were estimated. a dynamic population model for CO... more A323 ous abstinence rate and intervention costs were estimated. a dynamic population model for COPD was used to project the long-term (cost-)effectiveness of one year implementation of minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy for 50% of the smoking COPD patients compared to usual care. Time horizon was 25 years. Uncertainty and one-way sensitivity analyses were performed for variations in (the calculation of) the abstinence rates, the type of projection, intervention costs and discount rates. RESULTS: Nine studies were selected. The average 12 months continuous abstinence rates were estimated to be 1.4% for usual care, 2.6% for minimal counseling, 6.0% for intensive counseling and 12.3% for pharmacotherapy. Compared to usual care, the costs per QALY gained for minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy were c16,900, c8,200 and c2,400, respectively. Results were most sensitive to variations in abstinence rates and discount rates. CONCLUSIONS: Compared to usual care intensive counseling and pharmacotherapy resulted in low costs per QALY gained with ratios comparable to results presented for smoking cessation in the general population. Compared to intensive counseling alone, intensive counseling plus pharmacotherapy was cost saving and dominated the other interventions.

Value in Health, 2010

A323 ous abstinence rate and intervention costs were estimated. a dynamic population model for CO... more A323 ous abstinence rate and intervention costs were estimated. a dynamic population model for COPD was used to project the long-term (cost-)effectiveness of one year implementation of minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy for 50% of the smoking COPD patients compared to usual care. Time horizon was 25 years. Uncertainty and one-way sensitivity analyses were performed for variations in (the calculation of) the abstinence rates, the type of projection, intervention costs and discount rates. RESULTS: Nine studies were selected. The average 12 months continuous abstinence rates were estimated to be 1.4% for usual care, 2.6% for minimal counseling, 6.0% for intensive counseling and 12.3% for pharmacotherapy. Compared to usual care, the costs per QALY gained for minimal counseling, intensive counseling and intensive counseling plus pharmacotherapy were c16,900, c8,200 and c2,400, respectively. Results were most sensitive to variations in abstinence rates and discount rates. CONCLUSIONS: Compared to usual care intensive counseling and pharmacotherapy resulted in low costs per QALY gained with ratios comparable to results presented for smoking cessation in the general population. Compared to intensive counseling alone, intensive counseling plus pharmacotherapy was cost saving and dominated the other interventions.