How to Cost the Implementation of Major System Change for Economic Evaluations: Case Study Using Reconfigurations of Specialist Cancer Surgery in Part of London, England.

BACKGROUND: Studies have been published regarding the impact of major system change (MSC) on care quality and outcomes, but few evaluate implementation costs or include them in cost-effectiveness analysis (CEA). This is despite large potential costs of MSC: change planning, purchasing or repurposing assets, and staff time. Implementation costs can influence implementation decisions. We describe our framework and principles for costing MSC implementation and illustrate them using a case study. METHODS: We outlined MSC implementation stages and identified components, using a framework conceived during our work on MSC in stroke services. We present a case study of MSC of specialist surgery services for prostate, bladder, renal and oesophagogastric cancers, focusing on North Central and North East London and West Essex. Health economists collaborated with qualitative researchers, clinicians and managers, identifying key reconfiguration stages and expenditures. Data sources (n = approximately 100) included meeting minutes, interviews, and business cases. National Health Service (NHS) finance and service managers and clinicians were consulted. Using bottom-up costing, items were identified, and unit costs based on salaries, asset costs and consultancy fees assigned. Itemised costs were adjusted and summed. RESULTS: Cost components included options appraisal, bidding process, external review; stakeholder engagement events; planning/monitoring boards/meetings; and making the change: new assets, facilities, posts. Other considerations included hospital tariff changes; costs to patients; patient population; and lifetime of changes. Using the framework facilitated data identification and collection. The total adjusted implementation cost was estimated at £7.2 million, broken down as replacing robots (£4.0 million), consultancy fees (£1.9 million), staff time costs (£1.1 million) and other costs (£0.2 million). CONCLUSIONS: These principles can be used by funders, service providers and commissioners planning MSC and researchers evaluating MSC. Health economists should be involved early, alongside qualitative and health-service colleagues, as retrospective capture risks information loss. These analyses are challenging; many cost factors are difficult to identify, access and measure, and assumptions regarding lifetime of the changes are important. Including implementation costs in CEA might make MSC appear less cost effective, influencing future decisions. Future work will incorporate this implementation cost into the full CEAs of the London Cancer MSC. TRIAL REGISTRATION: Not applicable.

Demographic and socioeconomic patterns in healthcare-seeking behaviour for respiratory symptoms in England: a comparison with non-respiratory symptoms and between three healthcare services.

OBJECTIVE: This study will analyse respiratory contacts to three healthcare services that capture more of the community disease burden than acute data sources, such as hospitalisations. The objective is to explore associations between contacts to these services and the patient's age, gender and deprivation. Results will be compared between healthcare services, and with non-respiratory contacts to explore how contacts differ by service and illness. It is crucial to investigate the sociodemographic patterns in healthcare-seeking behaviour to enable targeted public health interventions. DESIGN: Ecological study. SETTING: Surveillance of respiratory contacts to three healthcare services in England: telehealth helpline (NHS111); general practitioner in-hours (GPIH); and general practitioner out of hours unscheduled care (GPOOH). PARTICIPANTS: 13 million respiratory contacts to NHS111, GPIH and GPOOH. OUTCOME MEASURES: Respiratory contacts to NHS111, GPIH and GPOOH, and non-respiratory contacts to NHS111 and GPOOH. RESULTS: More respiratory contacts were observed for females, with 1.59, 1.73, and 1.95 times the rate of contacts to NHS111, GPOOH and GPIH, respectively. When compared with 15-44 year olds, there were 37.32, 18.66 and 6.21 times the rate of respiratory contacts to NHS111, GPOOH and GPIH in children <1 year. There were 1.75 and 2.70 times the rate of respiratory contacts in the most deprived areas compared with the least deprived to NHS111 and GPOOH. Elevated respiratory contacts were observed for males <5 years compared with females <5 years. Healthcare-seeking behaviours between respiratory and non-respiratory contacts were similar. CONCLUSION: When contacts to services that capture more of the disease burden are explored, the demographic patterns are similar to those described in the literature for acute systems. Comparable results were observed between respiratory and non-respiratory contacts suggesting that when a wider spectrum of disease is explored, sociodemographic factors may be the strongest influencers of healthcare-seeking behaviour.

Daily adaptive radiotherapy for patients with prostate cancer using a high field MR-linac: Initial clinical experiences and assessment of delivered doses compared to a C-arm linac.

INTRODUCTION: MR-guided adapted radiotherapy (MRgART) using a high field MR-linac has recently become available. We report the estimated delivered fractional dose of the first five prostate cancer patients treated at our centre using MRgART and compare this to C-Arm linac daily Image Guided Radiotherapy (IGRT). METHODS: Patients were treated using adapted treatment plans shaped to their daily anatomy. The treatments were recalculated on an MR image acquired immediately prior to treatment delivery in order to estimate the delivered fractional dose. C-arm linac non-adapted VMAT treatment plans were recalculated on the same MR images to estimate the fractional dose that would have been delivered using conventional radiotherapy techniques using a daily IGRT protocol. RESULTS: 95% and 93% of mandatory target coverage objectives and organ at risk dose constraints were achieved by MRgART and C-arm linac delivered dose estimates, respectively. Both delivery techniques were estimated to have achieved 98% of mandatory Organ At Risk (OAR) dose constraints whereas for the target clinical goals, 86% and 80% were achieved by MRgART and C-arm linac delivered dose estimates. CONCLUSIONS: Prostate MRgART can be delivered using the a high field MR-linac. Radiotherapy performed on a C-arm linac offers a good solution for prostate cancer patients who present with favourable anatomy at the time of reference imaging and demonstrate stable anatomy throughout the course of their treatment. For patients with critical OARs abutting target volumes on their reference image we have demonstrated the potential for a target dose coverage improvement for MRgART compared to C-arm linac treatment.

Potential added value of the new emergency care dataset to ED-based public health surveillance in England: an initial concept analysis.

INTRODUCTION: For the London Olympic and Paralympic Games in 2012, a sentinel ED syndromic surveillance system was established to enhance public health surveillance by obtaining data from a selected network of EDs, focusing on London. In 2017, a new national standard Emergency Care Dataset was introduced, which enabled Public Health England (PHE) to initiate the expansion of their sentinel system to national coverage. Prior to this initiative, we estimated the added value, and potential additional resource use, of an expansion of the sentinel surveillance system. METHODS: The detection capabilities of the sentinel and national systems were compared using the aberration detection methods currently used by PHE. Different scenarios were used to measure the impact on health at a local, subnational and national level, including improvements to sensitivity and timeliness, along with changes in specificity. RESULTS: The biggest added value was found to be for detecting local impacts, with an increase in sensitivity of over 80%. There were also improvements found at a national level with outbreaks being detected earlier and smaller impacts being detectable. However, the increased number of local sites will also increase the number of false alarms likely to be generated. CONCLUSION: We have quantified the added value of national ED syndromic surveillance systems, showing how they will enable detection of more localised events. Furthermore, national systems add value in enabling timelier public health interventions. Finally, we have highlighted areas where extra resource may be required to manage improvements in detection coverage.

Social patterning of telephone health-advice for diarrhoea and vomiting: analysis of 24 million telehealth calls in England.

OBJECTIVES: Gastrointestinal (GI) infections are common and most people do not see a physician. There is conflicting evidence of the impact of socioeconomic status (SES) on risk of GI infections. We assessed the relationship between SES and GI calls to two National Health Service (NHS) telephone advice services in England. METHODS: Over 24 million calls to NHS Direct (2010-13) and NHS 111 (2013-15) were extracted from Public Health England (PHE) syndromic surveillance systems. The relationship between SES and GI calls was assessed using generalised linear models (GLM). RESULTS: Adjusting for rurality and age-sex interactions, in NHS Direct, children in disadvantaged areas were at lower risk of GI calls; in NHS 111 there was a higher risk of GI calls in disadvantaged areas for all ages (0-4 years RR 1.27, 95% CI 1.25-1.29; 5-9 years RR 1.43, 95% CI 1.36-1.51; 10-14 years RR 1.36, 95% CI 1.26-1.41; 15-19 years RR 1.59, 95% CI 1.52-1.67; 20-59 years RR 1.50, 95% CI 1.47-1.53, 60 years and over RR 1.12, 95% CI 1.09-1.14). CONCLUSIONS: Disadvantaged areas had higher risk of GI calls in NHS 111. This may relate to differences in exposure or vulnerability to GI infections, or propensity to call about GI infections.

Google search patterns monitoring the daily health impact of heatwaves in England: How do the findings compare to established syndromic surveillance systems from 2013 to 2017?

One of the implications of climate change is a predicted increase in frequent and severe heatwaves. The impact of heatwaves on the health of the population is captured through real-time syndromic healthcare surveillance systems monitored daily in England during the summer months. Internet search data could potentially provide improved timeliness and help to assess the wider population health impact of heat by capturing a population sub-group who are symptomatic but do not seek healthcare. A retrospective observational study was carried out from June 2013 to September 2017 in England to compare daily trends in validated syndromic surveillance heat-related morbidity indicators against symptom-based heatwave related Google search terms. The degree of correlation was determined with Spearman correlation coefficients and lag assessment was carried out to determine timeliness. Daily increases in frequency in Google search terms during heatwave events correlated well with validated syndromic indicators. Correlation coefficients between search term frequency and syndromic indicators from 2013 to 2017 were highest with the telehealth service NHS 111 (range of 0.684-0.900 by search term). Lag analysis revealed a similar timeliness between the data sources, suggesting Google data did not provide a delayed or earlier signal in the context of England's syndromic surveillance systems. This work highlights the potential benefits for countries which lack established public health surveillance systems to monitor heat-related morbidity and the use of internet search data to assess the wider population health impact of exposure to heat.

A standardized methodology for the surveillance of antimicrobial prescribing linked to clinical indications in primary care.

Background: A key component of strategies to reduce antimicrobial resistance is better antimicrobial prescribing. The majority of antibiotics are prescribed in primary care. While many existing surveillance systems can monitor trends in the quantities of antibiotics prescribed in this setting, it can be difficult to monitor the quality of prescribing as data on the condition for which prescriptions are issued are often not available. We devised a standardized methodology to facilitate the monitoring of condition-specific antibiotic prescribing in primary care. Methods: We used a large computerized general practitioner database to develop a standardized methodology for routine monitoring of antimicrobial prescribing linked to clinical indications in primary care in the UK. Outputs included prescribing rate by syndrome and percentages of consultations with antibiotic prescription, for recommended antibiotic, and of recommended treatment length. Results: The standardized methodology can monitor trends in proportions of common infections for which antibiotics were prescribed, the specific drugs prescribed and duration of treatment. These data can be used to help assess the appropriateness of antibiotic prescribing and to assess the impact of prescribing guidelines. Conclusions: We present a standardized methodology that could be applied to any suitable national or local database and adapted for use in other countries.

A Monte Carlo Approach to Skill-Based Automated Playtesting.

In order to create well-crafted learning progressions, designers guide players as they present game skills and give ample time for the player to master those skills. However, analyzing the quality of learning progressions is challenging, especially during the design phase, as content is ever-changing. This research presents the application of Stratabots-automated player simulations based on models of players with varying sets of skills-to the human computation game Foldit. Stratabot performance analysis coupled with player data reveals a relatively smooth learning progression within tutorial levels, yet still shows evidence for improvement. Leveraging existing general gameplaying algorithms such as Monte Carlo Evaluation can reduce the development time of this approach to automated playtesting without losing predicitive power of the player model.

Socioeconomic and geographical variation in general practitioner consultations for allergic rhinitis in England, 2003-2014: an observational study.

OBJECTIVE: Allergic rhinitis (AR) is a global health problem, potentially impacting individuals' sleep, work and social life. We aimed to use a surveillance network of general practitioners (GPs) to describe the epidemiology of AR consultations in England. SETTING: A large GP surveillance network covering approximately 53% of the English population. METHODS: GP consultations for AR across England between 30 December 2002 and 31 December 2014 were analysed. Using more granular data available between 2 April 2012 and 31 December 2014 rates and rate ratios (RR) of AR were further analysed in different age groups, gender, rural-urban classification and index of multiple deprivation score quintile of location of GP. RESULTS: The mean weekly rate for AR consultations was 19.8 consultations per 100 000 GP registered patients (range 1.13-207), with a regular peak occurring during June (weeks 24-26), and a smaller peak during April. Between 1 April 2012 and 31 December 2014, the highest mean daily rates of consultations per 1 00 000 were: in age group 5-14 years (rate=8.02, RR 6.65, 95% CI 6.38 to 6.93); females (rate=4.57, RR 1.12 95% CI 1.12 to 1.13); persons registered at a GP in the most socioeconomically deprived quintile local authority (rate=5.69, RR 1.48, 95% CI 1.47 to 1.49) or in an urban area with major conurbation (rate=5.91, RR 1.78, 95% CI 1.69 to 1.87). CONCLUSIONS: AR rates were higher in those aged 5-14 years, females and in urban and socioeconomically deprived areas. This needs to be viewed in the context of this study's limitations but should be considered in health promotion and service planning.

Novel public health risk assessment process developed to support syndromic surveillance for the 2012 Olympic and Paralympic Games.

Background: Syndromic surveillance aims to provide early warning and real time estimates of the extent of incidents; and reassurance about lack of impact of mass gatherings. We describe a novel public health risk assessment process to ensure those leading the response to the 2012 Olympic Games were alerted to unusual activity that was of potential public health importance, and not inundated with multiple statistical 'alarms'. Methods: Statistical alarms were assessed to identify those which needed to result in 'alerts' as reliably as possible. There was no previously developed method for this. We identified factors that increased our concern about an alarm suggesting that an 'alert' should be made. Results: Between 2 July and 12 September 2012, 350 674 signals were analysed resulting in 4118 statistical alarms. Using the risk assessment process, 122 'alerts' were communicated to Olympic incident directors. Conclusions: Use of a novel risk assessment process enabled the interpretation of large number of statistical alarms in a manageable way for the period of a sustained mass gathering. This risk assessment process guided the prioritization and could be readily adapted to other surveillance systems. The process, which is novel to our knowledge, continues as a legacy of the Games.

Introduction of Renal Key Performance Indicators Associated with Increased Uptake of Peritoneal Dialysis in a Publicly Funded Health Service.

♦ BACKGROUND: Increased demand for treatment of end-stage kidney disease has largely been accommodated by a costly increase in satellite hemodialysis (SHD) in most jurisdictions. In the Australian State of Victoria, a marked regional variation in the uptake of home-based dialysis suggests that use of home therapies could be increased as an alternative to SHD. An earlier strategy based solely on increased remuneration had failed to increase uptake of home therapies. Therefore, the public dialysis funder adopted the incidence and prevalence of home-based dialysis therapies as a key performance indicator (KPI) for its health services to encourage greater uptake of home therapies. ♦ METHODS: A KPI data collection and bench-marking program was established in 2012 by the Victorian Department of Health and Human Services, with data provided monthly by all renal units in Victoria using a purpose-designed website portal. A KPI Working Group was responsible for analyzing data each quarter and ensuring indicators remained accurate and relevant and each KPI had clear definitions and targets. We present a prospective, observational study of all dialysis patients in Victoria over a 4-year period following the introduction of the renal KPI program, with descriptive analyses to evaluate the proportion of patients using home therapies as well as home dialysis modality survival. ♦ RESULTS: Following the introduction of the KPI program, the net growth of dialysis patient numbers in Victoria remained stable over 4 years, at 75 - 80 per year (approximately 4%). However, unlike the previous decade, about 40% of this growth was through an increase in home dialysis, which was almost exclusively peritoneal dialysis (PD). The increase was identified particularly in the young (20 - 49) and the elderly (> 80). Disappointingly, however, 67% of these incident patients ceased PD within 2 years of commencement, 46% of whom transferred to SHD. ♦ CONCLUSIONS: Introduction of a KPI program was associated with an increased uptake of PD but not home HD. This change in clinical practice restricted growth of SHD and reduced pressure on satellite services. The effect was offset by a modest PD technique survival. Many patients in whom PD was unsuccessful were subsequently transferred to SHD rather than home HD.

RCGP Research and Surveillance Centre Annual Report 2014-2015: disparities in presentations to primary care.

BACKGROUND: The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) comprises over 100 general practices in England, with a population of around 1 million, providing a public health surveillance system for England and data for research. AIM: To demonstrate the scope of data with the RCGP Annual Report 2014-2015 (May 2014 to April 2015) by describing disparities in the presentation of six common conditions included in the report. DESIGN AND SETTING: This is a report of respiratory and communicable disease incidence from a primary care sentinel network in England. METHOD: Incidence rates and demographic profiles are described for common cold, acute otitis media, pneumonia, influenza-like illness, herpes zoster, and scarlet fever. The impact of age, sex, ethnicity, and deprivation on the diagnosis of each condition is explored using a multivariate logistic regression. RESULTS: With the exception of herpes zoster, all conditions followed a seasonal pattern. Apart from pneumonia and scarlet fever, the odds of presenting with any of the selected conditions were greater for females (P<0.001). Older people had a greater probability of a pneumonia diagnosis (≥75 years, odds ratio [OR] 6.37; P<0.001). Common cold and influenza-like illness were more likely in people from ethnic minorities than white people, while the converse was true for acute otitis media and herpes zoster. There were higher odds of acute otitis media and herpes zoster diagnosis among the less deprived (least deprived quintile, OR 1.32 and 1.48, respectively; P<0.001). CONCLUSION: The RCGP RSC database provides insight into the content and range of GP workload and provides insight into current public health concerns. Further research is needed to explore these disparities in presentation to primary care.

Monitoring the effect of air pollution episodes on health care consultations and ambulance call-outs in England during March/April 2014: A retrospective observational analysis.

There is an increasing body of evidence illustrating the negative health effects of air pollution including increased risk of respiratory, cardiac and other morbid conditions. During March and April 2014 there were two air pollution episodes in England that occurred in close succession. We used national real-time syndromic surveillance systems, including general practitioner (GP) consultations, emergency department attendances, telehealth calls and ambulance dispatch calls to further understand the impact of these short term acute air pollution periods on the health seeking behaviour of the general public. Each air pollution period was comparable with respect to particulate matter concentrations (PM10 and PM2.5), however, the second period was longer in duration (6 days vs 3 days) and meteorologically driven 'Sahara dust' contributed to the pollution. Health surveillance data revealed a greater impact during the second period, with GP consultations, emergency department attendances and telehealth (NHS 111) calls increasing for asthma, wheeze and difficulty breathing indicators, particularly in patients aged 15-64 years. Across regions of England there was good agreement between air quality levels and health care seeking behaviour. The results further demonstrate the acute impact of short term air pollution episodes on public health and also illustrate the potential role of mass media reporting in escalating health care seeking behaviour.

Estimating the burden of heat illness in England during the 2013 summer heatwave using syndromic surveillance.

BACKGROUND: The burden of heat illness on health systems is not well described in the UK. Although the UK generally experiences mild summers, the frequency and intensity of hot weather is likely to increase due to climate change, particularly in Southern England. We investigated the impact of the moderate heatwave in 2013 on primary care and emergency department (ED) visits using syndromic surveillance data in England. METHODS: General practitioner in hours (GPIH), GP out of hours (GPOOH) and ED syndromic surveillance systems were used to monitor the health impact of heat/sun stroke symptoms (heat illness). Data were stratified by age group and compared between heatwave and non-heatwave years. Incidence rate ratios were calculated for GPIH heat illness consultations. RESULTS: GP consultations and ED attendances for heat illness increased during the heatwave period; GPIH consultations increased across all age groups, but the highest rates were in school children and those aged ≥75 years, with the latter persisting beyond the end of the heatwave. Extrapolating to the English population, we estimated that the number of GPIH consultations for heat illness during the whole summer (May to September) 2013 was 1166 (95% CI 1064 to 1268). This was double the rate observed during non-heatwave years. CONCLUSIONS: These findings support the monitoring of heat illness (symptoms of heat/sun stroke) as part of the Heatwave Plan for England, but also suggest that specifically monitoring heat illness in children, especially those of school age, would provide additional early warning of, and situation awareness during heatwaves.

London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology.

Mass gatherings are regarded as potential risks for transmission of infectious diseases, and might compromise the health system of countries in which they are hosted. The evidence for increased transmission of infectious diseases at international sporting mass gatherings that attract many visitors from all over the world is not clear, and the evidence base for public health surveillance, epidemiology, and response at events such as the Olympics is small. However, infectious diseases are a recognised risk, and public health planning is, and should remain, a crucial part of the overall planning of sporting events. In this Series paper, we set out the planning and the surveillance systems that were used to monitor public health risks during the London 2012 Olympic and Paralympic Games in the summer of 2012, and draw attention to the public health issues-infectious diseases and chemical, radiation, and environmental hazards-that arose. Although the absolute risk of health-protection problems, including infectious diseases, at sporting mass gatherings is small, the need for reassurance of the absence of problems is higher than has previously been considered; this could challenge conventional public health surveillance systems. Recognition of the limitations of health-surveillance systems needs to be part of the planning for future sporting events.

An assessment of the demographic and clinical correlates of the dimensions of alcohol use behaviour.

AIMS: To identify population-based clinical and demographic correlates of alcohol use dimensions. METHODS: Using data from a population-based sample of Great Britain (n = 7849), structural equation modelling (SEM) was used to identify associations between demographic and clinical variables and two competing dimensional models of the Alcohol Use Disorders Identification Test (AUDIT). RESULTS: A two-factor SEM fit best. In this model, Factor 1, alcohol consumption, was associated with male sex, younger age, lower educational attainment, generalized anxiety disorder (GAD) and suicide attempts. Factor 2, alcohol-related problems, was associated with the demographic variables (to a lesser extent) and to a wider range of clinical variables, including depressive episode, GAD, mixed anxiety and depressive disorder, obsessive compulsive disorder, phobia, suicidal thoughts and suicide attempts. The one-factor SEM was associated with demographic and all assessed clinical correlates; however, this model did not fit the data well. CONCLUSIONS: Two main conclusions justify the two-factor approach to alcohol use classification. First, the model fit was considerably superior and, second, the dimensions of alcohol consumption and alcohol-related problems vary considerably in their associations with measures of demographic and clinical risk. A one-factor representation of alcohol use, for instance, would fail to recognize that measures of affective/anxiety disorders are more consistently related to alcohol-related problems than to alcohol consumption. It is suggested therefore that to fully understand the complexity of alcohol use behaviour and its associated risk, future research should acknowledge the basic underlying dimensional structure of the construct.

International reproducibility of single breathhold T2* MR for cardiac and liver iron assessment among five thalassemia centers.

PURPOSE: To examine the reproducibility of the single breathhold T2* technique from different scanners, after installation of standard methodology in five international centers. MATERIALS AND METHODS: Up to 10 patients from each center were scanned twice locally for local interstudy reproducibility of heart and liver T2*, and then flown to a central MR facility to be rescanned on a reference scanner for intercenter reproducibility. Interobserver reproducibility for all scans was also assessed. RESULTS: Of the 49 patients scanned, the intercenter reproducibility for T2* was 5.9% for the heart and 5.8% for the liver. Local interstudy reproducibility for T2* was 7.4% for the heart and 4.6% for the liver. Interobserver reproducibility for T2* was 5.4% for the heart and 4.4% for the liver. CONCLUSION: These data indicate that T2* MR may be developed into a widespread test for tissue siderosis providing that well-defined and approved imaging and analysis techniques are used.

Methods for determining disease burden and calibrating national surveillance data in the United Kingdom: the second study of infectious intestinal disease in the community (IID2 study).

BACKGROUND: Infectious intestinal disease (IID), usually presenting as diarrhoea and vomiting, is frequently preventable. Though often mild and self-limiting, its commonness makes IID an important public health problem. In the mid 1990s around 1 in 5 people in England suffered from IID a year, costing around pound0.75 billion. No routine information source describes the UK's current community burden of IID. We present here the methods for a study to determine rates and aetiology of IID in the community, presenting to primary care and recorded in national surveillance statistics. We will also outline methods to determine whether or not incidence has declined since the mid-1990s. METHODS/DESIGN: The Second Study of Infectious Intestinal Disease in the Community (IID2 Study) comprises several separate but related studies. We use two methods to describe IID burden in the community - a retrospective telephone survey of self-reported illness and a prospective, all-age, population-based cohort study with weekly follow-up over a calendar year. Results from the two methods will be compared. To determine IID burden presenting to primary care we perform a prospective study of people presenting to their General Practitioner with symptoms of IID, in which we intervene in clinical and laboratory practice, and an audit of routine clinical and laboratory practice in primary care. We determine aetiology of IID using molecular methods for a wide range of gastrointestinal pathogens, in addition to conventional diagnostic microbiological techniques, and characterise isolates further through reference typing. Finally, we combine all our results to calibrate national surveillance data. DISCUSSION: Researchers disagree about the best method(s) to ascertain disease burden. Our study will allow an evaluation of methods to determine the community burden of IID by comparing the different approaches to estimate IID incidence in its linked components.

Long-term economic costs of psychological problems during childhood.

Childhood psychological conditions including depression and substance abuse are a growing concern among American children, but their long-term economic costs are unknown. This paper uses unique data from the US Panel Study of Income Dynamics (PSID) following groups of siblings and their parents for up to 40 years prospectively collecting information on education, income, work, and marriage. Following siblings offers an opportunity to control for unobserved family and neighborhood effects. A retrospective child health history designed by the author was placed into the 2007 PSID wave measuring whether respondents had any of 14 childhood physical illnesses or suffered from depression, substance abuse, or other psychological conditions. Large effects are found on the ability of affected children to work and earn as adults. Educational accomplishments are diminished, and adult family incomes are reduced by 20% or $10,400 per year with $18,000 less family household assets. Lost income is partly a consequence of seven fewer weeks worked per year. There is also an 11% point lower probability of being married. Controlling for physical childhood diseases shows that these effects are not due to the co-existence of psychological and physical diseases, and estimates controlling for within-sibling differences demonstrate that these effects are not due to unobserved common family differences. The long-term economic damages of childhood psychological problems are large-a lifetime cost in lost family income of approximately $300,000, and total lifetime economic cost for all those affected of 2.1 trillion dollars.