*** Data Entry Form ***
    
COST EFFECTIVENESS - CALCULATOR AND GRAPHER  
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*** Data Entry Form ***
(Modify values in yellow boxes and hit "calculate" button)
 
 I. TITLE OF ANALYSIS:  
II. STUDY OBJECTIVES:  
III. STUDY PERSPECTIVE: Society Patient   Payer Provider Miscellaneous  
IV. TYPE OF ANALYSIS: COI CMA   CBA CEA CUA    
V. TREATMENT OPTIONS:        
  Names of Treatment:        
  Disease/Symptom:            
  Major Outcome Measure:        
VI. COST FACTORS            
  A. DIRECT COSTS:            
     ( HEALTH CARE RESOURCES)          
           
           
           
           
           
           
           
           
                 
  B. DIRECT COSTS:                
     (NON-HEALTH CARE RESOURCES)            
           
           
           
           
    TOTAL DIRECT COSTS      
  C. INDIRECT COSTS (BENEFITS)          
               
  Morbidity & Mortality (time gained for work yrs)      
  Salary per year            
  Morbidity & Mortality (benefit gained $)      
         
         
  D. QUALITY OF LIFE        
         
         
  Quality of Life -- Adjustment Factor        
  Quality Adjusted Life Years        
               
VII. ANALYSIS OPTIONS        
        Outcomes Outcomes    
For COI (direct and indirect costs of illness)    DOLLARS  DOLLARS      
For CMA ( outcomes are assumed equal)    EQUAL  EQUAL      
For CEA ( outcomes in natural units.)      Yrs,mmHg,etc.  Yrs,mmHg,etc.      
For CBA [NPV] ( outcomes all in dollars)    DOLLARS  DOLLARS      
For CUA ( outcomes in utiles,QALYs)      QALYs, DALYs, etc  QALYs,DALYs, etc      
           
VIII. CALCULATED RESULTS:        
(Ratios are Input Costs divided by Outcomes.)        
       
COI (direct and indirect costs of illness)   COI    
CMA ( input costs only, outcomes equal)   CMA    
CEA (cost over effect ratio)   CEA    
CBA [NPV] (benefit minus input cost)   CBA    
CUA (cost over utility adjusted effect)   CUA    
               
     
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*** Data Entry Form ***
  
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