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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2006.04.015 Byline: Betty Tang (a), Ellen Jamieson (a), Michael Boyle (a), Anne Libby (b), Amiram Gafni (c), Harriet MacMillan (a) Keywords: Child abuse; Health care expenditures; Canada; Health utilization; Women Abstract: Childhood maltreatment is a common and serious problem for women, particularly in relation to impairment in adulthood. To our knowledge, no system-wide study has addressed the influence of childhood maltreatment on the cost of these women's adult health service utilization. This paper examines this relationship. The 1990 Ontario Health Survey (OHS) gathered information regarding determinants of physical health status and the use of health services. The 1991 Ontario Mental Health Supplement (OHSUP) examined a variety of childhood experiences as well as the prevalence of psychiatric disorders from a sample of OHS respondents. These were province-wide population health surveys of a probability-based sample of persons aged 15 years and older living in household dwellings in Ontario. The OHSUP randomly selected one member from each participating OHS household to be interviewed regarding personal experiences and mental health. This analysis used data from women aged 15-64 who participated in both the OHS and OHSUP. Self-reported health service utilization was collected in four groups of women -- those who reported no history of child abuse, those with a history of physical abuse only, those who reported sexual abuse only, and those who reported both physical and sexual (combined) abuse. We hypothesized that a history of child abuse would result in greater adult health care costs. The results indicated that having a history of combined abuse nearly doubles mean annual ambulatory self-reported health care costs to $775 (95% CI $504-$1045) compared to a mean cost of $400 with no abuse (95% CI $357-$443). Median annual ambulatory self-reported health care costs were also increased in the combined abuse group, to $314 (95% CI $220-$429), compared to $138 (95% CI $132-$169) in those with no abuse. We conclude that child abuse in women is significantly associated with increased adult self-reported health care costs. Author Affiliation: (a) Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ont., Canada L8N 3Z5 (b) Department of Psychiatry, University of Colorado Health Sciences Centre, USA (c) Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont., Canada L8N 3Z5

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2005.10.023 Byline: Amiram Gafni, Stephen Birch Keywords: Economic evaluation; Cost-effectiveness analysis; Decision rules; Incremental cost-effectiveness ratio; Health care costs Abstract: Despite the central role of the threshold incremental cost-effectiveness ratio (ICER), or lambda (I'), in the methods and application of cost-effective analysis (CEA), little attention has been given to the determining the value of I'. In this paper we consider 'what explains the silence of the I''? The concept of the threshold ICER is critically appraised. We show that there is 'silence of the I'' with respect to justification of the value of ICER thresholds, their use in decision-making and their relationship to the opportunity cost of marginal resources. Moreover, the 'sound of silence' extends to both 'automatic cut-off' and more sophisticated approaches to the use of I' in determining recommendations about health care programs. We argue that the threshold value provides no useful information for determining the efficiency of using available resources to support new health care programs. On the contrary, the threshold approach has lead to decisions that resulted in increased expenditures on health care programs and concerns about the sustainability of public funding for health care programs without any evidence of increases in total health gains. To improve efficiency in resource allocation, decision-makers need information about the opportunity costs of programs. Author Affiliation: McMaster University, Hamilton, Ont., Canada

The prevalence of mental health problems, some of which seem to be occurring among younger cohorts, leads researchers and policy-makers to search for practical solutions to reduce the burden of suffering on children and their families, and the costs to society both immediate and long term. Numerous programs are in place to reduce or alleviate problem behaviour or disorders and/or assist positive youth development. Evaluated results are dispersed throughout the literature. To assess findings and determine common elements of effective children's services, a literature search was undertaken for evidence-based evaluations of non-clinical programs for school-age children. Prescriptive comments aim to inform service-providers, policy-makers and families about best practices for effective services such as: early, longterm intervention including reinforcement, follow-up and an ecological focus with family and community sector involvement; consistent adult staffing; and interactive, non-didactic programming adapted to gender, age and cultural needs. Gaps are identified in our understanding of efficiencies that result from effective programs. Policy implications include the need to develop strategies for intersectoral interventions, including: new financing arrangements to encourage (not penalize) interagency cooperation and, to ensure services reach appropriate segments of the population; replication of best practices; and publicizing information about benefits and cost savings. In many jurisdictions legislative changes could create incentives for services to collaborate on service delivery. Joint decision-making would require intersectoral governance, pooling of some funding, and policy changes to retain savings at the local level. Savings could finance expansion of services for additional youth. Keywords: Children; School-age; Mental health; Effective programs; Efficiency; Review

Much research has been devoted to handling uncertainty in cost-effectiveness analysis. The current literature suggests summarizing uncertainty in cost-effectiveness analysis using acceptability curves or net health benefits. These approaches, however, focus only on uncertainty associated with costs and effects of the programs under consideration. In the real world, most decision-makers have to fund a portfolio of health care programs. Therefore, a more comprehensive approach would include in the analysis the uncertainty of costs and effects of all programs supported by the fixed budget. This paper extends the decision rule described by Birch and Gafni (J. Health Econ. 11(3) (1992) 279) within the context of a portfolio of programs when costs and effects are uncertain and resources constrained. Keywords: Cost-effectiveness analysis; Uncertainty; Sensitivity analysis; Portfolio; Resource constraints

In recent years there has been a growth in the advocacy of shared decision making (SDM) between clinicians and patients as a way of practicing medicine. Although there is a range of perspectives on what SDM means, in essence it refers to greater involvement of the individual patient in deliberations about appropriate forms of clinical management. The patient's perception of the role of the doctor in SDM is crucial: for it to work successfully, the patient needs to be able to be confident that the doctor is focused on which treatment will generate the greatest benefit for them. However, the doctor also has responsibilities to others, in particular to other patients and potential patients within the collectively funded health care system. This dual responsibility can create a range of dilemmas for the clinician in the context of SDM: Should they inform patients about all effective treatments or just those that the health care system considers cost-effective? Do they risk losing patients from their books if they inform patients about their responsibilities to the health care system? SDM also raises questions about the wider principles of the health care system: Are its equity principles consistent with SDM? Should patients with a strong preference for an effective but non-cost-effective treatment be permitted to pay for it privately? This paper describes the nature of the conflicts that are likely to emerge if SDM diffuses within collectively funded health care systems, and considers a range of policy responses. It argues that the risk of conflict may be reduced by making a clear distinction between clinical guidelines (focusing on effectiveness) and system guidelines (focusing on cost-effectiveness). Keywords: Shared decision making; Cost-effectiveness; Collectively funded health care systems; Guidelines

This 5-year study conducted in Ontario, Canada is designed to assess the effects and expense of adding a mix of provider-initiated interventions to the health and social services typically used in a self-directed manner by sole-support parents and their children receiving social assistance in a national system of health and social insurance. Results from a 2-year interim analysis show that providing social assistance families with proactive comprehensive care (health promotion, employment retraining, and recreation activities for children) compared to allowing families to fend for themselves in a self-directed manner, results in 15% more exits from social assistance within 1 year and substantial savings to society in terms of social assistance payouts. It is no more expensive to provide health and social services in a comprehensive fashion, and equivalent reductions in parent mood disorder and child behavior disorders, as well as equivalent increases in parent social adjustment and child competence levels were also observed. This study presents clear evidence that providing comprehensive care to social assistance recipients produces tremendous short- and long-term financial gains and societal benefits. Keywords: Single parents; Social assistance; Effectiveness; Cost; Provider-initiated

Much concern has been expressed about increasing health costs associated with an aging population. In relation to chronic conditions, this study demonstrates that cost seems to be a function of adjustment to the chronic condition rather than of age in and of itself. We know from previous work that people with poor psychosocial adjustment cost considerably more than do people who are either moderately or well adjusted and this study shows that older, poorly adjusted persons are no more costly than their younger counterparts. Key words - chronic illness, adjustment, cost, aged, illness behaviour

Shared decision-making is increasingly advocated as an ideal model of treatment decision-making in the medical encounter. To date, the concept has been rather poorly and loosely defined. This paper attempts to provide greater conceptual clarity about shared treatment decision-making, identify some key characteristics of this model, and discuss measurement issues. The particular decision-making context that we focus on is potentially life threatening illnesses, where there are important decisions to be made at key points in the disease process, and several treatment options exist with different possible outcomes and substantial uncertainty. We suggest as key characteristics of shared decision-making (1) that at least two participants - physician and patient be involved; (2) that both parties share information; (3) that both parties take steps to build a consensus about the preferred treatment; and (4) that an agreement is reached on the treatment to implement. Some challenges to measuring shared decision-making are discussed as well as potential benefits of a shared decision-making model for both physicians and patients. Key words - shared treatment decision-making, physician/patient communication

In this paper we critically appraise the appropriateness and validity from an economic perspective of alternative preference-based approaches to measuring outcomes in economic evaluations of health care interventions. We describe the properties of an outcome measure for economic evaluation to make it compatible with the principles of economics when applied to the problem of resource allocation. We also describe the difference and similarities between the psychometric and the economic approaches for the measurement of outcome. Using these properties we critically appraise the use of QALY and HYE methods of measuring individual and social preferences for health outcome. We argue that the most advanced measure currently available that meets these required properties is the HYE. Because the HYE, unlike the QALY, has its foundations in utility theory under uncertainty, it neither assumes particular formulations of the individual utility function, nor is it incompatible with the principles of economics. As such it represents a further stage in the continuing development of methods for economic evaluation of health care programmes. Key words - economic evaluation, cost utility analysis, QALYs, utility theory

Bridges and Terris (Soc. Sci. Med. (2004)) critique our paper on the alternative decision rule of economic evaluation in the presence of uncertainty and constrained resources within the context of a portfolio of health care programs (Sendi et al. Soc. Sci. Med. 57 (2003) 2207). They argue that by not adopting a formal portfolio theory approach we overlook the optimal solution. We show that these arguments stem from a fundamental misunderstanding of the alternative decision rule of economic evaluation. In particular, the portfolio theory approach advocated by Bridges and Terris is based on the same theoretical assumptions that the alternative decision rule set out to relax. Moreover, Bridges and Terris acknowledge that the proposed portfolio theory approach may not identify the optimal solution to resource allocation problems. Hence, it provides neither theoretical nor practical improvements to the proposed alternative decision rule. Keywords: Cost-effectiveness analysis; Uncertainty; Portfolio theory