Cost Implications for Automaker Compliance of Zero Emissions Vehicle Requirements.

While there are many automotive regulations in the United States, few studies in the literature examine the interaction between different rules. We investigate the cost implications of enforcing the national Corporate Average Fuel Economy (CAFE) and greenhouse gas (GHG) emissions standards and the Zero Emissions Vehicle (ZEV) requirements simultaneously. We construct a new "Cost Optimization Modeling for Efficiency Technologies" (COMET) to understand how vehicle manufacturers implement fuel economy technologies to comply with multiple regulations. We consider a variety of scenarios to measure the interaction between regulations and how they may lead to changes in technology costs. In 2025, unit costs reach $1,600 per vehicle on average to comply with CAFE/GHG and increase to $2,000 per vehicle on average to comply with both CAFE/GHG and ZEV. Unit costs for both regulations are less than the sum of the two because vehicles produced to comply with the ZEV program count toward compliance with the CAFE.

Addition of Docetaxel to First-line Long-term Hormone Therapy in Prostate Cancer (STAMPEDE): Modelling to Estimate Long-term Survival, Quality-adjusted Survival, and Cost-effectiveness.

BACKGROUND: Results from large randomised controlled trials have shown that adding docetaxel to the standard of care (SOC) for men initiating hormone therapy for prostate cancer (PC) prolongs survival for those with metastatic disease and prolongs failure-free survival for those without. To date there has been no formal assessment of whether funding docetaxel in this setting represents an appropriate use of UK National Health Service (NHS) resources. OBJECTIVE: To assess whether administering docetaxel to men with PC starting long-term hormone therapy is cost-effective in a UK setting. DESIGN, SETTING, AND PARTICIPANTS: We modelled health outcomes and costs in the UK NHS using data collected within the STAMPEDE trial, which enrolled men with high-risk, locally advanced metastatic or recurrent PC starting first-line hormone therapy. INTERVENTION: SOC was hormone therapy for ≥2 yr and radiotherapy in some patients. Docetaxel (75mg/m2) was administered alongside SOC for six three-weekly cycles. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The model generated lifetime predictions of costs, changes in survival duration, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS AND LIMITATIONS: The model predicted that docetaxel would extend survival (discounted quality-adjusted survival) by 0.89 yr (0.51) for metastatic PC and 0.78 yr (0.39) for nonmetastatic PC, and would be cost-effective in metastatic PC (ICER £5514/QALY vs SOC) and nonmetastatic PC (higher QALYs, lower costs vs SOC). Docetaxel remained cost-effective in nonmetastatic PC when the assumption of no survival advantage was modelled. CONCLUSIONS: Docetaxel is cost-effective among patients with nonmetastatic and metastatic PC in a UK setting. Clinicians should consider whether the evidence is now sufficiently compelling to support docetaxel use in patients with nonmetastatic PC, as the opportunity to offer docetaxel at hormone therapy initiation will be missed for some patients by the time more mature survival data are available. PATIENT SUMMARY: Starting docetaxel chemotherapy alongside hormone therapy represents a good use of UK National Health Service resources for patients with prostate cancer that is high risk or has spread to other parts of the body.

Reducing the risk of injury from table saw use: the potential benefits and costs of automatic protection.

The use of table saws in the United States is associated with approximately 28,000 emergency department (ED) visits and 2,000 cases of finger amputation per year. This article provides a quantitative estimate of the economic benefits of automatic protection systems that could be designed into new table saw products. Benefits are defined as reduced health-care costs, enhanced production at work, and diminished pain and suffering. The present value of the benefits of automatic protection over the life of the table saw are interpreted as the switch-point cost value, the maximum investment in automatic protection that can be justified by benefit-cost comparison. Using two alternative methods for monetizing pain and suffering, the study finds switch-point cost values of $753 and $561 per saw. These point estimates are sensitive to the values of inputs, especially the average cost of injury. The various switch-point cost values are substantially higher than rough estimates of the incremental cost of automatic protection systems. Uncertainties and future research needs are discussed.

The benefits and costs of new fuels and engines for light-duty vehicles in the United States.

Rising oil prices and concerns about energy security and climate change are spurring reconsideration of both automobile propulsion systems and the fuels that supply energy to them. In addition to the gasoline internal combustion engine, recent years have seen alternatives develop in the automotive marketplace. Currently, hybrid-electric vehicles, advanced diesels, and flex-fuel vehicles running on a high percentage mixture of ethanol and gasoline (E85) are appearing at auto shows and in driveways. We conduct a rigorous benefit-cost analysis from both the private and societal perspective of the marginal benefits and costs of each technology--using the conventional gasoline engine as a baseline. The private perspective considers only those factors that influence the decisions of individual consumers, while the societal perspective accounts for environmental, energy, and congestion externalities as well. Our analysis illustrates that both hybrids and diesels show promise for particular light-duty applications (sport utility vehicles and pickup trucks), but that vehicles running continuously on E85 consistently have greater costs than benefits. The results for diesels were particularly robust over a wide range of sensitivity analyses. The results from the societal analysis are qualitatively similar to the private analysis, demonstrating that the most relevant factors to the benefit-cost calculations are the factors that drive the individual consumer's decision. We conclude with a brief discussion of marketplace and public policy trends that will both illustrate and influence the relative adoption of these alternative technologies in the United States in the coming decade.

The assessment of patient life-expectancy: how accurate are urologists and oncologists?

OBJECTIVE: To assess the degree of accuracy, precision and consistency with which consultant urologists, oncologists and junior doctors predict a patient's 10-year life-expectancy. SUBJECTS AND METHODS: Eighteen doctors of varying seniority independently examined 70 patient case scenarios containing detailed medical histories; 13 of these cases were duplicate scenarios. Bland-Altman analyses were used to compare doctors' estimates of the probability of each hypothetical patient surviving 10 years with that calculated using actuarial methods. Intra- and interdoctor reliability were also assessed. RESULTS: Compared with actuarial estimates, doctors underestimated the 10-year survival probability by an overall mean of 10.8% (95% confidence interval, 10.1-11.5%). The 18 individual doctors ranged from a mean underestimation of 33.2% to a mean overestimation of 3.9%. Variation around these means was considerable for each doctor, the standard deviations being 14.5-20.9%. Inter-doctor reliability was 0.58, while overall intra-doctor reliability was 0.74, but for individual doctors was 0.31-0.94. Junior doctors were less accurate in their predictions than the senior doctors. Five doctors tended to overestimate where life-expectancy was poor and underestimate where it was good. CONCLUSIONS: Doctors were poor at predicting 10-year survival, tending to underestimate when compared with actuarial estimates. There was also substantial variability both within and between doctors. The inaccuracy, imprecision and inconsistency amongst the doctors in assessing patient life-expectancy is an important finding and has significant implications for managing patients. Many patients may be denied treatment after a pessimistic assessment of life-expectancy and (less commonly) some may inappropriately be offered treatment after an optimistic assessment. The particular inaccuracy in junior doctors compared with their senior colleagues also highlights the need for training. The development of a tool to assist in both training and clinical practice has the potential to improve doctors' decision-making and patient care.

Rationing decisions and individual responsibility for illness: are all lives equal?

OBJECTIVES: This survey measured individuals' rationing allocation choices for situations in which patients are deemed to hold personal responsibility for their diseases and the influence of different arguments on such choices. METHODS: The association between allocation decisions for liver disease and asthma and the belief that a patient was responsible for his or her illness was modeled using multivariable regression analysis, controlling for the effect of arguments on choices. RESULTS: In data from 310 returned surveys (43% response rate), respondents were 10 to 17 times more likely to allocate liver transplants or asthma treatment to patients they deemed not responsible for their illnesses than to patients they deemed responsible for their conditions (liver transplants: odds ratio [OR] = 10.3, 95% confidence interval ([CI] = 2.5-42.1; asthma: OR = 16.8, 95% CI = 2.1-136.6). CONCLUSIONS: Personal responsibility for illness was an important consideration in respondents' rationing allocation decisions. These choices appeared to be stable although possibly influenced by respondents' interpretations of the survey scenarios and decision tasks.

A revised economic analysis of restrictions on the use of cell phones while driving.

Evidence that cell phone use while driving increases the risk of being involved in a motor vehicle crash has led policymakers to consider prohibitions on this practice. However, while restrictions would reduce property loss, injuries, and fatalities, consumers would lose the convenience of using these devices while driving. Quantifying the risks and benefits associated with cell phone use while driving is complicated by substantial uncertainty in the estimates of several important inputs, including the extent to which cell phone use increases a driver's risk of being involved in a crash, the amount of time drivers spend using cell phones (and hence their aggregate contribution to crashes, injuries, and fatalities), and the incremental value to users of being able to make calls while driving. Two prominent studies that have investigated cell phone use while driving have concluded that the practice should not be banned. One finds that the benefits of calls made while driving substantially exceed their costs while the other finds that other interventions could reduce motor vehicle injuries and fatalities (measured in terms of quality adjusted life years) at a lower cost. Another issue is that cell phone use imposes increased (involuntary) risks on other roadway users. This article revises the assumptions used in the two previous analyses to make them consistent and updates them using recent data. The result is a best estimate of zero for the net benefit of cell phone use while driving, a finding that differs substantially from the previous study. Our revised cost-effectiveness estimate for cell phone use while driving moves in the other direction, finding that the cost per quality adjusted life year increases modestly compared to the previous estimate. Both estimates are very uncertain.

Assessing preferences for prevention versus treatment using willingness to pay.

BACKGROUND: Rising health care costs and limited resources necessitate trade-offs between resources allocated toward prevention and those toward treatment. Information from opinion polls suggests citizens favor spending a higher proportion of all health care dollars on prevention rather than treatment. OBJECTIVES: To assess the policy implications of willingness to pay (WTP) for use in cost-benefit analysis (CBA) as a method for capturing individual preferences for prevention and treatment in the context of resource allocation decisions. METHODS: The authors recruited a random sample of 1456 US residents age 18 years and greater by telephone using random-digit dialing. The survey was designed as a 3-stage (phone-mail-phone) process and was conducted between December 1998 and March 1999. For all persons completing the survey (N = 1104), the authors 1st collected respondents' opinions about the costs and effectiveness of prevention versus treatment programs in general. Half of respondents were then asked to state their WTP for a hypothetical prevention scenario and half were asked to state their WTP for a hypothetical treatment scenario. Both scenarios were specific to the same health context and included an identical reduction in mortality risk. RESULTS: WTP for treatment was significantly greater than WTP for prevention, $665 and $223, respectively. Prior opinions on the relative effectiveness afforded by preventive and treatment interventions moderately influenced the WTP estimates for persons randomized to either scenario. Prior opinions on costs had no significant effect on WTP estimates for either scenario. WTP significantly increased with age and household income in the full sample but was not significantly affected by gender or educational attainment. CONCLUSIONS: The aggregated WTP responses from the prevention and treatment scenarios presented in our study would imply that treatment is more strongly preferred by society than prevention when the health context is the same and benefits of each are held constant. A better understanding is needed of the discrepancy between citizens' stated preferences for prevention (e.g., through polling) and our findings that they were willing to pay substantially more for treatment than for prevention.

Validating benefit and cost estimates: the case of airbag regulation.

Preregulation estimates of benefits and costs are rarely validated after regulations are implemented. This article performs such a validation for the mandatory automobile airbag requirement. We found that the original 1984 model used to estimate benefits became invalid when 1997 values were input into that 1984 model. However, using a published 1997 cost-effectiveness model, we demonstrate, by replacing the model inputs with the values from 1984, that the 1997 cost-effectiveness ratios, based on real-world crash data and tear-down cost data, are less attractive than what would have been originally anticipated. The three most important errors in the 1984 input values are identified: the overestimation of airbag effectiveness, the overestimation of baseline fatality/injury rates, and the underestimation of manual safety belt use. This case study, which suggests that airbags are a reasonable investment in safety, shows that the regulatory analysis tools do not always produce findings that are biased against health, safety, and environmental regulation. Future validation studies of health, safety, and environmental regulation should focus on validation of benefit and risk estimates, areas where we found significant error, as well as on cost estimates.