Expanded newborn screening for genetic and metabolic disorders: modeling costs and outcomes

Newborn screening for genetic and metabolic disorders is a state-based public health program in the United States, for the elimination and/or reduction of associated mortality, morbidity, and disabilities. As new technologies for newborn screening and new interventions for treatment are realized, it will be increasingly important for health leaders and policymakers to have data to inform their decisions regarding expanding newborn testing. The entire costs of a screening program, including not only instrumentation but also labor and time costs; initial, repeat, and confirmatory testing; screening sensitivity and specificity; and short and long-term followup, should be considered in decisions regarding expansion of screening programs. The decision model cited in this study can serve as a tool in exploring alternatives for critical decisions regarding the addition of new disorders to existing newborn screening panels. The evaluation of genetic disorders in this study can be used as a prototype of an approach to evaluating screening for any newborn genetic/metabolic disorder.     

Using stated preference discrete choice modelling to inform health care decision-making: A pilot study of breast screening participation

This study was an important start to explore the feasibility of applying stated preference discrete choice modelling (SPDCM) for use in developing breast screening participation enhancement strategies. It needs to be followed by further research to establish model validity and authoritative results. In the meantime a random effects binary probit choice model was estimated using a main effects with selected 2-way interaction design and a convenience sample of Australian breast cancer screening participants. A response rate of 48% was obtained. Clear preferences for different service configurations were revealed and used to demonstrate how potential strategies to enhance future participation rates of women placed on routine recall could be identified. As anticipated accuracy of screening was the most important attribute of the service to influence the probability of uptake but others were screening time, travel time, information about screening benefits and the desire for privacy lending support to the view that benefit assessment goes beyond health factors. In summary, the SPDCM approach can be regarded as a judicious approach for helping decision-makers improve screening participation.     

Projecting total costs and health consequences of increasing mt-sDNA utilization for colorectal cancer screening from the payer and integrated delivery network perspectives

Abstract

Aims: To evaluate total costs and health consequences of a colorectal cancer (CRC) screening program with colonoscopy, fecal immunochemical tests (FIT), and expanded use of multitarget stool DNA (mt-sDNA) from the perspectives of Integrated Delivery Networks (IDNs) and payers in the United States.

Materials and methods: We developed a budget impact and cost-consequence model that simulates CRC screening for eligible 50- to 75-year-old adults. A status quo scenario and an increased mt-sDNA scenario were modeled. The status quo includes the current screening mix of colonoscopy (83%), FIT (11%), and mt-sDNA (6%) modalities. The increased mt-sDNA scenario increases mt-sDNA utilization to 28% over 10 years. Costs for both the IDN and the payer perspectives incorporated diagnostic and surveillance colonoscopies, adverse events (AEs), and CRC treatment. The IDN perspective included screening program costs, composed of direct nonmedical (e.g. patient navigation) and indirect (e.g. administration) costs. It was assumed that IDNs do not incur the costs for stool-based screening tests or bowel preparation for colonoscopies.

Results: In a population of one million covered lives, the 10-year incremental cost savings incurred by increasing mt-sDNA utilization was $16.2 M for the IDN and $3.3 M for the payer. The incremental savings per-person-per-month were $0.14 and $0.03 for the IDN and payer, respectively. For both perspectives, increased diagnostic colonoscopy costs were offset by reductions in screening colonoscopies, surveillance colonoscopies, and AEs. Extending screening eligibility to 45- to 75-year-olds slightly decreased the overall cost savings.

Limitations: The natural history of CRC was not simulated; however, many of the utilized parameters were extracted from highly vetted natural history models or published literature. Direct nonmedical and indirect costs for CRC screening programs are applied on a per-person-per modality basis, whereas in reality some of these costs may be fixed.

Conclusions: Increased mt-sDNA utilization leads to fewer colonoscopies, less AEs, and lower overall costs for both IDNs and payers, reducing overall screening program costs and increasing the number of cancers detected while maintaining screening adherence rates over 10 years.     

Cervical cancer prevention in Morocco: a model-based cost-effectiveness analysis

Abstract

Objective: Cervical cancer is a huge public health issue in Morocco which represents the second most frequent and fatal cancer among women. Countries that have not yet introduced the HPV vaccine could benefit greatly, but before implementation it is necessary to perform country-specific economic assessments that include current screening practices.

Methods: A Markov model was developed to simulate the natural history of HPV and cervical cancer so as to calculate the long-term health benefits and costs of HPV vaccination and current screening by visual inspection with acetic acid (VIA). Starting from a previous transition probability matrix used for a model from Spain, the present model was calibrated to cervical cancer incidence from Morocco. Cost survey data was used to estimate the cost of screening and clinical procedures from the public healthcare perspective. Incremental cost-effectiveness ratios were calculated as 2018US$ per additional year of life saved (YLS) and both costs and health outcomes were discounted at 3%.

Results: The expected reduction in lifetime risk of cervical cancer for current screening would be 14% at a cost of US$551/YLS compared with no intervention, assuming VIA every 3 years in women aged 30–49 at 10% coverage. HPV vaccination of pre-adolescent girls at 70% coverage would reduce the lifetime risk of cervical cancer by 62% at a cost of US$1,150/YLS, compared with no intervention. When implementing HPV vaccination in combination with current screening, vaccination would be dominated, and the combined strategy would provide a 69% reduction at a cost of US$2,843/YLS, compared with screening alone. Current screening would be dominated by vaccination when screening coverage is higher than 15%, whereas the combined strategy rapidly exceeds US$4,000/YLS.

Conclusions: HPV vaccination could be highly effective and cost-effective in Morocco. Current screening would be good value for money compared with no intervention, but scaling-up screening coverage would make it inefficient compared with vaccination.     

大型高新技术企业NPD创意筛选模型研究

创意筛选对于大型高新技术企业新产品开发具有重要意义。在梳理相关文献的基础上,提出大型高新技术企业新产品开发创意筛选的概念模型,并针对创意筛选实践中的关键问题,运用BFPRT算法进行处理,构建了大型高新技术企业创意筛选实施过程,具有一定的理论与实践借鉴意义。     

Cost-effectiveness of targeted screening for the identification of patients with atrial fibrillation: evaluation of a machine learning risk prediction algorithm

Abstract

Aims: As many cases of atrial fibrillation (AF) are asymptomatic, patients often remain undiagnosed until complications (e.g. stroke) manifest. Risk-prediction algorithms may help to efficiently identify people with undiagnosed AF. However, the cost-effectiveness of targeted screening remains uncertain. This study aimed to assess the cost-effectiveness of targeted screening, informed by a machine learning (ML) risk prediction algorithm, to identify patients with AF.

Methods: Cost-effectiveness analyses were undertaken utilizing a hybrid screening decision tree and Markov disease progression model. Costs and outcomes associated with the detection of AF compared traditional systematic and opportunistic AF screening strategies to targeted screening informed by a ML risk prediction algorithm. Model analyses were based on adults ≥50?years and adopted the UK NHS perspective.

Results: Targeted screening using the ML risk prediction algorithm required fewer patients to be screened (61 per 1,000 patients, compared to 534 and 687 patients in the systematic and opportunistic strategies) and detected more AF cases (11 per 1,000 patients, compared to 6 and 8?AF cases in the systematic and opportunistic screening strategies). The targeted approach demonstrated cost-effectiveness under base case settings (cost per QALY gained of £4,847 and £5,544 against systematic and opportunistic screening respectively). The targeted screening strategy was predicted to provide an additional 3.40 and 2.05 QALYs per 1,000 patients screened versus systematic and opportunistic strategies. The targeted screening strategy remained cost-effective in all scenarios evaluated.

Limitations: The analysis relied on assumptions that include the extended period of patient life span and the lack of consideration for treatment discontinuations/switching, as well as the assumption that the ML risk-prediction algorithm will identify asymptomatic AF.

Conclusions: Targeted screening using a ML risk prediction algorithm has the potential to enhance the clinical and cost-effectiveness of AF screening, improving health outcomes through efficient use of limited healthcare resources.     

信贷审批权配置效率的实证分析

运用Bankscope全球银行与金融机构分析数据库,实证分析了银行信贷审批权的配置对银行经营绩效的影响。研究发现,银行信贷审批权限对其经营绩效没有显著影响。这意味着信贷审批权的上收并不一定会改进银行经营绩效。银行把信贷审批权上收,虽然可以在一定程度上减少代理人的道德风险,降低代理成本,但是银行信息成本可能会增加。因此,银行在进行贷款审批权的配置时需要综合考虑代理成本和信息成本．不应该搞“一刀切”,一味地把信贷审批权上收。     

Expansion and welfare in microfinance: A screening model

The expansion of microfinance has triggered concerns of rising indebtedness, and higher default and interest rates. Using a screening model, we show that even if interest and default rates increase due to expansion, borrower welfare may improve. This is because: (i) all borrowers previously denied credit can obtain loans, and (ii) screening costs for pre-existing borrowers go down. Hence, policies that seek to regulate interest and screening levels can be counterproductive.     

Screening,ability, and the productivity of education in Malaysia

The test of the strong version of the screening hypothesis proposed by Psacharopoulos is applied to the case of a LDC with further extensions to allow for interaction terms and differences in ability. The results do not support the strong version of the screening hypothesis.     

热断层（TTM）技术作为口岸传染病自动筛查手段的探讨

目的探讨TTM扫描成像在口岸传染病监测工作中的适用价值。方法总结口岸现行以红外测温为基础的传染病筛查模式存在的不足,深入分析TTM技术的优势,结合北京检验检疫局应用TTM技术筛查口岸常见传染病的研究成果,探讨TTM技术作为口岸一种传染病自动筛查手段的可行性。结果经对比现场红外测温筛查手段和TTM技术手段,结合北京检验检疫局的探索性研究和初步应用,TTM技术口岸常见传染病具有很高的阳性检出率并完全满足疾病筛查的要求。结论热断层技术在作为口岸传染病一种自动筛查手段具有较高的推广应用价值。     

Multidimensional screening under nonlinear costs: Limits of standard approach

We generalize the usual screening approach and conditions for efficiency-at-the-top and acyclic property from linear to fixed-plus-separable or concave costs and multidimensional commodities. But under non-concave costs, like capacity constraints, an example shows a cycle in the solution graph. The cycle makes the standard screening solution non-implementable and approach inadequate.     

On education,screening and human capital

The paper tests the hypothesis that educational attainment acts, inter alia, as a screening device for worker selection by comparing the average educational level of pairs of screened and non-screened groups within similar occupational categories. The results, based on Israeli data, support the view that strong screening effects are at work.     

Competitive screening and information transmission

We consider a model in which schools and colleges compete for high-ability students, which are independently identified through a costly screening procedure. This independence creates a channel through which students' preferences affect the strategic interaction between schools: students with competing offers accept the most-preferred one, increasing the screening costs of unpopular schools. When preferences between schools are more heterogeneous, schools screen more, increasing the proportion of students with multiple offers, but paradoxically reducing the extent to which their preferences determine their outcomes. By observing the students' schools of origin, colleges can free-ride of the fierce competition that occurs during screening.     

Evidence on the weak and the strong versions of the screening hypothesis in the United States

This paper extends the works of Psacharopoulos (1979), Lee (1980), and Liu and Wong (1982) by controlling for differences in ability and testing both versions of the screening hypothesis. Using micro data from the United States, the empirical results do not support either the theoretical strong or weak versions of the screening hypothesis.     

Collateralized Lending by Indian Banks: Some Explanations and Policy Implications

This paper draws a parallel between the extent of unsecured lending that a bank does and the screening effort extended by the bank. Since unsecured lending requires screening on the part of the bank, higher the percentage of unsecured loans in total loans, higher is likely to be the screening effort while processing loan applications. Using panel data relating to banks in India, we find that on an average a higher extent of screening effort or unsecured loans is likely to be provided by banks that are large, have low level of non-performing assets, and are in the private sector. Further, persistence in the extent of unsecured lending seems to suggest that any change in unsecured lending/ screening effort is likely to be rather slow.

     

Identifying cost-effective screening algorithms for active hepatitis C virus infections in a high prevalence setting

Objective: To evaluate the cost-effectiveness of different screening patterns for active chronic hepatitis C virus (HCV) infections utilizing the hepatitis C core antigen test compared to standard care in the context of a general screening program in a high-prevalence country.

Methods: This study developed a decision analytic model to estimate the cost-effectiveness of four screening algorithms for the detection of active HCV infections among asymptomatic individuals with an unknown HCV status in a context of high (>5%) HCV prevalence. Three algorithms started with a serological test for antibodies (AB) followed by a nucleic acid test for HCV-RNA (RNA), the HCVAg (AG) assay, or both. An additional single marker screening strategy with AG was added to the analysis. By the example of the Republic of Georgia, strategies were compared in terms of total costs for screening and diagnosis of an active infection from a health system perspective.

Results: Replacing RNA with AG for confirmation of positive AB identified fewer active infections (–110 per 100,000 screened subjects) at significantly reduced total costs (–$2.74 per screened) and costs per diagnosed infection (–$44). Adding a subsequent RNA confirmatory test on AG negative results captured at least the same rate compared to the standard (AB followed by RNA) at still reduced costs (–$1.16 per subject screened, –$22 per case detected). Utilizing AG as the frontline test revealed the highest detection rate (97.9%) at the highest costs (+$3.80 per subject, +$323 per case detected vs standard).

Conclusion: A combined pattern of HCV AB screening followed by sequential confirmation with AG and RNA on AG negatives would provide equal or better diagnostic performance at lower cost over a broad range of scenarios. Potential long-term consequences of screening strategies to patients and society have to be considered, since the latency period for HCV to develop into severe liver disease is long.     

教育与劳动力市场关系研究

教育是多层次递进式的,经过多次甄别筛选,将劳动力纳入高低不同的生产力群体;教育也是多方向发散式的,当具备了基本的学习能力之后,会接受不同类型的专业教育,掌握不同的生产技能。这样,教育甄别筛选出高生产力者,并使其具有不同的生产技能,确定了劳动者所从事的专业领域以及在求职序列中的排位,决定了个体在劳动力市场中的最初定位点,实现了对劳动力的初步配置。本文在研究教育与劳动力市场关系的基础上,建立了教育对劳动力的甄别配置模型,并对我国劳动力市场中教育甄别配置功能的效率问题进行了探讨。     

Public health impact of comprehensive hepatitis C screening and treatment in the French baby-boomer population

Objective: To estimate the public health impact of comprehensive hepatitis C virus (HCV) screening and access to all-oral, interferon (IFN)-free direct-acting antivirals (DAAs) in the French baby-boomer population (1945–1965 birth cohorts).

Methods: A sequential, multi-cohort, health-state transition model was developed to assess the impact of different hepatitis C screening and treatment strategies on clinical and economic outcomes in the 1945–1965 birth cohorts. Patients newly-diagnosed with chronic HCV were projected each year from 2016 to 2036 under three screening scenarios (70% [low], 75% [intermediate], and 80% [high] HCV awareness in 2036). Healthcare costs and clinical outcomes (number of liver-related deaths, quality-adjusted life-years [QALYs], life-years [LYs] spent in sustained virologic response [SVR] or with decompensated cirrhosis, hepatocellular carcinoma, or liver transplant) were compared among five treatment strategies (no antiviral therapy; IFN?+?ribavirin?+?protease inhibitor for fibrosis stages F2–F4, IFN-based DAAs for stages F2–F4, IFN-free DAAs for stages F2–F4, and IFN-free DAAs for stages F0–F4).

Results: Diagnosis of HCV genotype 1 was projected for 4,953, 6,600, and 8,368 individuals in the low, intermediate, and high screening scenarios, respectively. In the intermediate scenario, IFN-free DAAs for stages F0–F4 had a favorable cost-effectiveness profile vs IFN-based or IFN-free treatment strategies for F2–F4 and offered the greatest return on investment (0.899 LYs gained in SVR and 0.933 QALYs per €10,000 invested).

Conclusion: Comprehensive HCV screening and access to all-oral, IFN-free DAAs is a cost-effective strategy that could help diminish the upcoming burden of HCV in the French baby-boomer population.     

SCREENING ETHICS WHEN HONEST AGENTS CARE ABOUT FAIRNESS*

A principal faces an agent with private information who is either honest or dishonest. Honesty involves revealing private information truthfully if the probability that the equilibrium allocation chosen by an agent who lies is small enough. Even the slightest intolerance for lying prevents full ethics screening whereby the agent is given proper incentives if dishonest and zero rent if honest. Still, some partial ethics screening may allow for taking advantage of the potential honesty of the agent, even if honesty is unlikely. If intolerance for lying is strong, the standard approach that assumes a fully opportunistic agent is robust.     

中国城乡居民收入差距核心影响因素筛选模型及实证

利用Frisch综合分析法构建了中国城乡居民收入差距核心影响因素筛选模型,并利用1991—2013年的数据进行了实证分析。经过初筛及逐步定量筛选,从海选出的60个影响因素中筛选得到4个核心影响因素——城乡二元结构、经济增长速度、外商及港澳台投资占GDP比例以及第一产业增加值占GDP比重,克服了现有研究不经海量筛选而易漏掉影响较大的因素以及数据陈旧而难以反映当前现状的不足。