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Objective: To estimate the health impact, financial costs, and cost-effectiveness of scaling-upcoverageofhumanpapillomavirus(HPV)vaccination(younggirls)andcervical cancer screening (women of screening age) for women in countries that will likely need donor assistance. Methods

We estimate the marginal rate of substitution of income for reduction in current annual mortality risk (the "value per statistical life" or VSL) using statedpreference surveys administered to independent samples of the general population of Chengdu China in 2005 and 2016. We evaluate the quality of estimates by the theoretical criteria that WTP for risk reduction should be strictly positive and nearly proportional to the magnitude of the risk reduction (evaluated by comparing answers between respondents) and test the effect of excluding respondents whose answers violate these criteria. For subsamples of respondents that satisfy the criteria, point estimates of the sensitivity of WTP to risk reduction are consistent with theory and yield estimates of VSL that are two to three times larger than estimated using the full samples. Between 2005 and 2016, estimated VSL increased sharply, from about 22,000 USD in 2005 to 550,000 USD in 2016. Income also increased substantially over this period. Attributing the change in VSL solely to the change in income implies an income elasticity of about 2.5. Our results suggest that estimates of VSL from stated-preference studies in which WTP is not close to proportionate to the stated risk reduction may be biased downward by a factor of two or more, and that VSL is likely to grow rapidly in a population with strong economic growth, which implies that environmental-health, safety, and other policies should become increasingly protective.

Little information exists on the cost structure of routine infant immunization services in low- and middle-income settings. Using a unique dataset of routine infant immunization costs from six countries, we estimated how costs were distributed across budget categories and programmatic activities, and investigated how the cost structure of immunization sites varied by country and site characteristics. The EPIC study collected data on routine infant immunization costs from 319 sites in Benin, Ghana, Honduras, Moldova, Uganda, Zambia, using a standardized approach. For each country, we estimated the economic costs of infant immunization by administrative level, budget category, and programmatic activity from a programme perspective. We used regression models to describe how costs within each category were related to site operating characteristics and efficiency level. Site-level costs (incl. vaccines) represented 77–93% of national routine infant immunization costs. Labour and vaccine costs comprised 14–69% and 13–69% of site-level cost, respectively. The majority of site-level resources were devoted to service provision (facility-based or outreach), comprising 48–78% of site-level costs across the six countries. Based on the regression analyses, sites with the highest service volume had a greater proportion of costs devoted to vaccines, with vaccine costs per dose relatively unaffected by service volume but non-vaccine costs substantially lower with higher service volume. Across all countries, more efficient sites (compared with sites with similar characteristics) had a lower cost share devoted to labour. The cost structure of immunization services varied substantially between countries and across sites within each country, and was related to site characteristics. The substantial variation observed in this sample suggests differences in operating model for otherwise similar sites, and further understanding of these differences could reveal approaches to improve efficiency and performance of immunization sites.

BackgroundEvidence on immunization costs is a critical input for cost-effectiveness analysis and budgeting, and can describe variation in site-level efficiency. The Expanded Program on Immunization Costing and Financing (EPIC) Project represents the largest investigation of immunization delivery costs, collecting empirical data on routine infant immunization in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia.MethodsWe developed a pooled dataset from individual EPIC country studies (316 sites). We regressed log total costs against explanatory variables describing service volume, quality, access, other site characteristics, and income level. We used Bayesian hierarchical regression models to combine data from different countries and account for the multi-stage sample design. We calculated output elasticity as the percentage increase in outputs (service volume) for a 1% increase in inputs (total costs), averaged across the sample in each country, and reported first differences to describe the impact of other predictors. We estimated average and total cost curves for each country as a function of service volume.ResultsAcross countries, average costs per dose ranged from $2.75 to $13.63. Average costs per child receiving diphtheria, tetanus, and pertussis ranged from $27 to $139. Within countries costs per dose varied widely—on average, sites in the highest quintile were 440% more expensive than those in the lowest quintile. In each country, higher service volume was strongly associated with lower average costs. A doubling of service volume was associated with a 19% (95% interval, 4.0–32) reduction in costs per dose delivered, (range 13% to 32% across countries), and the largest 20% of sites in each country realized costs per dose that were on average 61% lower than those for the smallest 20% of sites, controlling for other factors. Other factors associated with higher costs included hospital status, provision of outreach services, share of effort to management, level of staff training/seniority, distance to vaccine collection, additional days open per week, greater vaccination schedule completion, and per capita gross domestic product.ConclusionsWe identified multiple features of sites and their operating environment that were associated with differences in average unit costs, with service volume being the most influential. These findings can inform efforts to improve the efficiency of service delivery and better understand resource needs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-017-0942-1) contains supplementary material, which is available to authorized users.

Objective To examine the growth and evolution of the home health agency (HHA) market and to compare quality performance across HHA ownership categories. Data Source Agency characteristics were extracted from Medicare cost reports and Provider of Services file. Quality of care and patient characteristics were extracted from Quality of Patient Care Star Ratings and HHA Public Use File. Study Design Agency‐ and state‐level analyses were conducted to describe HHA market trends. Patient characteristics and quality measures were compared across ownership categories of interest. Data Collection/Extraction Methods All Medicare‐certified HHAs in operation, 2005‐2018. Principal Findings Over the study period, the HHA sector grew substantially, increasing from 7899 to 10 818 agencies, and chain‐owned HHAs doubled in number from 903 (11.4% of all agencies) to 1841 (17.0%). In 2018, across agency types, for‐profit nonchain agencies were the largest category both in the number of agencies (67.8%) and the number of Medicare enrollees served (40.7%). Additionally, for‐profit nonchain agencies grew most in total number, from 4293 (54.3%) to 7337 (67.8%), while for‐profit chain agencies grew most in the number of Medicare enrollees served, from 439 998 (12.9%) to 1 082 385 (28.3%). Regarding patient composition, for‐profit nonchain agencies served the highest proportion of dual eligible beneficiaries (42.2%) and African‐Americans (27.9%) among all agency types. Regarding quality performance, a higher star rating is significantly (P < .01) associated with chain agency status. Moreover, chain HHAs performed better on self‐reported process measures, and risk‐adjusted self‐reported outcome measures; however, they performed worse on risk‐adjusted claims‐based outcome measures. These results were similar across for‐profit and nonprofit chain agencies. Conclusion Chains play a growing role in the home health sector. Substantial differences in geographic distribution, patient composition, and quality performance were observed between chain‐ and nonchain HHAs. Examining the growth and performance of multi‐agency chains can help inform quality reporting and monitoring, assess payment adequacy, and facilitate greater transparency and accountability within the HHA marketplace.

Purpose Post-acute care is fast developing in China, yet a payment system for post-acute care has not been established. As stroke is the leading cause of mortality and disability in China, patients constitute a large share of post-acute-care patients among all hospitalized patients. This study was to identify the cost determinants and establish a case-mix classification of the post-acute care system for stroke patients in China. Patients and Methods A total of 5401 post-acute stroke patients in seven hospitals of Jinhua City from January 2018 to December 2020 were selected. Demographic characteristics, medical status, functional measures (eg, the Barthel Index, Mini-Mental State Examination, Gugging Swallowing Screen, Hamilton Depression Scale), and cost data were extracted. Generalized linear model (GLM) and quantile regression (QR) were conducted to determine the predictors of cost, and a case-mix classification model was established using the decision-tree analysis. Results The GLM regression revealed that gender, tracheostomy, complication or comorbidity (CC), activities of daily living (ADL), and cognitive impairment were the main variables significantly affecting the hospitalization expenses of post-acute stroke patients. The QR model showed that the gender, tracheostomy and CC factors had a more significant impact on per diem costs on the upper quantiles. In contrast, cognitive impairment had a more substantial effect on the lower quantiles, and ADL significantly impacted the central quantile. Using tracheostomy, CC, and ADL as node variables of the regression tree, 12 classes were generated. The case-mix classification performed reliably and robustly, as measured by the reduction in the variation statistic (RIV=0.46) and class-specific coefficients of variation (CV less than 1.0; range: 0.18–0.81). Conclusion QR has strengths in comprehensively identifying cost predictors across cost groups. Tracheostomy, CC, and ADL significantly can predict the expenses of post-acute care for stroke patients. The established case-mix classification system can inform the future payment policy of post-acute care in China.

Nationwide nursing home private-pay prices at the facility-level have not been available for researchers interested in studying this unique health care market. This study presents a new data source, Caregiverlist, for private-pay prices for private and semiprivate rooms for 12,000 nursing homes nationwide collected between 2008 and 2010. We link these data to publicly available national nursing home-level data sets to examine the relationship between price and nursing home characteristics. We also compare private-pay prices with average private-pay revenues per day for California nursing homes obtained from facilities’ financial filings. On average, private-pay prices were $224 per day for private rooms compared with $197 per day for semiprivate rooms. We find that nursing homes that are nonprofit, urban, hospital-based, have a special care unit, chain-owned, and have higher quality ratings have higher prices. We find average revenues per day in California to be moderately correlated with prices reported by Caregiverlist.