scholarly journals Impact of Dispensing Services in an Independent Community Pharmacy

Pharmacy ◽  
2019 ◽  
Vol 7 (2) ◽  
pp. 44
Author(s):  
Kaleb Payne ◽  
Elizabeth J. Unni ◽  
Benjamin Jolley
Keyword(s):  
Cost Saving ◽  
Community Pharmacy ◽  
Adverse Drug Events ◽  
Minimum Cost ◽  
Improve Medication Adherence ◽  
Potential Harm ◽  
Medication Therapy ◽  
The Cost ◽  
The Impact ◽  
Care Costs

With approximately 300 prescriptions dispensed per day in a typical community pharmacy, several activities take place to ensure the safe dispensing of medicines. While some of these activities are common for all prescriptions, others need further activities such as prescription clarification. These activities are important to avoid any potential harm to the patient and improve medication adherence. The objective of this study was to measure the impact of these additional dispensing services in a community pharmacy by evaluating the documented patient notes. Two-hundred patients with annotations on their profiles between 1 July and 31 August 2018 were randomly selected and 322 notes were analyzed. The average number of notes per patient was 1.6. The majority of the notes were about contacting the patient/caregiver for prescription clarification (86.8%). When analyzed based on Medication Therapy Problems, 54.7% were related to adherence and 35.4% to safety. Using the cost saving estimate from the literature for each averted adverse event, these activities resulted in a minimum cost saving of $10,458. This study was able to show the positive impacts that everyday dispensing services in an independent community pharmacy have on ensuring the safe use of medication, thus potentially preventing adverse drug events and reducing health care costs.

The cost implication of primary prevention in the HOPE 3 trial

2019 ◽  
Vol 5 (3) ◽  
pp. 266-271
Author(s):  
Andre Lamy ◽  
Eva Lonn ◽  
Wesley Tong ◽  
Balakumar Swaminathan ◽  
Hyejung Jung ◽  
...  
Keyword(s):  
Developing Countries ◽  
Primary Prevention ◽  
Cost Saving ◽  
Developed Countries ◽  
Sensitivity Analyses ◽  
Clinical Trial Registration ◽  
Pressure Lowering ◽  
The Cost ◽  
Care Costs ◽  
Country Specific

Abstract Aims The Heart Outcomes Prevention Evaluation-3 (HOPE-3) found that rosuvastatin alone or with candesartan and hydrochlorothiazide (HCT) (in a subgroup with hypertension) significantly lowered cardiovascular events compared with placebo in 12 705 individuals from 21 countries at intermediate risk and without cardiovascular disease. We assessed the costs implications of implementation in primary prevention in countries at different economic levels. Methods and results Hospitalizations, procedures, study and non-study medications were documented. We applied country-specific costs to the healthcare resources consumed for each patient. We calculated the average cost per patient in US dollars for the duration of the study (5.6 years). Sensitivity analyses were also performed with cheapest equivalent substitutes. The combination of rosuvastatin with candesartan/HCT reduced total costs and was a cost-saving strategy in United States, Canada, Europe, and Australia. In contrast, the treatments were more expensive in developing countries even when cheapest equivalent substitutes were used. After adjustment for gross domestic product (GDP), the costs of cheapest equivalent substitutes in proportion to the health care costs were higher in developing countries in comparison to developed countries. Conclusion Rosuvastatin and candesartan/HCT in primary prevention is a cost-saving approach in developed countries, but not in developing countries as both drugs and their cheapest equivalent substitutes are relatively more expensive despite adjustment by GDP. Reductions in costs of these drugs in developing countries are essential to make statins and blood pressure lowering drugs affordable and ensure their use. Clinical trial registration HOPE-3 ClinicalTrials.gov number, NCT00468923.

Clinical and economic evaluation of the effectiveness of the use of Riociguat for the treatment of patients with inoperable, recurrent or persistent chronic thromboembolic pulmonary hypertension under the conditions of the Republic of Kazakhstan

2020 ◽  
Vol 3-4 (213-214) ◽  
pp. 8-16
Author(s):  
Andrey Avdeyev ◽  
◽  
Murat Mukarov ◽  
Sabira Zhaugasheva ◽  
Lubov Piven ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Cost Effectiveness ◽  
Pharmacoeconomic Analysis ◽  
Chronic Thromboembolic Pulmonary Hypertension ◽  
Medication Therapy ◽  
First Choice ◽  
Hospitalization Costs ◽  
Thromboembolic Pulmonary Hypertension ◽  
The Cost ◽  
The Impact

Riociguat is included in international guidelines and local clinical protocols for the treatment of pulmonary hypertension (PH) and chronic thromboembolic pulmonary hypertension (CTEPH), where it is the first choice drug for the treatment of patients with inoperable, persistent and recurrent forms of CTEPH. Therefore, it is necessary to include this drug in the GVoFMC (The Guaranteed Volume of Free Medical Care) reimbursement lists and the CSHI (Compulsory Social Health Insurance) system, which will alleviate access to medication for patients suffering from PH and CTEPH. Purpose of the study. Determination of the cost effectiveness parameters of using riociguat in comparison with bosentan and combined therapy of bosentan/sildenafil in medication therapy of CTEPH. Material and methods. A Markov model of CTEPH dynamics in patients with riociguat prescription was developed in comparison with application of bosentan and sildenafil. Modeling step was 16 weeks, modeling horizon – 10 years. Direct medical costs per patient were taken into account in the model, including the cost of drug therapy, costs of outpatient visits due to CTEPH, hospitalization costs due to clinical deterioration of CTEPH, emergency calls. Results and discussion. The results of “cost-effectiveness” Markov pharmacoeconomic modeling showed that riociguat application reveals a dominant position in comparison with the practice of using bosentan with addition of sildenafil for specific therapy at deterioration of patient's condition up to III-IV functional class (FC). Riociguat is characterized by the best values of “cost effectiveness” coefficients according to efficiency criterion of FC increase and the “value of 6-min walk distance test”. The results of analysis of the impact on budget showed that inclusion of riociguat in GVoFMC/CSHI will lead to budget savings of 154 million tenge in the first year, 294 million tenge in the second year and 415 million tenge in the third year compared to the existing clinical practice without riociguat use. Conclusions. On the basis of conducted complex pharmacoeconomic analysis, the application of riociguat in patients with inoperable or persistent/ recurrent form of CTEPH is a more preferable strategy in comparison with the strategy of application of bosentan with addition of sildenafil and will allow to reduce budget expenses within the framework of GVoFMC and CSHI system. Keywords: pulmonary hypertension, chronic thromboembolic pulmonary hypertension, riociguat.

scholarly journals Clinical and Humanistic Outcomes of Community Pharmacy-Based Healthcare Interventions Regarding Medication Use in Older Adults: A Systematic Review and Meta-Analysis

Healthcare ◽  
2021 ◽  
Vol 9 (11) ◽  
pp. 1577
Author(s):  
Christina Malini Christopher ◽  
Bhuvan KC ◽  
Ali Blebil ◽  
Deepa Alex ◽  
Mohamed Izham Mohamed Ibrahim ◽  
...  
Keyword(s):  
Older Adults ◽  
Community Pharmacy ◽  
Risk Ratio ◽  
Adverse Drug Events ◽  
Meta Analysis ◽  
Medication Use ◽  
The Elderly ◽  
Humanistic Outcomes ◽  
Medication Reviews ◽  
The Impact

This review and meta-analysis aimed to determine the clinical and humanistic outcomes of community pharmacy-based interventions on medication-related problems of older adults at the primary care level. We identified randomized controlled trials (RCTs) examining the impact of various community pharmacy-based interventions from five electronic databases (namely, MEDLINE (Ovid), EMBASE (Ovid), CINAHL, APA PSYInfo, and Scopus) from January 2010 to December 2020. Consequently, we assessed these interventions’ clinical and humanistic outcomes on older adults and compared them with non-intervention. We included 13 RCTs in the current review and completed a meta-analysis with six of them. The included studies had a total of 6173 older adults. Quantitative analysis showed that patient education was significantly associated with an increase in the discontinuation of sedative–hypnotics use (risk ratio 1.28; 95% CI (1.20, 1.36) I2 = 0%, p < 0.00001). Moreover, the qualitative analysis showed that medication reviews and education with follow-ups could improve various clinical outcomes, including reducing adverse drug events, reducing uncontrolled health outcomes, and improving appropriate medication use among the elderly population. However, medication review could not significantly reduce the number of older adults who fall (risk ratio 1.25; 95% CI (0.78, 1.99) I2 = 0%, p = 0.36) and require hospitalization (risk ratio 0.72; 95% CI (0.47, 1.12) I2 = 45%, p = 0.15). This study showed that community pharmacy-based interventions could help discontinue inappropriate prescription medications among older adults and could improve several clinical and humanistic outcomes. However, more effective community pharmacy-based interventions should be implemented, and more research is needed to provide further evidence for clinical and humanistic outcomes of such interventions on older adults.

Fiscal reform: a computable general equilibrium (CGE) analysis for the Kingdom of Saudi Arabia

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Elizabeth Louisa Roos ◽  
Philip David Adams
Keyword(s):  
Saudi Arabia ◽  
Computable General Equilibrium ◽  
Tax Policy ◽  
Tax Revenue ◽  
Corporate Tax ◽  
Policy Simulation ◽  
Potential Harm ◽  
Content Type ◽  
The Cost ◽  
The Impact

Purpose This paper aims to provide a quantitative assessment of the broad economic effects of tax policy reform in the Kingdom of Saudi Arabia (KSA). Design/methodology/approach Using a dynamic computable general equilibrium (CGE) model of the KSA, three simulations are run. The first simulation is the baseline simulation, which generates growth paths of the Saudi economy in the absence of tax reform. In developing the baseline simulation, this study incorporates forecasts from the International Monetary Fund. The remaining simulations are policy simulations. A policy simulation deviates from the baseline simulation in response to a policy change. In the first policy simulation, this study introduces a value-added tax (VAT) that generates SAR 35bn. This study assumes budget neutrality with the additional tax revenue transferred to households via a lump sum payment. In the second policy simulation, this study introduces a corporate income tax that generates SAR 35bn. This study then calculates and compares the distortion these taxes introduce into the economy. Findings This study finds that although the introduction of new taxes increases government tax revenue, markets are distorted lowering efficiency and production. An introduction of VAT increases the cost of consumption relative to the cost of production. As a consequence, the real cost of labour increases lowering employment in the short run. Employment moves to the baseline, as wages adjust capital and real gross domestic product (GDP) is below base throughout the simulation period. The second simulation is an increase in the corporate tax rate with lowers the post-tax rates of return investors receive. This simulation shows that the negative impact on investment, capital and GDP is larger with the introduction of a corporate tax than with the VAT. Research limitations/implications Literature focusing on tax policy reform in the Gulf Cooperation Council and, specifically, Saudi Arabia is limited. This paper contributes to the literature by focusing on the following: understanding the impact and mechanisms through which changes in taxation impact the economy more generally; understanding the potential harm caused to allocative efficiency and production due to taxes; and ways in which fiscal reform might complement other reforms such as efforts to diversify the economy, labour market and energy price reforms. This improves the information base available to policymakers charged with designing an optimal tax system that meets all future requirements of a country such as the KSA. Originality/value The authors developed and applied a CGE model for the KSA to analyse the impact of VAT and corporate tax on the Saudi economy. To the best of the authors’ knowledge, there are no recent CGE models for Saudi Arabia that have been used for tax policy or quantifying the potential harm to the economy when new taxes are introduced.

Abstract MP76: Assessing the Impact of the "Health Bucks" Program on Cardiovascular Disease in New York City: A Modeling Study

Circulation ◽  
2020 ◽  
Vol 141 (Suppl_1) ◽  
Author(s):  
Heesun Eom ◽  
Stella S Yi ◽  
Daniel Bu ◽  
Rienna Russo ◽  
Brandon Bellows ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Health Care ◽  
New York ◽  
New York City ◽  
Health Care Costs ◽  
York City ◽  
Fruits And Vegetables ◽  
The Cost ◽  
The Impact ◽  
Care Costs

Background: Low fruit and vegetable (FV) consumption is considered one of the leading causes of deteriorating health outcomes, and has been linked to obesity, diabetes, and cardiovascular disease. Yet, few adults in New York City (NYC) consume the daily recommended amounts. In order to address the need for fresh and affordable fruits and vegetables, the NYC Department of Health and Mental Hygiene has implemented the “Health Bucks” program, which provides low-income population with coupons that can be used to purchase fruits and vegetetabls. Previous studies have shown the impact of the Health Bucks program on fruit and vegetable consumption; however, it is unclear how the program would influence cardiovascular health and the associated health care costs in the long term. Objective: To estimate the health and economic impact of the Health Bucks program using a validated microsimulation model of cardiovascular disease (CVD) in NYC. Methods: We used the Simulations for Health Improvement and Equity (SHINE) CVD Model to estimate the impact of the Health Bucks program on lifetime CVD events and direct medical costs (2019 USD). We considered different program strengths by assuming the program can reduce the cost of fruits and vegetables by 20%, 30%, and 40%. Population characteristics were estimated based on data from the 2013-2014 NYC Health and Nutrition Examination Survey. CVD risk factor trajectories and risk of incident CVD events were derived from six pooled longitudinal US cohorts. Policy effects were derived from the literature. We run 1,000 simulations to account for uncertainties in the parameter. We discounted costs by 3% and reported health care costs in 2019 dollars. Results: A Health Bucks program that can reduce the cost of fruits and vegetables by 20%, 30%, and 40% would prevent 2,690 (95% CI: -14,793, 20,173), 27,386 (95% CI: 9,967, 44,805), and 50,014 (95% CI: 15,227, 50,014) coronary heart disease events, respectively, over the simulated lifetimes of the NYC population. The program would also prevent 47,469 (95% CI: 35,008, 59,931), 59,127 (95% CI: 46,676, 71,579), and 85,359 (95% CI: 72,902, 97,815) stroke events based on the price reduction level. The program would result in savings in health care costs, ranged from $937 million to $1.8 billion based on the price reduction level over the lifetime or from $19 million to $37 million annually. Conclusions: We projected that the Health Bucks program could prevent a significant number of CVD events among adults in NYC and yield substantial health care cost savings. Public health practitioners and policymakers may consider adopting this program in other locations.

scholarly journals Impact of the Maximum Number of Switching Reconfigurations on the Cost Saving in Network Function Virtualization Environments with Elastic Optical Interconnection

2019 ◽  
Vol 9 (23) ◽  
pp. 5167
Author(s):  
Vincenzo Eramo ◽  
Francesco G. Lavacca ◽  
Tiziana Catena
Keyword(s):  
Computational Complexity ◽  
Cost Saving ◽  
Virtual Machines ◽  
New Technology ◽  
Network Function Virtualization ◽  
Optical Interconnection ◽  
Network Function ◽  
Network Functions ◽  
The Cost ◽  
The Impact

Network Function Virtualization is based on the virtualization of the network functions and it is a new technology allowing for a more flexible allocation of cloud and bandwidth resources. In order to employ the flexibility of the technology and to adapt its use according to the traffic variation, reconfigurations of the cloud and bandwidth resources are needed by means of both migration of the Virtual Machines executing the network functions and reconfiguration of circuits interconnecting the Virtual Machines. The objective of the paper is to study the impact of the maximum number of switch reconfigurations on the cost saving that the Networking Function Virtualization technology allows us to achieve. The problem is studied in the case of a scenario with an elastic optical network interconnecting datacenters in which the Virtual Machines are executed. The problem can be formulated as an Integer Linear Programming one introducing a constraint on the maximum number of switch reconfigurations but due to its computational complexity we propose a low computational complexity heuristic allowing for results close to the optimization ones. The results show how the limitation on the number of possible reconfigurations has to be taken into account to evaluate the effectiveness in terms of cost saving that the Virtual Machine migrations in Network Function Virtualization environment allows us to achieve.

Efficient Energy Management System Based on GA and Classical Boolean Approach

2016 ◽  
Vol 15 (03) ◽  
pp. 1650012
Author(s):  
Musbah Abdulgader ◽  
Cheng Yang ◽  
Devinder Kaur
Keyword(s):  
Cost Saving ◽  
Energy Management ◽  
Cost Savings ◽  
Department Of Energy ◽  
Time Data ◽  
Storage Unit ◽  
Energy Storage Unit ◽  
Load Demand ◽  
The Cost ◽  
The Impact

In this paper, two intelligent strategies for energy management unit for a home integrated with smart grid are proposed. The strategies are based on classical Boolean and genetic algorithm (GA). The objective is to optimize the cost saving for the end consumer. The price of energy varies by the hour depending on the load on the grid. The two strategies predict when and by how much the storage unit installed in the house should charge and release for 24 h of the day, satisfying the constraint that the load demand of the house at any particular hour should always be met. The strategies were tested by real time data collected by the Department of Energy for a typical house in the Chicago, Illinois region for the year 2013. Both the strategies achieve cost savings; however, it has been found that GA-based strategy results in higher cost saving. The impact of the capacity of the energy storage unit (ESU) on the cost saving has been analyzed for a GA strategy and cost saving obtained when the capacity of ESU is 1.5 times and 2 times the house hold load at any given hour is presented.

scholarly journals What Is the Cost of Disease Progression Among Patients with Indolent or Aggressive Non-Hodgkin Lymphoma (NHL)?

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 5957-5957
Author(s):  
Nicole Engel-Nitz ◽  
Stacey Dacosta Byfield ◽  
Timothy Bancroft ◽  
Anderson J. Amy ◽  
Carolina Reyes ◽  
...  
Keyword(s):  
Health Care ◽  
Index Date ◽  
Progressive Disease ◽  
Hospice Care ◽  
Diagnosis Codes ◽  
Equity Ownership ◽  
The Cost ◽  
The Impact ◽  
Care Costs

Abstract Background: The natural histories of aggressive and indolent NHL vary in terms of the timing and pattern of disease progression. However, little is known about the impact of progression of disease (PD) on costs, and in particular how this differs between aggressive and indolent subtypes of NHL. This study examined patterns of care and outcomes for patients with aggressive and indolent NHL, and the impact of PD on health care costs. Methods: To identify cases of NHL, this retrospective studyused medical and pharmacy claims from a large national US health plan to identify commercially insured and Medicare Advantage (MA) patients age ≥18 years from 1/2007 - 8/2014 with ≥2 medical claims for NHL based on ICD-9-CM diagnosis codes. Patients were divided into cohorts of aggressive (AGG) NHL and indolent (IND) and based on diagnosis codes. Patients were required to have ≥1 claim for systemic anti-cancer therapy, with the index date being defined as the first observed claim for such therapy. Continuous enrollment in the health plan for 6 months prior to (baseline period), and ≥6 months after, the index date (variable follow-up period) was required; patients with <6 months of follow-up due to death were included. An algorithm to identify line of therapy (LOT) periods was implemented. PD was defined as: start of a second LOT, receipt of hospice care (based on procedure or revenue codes) or death (based on Social Security Administration death data). Health care costs were calculated over 6-month periods of follow-up (6, 12, 18, 24 months), with costs calculated for pharmacy, inpatient hospital, ambulatory, and other sites of service. Results: A total of 1,197 AGG and 2,454 IND patients met study criteria. Progression was experienced by 40.6% of AGG and 49.4% of IND patients respectively during the entire study period; 6-month progression was 18.9% (AGG) and 18.5% (IND). Compared to patients without PD during the study period, patients who progressed had higher average costs over each time period: in the first 6-months, costs were $138,957 PD vs. $108,607 for non-PD among AGG, and $114,644 PD vs. $80,873 for non-PD among IND (Figure, Table). Similarly, total costs for PD were higher than non-PD over 12, 18, and 24 months (Figure). Costs by site of service were higher for PD patients compared to non-PD patients among both the AGG and IND groups, particularly for inpatients costs; the table shows costs by site of service for the first 6 months, and results were similar over 12, 18, and 24 months. A higher proportion of AGG patients died compared with IND patients. Approximately one third of patients who died used hospice services among AGG and IND, and of these, 90.1% of AGG and 91.3% of IND used 3 or more days of hospice care. Conclusion: Among both aggressive and indolent NHL populations, costs were higher for patients with progressive versus without progressive disease, and increased over longer follow-up time. Patients with aggressive NHL had higher costs compared with patients with indolent NHL for both progressive and non-progressive disease. This study is the first to quantify systematically the cost of progression in NHL, both indolent and aggressive, and can inform efforts to improve value-based care, taking into account costs not just of therapy, but of subsequent progression. Disclosures Engel-Nitz: Optum: Employment, Other: UnitedHealth Group stock. Dacosta Byfield:UnitedHealth Group: Equity Ownership; Optum: Employment. Bancroft:Optum: Employment, Other: UnitedHealth Group stock. Amy:Optum: Employment, Other: UnitedHealth Group stock. Reyes:Genentech: Employment; Roche: Equity Ownership.

scholarly journals Pneumococcal conjugate vaccination in The Gambia: health impact, cost effectiveness and budget implications

2021 ◽  
Vol 6 (12) ◽  
pp. e007211
Author(s):  
Clint Pecenka ◽  
Effua Usuf ◽  
Ilias Hossain ◽  
Sana Sambou ◽  
Elisabeth Vodicka ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Cost Saving ◽  
Low Income ◽  
Pneumococcal Vaccination ◽  
The Gambia ◽  
Low Income Countries ◽  
Birth Cohorts ◽  
The Cost ◽  
Conjugate Vaccination ◽  
The Impact

IntroductionIntroducing pneumococcal conjugate vaccine (PCV) in many low-income countries has contributed to reductions in global childhood deaths caused by Streptococcus pneumoniae. Many low-income countries, however, will soon reach an economic status leading to transition from Gavi, the Vaccine Alliance vaccine funding support and then face increased expenditure to continue PCV programmes. Evaluating the cost-effectiveness of PCV in low-income countries will inform such country decisions.MethodsWe used empiric data on the costs of vaccine delivery and pneumococcal disease and PCV programme impact on disease among children less than 5 years old in The Gambia. We used the UNIVAC cost-effectiveness modelling tool to compare the impact and cost-effectiveness of pneumococcal conjugate vaccination to no vaccination over 20 birth cohorts starting in 2011. We calculated costs per disability-adjusted-life-year (DALY) averted from government and societal perspectives and undertook scenario and probabilistic sensitivity analysis.ResultsWe projected that, over 20 years, PCV in The Gambia could avert 117 000 total disease episodes in children less than 5 years old, including outpatient and hospitalised pneumonia, pneumococcal sepsis and meningitis (including sequelae). Vaccination could avert 9000 outpatient pneumonia visits, 88 000 hospitalisations and 3300 deaths due to pneumonia, meningitis and sepsis. Approximately 100 000 DALYs are expected to be averted. Averted visits and hospitalisations represent US$4 million in healthcare costs expected to be saved by the government and US$7.3 million if household costs are included. The cost of the vaccination programme is estimated at US$2 million. In the base scenario, most alternative scenarios and nearly 90% of the probabilistic scenarios, pneumococcal vaccination is cost saving in The Gambia.ConclusionPneumococcal conjugate vaccination is expected to generate substantial health gains and is likely to be cost saving in The Gambia. Policymakers in similar settings should be confident to maintain their PCV programmes.

scholarly journals Parents and offspring in an evolutionary game: the effect of supply on demand when costs of care vary

2011 ◽  
Vol 279 (1726) ◽  
pp. 109-115 ◽  
Author(s):  
Uri Grodzinski ◽  
Rufus A. Johnstone
Keyword(s):  
Evolutionary Game ◽  
Cost Of Care ◽  
Quantitative Relation ◽  
Costs And Benefits ◽  
Parental Responsiveness ◽  
Opposite Case ◽  
On Demand ◽  
The Cost ◽  
The Impact ◽  
Care Costs

Current models of parent–offspring communication do not explicitly predict the effect of parental food supply on offspring demand (ESD). However, existing theory is frequently interpreted as predicting a negative ESD, such that offspring beg less when parental supply is high. While empirical evidence largely supports this interpretation, several studies have identified the opposite case, with well-fed offspring begging more than those in poorer condition. Here, we show that signalling theory can give rise to either a negative or a positive ESD depending on the precise form of costs and benefits. Introducing variation among parents in the cost of care, we show that the ESD may change sign depending upon the quantitative relation between two effects: (i) decreased supply leads to increased begging because of an increase in marginal fitness benefit of additional resources to offspring, (ii) decreased supply leads to reduced begging because it is associated with a decrease in parental responsiveness, rendering begging less effective. To illustrate the interplay between these two effects, we show that Godfray's seminal model of begging yields a negative ESD when care is generally cheap, because the impact of supply on the marginal benefits of additional resources then outweighs the associated changes in parental responsiveness to begging. By contrast, the same model predicts a positive ESD when care is generally costly, because the impact of care costs on parental responsiveness then outweighs the change in marginal benefits.

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