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Objectives: Some pregnant women are not ready or do not want to quit smoking completely, and currently there is no support provided for these women in the UK. Offering help to reduce smoking could reduce the health risks associated with smoking and increase the limited reach of the NHS Stop Smoking Services (SSS) for pregnant women. This study aimed to design and evaluate a hypothetical intervention aimed at pregnant women who are not yet ready or do not want to quit smoking entirely.Methods: A hypothetical intervention, the Reduced Smoking During Pregnancy (RSDP) intervention, was conceptualised based on the best available evidence. The intervention was evaluated, using a decision-analytic model developed for SDP interventions. Two different scenarios, a base-case and a cautious-case were developed, and a cost-utility analysis and return on investment analysis were conducted. The uncertainty around the estimates was assessed, using deterministic and probabilistic sensitivity analyses.Results: The RSDP intervention could prevent the loss of 13 foetuses and generate 43 quitters 1 year after delivery per 1000 women. In the lifetime analysis, the intervention was cost-effective in both scenarios, with an incremental cost of £363 (95% CI £29 to £672) and 0.44 (95% CI 0.32 to 0.53) QALYs gained in the base-case.Conclusions: The study found that the hypothetical reduction intervention would produce significant health benefits, reduce smoking and be cost-effective. Offering pregnant smokers help to reduce smoking could reduce health inequalities, widen the reach of SSS and improve health. This economic evaluation of a novel, intensive intervention could inform the piloting of such interventions. [ABSTRACT FROM AUTHOR]

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Effective biodiversity conservation requires responding to threats in a timely fashion. This requires understanding the impacts of threats on biodiversity and when management needs to be implemented. However, most ecological systems face multiple threats, so monitoring to assess their impacts on biodiversity is a complex task. Indicators help simplify the challenge of monitoring but choosing the best indicator(s) to inform management is not straightforward.We provide a decision framework that can help identify optimal indicators to trigger management in a system faced with multiple threats. The approach evaluates indicators based on criteria spanning monitoring efficiency, management outcomes and the economic constraints for decision‐making. Critical decision factors (or parameters) are identified and detailed in a six‐step process to estimate the cost‐effectiveness of alternate indicators, including threat impacts, sensitivity of indicators to detect change, and the benefits, costs and feasibility of alternative indicators and management actions.Using the Kimberley as a case study, we evaluate 18 indicators for informing management of three key threats in the region: fire and grazing, feral cat predation, and weeds. We show that indicator selection based on our approach can help improve the expected outcome of management decisions under limited resources. By accounting for multiple factors in estimating benefit and costs of monitoring, our approach improves on common approaches that select indicators based only on whether they are sensitive to change and/or cheap to monitor. We also identify how uncertainty in decision factors influences indicator selection.Although cost‐effectiveness analyses are gaining popularity, ours is the first study to integrate multiple selection criteria using a return on investment framework to compare indicators for monitoring multiple threats and triggering management. [ABSTRACT FROM AUTHOR]

School leaders are tasked with addressing a variety of academic, behavioral, and social–emotional concerns but struggle to do so with limited resources. Because resources are limited, researchers and practitioners need to consider not only what works but also at what cost. Economic evaluations apply specific methods to assess and contextualize the costs and effects of evidence-based practices to help compare interventions and proactively inform resource allocation, but these have rarely been conducted in school psychology. The goals of this special issue are to define economic evaluation methods that could be used in school psychology, to highlight research examining the cost-effectiveness of evidence-based practices, and to examine the costs of translating and scaling evidence-based practices to bridge the research–practice gap. In this introductory article, we describe several methods for conducting economic evaluations, provide empirical demonstrations of these methods, and outline available resources for readers to conduct economic evaluations in the future. [ABSTRACT FROM AUTHOR]

Objective: The objective of this paper is to determine an upper price limit for an orphan drug by taken a broader perspective and, including also other monetary and non-monetary values for the society. Methods: This model is based on the expected free cash flows and the required minimum rate of return for the investor. In addition we calculated an innovation premium resulting from cost savings due to the substitution effect and the monetary gain in QALYs of a new medicine. We selected Spinraza®, a first in class drug with only best supportive care as comparator, and Perjeta®, a first in class drug with already an actual treatment as comparator. Results: The results show that Spinraza® leads to an innovation premium of € 78,966 and Perjeta® shows an innovation premium of € 4,388, because there were no cost savings. The analyses show the outcomes are sensitive to discount rate for QALYs. Conclusion: The break-even price from only an investor perspective may not reflect the value of drug from a broader perspective. This study shows drug prices based on an innovation premium may be more representative of the actual value of innovation for the society. [ABSTRACT FROM AUTHOR]

There are no studies that have specifically investigated the cost-effectiveness of cascade screening of children for heterozygous familial hypercholesterolemia (FH) and treatment of affected individuals with statins to prevent coronary heart disease (CHD). This study explores the cost-effectiveness of this strategy from the perspective of the Australian public healthcare system. A lifetime Markov model with four health states (Alive without CHD, Alive with CHD, Dead from fatal CHD, and Dead from other causes) was developed to simulate the progression of ten-year-old children screened for FH and treated immediately with statins if found to have FH. The underlying prevalence of FH in this target population was assumed to be 56.8%, and the sensitivity and specificity of testing were 100%. The comparator was usual care, which assumed that subjects started statins spontaneously at a later point or when they experienced a cardiovascular event. The effect of reducing low-density lipoprotein cholesterol (LDL-C) on the risk of a first event at each age assumed that risk was proportional to total lifetime exposure and was implemented using Mendelian randomisation analysis data. Cost and other outcome data were sourced from published sources. Outcome of interests were costs in Australian dollars (AUD), life years gained (LYG) and quality-adjusted life years (QALYs) gained, as well as incremental cost-effectiveness ratios (ICERs) of costs per LYG and per QALY gained. All future costs and outcomes were discounted by 5% annually. Undiscounted results showed that compared with usual care, cascade screening of ten year-old children for FH and initiation of treatment of affected individuals saved 7.77 LYG and 7.53 QALYs per person over a lifetime. With 5% annual discounting, there were 0.97 LYG and 1.07 QALYs gained per person, at net reduction cost of -$1134. The cascade screening of ten-year-old children for FH and initiation of treatment compared to usual case was a cost saving approach. In 51.2% of iterations, screening and initiation with statin were cost saving and in 48.8% of iterations were cost-effective. In most of the one-way sensitivity and scenario analyses, the ICER stayed within the accepted Australian threshold. Compared to usual care, cascade screening of ten-year-old children for FH and treating affected individuals are likely to be cost saving. Image 1 • The cost-effectiveness of screening children for familial hypercholesterolemia (FH) and treatment is unknown. • A Markov model was developed to simulate the lifetime progression of ten-year-olds. • Cascade screening children for FH and treating are likely to be cost saving. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To evaluate potential health and economic returns from implementing smoking cessation interventions in Hungary. Methods: The EQUIPTMOD, a Markov‐based economic model, was used to assess the cost‐effectiveness of three implementation scenarios: (a) introducing a social marketing campaign; (b) doubling the reach of existing group‐based behavioural support therapies and proactive telephone support; and (c) a combination of the two scenarios. All three scenarios were compared with current practice. The scenarios were chosen as feasible options available for Hungary based on the outcome of interviews with local stakeholders. Life‐time costs and quality‐adjusted life years (QALYs) were calculated from a health‐care perspective. The analyses used various return on investment (ROI) estimates, including incremental cost‐effectiveness ratios (ICERs), to compare the scenarios. Probabilistic sensitivity analyses assessed the extent to which the estimated mean ICERs were sensitive to the model input values. Results: Introducing a social marketing campaign resulted in an increase of 0.3014 additional quitters per 1 000 smokers, translating to health‐care cost‐savings of €0.6495 per smoker compared with current practice. When the value of QALY gains was considered, cost‐savings increased to €14.1598 per smoker. Doubling the reach of existing group‐based behavioural support therapies and proactive telephone support resulted in health‐care savings of €0.2539 per smoker (€3.9620 with the value of QALY gains), compared with current practice. The respective figures for the combined scenario were €0.8960 and €18.0062. Results were sensitive to model input values. Conclusions: According to the EQUIPTMOD modelling tool, it would be cost‐effective for the Hungarian authorities introduce a social marketing campaign and double the reach of existing group‐based behavioural support therapies and proactive telephone support. Such policies would more than pay for themselves in the long term. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To assess the cost‐effectiveness of alternative smoking cessation scenarios from the perspective of the Spanish National Health Service (NHS). Design: We used the European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD), a Markov‐based state transition economic model, to estimate the return on investment (ROI) of: (a) the current provision of smoking cessation services (brief physician advice and printed self‐helped material + smoking ban and tobacco duty at current levels); and (b) four alternative scenarios to complement the current provision: coverage of proactive telephone calls; nicotine replacement therapy (mono and combo) [prescription nicotine replacement therapy (Rx NRT)]; varenicline (standard duration); or bupropion. A rate of 3% was used to discount life‐time costs and benefits. Setting: Spain. Participants: Adult smoking population (16+ years). Measurements: Health‐care costs associated with treatment of smoking attributable diseases (lung cancer, coronary heart disease, chronic obstructive pulmonary infection and stroke); intervention costs; quality‐adjusted life years (QALYs). Costs and outcomes were summarized using various ROI estimates. Findings: The cost of implementing the current provision of smoking cessation services is approximately €61 million in the current year. This translates to 18 quitters per 1000 smokers and a life‐time benefit–cost ratio of 5, compared with no such provision. All alternative scenarios were dominant (cost‐saving: less expensive to run and generated more QALYs) from the life‐time perspective, compared with the current provision. The life‐time benefit–cost ratios were: 1.87 (proactive telephone calls); 1.17 (Rx NRT); 2.40 (varenicline‐standard duration); and bupropion (2.18). The results remained robust in the sensitivity analysis. Conclusions: According to the EQUIPTMOD modelling tool it would be cost‐effective for the Spanish authorities to expand the reach of existing GP brief interventions for smoking cessation, provide pro‐active telephone support, and reimburse smoking cessation medication to smokers trying to stop. Such policies would more than pay for themselves in the long run. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To evaluate costs, effects and cost‐effectiveness of increased reach of specific smoking cessation interventions in Germany. Design: A Markov‐based state transition return on investment model (EQUIPTMOD) was used to evaluate current smoking cessation interventions as well as two prospective investment scenarios. A health‐care perspective (extended to include out‐of‐pocket payments) with life‐time horizon was considered. A probabilistic analysis was used to assess uncertainty concerning predicted estimates. Setting: Germany. Participants: Cohort of current smoking population (18+ years) in Germany. Interventions: Interventions included group‐based behavioural support, financial incentive programmes and varenicline. For prospective scenario 1 the reach of group‐based behavioral support, financial incentive programme and varenicline was increased by 1% of yearly quit attempts (= 57 915 quit attempts), while prospective scenario 2 represented a higher reach, mirroring the levels observed in England. Measurements: EQUIPTMOD considered reach, intervention cost, number of quitters, quality‐of‐life years (QALYs) gained, cost‐effectiveness and return on investment. Findings: The highest returns through reduction in smoking‐related health‐care costs were seen for the financial incentive programme (€2.71 per €1 invested), followed by that of group‐based behavioural support (€1.63 per €1 invested), compared with no interventions. Varenicline had lower returns (€1.02 per €1 invested) than the other two interventions. At the population level, prospective scenario 1 led to 15 034 QALYs gained and €27 million cost‐savings, compared with current investment. Intervention effects and reach contributed most to the uncertainty around the return‐on‐investment estimates. At a hypothetical willingness‐to‐pay threshold of only €5000, the probability of being cost‐effective is approximately 75% for prospective scenario 1. Conclusions: Increasing the reach of group‐based behavioural support, financial incentives and varenicline for smoking cessation by just 1% of current annual quit attempts provides a strategy to German policymakers that improves the population's health outcomes and that may be considered cost‐effective. [ABSTRACT FROM AUTHOR]

Project prioritization protocols are an important tool for allocating conservation resources efficiently, and have been applied to a range of species and ecosystems. Current approaches are inadequate when applied to species with distinct threats impacting different and/or multiple life history stages, such as sea turtles. We develop a model that integrates the benefit of any management project on a population by way of its expected population growth rate, including projects targeting different and/or multiple life history stages. To illustrate its utility, we prioritize projects for investment relevant to Australia's eastern population of Flatback turtle ( Natator depressus). We rely upon expert-elicitation to estimate individual benefit parameters, feasibility, and cost, and calculate the cost-effectiveness of each project. The most cost-effective project was not the most feasible, cheapest, or most beneficial. Our approach will help managers make efficient decisions that account for the full range of threats operating on a population. [ABSTRACT FROM AUTHOR]

In conservation, as in most other subjects, there is a division of expenditure into problem identification, solution testing, and practice. However, research concentrates on problem identification rather than solution testing. We calculate the return on the investment of research (a PhD thesis) examining the effectiveness of conservation interventions for birds of prey in three European countries. We show that the economic return from investing in a PhD thesis could be substantial, in the order of hundreds of thousands euros over 10 years or a return on investment of between 292% and 326% over that period. We derived the values of return on investment by first setting a common biological target (the total number of raptor fledglings produced per year). We then compared overall costs in achieving such target via the wide implementation of the results from the thesis (i.e., allocating resources to the most effective intervention) versus a business as usual scenario. We identify other theses that also show considerable benefits in improving effectiveness. We suggest that further research examining effectiveness would be cost-effective in improving practice. [ABSTRACT FROM AUTHOR]

Resources for conserving biodiversity are invariably insufficient. This situation creates the need for transparent, systematic frameworks to help stakeholders prioritize the allocation of resources across multiple management actions. We developed a novel framework that explicitly prioritizes actions to minimize the impacts of several threats across a species' range. The framework uses a budget constraint and maximizes conservation outcomes from a set of management actions, accounting for the likelihood of the action being successfully applied and accepted by local and indigenous communities. This approach is novel in that it integrates local knowledge and expert opinion with optimization software, thereby minimizing assumptions about likelihood of success of actions and their effectiveness. To test the framework, we used the eastern Gulf of Carpentaria and Torres Strait population of the flatback turtle, Natator depressus, as a case study. This approach allowed the framework to be applied in a data-poor context, a situation common in conservation planning. The framework identified the best set of actions to maximize the conservation of flatback eggs for scenarios with different budgets and management parameters and allowed comparisons between optimized and preselected scenarios. optimized scenarios considered all implementable actions to explore how to best allocate resources with a specified budget and focus. Preselected scenarios were used to evaluate current allocations of funds and/or potential budget allocations suggested by different stakeholders. scenarios that used a combination of aerial and ground strategies to reduce predation of eggs performed better than scenarios that focused only on reducing harvest of eggs. The performances of optimized and preselected scenarios were generally similar among scenarios that targeted similar threats. However, the costeffectiveness of optimized scenarios was usually higher than that of preselected scenarios, demonstrating the value of conducting a systematic optimization approach. our method provides a foundation for more effective conservation investments and guidance to prioritize actions within recovery plans while considering the sociopolitical and cultural context of decisions. The framework can be adapted easily to a wide range of species, geographical scales, and life stages. [ABSTRACT FROM AUTHOR]

Fences that exclude alien invasive species are used to reduce predation pressure on reintroduced threatened wildlife. Planning these continuously managed systems of reserves raises an important extension of the Single Large or Several Small (SLOSS) reserve planning framework: the added complexity of ongoing management. We investigate the long-term costefficiency of a single large or two small predator exclusion fences in the arid Australian context of reintroducing bilbies Macrotis lagotis, and we highlight the broader significance of our results with sensitivity analysis. A single fence more frequently results in a much larger net cost than two smaller fences. We find that the cost-efficiency of two fences is robust to strong demographic and environmental uncertainty, which can help managers to mitigate the risk of incurring high costs over the entire life of the project. [ABSTRACT FROM AUTHOR]

Background: More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women.Methods: All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership.Discussion: This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population.Trial Registration: Clinicaltrials.gov, NCT03267563 . Registered June 14, 2018. [ABSTRACT FROM AUTHOR]

Abstract: Background and Aims: Although clear benefits are associated with reducing smoking, there is increasing pressure on public health providers to justify investment in tobacco control measures. Decision‐makers need tools to assess the Return on Investment (ROI)/cost‐effectiveness of programmes. The EQUIPT project adapted an ROI tool for England to four European countries (Germany, the Netherlands, Spain and Hungary). EQUIPTMOD, the economic model at the core of the ROI tool, is designed to assess the efficiency of packages of smoking cessation interventions. The objective of this paper is to describe the methods for EQUIPTMOD and identify key outcomes associated with continued and cessation of smoking. Methods: EQUIPTMOD uses a Markov model to estimate life‐time costs, quality‐adjusted life years (QALYs) and life years associated with a current and former smoker. It uses population data on smoking prevalence, disease prevalence, mortality and the impact of smoking combined with associated costs and utility effects of disease. To illustrate the tool's potential, costs, QALYs and life expectancy were estimated for the average current smoker for five countries based on the assumptions that they continue and that they cease smoking over the next 12 months. Costs and effects were discounted at country‐specific rates. Results: For illustration, over a life‐time horizon, not quitting smoking within the next 12 months in England will reduce life expectancy by 0.66, reduce QALYs by 1.09 and result in £4961 higher disease‐related health care costs than if the smoker ceased smoking in the next 12 months. For all age–sex categories, costs were lower and QALYs higher for those who quit smoking in the 12 months than those who continued. Conclusions: EQUIPTMOD facilitates assessment of the cost effectiveness of smoking cessation strategies. The demonstrated results indicate large potential benefits from smoking cessation at both an individual and population level. [ABSTRACT FROM AUTHOR]