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Aggregation Issues Once the product and unit of measurement are defined order cozaar with a visa, one needs a formula to aggregate price changes across the individual products to obtain an aggregate statistic order cozaar on line amex. The Fisher formula is a superlative index number formula that has been shown to be superior to other aggregation formulas (Diewert 1992) order genuine cozaar line. As discussed below, “chaining” indexes provides a way to bring new goods into the indexes more rapidly and, thus, more closely track the composition of goods sold in the market. We also discuss the Laspeyres index, as it is often used in official price indexes and cost decompositions. Price Indexes Price indexes provide a way to measure aggregate price change over some period by comparing the cost of purchasing a market basket at different points in time. The simplest formula is the familiar Laspeyres index, which is usually written: L I 0,1= [Σi Pi,1 Qi,0/ Σi Pi,0 Qi,0 ] (1) where 0 and 1 denote two periods in time, a base and current period, respectively, and i indexes goods that are sold in both periods. The Laspeyres tracks the cost of buying the Qi,0 basket at period 0 prices with the cost of buying it at period 1 prices. The index can also be written as a weighted average of price change: L I 0,1 = Σi wi,0 Pi,1 / Pi,0 (2) where the weights, wi,0, are the base period expenditure shares and the price relatives, Pi,1 / Pi,0 measure the price changes for individual drugs. The weights, or shares, are often called “relative importances” and have been the focus of much of the work in the literature. Written this way, it is easy to see that products in the base period market basket are only included in the index if they are sold in both periods (i. That is, the index does not include price change for new goods— 8 goods that entered the market between the two periods—or for goods that exited the market after the base period. Moreover, for goods that were sold in both periods, the Laspeyres fixes the relative importance of these goods at the base period levels and therefore does not reflect any changes in the composition of goods sold over time. A Fisher Ideal index provides relative importances that are more closely aligned with the composition of goods sold over time. It is normally written as: F 1/2 I 0,1 = { [Σi Pi,1 Qi,0/ Σi Pi,0 Qi,0 ] [Σi Pi,1 Qi,1/Σi Pi,0 Qi,1 ] } (3) It is an average (a geometric average) of the Laspeyres index—the first term—and the 3 Paasche index—the second term. The Paasche index is similar to the Laspeyres except that it uses a different market basket to measure price change—it compares the actual cost of buying the bundle in period 1 (Σi Pi,1 Qi,1) to what it would have cost to buy that bundle at period 0 prices (Σi Pi,0 Qi,0). The Fisher index may also be written as a ratio of weighted averages: F 1/2 I 0,1 = { Σi wi,0 Pi,1 / Pi,0 ] / [Σi wi,0 Pi,0 / Pi,1] } (4) with the Laspeyres in the numerator and the inverse of a Paasche in the denominator. Here it is easy to see that, unlike the Laspeyres, the Fisher uses expenditure shares from both periods. So, as market shares change over time, the Fisher places a higher weight on goods that are gaining market share whereas the Laspeyres does not. Just like the Laspeyres, however, this index ignores the entry of new goods and the exit of older goods. In a dynamic industry such as pharmaceuticals, the omission of new and exiting drugs can have important empirical implications. For drugs, the evidence is that pricing for new drugs can be very different from that of older, more established drugs, indicating that an index that includes new drugs will likely show different price growth than one that does not (Berndt 2002). One way to better incorporate any price change for new drugs is to construct indexes over shorter spans of time and to cumulate, or chain, the resulting price indexes. One could construct two Fisher price indexes, one for price change from F F 2003 to 2004 (I 2003,2004 ) and another for price change from 2004 to 2005 (I 2004,2005). While the only new drugs included in (4) are those introduced in 2003, the chained F index includes drugs introduced in 2004 in the I 2004,2005 index. Chained indexes thus provide a way of folding in new goods more quickly and so the index more closely tracks prices for the goods actually sold in the market. However, as discussed earlier, it is widely understood that the applicability of this theory in the health care setting is tenuous at best. Fortunately, there are other criteria that one can use to compare the relative merits of these formulas. In his “axiomatic approach,” Diewert (1992) considers about 20 properties that one would like to see in a price index. For example, one property is a time-reversal test which requires that if the prices and quantities in the two periods being compared are interchanged the resulting price index is the reciprocal of the original price index. Diewert showed that the Fisher index formula met this and other criteria better than other available formulas. Empirical results An important contribution of the empirical literature was to demonstrate that the choice of formula and chaining method matters. The Fisher formula takes into account any changes in the relative importance of drugs over time, whereas the Laspeyres formula does not. For example, in their study of drugs sold by four companies making up about 25% of the market, Berndt, 10 Griliches and Rosett (1993) found that price growth in chained indexes was slower than that in fixed-based indexes. But, in their study of antidepressant drugs, Berndt, Cockburn and Griliches (1996) found the opposite—chained Laspeyres tended to show faster price growth than the unchained counterparts. Which way it goes depends on how fast prices for new goods grow relative to established goods, and how the composition of drugs in the market is changing over time. This says that folding in new goods into the index more quickly yields indexes that grow slower and suggests that, in our sample, prices of new drugs grow slower than those of older drugs. First, the chained price indexes show faster (not slower) price growth than the unchained ones. This reflects the fact that prices for new molecules grow faster than those of older molecules that include generics: as molecules lose patent protection, the diffusion of the less expensive generics pushes down the price of the molecule. Hence, folding in new molecules faster—as the chained indexes do—yields an index that includes molecules with faster price growth and so the chained index grows faster. The unchained Laspeyres—the dotted line in chart 2—grows until mid- 2004 and then exhibits a declining trend through the last quarter in our data. This contour is driven entirely by the influx of generics into the market over this period. The pattern we see in the price index is mirrored in the number of generic prescriptions as a share of total: the rise in prices in the earlier period is associated with a decline in the generic share and the subsequent decline in the price index coincides with sustained increases in 11 the generic share. The patterns in the Fisher and Laspeyres indexes are similar because both indexes include the same molecules (both exclude entry and exit). But, the Fisher shows slightly faster price growth because molecules with the fastest price growth also gain market share over time and thus have a bigger weight in the Fisher index than in the Laspeyres. Summing up, chained and unchained indexes can show very different rates of price growth. Implications for decompositions of spending growth Spending on prescription drugs grew 30.

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During manic episodes order 50 mg cozaar fast delivery, symptoms may include:13 order genuine cozaar, 14 Mood • Elevated buy cozaar no prescription, high, or euphoric mood without a clear cause • Irritable, angry, or raging mood that is out of proportion to any reasonable cause The information contained in this guide is not intended as, and is not a substitute for, professional medical ParentsMedGuide. One of the mood symptoms must be irritability or elation to be diagnosed with mania. Also, these symptoms cannot be explained by other medical, neurologic, or mental health conditions and must impair or change the child’s normal functioning. Thinking • Thoughts of suicide or death or a suicide attempt Currently, no biological • Diffculty concentrating, remembering, and making decisions test can determine if your child has bipolar Energy disorder—not blood • Decreased energy or a feeling of fatigue or of being “slowed down” tests, genetic testing, or brain scans. Behavior • Restlessness or irritability • Sleeping too much or not enough • Unintended weight loss or gain • Social isolation A depressive episode is diagnosed if a person has a depressed mood or loss of interest or pleasure along with a number of the symptoms listed above that last most of the day, nearly every day, for two weeks or longer. When depressed, children and adolescents often express their depression as physical complaints, such as headaches, stomachaches, or feeling tired. Signs of depression in children and adolescents also can include poor performance in school, social isolation, and extreme sensitivity to rejection or failure. While many children and adolescents with bipolar disorder will appear irrita- ble, irritability does not always indicate that a child has bipolar disorder. There are many reasons why a child may be irritable, including being tired or hungry. Visit a board-certifed child and adolescent psychiatrist with experience In between mood episodes, children and adolescents can diagnosing and treating bipolar disorder have periods normal moods and behaviors. If the child is very young (a preschool child, for example), ask the doctor his or her experience in treating children, How do the symptoms of bipolar disorder especially young children. Give your child’s doctor a complete medical history of your family and For many parents, it is sometimes diffcult to think of their your child. For this reason, it is critical that with his or her doctor at length and parents and the child’s doctor be attuned to whether mood over time. Scheduling regular sessions with the doctor will help establish the and behavior are signifcant departures from the child’s course and pattern of the illness. It also is important to note how long the mood cycles last, how intense they are, and whether they 5. Make your immediate family, as well One way to distinguish bipolar mood cycles from normal as others who interact with your child, mood swings is to ask: available to your child’s doctor. Many times, an accurate diagnosis • If your child’s mood shift lasts only an hour or two, can it requires multiple visits to the doctor be explained by other factors? Children suspected of having bipolar disorder also must be evaluated for • Do your child’s mood shifts cause problems with his or her other mental health issues, such as social and family life? Work with the doctor to monitor your cent psychiatrist determine whether your child has bipolar child’s progress. Schedule regular disorder, another mood disorder, or mood and behavior that follow-up appointments to monitor treatment outcomes and side effects. Collecting a complete medical history that includes a family history as well as the child’s current symptoms is the frst step in making a mental health diagnosis—regardless of the disorder. Information from parents, teachers, “Getting a diagnosis and people who know the child also is important. Other healthcare professionals of stumbling in the who are familiar with the symptoms and treatment of bipolar disorder in dark. Because of the nature of this illness, it may take several visits before the doctor can determine whether your child has experienced a manic or depressive episode, or if other mental health issues, learning disorders, or if normal development can explain the symptoms. A few children have symptoms so severe that the parents and the doctor agree that some type of treatment must begin immediately—even before a diagnosis can be confrmed. A child and adolescent psychiatrist is a medical Obtaining an accurate diagnosis of any mental health disorder, including doctor who has bipolar disorder, in very young children (preschoolers, for example) is completed at least extremely diffcult. Preschool children with severe mood and behavioral issues should be screened for developmental disorders, parent-child issues, three years of adult and temperamental diffculties as well as bipolar disorder. Ideally, a child and adolescent psychiatrist should be sought, even if travel is required. If a child and adolescent psychiatrist is not available nearby, one located outside of your local community can make a diagnosis and help design a treatment plan. If availability is a problem parents also can look for an adult psychiatrist who has experience treating children and adolescents. Other specialists who may be able to help diagnose and treat children suspected of having bipolar disorder include developmental and behavioral pediatri- cians, pediatric neurologists, neuro-developmental pediatricians, clinical child psychologists, and developmental psychologists. Later, when some of the symptoms of childhood bipolar disorder overlap with the symp- I was a teenager, my toms of these other conditions. Unfortunately, many childhood and adolescent psychiatric disorders do not always respond to the initial attempts at medica- frst thought. Therefore, children who do not respond to treatment can be —a young adult with bipolar misdiagnosed. Depression can be particularly diffcult to differentiate from bipolar disorder because it is of the one symptoms of bipolar disorder. Also, depressed children and adolescents often seem irritable, which can be a symptom of bipolar disorder. Research shows that two-thirds of children diagnosed with bipolar disorder have at least one additional mental health or learning disorder. Coexisting conditions can make diagnosing and treating bipolar disorder more diffcult and create more challenges for a child to overcome. If your child’s doctor determines that your child has one or more coexisting conditions, a treatment plan should be developed to address each coexisting “Before I was condition as well as the bipolar disorder. Now, I realize a coexisting condition often include one or more medications as well as that I was self- psychosocial treatment. Also, the onset of bipolar symptoms appears to be a risk factor for developing an addiction to drugs or alcohol. A recent study found the rate of substance use among adolescents with bipolar disorder was 6 times higher (24 percent compared to 4 percent) than among adolescents without mood disorders. Recent research also supports this approach, fnding that patients with bipolar disorder who abuse drugs or alcohol have more diffculty controlling the symptoms of the disorder than those who do not. These people are more likely to be extremely irritable, resistant to treatment, and to require hospitalization. In one study, lithium signifcantly reduced the risk of adolescents with bipolar disorder using substances of abuse.