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An average increase of $18 in drug expenditure was related to a $71 reduction in nondrug spending Moreover, individuals who used newer drugs were signi cantly less likely to die or to experience work absenteeism than individuals who used older drugs Apparently, newer, more effective medicines were ef cient treatment substitutes for older medicines From an economic perspective, the health care system can be viewed as a production function in which many inputs are combined through some process (medical care) to produce certain outputs or health outcomes (Fig 121) In an economic sense, many of the inputs to health care production, such as pharmacogenomics-based drugs, are substitutes for or complements to other inputs That is, they may be used in place of or in addition to the current, standard mode of treatment.

1. R. Jones, Introduction to MFC Programming with Visual C++, Prentice-Hall, 2000. 2. G. Shepherd, Programming with Microsoft Visual C++.Net, Microsoft Press, 2003. 3. D. J. Kruglinski, S. Wingo, and G. Shepherd, Programming Visual C++, Microsoft Press, 1998.

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The concept of community of practice has been acritically introduced in previous chapters. It evokes the community of scholars that has formed around this concept and has had the great merit of innovating the study of organizational learning. While recognizing this merit, however, I want nevertheless to offer some re ections on how in being used the concept has changed. I propose to turn it upside down. The scholars who rst developed the concept had backgrounds in anthropology or in educational or social psychology. However dif cult and ultimately restrictive disciplinary distinctions may be, it is important to locate the historical and disciplinary provenance of a concept in order to understand how it has been transformed by being transferred to different contexts, and also to bring criticisms against it which are constructive and not pointlessly iconoclastic.1 If we re-read the book by Lave and Wenger (1991) which rst systematized the concept of community of practice, we nd that the concept is based on the empirical study of ve types of apprenticeship in crafts or craft-like forms of production.These are ethnographic studies of trades in contexts which were not always organizational, and not always in industrialized societies. Lave and Wenger examine apprenticeship learning among Yucatec midwives in Mexico, among Vai and Gola tailors in Liberia, in the work-learning settings of American navy quar-

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Treatment substitution may cause the unit costs to change (increase or decrease), while outcomes are likely to improve In addition to treatment substitution effects, new technologies also affect utilization and expenditure through treatment expansion That is, when newer, more effective treatments are introduced, conditions tend to be diagnosed and treated more frequently than in the absence of these newer regimens (Cutler and McClellan, 2001) Pharmacogenomics-based drug therapies and improvements in genetic testing are certain to impact the health care system through their treatment substitution and expansion effects To accurately assess the value (economic impact) of pharmacogenomics, a long-term health system perspective is especially important Such a perspective includes not only the direct costs and bene ts of health care interventions but also the indirect and intangible costs and bene ts such as changes in productivity and health-related quality of life.

#include <pls.h> TInt InitializeGlobals(Globals* pglobals) { pglobals->gref = 0; pglobals->gerr = 0; // Initializer must return KErrNone to indicate success. // Else the Pls routine panics. return KErrNone; } struct Globals* GetGlobals() { return Pls<Globals>(KDllSecureId, &InitializeGlobals); }

GIS, see geographic information systems (GIS) GLIM, 244, 246, 246 global optimality, see optimization algorithm, global optimality Gnu Multiple Precision (GMP), 93 Goodman s regression, see ecological inference, Goodman s regression hat matrix, 251 Hessian, 103, 105, 143 bootstrapping approach, 174 175 derivative approach, 174 inversion, 10 11, 194 195 invertibility, 143 nonpositive de nite, 149 noninvertible, 262 263 causes, 149 numerical example, 166, 169 positive de nite, 262 processing, numerical example, 163 171 respeci cation, 146, 175 singular, 149 heuristic, 30, 32 40 de ned, 16 highest posterior density, 109 113, 148, 263 average coverage criterion, 110 average length criterion, 110 de nition, 109 highest average coverage criterion, 110 simulation methods, 112 worst outcome criterion, 111 HPD, see highest posterior density ICPSR, see Inter-University Consortium for Political and Social Research implementation de ned, 16, 19 error, 21 22, 258 implementation uncertainty, 197 importance ratio, 160 importance sampling, 147, 160 163 algorithm, 160 161

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Although medical advances emanating from the Human Genome Project (HGP) will be highly effective and patient speci c, they will also be very expensive by today s standards From an economic perspective, these new interventions should be evaluated for their marginal bene ts and costs As a society, we will be.

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