Public Tariffs Research Articles

Cost-benefit analysis of stroke rehabilitation in Iran

ABSTRACT Background The economic evaluation of medication interventions for stroke has been the subject of much economic research. This study aimed to examine the cost-benefit of multidisciplinary rehabilitation services for stroke survivors in Iran. Methods This economic evaluation was conducted from the payer’s perspective with a lifetime horizon in Iran. A Markov model was designed and Quality-adjusted life years (QALYs) were the final outcomes. First, to evaluate the cost-effectiveness, the incremental cost-effectiveness ratio (ICER) was calculated. Then, using the average net monetary benefit (NMB) of rehabilitation, the average Incremental Net Monetary Benefit (INMB) per patient was calculated. The analyses were carried out separately for public and private sector tariffs. Results While considering public tariffs, the rehabilitation strategy had lower costs (US$5320 vs. US$ 6047) and higher QALYs (2.78 vs. 2.61) compared to non-rehabilitation. Regarding the private tariffs, the rehabilitation strategy had slightly higher costs (US$6,698 vs. US$6,182) but higher QALYs (2.78 vs. 2.61) compared to no rehabilitation. The average INMB of rehabilitation vs non-rehabilitation for each patient was estimated at US$1518 and US$275 based on Public and private tariffs, respectively. Conclusion Providing multidisciplinary rehabilitation services to stroke patients was cost-effective and has positive INMBs in public and private tariffs.

Cost-Effectiveness of Breast Cancer Screening in Shiraz, Iran.

Breast cancer is the most common cancer in the world, which accounts for 21.4% of all kinds of cancers for women in Iran. However, the treatment of breast cancer is costly and given that the budget devoted to the healthcare sector is limited, the present study aimed to investigate the cost-effectiveness of breast cancer screening for women, who referred to breast clinic located in Shahid Motahari clinic affiliated to Shiraz University of Medical Sciences, Shiraz city, Iran in 2017-2018. This study is a cross-sectional study analyzing the cost-effectiveness of breast cancer screening versus no screening. The study was conducted on 3500 women, who referred to the breast clinic in Motahari clinic, at 2017-2018 in Shiraz, Iran. The patients were identified and direct costs, which were correlated to cancer breast screening, were calculated based on the patients' records with public tariff per person. Tree age pro 2011 used to analyze cost effectiveness. Based on the results obtained, the expected cost of screening and no screening were 7556 $ppp and 7840 $ppp, respectively. Given their difference in effectiveness (16%), screening was dominant (less costly and more effective) compared to no screening. Tornado diagram showed that the results had the maximum sensitivity to the increase in screening cost. In general, according to the results obtained from the current study, the screening was more cost effective compared with no screening.

THE STUDY OF THE CROSS-BORDER TRANSPORTATION OF GRAIN CARGO BY ROAD AND RAIL

The article examines the cross-border transportation of grain cargo by road and rail. In order to conduct a detailed analysis, the organization of grain transportation from Ukraine to Germany by rail and road on the route Lukiv, Ukraine – Rostock, Germany is studied. The article analyzes the time of cargo transportation on the route with a breakdown by type of operation: – time under cargo and customs operations; downtime under technical operations; and time in motion. The route and running speeds of grain transportation by road and rail are calculated. The main «bottlenecks" in the technology of cross-border transportation of grain cargo from Ukraine are identified. For a comprehensive assessment of the advantages and disadvantages of using rail or road transport for the transportation of grain cargo, the cost of the route under study was calculated. A comparative analysis of the cost of grain transportation when choosing different transportation schemes is carried out. The dependence of the cost of transportation on the distance is constructed. The areas of economic feasibility of using road transport in comparison with rail transport are found. A comparative analysis of the tariff systems for long-distance grain transportation in the export traffic of various railway carriers with options for transportation by road has shown the competitiveness of the road tariff in the transportation area up to 130 km. Based on the dependencies of the tariff for the transportation of 1 ton of grain by railroad carriers and road transport on the transportation distance calculated according to public tariffs, the author identified zones of economic feasibility of using road transport. The first zone of expediency of using road transport compared to the lowest railroad tariff of DB Cargo Polska S.A. is within 50 km. The second zone according to the tariff of JSC Ukrzaliznytsia is up to 94 km. The third zone according to PKP Cargo S.A. is up to 130 km. The article concludes that cross-border transportation of grain cargoes by road and rail from Ukraine to Germany is efficient.

Public Management of Railway Transport Development based on the Principles of a Systematic Approach

The article is devoted to scientific and applied research on the problem of the formation and implementation of a universal, efficient and effective public management system for the development of railway transport in the changing socio-economic and political conditions of Ukraine. The definition of the category “public management of railway transport” and the problems of the railway industry as a whole was clarified. A universal, efficient and effective system of public management for the development of railway transport has been formed, containing all the necessary aspects: entrance to the system, working subsystems, exit, external environment, feedback, as well as the components and elements that are part of them. It has been proven that entrance into the system is the defining management and organizational link of the entire system. The main directions of introduction and development of elements of working subsystems are analyzed. Proposals on operational and strategic directions of improvement of public management of railway industry development in the following areas are presented: improvement of legislative and regulatory framework; full separation of the functions of public administration from the economic functions of railway enterprises; the development and implementation of a new public tariff management system; development of a progressive approach to the organization and management of passenger transportation and the introduction of a public administration system in the international security. It was concluded that the effective operation of the developed system and the successful introduction of areas of improvement of public management for the development of the railway industry will achieve the following results: create conditions for the development of free competition in the industry; increase the competitiveness of the railway industry in Ukrainian and international markets; achieve the desired indicators of railway industry efficiency and innovation growth

Cost-Effectiveness and Cost-Utility Analysis of the Use of Clopidogrel and Pantoprazole in Comparison with Clopidogrel and Omeprazole for the Secondary Prevention of Myocardial Infarction in Iran.

Objective:Gastrointestinal bleeding, a side effect of clopidogrel, is usually prevented by proton-pump inhibitors (PPIs). Due to omeprazole's inhibitory effects on the liver enzyme CYP2C19, its concomitant use with clopidogrel is argued to increase the risk of myocardial infarction (MI) recurrence, as CYP2C19 activates clopidogrel. Pantoprazole as an alternative PPI has shown no inhibitory effect on CYP2C19. This study investigates the cost-effectiveness of concomitant use of clopidogrel and pantoprazole in MI patients compared to the simultaneous use of clopidogrel and omeprazole.Methods:We used the Markov-modeling technique with a hypothetical cohort of 1000 acute MI patients aged 55 years using Microsoft Excel 2013 software. The study was done from the payer perspective, and a lifetime horizon with 1-year cycles was considered in the model. Life-years gained (LYG) and quality-adjusted life-years (QALYs) were used to quantify the health effects of these interventions. Two separate scenarios of public tariffs and private tariffs with various discount rates (0%, 3%, and 7.2% discounts (only for costs)) were evaluated, and an incremental cost-effectiveness ratio (ICER) was used to report the results. One-way and probabilistic sensitivity analyses were used to deal with uncertainty. Data were sourced from published literature and tariff book of the Iranian ministry of health.Findings:The estimated ICERs were 342 USD/QALY and 236 USD/LYG per patient for the base-case scenario.Conclusion:Abiding by the WHO threshold for cost-effectiveness, the concomitant use of pantoprazole and clopidogrel can be considered cost-effective compared to the use of omeprazole and clopidogrel.

Costs and quality of care optimization in the remote monitoring of cardiac implantable electronic devices (CIEDs). A picture from Veneto, Northern Italy

Abstract Background Remote control/monitoring (RC/M) of cardiac implantable electronic devices (CIEDs) is still underutilized, with a significant heterogeneity of use across and within countries. Not all models are equivalent in terms of effectiveness and efficiency. Purpose This cost comparative study aimed to analyse different models of following patients with CIEDs in three districts (four implanting facilities) merged into the same administrative area, to assess the impact of RC/M on expenditure, and to propose a common practice with the objectives of standardisation of approach, optimisation of efficiency, and future capillary implementation of RC/M. Methods The workload related to CIED-patient follow-ups was assessed in four public hospitals reflecting three different models with different proportions of patients followed by RC/M and different modus operandi. All CIED-patients in charge were scrutinized at 31/08/2019. The workload analysis was based on one-year data, collected retrospectively. Costs were calculated in terms of nursing and physician hours and based on public tariffs. Five variables, identified as drivers of costs, were tested by the simulation model. The main outcome was a total expenditure and cost per patient followed by RC/M compared to the standard care (SC) (in-office only). Results A total of 6830 patients with CIEDs were followed, 34.8% by RC/M (five platforms, 19.7% high voltage devices). An additional 25.8% had monitorable devices. The proportion of RC/M-patients across centres was 63.3%, 60.6%, 51% and 2.65%. RC/M resulted more costly than SC in all hospitals. Modelling demonstrated the overall cost in the year 2018 to be €228,075. No single factor optimisation tested separately (number of transmissions, nursing time for each transmission revision, doctor time for transmission processing, nursing time for phone calls, time for single enrolment) was able to reduce the cost per patient below the cost of SC. Providing monitoring to all compatible patients increased the costs of total care to €248,785. After the optimisation of other factors, the additional benefit of extending RC/M to compatible devices was achieved, with the final result of a total expenditure of €128,181 and of €15.97 per RC/M-patient per year vs. €27.93 per SC-patient, below the reimbursement tariff of monitoring recently approved in Veneto (€25.55 per patient/year). Conclusion Real-world data from an unselected population confirmed the huge inconsistency in managing patients with CIEDs. RC/M was associated with a significant specific workload. RC/M may be cost-saving compared to the standard in-office follow-up; however, organisation needs to be optimised. Improvement can be achieved by implementing new standards for RC/M procedures using Lean Management tools. A common platform might be of help. Centralisation could represent a further step to ensure high quality service and to save money at the same time. Funding Acknowledgement Type of funding source: None

Budget impact analysis of lens material on the posterior capsule opacification (PCO) as a complication after the cataract surgery

BackgroundOver 300,000 cataract operations are performed in Poland every year, and the most common, late complication of cataract removal surgery is posterior capsule opacification (PCO). The risk of PCO depends on the lens material. Hydrophobic acrylic lenses cause PCO less frequently as lymphatic endothelial cells show lower affinity for the surface of the lens made of silicone. The objective of this study is to assess the economic impact of using hydrophobic acrylic lenses compared to using hydrophilic acrylic lenses for cataract treatment in the Polish inpatient and outpatient settings.MethodsA budget impact analysis (BIA) compared the economic outcomes associated with using hydrophobic acrylic lenses versus using hydrophilic lenses for patients undergoing cataract surgery. The BIA predicted annual expenses in the following scenarios: performing Nd:YAG to treat PCO within 2 and 3 years after implantation of hydrophobic or hydrophilic acrylic lenses for different lens structure. Data used to assess the frequency of PCO was determined in systematic literature review. Costs of current and predicted interventions were estimated based on average data from 19 Polish hospitals. Prices of health services were taken from official public tariff lists.ResultsThe use of a hydrophobic lens significantly limits the number of complications after cataract surgery relative to a hydrophilic lens. As hydrophobic lenses have a higher unit price their use increases the cost of treatment which currently is not reflected by adequate difference in price of the service. Total annual National Health Fund (NHF) expenses for 3-year follow-up model range from 139.1 million EUR to 143.1 million EUR depending on the lens structure, due to the cost of complications.ConclusionsBIA indicates the possibility of introducing surcharge for the use of hydrophobic lenses, which could increase the frequency of their use and reduce the number of complications after cataract surgery. It was estimated that total NHF expenses reach the minimum value for the surcharge at the level of 9 EUR. The surcharge of 14 EUR is the maximum value that does not increase the initial NHF expenses.

936-P: Annual Cost to Achieve Cost Effectiveness of Continuous Glucose Monitoring in Hypoglycemia-Unaware Type 1 Diabetes Patients Using Intensive Insulin in the United Kingdom

Background: Type 1 diabetes (T1D) patients with impaired awareness of hypoglycemia (IAH) face higher risk of severe hypoglycemic events. Continuous glucose monitoring (CGM) has been found to prevent severe hypoglycemic events in this population (van Beers 2016) compared to self-monitoring of blood glucose (SMBG). This study aimed to evaluate the annual cost of a hypothetical CGM intervention that would be cost-effective vs. SMBG in the United Kingdom (UK) according to a willingness-to-pay threshold of £30,000/QALY. Methods: The IQVIA Core Diabetes Model was used to run analyses over multiple time horizons (50-, 5-, and 1-year to test impact of assuming continued intervention effects over time) with an IAH population reflecting the IN CONTROL study (van Beers 2016). This study evaluated impact of CGM on hypoglycemia in an IAH population. CGM intervention effects included: odds ratio 0.45 for severe hypoglycemic events (requiring third party intervention); 0.03 utility benefit associated with reduced finger prick requirements of CGM (Matza 2016). HbA1c was assumed equivalent between CGM and SMBG. All other inputs reflected published literature and/or public tariffs, with costs in 2018 GBP. Threshold analyses were performed to identify the annual cost of intervention associated with incremental cost-effectiveness ratio (ICER) threshold £30,000/QALY over each time horizon. Sensitivity analyses were also performed on key input variables. Results: Over 50 years, up to £1,354 could be spent annually on CGM to achieve a £30,000/QALY ICER threshold. With shorter time horizons, the annual intervention cost to achieve cost-effectiveness was slightly lower, ranging from £1,344 over 5 years to £1,301 for a 1-year horizon. Conclusions: Based on recent evidence that CGM reduces severe hypoglycemia in IAH T1D patients, CGM can be considered cost-effective in the UK at costs per year of up to approximately £1,350. Disclosure S. Bilir: Employee; Self; IQVIA. C. Campbell: Consultant; Self; Abbott. R. Hellmund: Employee; Self; Abbott Laboratories. Stock/Shareholder; Self; Abbott Laboratories. J. Munakata: Employee; Self; IQVIA.

A successful Charter challenge to medicare? Policy options for Canadian provincial governments.

In September 2016, a case went to trial in British Columbia that seeks to test the constitutionality of provincial laws that (1) ban private health insurance for medically necessary hospital and physician services; (2) ban extra-billing (physicians cannot charge patients more than the public tariff); and (3) require physicians to work solely for the public system or 'opt-out' and practice privately. All provinces have similar laws that have been passed to meet the requirements of federal legislation, the Canada Health Act (and thus qualify for federal funds). Consequently, a finding of unconstitutionality of one or more of these laws could have a very significant impact on the future of Canada's single-payer system ('medicare'). However, should the court find that a particular law is not in compliance with the Canadian Charter of Rights and Freedoms, the baton is then passed back to the government which may respond with other laws or policies that they believe to be constitutionally compliant. The ultimate impact of any successful Charter challenge to laws protecting medicare from privatization will thus significantly depend on how Canadian governments respond. Provincial governments could allow privatization to undercut equity and access, or they could respond creatively with new legal and policy solutions to both improve equity and access and tackle some of the problems that have long bedeviled Canadian medicare. This paper provides an understanding - grounded in comparative health systems evidence - of law and policy options available to Canadian lawmakers for limiting two-tier care in the wake of any successful challenge to existing laws. The paper presents the results of a large inter-disciplinary, comparative study, started in 2015, that systematically reviewed the legal and broader regulatory schemes used to regulate the public/private divide in 15 Organization for Economic Co-Operation and Development countries with a particular eye to what the effect of such regulations would be upon wait times.

PP166 RedETS: 10 Years Of Economic HTA (Medical Devices) In Spain, 2006–2016

Introduction:RedETS, created in 2006, is the Spanish network of health technology assessment agencies. The objective of this work is to describe and assess the quality of the full economic evaluation reports on medical devices (FEEMD) carried out by RedETS.Methods:The FEEMD were identified through the RedETS website publications database. Assessments about screening technologies were not included. The characteristics of FEEMD were analyzed using a formal RedETS HTA quality checklist. The characteristics extracted were analyzed through a descriptive univariate analysis.Results : Twenty-six FEEMD were found. The publication years were distributed quite uniformly over time (approximately 2/year), although 7 were published in 2008 and 7 in 2013. Thirteen studies analyzed cost-utility, ten cost-effectiveness but not utility, and three both. The most frequent medical devices (MD) class analyzed were “In vitro diagnosis MD” (n = 8) and Class III products (8). The most frequent sources to analyze effectiveness were literature (22) and data collected through ad hoc studies (6). The main sources of unit costs were official public tariffs (14), manufacturers direct values (10) analytical accounting of one/more centers or regions (11) and DRGs (7). In relation to the modelling used, 14 evaluations performed Markov models and 7 decision trees. The perspective of 23 studies was that of the National Health System (NHS), and the rest corresponded to the perspective of a specific region (2) or social perspective (1). All studies analyzing time horizons greater than 1.5 years, except for 1, applied discount rates in the modelling. All studies included a sensitivity analysis.Conclusions:The economic evaluations of MD published by the RedETS accomplish most of the quality checklist aspects and are therefore exhaustive. These FEEMD have been used in the framework of decision making for an efficient management of the NHS basic portfolio.

TARIFFS AND TICKETING INTEGRATION OF COLLECTIVE PUBLIC TRANSPORT IN THE REGION AT THE EXAMPLE OF POMORSKIE VOIVODESHIP

Public transport in the region should be integrated in terms of tariffs and ticketing system. The objective of this article is to present the requirements and project of the tariffs and ticketing integration regarding public transport in the region on the example of Pomorskie Voivodeship. The article begins with information on the circumstances of tariffs and ticketing integration in public transport and models of tariffs integration regarding the said transport in the region. Further the article presents the issue of tariffs and ticketing integration in Pomorskie Voivodeship, where the polycentric metropolis of Gdansk Bay is located. The subsequent parts of the article are devoted to the electronic ticketing system as an instrument of the tariffs and ticketing integration in Pomorskie Voivodeship, and the project of tariffs and ticketing integration within the said area. The implementation and functioning of the tariffs and ticketing integration in the region, satisfactory for the passengers, results from accepting the principles of integrated ticket settlements by the integration participants, based on data regarding the completed travels. In Pomorskie Voivodeship it is planned to start the electronic ticket system providing such data.

Cost-effectiveness evaluation of aspirin in primary prevention of myocardial infarction amongst males with average cardiovascular risk in Iran.

Aspirin is one of the certified medicines commonly used for the secondary prevention of myocardial infarction (MI). Aspirin side effects and gastrointestinal bleeding, in particular, have arisen debates on its use for the primary prevention of MI. The present research evaluates the cost-effectiveness of the use of aspirin in the primary prevention of MI among Iranian men with average cardiovascular disease (CVD) risk, using Markov modeling technique. The incremental cost-effectiveness ratios (ICERs) estimated to be 864 USA dollars (USD) per quality-adjusted life years (QALY) gained and 782 USD per life years gained (LYG) for each patient in the base-case scenario (public tariffs and no discounting). This research proves cost-effectiveness of the use of aspirin in the primary prevention of MI in targeted population, since the assessed ICERs are quite under the recommended threshold by WHO which is one gross domestic product (GDP) per capita ($5315.1 for Iran in 2015).

Design and simulation of a PV-grid connected system

This work presents the design and simulation of 10 kW grid-connected photovoltaic PV systems as feasible power generators for the Hashemite University campus 32.05°N, 36.06°E. The simulation is performed to justify the accuracy and reliability of such design using PV-SOL and Meteonorm simulation software. In the primary simulation runs a set of parameters including the module power, PV-solar panel size, inverter type, global radiation and angle of inclination were used. The results of those runs lead to the final simulation parameters which are used for the 10 kW PV system. This work also presents a comparison between the performances of different PV panel sizes and different inclination angles. The final design of 10-kW PV-system consists of 33 PV panels of 300 W each and three inverters of 3.4 kW each. In order to highlight the economical and ecological effectiveness and the promising potential of the proposed system, a comparison between the costs of one kWh generated by our system with that of the public electricity tariff has been conducted.

SAT0513 Hospital Burden of Gout, Pseudogout and Other Crystal Arthropathies in France from 2009 to 2011

ObjectivesTo describe hospital economic burden of microcrystal arthropathies in France from 2010 to 2012 using French Hospital National DatabaseMethodsData were extracted from the French Hospital National Database. We selected all...

PDB66 - The Cost-Utility of Insulin Degludec Compared with Current Standard of Care in the Management of Type One and Type Two Diabetes Mellitus in Belgium

Insulin degludec (IDeg) is a basal insulin with an ultra-long duration of action for management of patients with type 1 (T1DM) and patients with type 2 (T2DM) diabetes. IDeg has demonstrated efficacious blood glucose control, with less hypoglycaemic events, and with an option for flexibility in dose time, compared with insulin glargine (IGlar). The objective was to assess the cost-effectiveness of IDeg in Belgium, compared with IGlar. The analysis focused on patients in three treatment regimens: T1DM, T2DM treated with basal insulin in combination with oral anti-diabetics (BOT) and T2DM treated with basal-bolus (BB). A one-year cost-utility model driven by differences in hypoglycaemia was used. Published dis-utilities for hypoglycaemic events were multiplied by the rate of hypoglycaemia to calculate quality-adjusted life years (QALYs). Costs and utilities were also calculated for potential use of less blood glucose test strips. A utility gain was attributed to the additional benefit of dosing flexibility. Unit costs pertained to public tariffs and reflected the payer perspective in Belgium. Baseline incidence rates of hypoglycaemic events and related resource utilization pertained to a Belgian patient-reported outcomes study. Hospitalization costs following severe hypoglycaemia were estimated using the IMS Hospital Disease Database. IDeg was associated with an incremental cost-effectiveness ratio of 14,677€/QALY in T1DM, 4,976€/QALY in T2DM BOT, and 12,930€/QALY in T2DM BB. Univariate and probabilistic sensitivity analyses confirmed robust results. Results were most sensitive to variations in number of IGlar doses per day, and number of glucose-monitoring tests. At a willingness to pay threshold of 30,000€/QALY, IDeg would be cost-effective in 54%, 100% and 93% of the cases in the T1DM, T2DM BOT or T2DM BB treatment regimens respectively. These analyses demonstrate that IDeg is cost-effective in Belgium, when used in patients with T1DM and T2DM currently treated with long-acting insulin analogues.

Patient and Public Preferences for Health States Associated with AMD

Health utility values suitable for calculating quality-adjusted life-years are increasingly used to assess the cost-effectiveness of treatments for age-related macular degeneration (AMD). In the United States, health utilities are usually derived from the patients' own valuation or modeled using visual acuity as a surrogate outcome. In the United Kingdom and throughout Europe, health utilities are derived from public valuations. Our aim was to test if utility values for health states associated with AMD elicited directly from patients were different from those calculated from public tariffs for health-related quality of life (HRQoL) questionnaires. Generic preference-based HRQoL questionnaires (EQ-5D and SF-6D) and the time trade-off (TTO) and visual analog scale (VAS) valuation techniques were administered to a sample of UK patients with AMD (N = 60). Health utilities were calculated using standard general population tariffs for the patient EQ-5D and SF-6D health states and directly from patient TTO and VAS scores. Mean utilities derived from the public tariffs were significantly higher than from patients' valuation (mean [±SD], 0.613 (±0.275) for the EQ-5D and 0.628 (±0.114) for the SF-6D compared with 0.481 [±0.411] for the TTO and 56.7 [±21.8] for the VAS score; p < 0.001). The EQ-5D was not significantly different from the SF-6D (p > 0.6). Visual acuity in the better seeing eye was not associated with any utility measure (all r < 0.08; p > 0.2). Patient and public preferences for health states associated with AMD are different, with patients valuing their health state more severely than the public tariffs of commonly used HRQoL questionnaires. Visual acuity did not predict health utility using any measure, and therefore, care should be taken when using visual acuity as a surrogate measure for utility in health economic analyses.

Ocean shipping deregulation restructures the liner shipping industry

Significant pro-competitive changes were made to the Shipping Act by the Ocean Shipping Reform Act (OSRA). The most notable of these was the shift away from public tariffs and publicly available contract rates to confidential rates using individually negotiated service contracts. The number of individual member service contracts has risen dramatically since OSRA went into effect in 1999. These statistics support the argument that OSRA was able to bring more competition to the industry. However, the theory and empirical evidence of the Act’s success in improving the performance of the liner industry serving the Transatlantic and Transpacific trade routes, which are two major trunk roads subject to the jurisdiction of the US, are not so compelling. This article employs the theory of joint product to assess the impact of OSRA on the shipping market structure and competition of two major east–west arteries after 1999. This article considers head haul and backhaul container shipments as joint products. Two simple statistical equations are derived to reinterpret Smith’s condition of joint product. The empirical results confirm that the market structure of Transatlantic and Transpacific trade lanes are competitive.

Ocean shipping reform act promotes competition in the trans-Atlantic trade route

Substantial pro-competitive changes were made to the Shipping Act by the Ocean Shipping Reform Act (OSRA). Of these changes, the most notable was the shift away from public tariffs and publicly available contract rates to confidential rates using individually negotiated service contracts. The number of individual member service contracts has risen dramatically since OSRA went into effect in 1999. These statistics from reports of the European Commission support the argument that OSRA was able to instill more competition into the industry. However, the empirical evidence on the Act's success in improving the performance of the containerized liner industry serving the Trans-Atlantic trade route is not so compelling. This paper applies the theory of joint product to assess the impact of OSRA on the structure and competition of shipping market after 1999. Trans-Atlantic eastbound and westbound routes were regarded as joint products. A simple statistical equation is derived to reinterpret Smith's condition of joint product. Empirical results obtained confirm the competitive market structure of the Trans-Atlantic trade route.

Driving cost factors in adult outpatients with refractory epilepsy: A daily clinical practice in clinics of neurology in Spain

To explore the association between patient-reported-outcomes measurements and costs in adult outpatients with drug refractory epilepsy (DRE) in Spain. Secondary analysis of a cross-sectional study to determine resources utilization and related costs of refractory epilepsy in Spain (LINCE study). Consecutive adult outpatients fulfilling criteria for DRE were analyzed. Health-related quality of life (HRQoL), anxiety and depression, self-perceived health status and patient's satisfaction with treatment were assessed respectively by QOLIE-10, HAD scales, EQ-5D-VAS and SATMED-Q questionnaire. Costs were estimated from public tariffs computing healthcare and non-healthcare resources use in the year 2005. Seven hundred sixty two consecutive patients (728 (95.5%) valuables; 50.8% males, 40.5+/-13.5 years) were analyzed. Severe levels of anxiety and depression were both associated with higher costs: from a mean yearly total cost of 6291 euros +/- 7748 (no anxiety) to 10325.8 euros +/-9900.8 (severe), p<0.0012 and from 5983.5 euros +/-6726.1 (no depression) to 12691.4 euros +/-11745.9 (severe), p<0.0001. Total yearly cost was inversely associated with HRQoL, self-perceived health status and satisfaction with treatment: from 11517.3 euros +/-11449.2 to 5430.2 euros +/-7776.6, first and tenth QOLIE-10 decile intervals, respectively, from 11494 euros +/- 11668 to 5334.3 +/- 7606, first and tenth VAS decile intervals, respectively, and from 9762.6 euros +/- 9956.6 to 4746.4 euros +/- 5616.7, first and tenth SATMED-Q decile intervals, respectively, p<0.0001. Higher costs of refractory epilepsy were associated with poorer patient-reported-outcomes scores. These findings may be of interest for both health decision makers and clinicians when evaluating the resources devoted to epilepsy.

Proton Pump Inhibitors in Acute Treatment of Reflux Oesophagitis

Gastro-oesophageal reflux disease is a common medical problem that places a significant financial burden on outpatient pharmaceutical expenditure. A substantial proportion of this expenditure can be attributed to the use of proton pump inhibitors (PPIs). The aim of this analysis was to evaluate the cost-effectiveness of PPIs currently licensed in Italy in the acute treatment of reflux oesophagitis. A decision analysis model that simulated the sequential management of reflux oesophagitis over the course of 8 weeks was constructed. Healing rates were derived from a published meta-analysis of PPIs for reflux oesophagitis. Costs of PPIs were based on retail prices in Italy, endoscopies and specialist (outpatient) visits were costed on the basis of public tariffs, and opportunity costs were calculated for general practitioner visits. The clinical effectiveness of a PPI was measured in terms of the proportion of patients healed at 8 weeks. An incremental cost-effectiveness analysis was performed, using omeprazole, the recognised 'gold standard' PPI in Italy, as the common comparator. The perspective of the analysis was the Italian National Health System (NHS). A sensitivity analysis was conducted in which the key parameters in the model were varied according to a Monte Carlo simulation of 1000 patients. Esomeprazole 40 mg/day was a dominant treatment option compared with omeprazole 20 mg/day (88.8% patients healed vs 82.2%, respectively; total treatment cost euro164.85 vs euro169.56, respectively (year of costing, 2002). Furthermore, on the basis of the 95% CIs generated by the Monte Carlo simulation, esomeprazole 40 mg/day appears to be more cost-effective than both lansoprazole 30 mg/day and pantoprazole 40 mg/day. Esomeprazole 40 mg/day can be considered a cost-effective treatment option for the acute treatment of reflux oesophagitis in Italy.