Effect of hydrodynamic and ecosystem conditions on persistent organic pollutant temporal-spatial variations in the Yellow Sea

Coastal seas are important pools of persistent organic pollutants (POPs) discharged from land. Considering the complex conditions in coastal seas and various biochemical features of POPs, special temporal-spatial variations in POPs have been reported. To understand these variations, we developed a three-dimensional hydrodynamic-ecosystem-POP coupled model and applied it to the Yellow Sea. We selected two POP species (polychlorinated biphenyl congener 153 (PCB-153) and decabromodiphenyl ether (BDE-209)), which have different biochemical properties, as target materials. The dissolved PCB-153 simulated concentration was high in late spring and low in autumn, whereas that of BDE-209 was high in summer and low in winter. Both PCB-153 and BDE-209 showed high particle-bound concentrations in early spring. In summer, dissolved PCB-153 accumulated at the sea bottom, whereas dissolved BDE-209 accumulated at the sea surface. Seasonal and spatial variation differences in the two POPs are likely caused by greater Henry's Law Constant (H') and bioconcentration factor (BCF) of PCB-153 than that of BDE-209, which leads to higher volatilization and stronger absorption by the particles for PCB-153 than BDE-209. As a component of such differences, the "biological pump" of PCB-153 in the central Yellow Sea is more apparent than that of BDE-209.

Nitrate budget of a terrestrial-to-marine continuum in South China: Insights from isotopes and a Markov chain Monte Carlo model

Anthropogenic nitrate (NO3-) production has been increasing and is exported to the ocean via river networks, causing eutrophication and ecological damage. While studies have focused on river NO3- pollution, what has been lacking is the quantification of the sources of NO3- in coastal rivers. This study applied the dual isotopes (δ15N/δ18O-NO3-) to quantify the sources and their fluxes of NO3- in two inflow rivers of the Qinzhou Bay. By adding our results to the NO3- source apportionment in Qinzhou Bay, we, for the first time, established the NO3- budgets of the terrestrial-to-marine continuum in both high- and low-flow seasons. We quantitatively showed the direct and indirect roles (e.g., the stimulation of nitrification by sewage ammonium-NH4+) of terrestrial sources in driving the high NO3- loading in the estuary. The results highlighted the necessity to consider coastal rivers and estuary as a whole, which could shed light on the effective reduction of NO3- pollution in coastal environments.

Economic Considerations and Cost-Saving Strategies for Nonsterile Compounding Education

OBJECTIVE

To determine the economic considerations, including cost-saving strategies, associated with nonsterile compounding education for students in schools and colleges of pharmacy across the United States.

METHODS

An electronic survey was sent to the American Association of Colleges of Pharmacy Pharmaceutics Section and Laboratory Instructor's Special Interest Group members. Quantitative and qualitative data were collected about the institution, student cohorts, compounding courses, equipment, budgets, personnel, and cost-saving measures. Descriptive statistics were calculated using SPSS. Open-ended responses were used by respondents if the primary question could not adequately capture their institution-specific information. These answers were added to the study findings.

RESULTS

Of 555 surveys sent, 46 were completed. Reported annual compounding budgets ranged from $3000 to $96,000. Reported annual equipment maintenance costs ranged from $400 to $18,000. Fifty percent of respondents reported students shared equipment, and 29.6% collected a lab fee from students to offset costs. Approximately half of respondents reported the use of cost-saving measures, including contract pricing, purchasing supplies in bulk, price comparisons, use of simulated drugs, re-use of personal protective equipment, and procurement of donations. Fifty percent of respondents employed laboratory assistants to support nonsterile compounding sessions, with paid positions ranging from $200 to $1000 per semester.

CONCLUSION

Findings from this study may assist pharmacy administrators and course directors in evaluating the costs associated with nonsterile compounding education across the Academy and, more importantly, determining ways to reduce such costs while maintaining the intent and quality of these courses.

Budgeting in Healthcare Systems and Organizations: A Systematic Review

Background

Budgeting is the process resource allocation to produce the best output according to the revenue levels involved. Among the constraints that healthcare organizations, including hospitals, both in the public and private sectors, grapple with is budgetary constraints. Therefore, cost control and resource management should be considered in healthcare organizations under such circumstances.

Methods

We aimed to identify methods of budgeting in healthcare systems and organizations as a systematic review. To extract and analyze the data, a form was designed by the researcher to define budgeting methods proposed in the literature and to identify their strengths, weaknesses, and dimensions. The search was conducted in Google Scholar, Web of science, Pub med and Scopus databases covering the period 1990-2022.

Results

Overall, 33 articles were included in the study for extraction and final analysis. The study results were reported in four main themes: healthcare system budgeting, capital budgeting, global budgeting, and performance-based budgeting.

Conclusion

Each budgeting approach has its own pros and cons and requires meeting certain requirements. These approaches are selected and implemented depending on each country's infrastructure and conditions as well as its organizations. These infrastructures need to be thoroughly examined before implementing any budgeting method, and then a budgeting method should be selected accordingly.

Pediatric unit spending in the North of Italy during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, accesses to pediatric health care services decreased, as well as the consumption of traditional drugs, while the median cost per patient at the emergency department slightly increased and the cost of pediatric COVID-19 admissions to the pediatric ward too. Overall spending of a secondary level Pediatric Unit in the last two years has not been previously reported.

METHODS

This is a retrospective study conducted by the Pediatric Unit of S. Chiara Hospital of Trento, North of Italy. We collected data on consumption and spending before and during the COVID-19 pandemic (between January 2018 and December 2022).

RESULTS

The total spending ranged from 2.141.220 to 2.483.931 euros between 2018 and 2022. COVID-19 spending accounted only for 5-8% of the overall budget, while two macro-areas of spending were identified: (i) biologic drugs for inherited metabolic diseases (IMDs), that impacted for 35.4-41.3%, and (ii) technology devices for type 1 diabetes (T1D), that accounted for 41.6-32.8% of the overall budget, in 2021 and 2022, respectively. Analysis of costs along with the different health care services revealed that: (i) the spending for COVID-19 antigen tests and personal protective equipment had a major impact on the Emergency room budget (from 54 to 68% in the two years); (ii) biological drugs accounted mainly on the Pediatric Ward (for 57%), Day Hospital (for 74%) and rare disease center budget (for 95% of the spending); (iii) the cost for T1D devices was mainly due to continuous glucose monitoring, and impacted for the 97% of the outpatient clinic budget.

CONCLUSIONS

The main impact on the budget was not due to COVID-19 pandemic related costs, but to the costs for biologic drugs and T1D devices. Therefore, cost savings could be mainly achieved through generic and biosimilars introduction and with inter-regionals calls for technology devices. We emphasize how the control of spending in pediatric hospital care has probably moved from the bedside (savings on traditional drugs as antibiotics) to the bench of national or inter-regional round tables, to obtain discounts on the costs of biologic drugs and medical devices. Here we provide for the first-time in literature, data for bench-marking between secondary level Pediatric Units before and during the COVID-19 pandemic.

Modeling historical budget for β-Hexachlorocyclohexane (HCH) in the Arctic Ocean: A contrast to α-HCH

The historical annual loading to, removal from, and cumulative burden in the Arctic Ocean for β-hexachlorocyclohexane (β-HCH), an isomer comprising 5-12% of technical HCH, is investigated using a mass balance box model from 1945 to 2020. Over the 76 years, loading occurred predominantly through ocean currents and river inflow (83%) and only a small portion via atmospheric transport (16%). β-HCH started to accumulate in the Arctic Ocean in the late 1940s, reached a peak of 810 t in 1986, and decreased to 87 t in 2020, when its concentrations in the Arctic water and air were ∼30 ng m^-3 and ∼0.02 pg m^-3, respectively. Even though β-HCH and α-HCH (60-70% of technical HCH) are both the isomers of HCHs with almost identical temporal and spatial emission patterns, these two chemicals have shown different major pathways entering the Arctic. Different from α-HCH with the long-range atmospheric transport (LRAT) as its major transport pathway, β-HCH reached the Arctic mainly through long-range oceanic transport (LROT). The much higher tendency of β-HCH to partition into the water, mainly due to its much lower Henry's Law Constant than α-HCH, produced an exceptionally strong pathway divergence with β-HCH favoring slow transport in water and α-HCH favoring rapid transport in air. The concentration and burden of β-HCH in the Arctic Ocean are also predicted for the year 2050 when only 4.4-5.3 t will remain in the Arctic Ocean under the influence of climate change.

Combination of pricing and inventory policies for deteriorating products with sustainability considerations

Economic, environmental, and social criteria are all being taken into consideration simultaneously when determining pricing policies or inventory levels in sustainable production management. The combination of pricing and inventory policies is an important source of leverage for the efficient management of perishable products. This paper, among the first studies, proposes the problem of devising optimal pricing and inventory management decisions simultaneously where the environmental and social criteria are contributed for perishable complementary products replenished and sold by the same company. This study considers two interrelated price-sensitive linear demand functions to consider the possibility of shortage with both budget and warehouse capacity constraints. Another contribution of the proposed model is to consider an upper bound for environmental pollution and a lower bound for job opportunities as the constraints to the model. As a complex optimization model, the challenge of complexity is addressed by a heuristic algorithm for finding an optimal solution. After an extensive analysis using numerical examples, some managerial insights are concluded from the results. One finding from these analyses confirms that the total capacity of the warehouse, the total available budget, carbon emissions, and variable job opportunities have a high impact on the optimal solution to find a balance between sustainability criteria for making pricing and inventory policies.

Determinants of local government deficit: evidence from Spanish municipalities

Understanding the determinants of fiscal deficits is justified by the fact that persistent deficits rapidly lead to the accumulation of public debt. Therefore, the aim of this paper is to analyze the factors that explained the fiscal deficits of Spanish municipalities in the period 2011-2020. The deficit at the municipal level for Spain is explained by considering several determinants covering socioeconomic and political dimensions, such as GDP per capita, unemployment rate, population, political participation, political sign of the ruling party or political force, among others. The method of moments quantile regression (MMQ) and mean group (MG) estimator are applied for the overall sample and for each group of municipalities. In addition, the causality between the deficit and the explanatory variables is analyzed using the Juodis et al. (2021) test. It is found that economic growth only has a long-term beneficial effect on the deficit as it reduces the deficit at all quantile levels except at the 10% quantile. Unemployment increases the deficit in both the short and long run. Political participation and right-wing political parties contribute to the growth of the deficit in the higher quantiles. To reduce the budget deficit, the analysis shows that unemployment should be reduced and economic growth should be boosted. The results are robust to those based on mean group estimators. With this paper, we contribute to the scarce literature on deficit determinants by analyzing the determinants for Spanish municipalities. Furthermore, our findings have important implications for politicians, citizens and stakeholders.

Arctic methylmercury cycling

Anthropogenic mercury (Hg) undergoes long-range transport to the Arctic where some of it is transformed into methylmercury (MeHg), potentially leading to high exposure in some Arctic inhabitants and wildlife. The environmental exposure of Hg is determined not just by the amount of Hg entering the Arctic, but also by biogeochemical and ecological processes occurring in the Arctic. These processes affect MeHg uptake in biota by regulating the bioavailability, methylation and demethylation, bioaccumulation and biomagnification of MeHg in Arctic ecosystems. Here, we present a new budget for pools and fluxes of MeHg in the Arctic and review the scientific advances made in the last decade on processes leading to environmental exposure to Hg. Methylation and demethylation are key processes controlling the pool of MeHg available for bioaccumulation. Methylation of Hg occurs in diverse Arctic environments including permafrost, sediments and the ocean water column, and is primarily a process carried out by microorganisms. While microorganisms carrying the hgcAB gene pair (responsible for Hg methylation) have been identified in Arctic soils and thawing permafrost, the formation pathway of MeHg in oxic marine waters remains less clear. Hotspots for methylation of Hg in terrestrial environments include thermokarst wetlands, ponds and lakes. The shallow sub-surface enrichment of MeHg in the Arctic Ocean, in comparison to other marine systems, is a possible explanation for high MeHg concentrations in some Arctic biota. Bioconcentration of aqueous MeHg in bacteria and algae is a critical step in the transfer of Hg to top predators, which may be dampened or enhanced by the presence of organic matter. Variable trophic position has an important influence on MeHg concentrations among populations of top predator species such as ringed seal and polar bears distributed across the circumpolar Arctic. These scientific advances highlight key processes that affect the fate of anthropogenic Hg deposited to Arctic environments.

Hospital-related costs of sepsis around the world: A systematic review exploring the economic burden of sepsis

AIM

The aim of this study was to examine the quality of manuscripts reporting sepsis health care costs and to provide an overview of hospital-related expenditures for sepsis in adult patients around the world.

METHODS

We systematically searched the PubMed, EMBASE, Cochrane and Google Scholar to identify relevant studies between January 2010 and January 2022. We selected articles that provided costs and cost-effectiveness analyses, defined sepsis and described their cost calculation method. All costs were adjusted to 2020 US dollars. Medians and interquartile ranges (IQRs) for various costs of sepsis were calculated. The quality of economic studies was assessed using the Drummond 10-item checklist.

RESULTS

Overall, 26 studies met our eligibility criteria. The mean total hospital costs per patient varied largely, between €1101 and €91,951. The median (IQR) of the total sepsis costs per country were €36,191 (€17,158 - €53,349), which equals €50 (€34 - €84) per capita annually. The relative amount of healthcare budget spent on sepsis was 2.65%, which equals 0.33% of the gross national product (GNP).

CONCLUSION

While general sepsis costs are high, there is considerable variability between countries regarding the costs of sepsis. Further studies examining the impact on sepsis costs, especially on the general ward, can help justify, design and monitor initiatives on prevention, diagnosis, and treatment of this time-critical and potentially preventable disease.

Pharmaceutical pricing in Europe: time to take the right direction

A price stems from the intersection between supply and demand curves in any common market. However, there are special markets where consumers do not pay for goods directly, and prescription drugs are a well-known example in healthcare. Drugs are mainly funded by public expenditure in well-established welfare systems like those of the Western European countries. However, the present era of austerity in public funding has made financial resources scarce in most European nations. Currently, the leading tendency for pharmaceutical pricing in Europe is direct negotiation with pharma companies. However, these negotiations are administratively burdensome, with costs not necessarily offsetting savings. Moreover, since any trade negotiation implies some degree of confidentiality to be effective these strategies are scantily transparent. When prices are set for many products through unavoidably arbitrary decisions, the final consequence is an irrational allocation of financial resources. Here, we raise a proposal to restore a reasonable balance between public equity objectives of health authorities and private profit incentives of the pharma industry in Europe, switching from pricing to budgeting. The underlying rationale of our proposal is to stop setting arbitrary prices in a context of market failure.

Distribution, behavior and budget of Pb in suspended particles in the Changjiang Estuary and adjacent east China sea

Content, isotopes and budget of Pb in suspended particulate matter (SPM) in the Changjiang Estuary and adjacent East China Sea (ECS) were determined to investigate the biogeochemical cycling of particulate Pb in coastal sea. The content of particulate Pb ranged from 11.3 to 669.4 μg/g in February (winter) and from 20.1 to 79.4 μg/g in August (summer). Except in surface water, particulate Pb content in August is higher than that in February. In lower water, particulate Pb and Th and SPM all decreased gradually from the estuary towards the sea, indicating their lithogenic origin from the Changjiang River. Particulate Pb displayed abnormally high concentration in February surface water, resulting from the atmospheric deposition of anthropogenic Pb in winter. ²⁰⁸Pb/²⁰⁶Pb and ²⁰⁷Pb/²⁰⁶Pb in surface water north to the estuary were higher than background values, suggesting anthropogenic disturbance of Pb. Particulate Pb content in the Changjiang River and the estuary had increased by 77-78% from the 1980s to 2016 due to pollution. Pb was also scavenged by organic matter, leading to higher Pb content in waters with high productivity. Budget of particulate Pb in the northern ECS was established. The Changjiang River contributed 97.0% and 58.1% of particulate Pb input in summer and winter half year, respectively. 88.8% of particulate Pb was deposited in the estuary and adjacent coastal sea in summer but 88.7% was exported with southward coastal currents in winter.

Budget Impact of Sequential Treatment with Biologics, Biosimilars, and Targeted Synthetic Disease-Modifying Antirheumatic Drugs in Thai Patients with Rheumatoid Arthritis

BACKGROUND

Targeted treatment of rheumatoid arthritis (RA) includes biological DMARDs (bDMARDs) and JAK inhibitors (JAKi). These agents are recommended at the same level on the basis of their efficacy and safety data. However, no local evidence of the impact of RA treatment regimens on total budget spending is available to date. This study aimed to explore the budget impact of different sequential targeted treatments in Thai patients with RA who failed at least three conventional synthetic DMARDs.

METHODS

We used the adapted model to evaluate the budget impact of adding tofacitinib in different order to RA targeted treatment regimens. The Thai RA population eligible for treatment was assessed on the basis of local prevalence and experts' opinion. Cost-impact analysis was evaluated for the treatment sequences of four different lines of targeted therapies using inputs like clinical efficacy, safety, and costs. The model used a decision tree structure with treatment nodes corresponding to treatment response outcomes for a cohort of patients. The comparisons included five bDMARDs [etanercept (ETN), infliximab (IFX), golimumab (GOL), rituximab (RTX), tocilizumab (TCZ) intravenous formulation], two JAKi [tofacitinib (TOF) and baricitinib (BAR)], and two IFX biosimilars (PF-06438179/GP1111 and CT-P13). A total of 80 treatment sequences within each containing four sequential first-, second-, third-, and fourth-line options were generated.

RESULTS

The findings of the base case scenario indicated the treatment sequence with RTX as first-line, followed by IFX biosimilar (PF-06438179/GP1111), TOF, and TCZ, respectively, produced the lowest budget impact of US $693.54 million. Sensitivity analyses confirmed the robustness of our findings.

CONCLUSION

The order of targeted therapy starting with RTX, then IFX biosimilar, TOF, and finally TCZ incurred the lowest budget impact over a 5-year time horizon for treating moderate to severe RA. Our findings may help payers and policy makers consider appropriate budget allocation on chronic non-communicable diseases, especially RA.

A review of appropriate indicators for need-based financial resource allocation in health systems

BACKGROUND

Optimal, need-based, and equitable allocation of financial resources is one of the most important concerns of health systems worldwide. Fulfilling this goal requires considering various criteria when allocating resources. The present study was conducted to identify the need indicators used to allocate health resources in different countries worldwide.

METHODS

A systematic review conducted on all published articles and reports on the need-based allocation of health financial resources in the English language from 1990 to 2020 in databases, including PubMed, Cochrane, and Scopus as well as those in Persian language databases, including magiran, SID, and Google and Google scholar search engines. After performing different stages of screening, appropriate studies were identified and their information were extracted independently by two people, which were then controlled by a third person. The extracted data were finally analyzed by content analysis method using MAXQDA 10 software.

RESULT

This search yielded 823 studies, of which 29 were included for the final review. The findings indicated that many need-based resource allocation formulas attempt to deal with health care needs using some weighting methods for individuals. In this regard, the most commonly used indicators were found as follows: age, gender, socio-economic status or deprivation, ethnicity, standardized mortality ratio (SMR), the modified health indicators (disease consequences, self-assessed health, and disability), geographical area / place of residence (geographical) (rural versus urban), cross-boundary flows, cost of services, and donations.

CONCLUSION

The indicators used in allocating the health systems' financial resources in each country should be designed in order to be simple and transparent and in accordance with the moral norms of that society. Moreover, these should be a good representative of the health needs of people in different geographical areas of that country. In addition, their related data should be available to an acceptable extent.

Macro and microeconomics of blue light cystoscopy with CYSVIEW® in non-muscle invasive bladder cancer

OBJECTIVE

To determine the estimated budget impact to practices that incorporate blue light cystoscopy (BLC) with hexaminolevulinate HCl (HAL) for the surveillance of non-muscle-invasive bladder cancer (NMIBC) in the clinic setting. With the introduction of advanced technologies in the clinic setting such as HAL, further cost comparative research is needed to justify HAL as a high value option.

MATERIAL AND METHODS

A budget impact model was developed from the facility perspective assessing projected costs at 2 years for a simulated facility with 50 newly diagnosed bladder cancer patients. Treatment and surveillance cystoscopy intervals were based on clinical guidelines. Clinical inputs, including tumor stage and grade at diagnosis, rates of recurrence and relative risk reduction when using BLC with HAL, were derived from published studies. Cost inputs were based on Medicare reimbursement rates and facility costs.

RESULTS

Use of BLC identified 9 additional recurrences over two years compared to white light cystoscopy alone. Use of flexible BLC for surveillance marginally increased costs to the practice, with a net difference of $0.76 per cystoscopy over 2 years.

CONCLUSIONS

From the office/clinic perspective, the model suggests that the use of flexible BLC for the surveillance of NMIBC may not impact cost per cystoscopy and identifies 9 recurrences over 2 years that would be missed using white light cystoscopy alone. These findings could have important implications in the management of NIMBC and help guide clinical practice guidelines that promote cost-effective care and improved patient outcomes.

Examining Player Engagement with and Attitudes Toward a Gambling Play Management System

Play management systems are prevention tools designed to help people who gamble avoid intemperate gambling outcomes by staying within predetermined budgets. This study examined gaming patrons' reported use of and attitudes towards the PlayMyWay play management system. We report upon the results of a survey of 1951 Marquee Rewards cardholders, including 153 individuals who were currently or previously enrolled in PlayMyWay. Users who did not enroll in PlayMyWay, despite knowing about it, typically said they did so because they believed that they did not need reminders and warnings about gambling. Although PlayMyWay users generally found the system easy to use, most reported that they paid little attention to notifications and tended to react negatively to them. Users who screened positive on the Brief Biosocial Gambling Screen were more likely to un-enroll from PlayMyWay, were less likely to report that they heeded notifications, and were more likely to respond negatively to notifications than users who screened negative. To improve the efficacy of PlayMyWay and similar play management systems, we recommend enhancing or adjusting on-machine messaging and highlighting additional features, such as play-tracking mechanisms, which could help to emphasize the idea that budget self-tracking is for everyone, not just people who might have gambling-related problems. Future research on play management systems should attempt to understand how to make budget compliance aspects of play management more effective.

Source, fate and budget of Dechlorane Plus (DP) in a typical semi-closed sea, China

Dechlorane Plus (DP), which has severe effects on marine ecosystems, has been proposed for listing under the Stockholm Convention as a persistent organic pollutant (POPs). This study was the first comprehensive investigation of the concentration and fate of DP in the Bohai Sea (BS) based on determination of river estuary water, river estuary sediment, surface seawater, bottom seawater, and sea sediments samples. The highest water DP levels were found in river estuary in Tianjin in North China due to the huge usage of DP in recent years, and spatial distribution analysis indicates it was mainly affected by regional high urbanization and emission of E-waste. The spatial distribution of DP in the BS was mainly affected by a combination of coastal hydrodynamics and land anthropogenic activities. On the basis of multi-box mass balance, simulations of DP in seawater showed an increase from 2014 to 2025, before leveling off at 184 pg L ^-1 by a constant DP input to the BS. Riverine discharge almost contributed to the total input (∼99%) and dominated the DP levels in the BS. Degradation of DP accounted for 55.3% and 78.1% of total DP output in seawater and sediment, respectively, indicating that degradation mainly affected decline of DP in the environment.

Distribution of Pu isotopes and 210Pb in the Bohai Sea and Yellow Sea: Implications for provenance and transportation

Particle-reactive radionuclides are useful for tracing sediment dynamics in marginal seas. We collected a suite of surface sediment samples in May 2014 from the Bohai Sea (BS) and Northern Yellow Sea (NYS) to observe the spatial distribution of Plutonium (Pu) isotopes and ²¹⁰Pb activities. ^239+240Pu activities ranged from 0.001 to 0.288 and 0.040-0.269 Bq kg^-1 in BS and NYS surface sediments, respectively. ²¹⁰Pb_ex shows a significant correlation with ^239+240Pu (r = 0.84, p < 0.01) that suggested these two nuclides were scavenged to the same grade. ²⁴⁰Pu/²³⁹Pu atom ratios in BS (0.173-0.256) and NYS (0.196-0.275) were slightly higher than the global fallout value of 0.18 and lower than the Pacific Proving Ground (PPG) value of 0.36, indicating that some fraction of Pu originating from the PPG was capable of being transported to the BS and NYS. Mass balance results showed that 41% of ^239+240Pu (8.9 × 10⁹ Bq yr^-1) and 18% of ²¹⁰Pb (2.4 × 10¹² Bq yr^-1) in the NYS originated in the oceanic input. In the BS, 63% of ²¹⁰Pb originated from atmospheric deposition and 84% of ^239+240Pu originated from riverine input. Using Pu and ²¹⁰Pb as tracers, we estimate that (1.8-2.6) × 10⁸ t yr^-1 and (3.6-3.8) × 10⁸ t yr^-1 of sedimentary particles could be transported from the BS to the NYS and from the NYS to the Southern Yellow Sea, respectively. Furthermore, the ²²⁶Ra/²³⁸U activity ratio distribution suggested that sedimentary particles derived from the Yellow River could be transported to the middle of the BS and coastal areas of the NYS.

Addressing budget reduction and reallocation on health-related resources during COVID-19 pandemic in malaria-endemic countries

The global COVID-19 pandemic has been affecting the maintenance of various disease control programmes, including malaria. In some malaria-endemic countries, funding and personnel reallocations were executed from malaria control programmes to support COVID-19 response efforts, resulting mainly in interruptions of disease control activities and reduced capabilities of health system. While it is principal to drive national budget rearrangements during the pandemic, the long-standing malaria control programmes should not be left behind in order to sustain the achievements from the previous years. With different levels of intensity, many countries have been struggling to improve the health system resilience and to mitigate the unavoidable stagnation of malaria control programmes. Current opinion emphasized the impacts of budget reprioritization on malaria-related resources during COVID-19 pandemic in malaria endemic countries in Africa and Southeast Asia, and feasible attempts that can be taken to lessen these impacts.

Dissolution kinetics of biogenic silica and the recalculated silicon balance of the East China Sea

We conducted field observations in the East China Sea (ECS) in 2010 and 2011 to determine the content and dissolution dynamics of bSiO₂ in sediments of the ECS. The influencing factors on bSiO₂ dissolution were investigated, and the regional silicon budget was recalculated. The sediment bSiO₂ content in the ECS varied from 143 to 583 μmol g^-1. The burial flux of bSiO₂ ranged from 0.11 to 19 mol m^-2 yr^-1 and gradually decreased eastward offshore from within and north of the Changjiang River. Continuous flow experiments showed that the solubility of bSiO₂ in surface sediments varied from 213 to 357 μM-Si, and the dissolution rate constant of bSiO₂ was 14.9-56.6 nmol g^-1 h^-1; both ranges are lower than those of other marginal seas, such as the Arabian and Scotia Seas. The release of soluble aluminum from lithogenic minerals was suggested to influence the pore water build-up of dissolved silica in the ECS. The silicon budget of the ECS was recalculated based on up-to-date research. Due to the low dissolution rate constant and high sediment accumulation rate, sediment bSiO₂ in the ECS is well preserved, with a burial efficiency of 81%; this accounts for 9.9% of the global burial rate and is significantly higher than that of the Yellow Sea and the global ocean average.

Budget line items for immunization in 33 African countries

When seeking to ensure financial sustainability of a health programme, existence of a line item in the Ministry of Health (MOH) budget is often seen as an essential, first step. We used immunization as a reference point for cross-country comparison of budgeting methods in Sub-Saharan African countries. Study objectives were to (1) verify the number and types of budget line items for immunization services, (2) compare budget execution with budgeted amounts and (3) compare values with annual immunization expenditures reported to WHO and UNICEF. MOH budgets for 2016 and/or 2017 were obtained from 33 countries. Despite repeated attempts, budgets could not be retrieved from five countries (Chad, Eritrea, Guinea Bissau, Somalia and South Sudan), and we were only able to gather budget execution from eight countries. The number of immunization line items ranged between 0 and 42, with a median of eight. Immunization donor funding was included in 10 budgets. Differences between budgeted amounts and expenditures reported to WHO and UNICEF were greater than 50% in 66% of countries. Immunization budgets per child in the birth cohort ranged from US$1.37 (Democratic Republic of Congo) to US$67.51 (Central African Republic), with an average of US$10.05. Out of the total Government health budget, immunization comprised between 0.04% (Madagascar) and 5.67% (Benin), with an average of 1.98% across the countries, when excluding on-budget donor funds. It was challenging to obtain MOH budgets in many countries and it was largely impossible to access budget execution reports, preventing us from assessing budget credibility. Large differences between budgets and expenditures reported to WHO and UNICEF are likely due to inconsistent interpretations of reporting requirements, diverse approaches to reporting donor funds, challenges in extracting the relevant information from public financial management systems and broader issues of public financial management capacity in MOH staff.

Historical evidence for economic effects of COVID-19

Like wars and socio-politic shifts, contagious diseases have changed the economics and politics of the world throughout history. In 2020, the world faced COVID-19, a globally effective virus leading to mass losses and socio-economic panic. Due to apparent psycho-social conditions, analyzing the potential economic effects of the COVID-19 pandemic was inevitable. Thus, discussing economic effects of previous global and regional epidemics is considered beneficial. This research evaluated most of the known epidemics and their effects on economics and socio-politics by reviewing scientific literature. In addition to the vast literature and observations on the ongoing process, we assessed the potential impacts of COVID-19 and potential ways to overcome these impacts. The most urgent socio-economic measures needed to combat the negative effects of a contagious disease are related to unemployment with its income effects and security of all sectors. To prevent persistent unemployment, service, retail, and even industrial sectors need to be supported. Additionally, we discussed the need for re-organizing the funding and managerial sustainability of healthcare services to be prepared for future.

Developing an Education Budget for Radiology Vice Chairs and Leaders: An ADVICER Template

RATIONALE AND OBJECTIVES

The Alliance of Directors and Vice Chairs in Education group identified the need to develop an education budget template as resource for our community. Having a framework and working knowledge of budgetary considerations is crucial to those with general oversight and executive managerial responsibility for departmental educational programs.

METHODS

An online survey was sent to all the Alliance of Directors and Vice Chairs in Education members. Survey questions included education funding sources, presence of vice chair of finance, expectation of revenue generation, existing education budget, funding decision-makers, education budget formulation and approval, vice chair of education's role in budget, education budget line items, and income statement review.

RESULTS

The survey response rate was 41/81 (51%). A majority 26/41 (63%) of respondents had an education budget that typically included funding for all medical students, residents, and fellows but only a minority of respondents report they developed 10/22 (45%), approved 6/22 (27%), or regularly reviewed 6/21 (29%) this budget. In sharp contrast was the role of department chairs and administrators, who presumably all participated in this process. To assist in education budget development and review, as well as meet the need to improve participants' financial accounting knowledge as a key tenet of faculty professional development, the authors developed sample budget templates and an income statement primer.

CONCLUSION

Our survey results suggested the need for an educational budget framework and financial accounting resources for those in radiology education posts, and resources have been provided.

One health approach in Nepal: Scope, opportunities and challenges

One Health (OH) is a collaborative effort to attain optimal health for people, animals and the environment. The concept of OH is still in its infancy in Nepal but is increasingly growing. The Government of Nepal (GoN) has taken some initiatives to tackle burgeoning problems such as antimicrobial resistance, highly pathogenic avian influenza and rabies using OH approach but there are several challenges at the level of implementation. Few non-governmental organizations support GoN to promote an OH approach. The major bottlenecks in implementing OH in Nepal include poor organizational structure to support OH, absence of a legal framework to implement OH, poor coordination among different governmental agencies, insufficient technical expertise, poor data sharing mechanism across sectors, limited budget and poor understanding at political level. We encourage GoN to address these gaps and prioritize the health problems where OH approach would give the best outcome. Institutional and legal frameworks need to be created to effectively implement an OH approach in Nepal. Increasing awareness among policy makers including political leadership and increasing regular government budget for OH activities would be helpful to promote OH in Nepal.

Error characterization of methane fluxes and budgets derived from a long-term comparison of open- and closed-path eddy covariance systems

Wetlands represent the dominant natural source of methane (CH₄) to the atmosphere. Thus, substantial effort has been spent examining the CH₄ budgets of global wetlands via continuous ecosystem-scale measurements using the eddy covariance (EC) technique. Robust error characterization for such measurements, however, remains a major challenge. Here, we quantify systematic, random and gap-filling errors and the resulting uncertainty in CH₄ fluxes using a 3.5 year time series of simultaneous open- and closed path CH₄ flux measurements over a sub-boreal wetland. After correcting for high- and low frequency flux attenuation, the magnitude of systematic frequency response errors were negligible relative to other uncertainties. Based on three different random flux error estimations, we found that errors of the CH₄ flux measurement systems were smaller in magnitude than errors associated with the turbulent transport and flux footprint heterogeneity. Errors on individual half-hourly CH₄ fluxes were typically 6%-41%, but not normally distributed (leptokurtic), and thus need to be appropriately characterized when fluxes are compared to chamber-derived or modeled CH₄ fluxes. Integrated annual fluxes were only moderately sensitive to gap-filling, based on an evaluation of 4 different methods. Calculated budgets agreed on average to within 7% (≤ 1.5 g - CH₄ m^-2 yr^-1). Marginal distribution sampling using open source code was among the best-performing of all the evaluated gap-filling approaches and it is therefore recommended given its transparency and reproducibility. Overall, estimates of annual CH₄ emissions for both EC systems were in excellent agreement (within 0.6 g - CH₄ m^-2 yr^-1) and averaged 18 g - CH₄ m^-2 yr^-1. Total uncertainties on the annual fluxes were larger than the uncertainty of the flux measurement systems and estimated between 7-17%. Identifying trends and differences among sites or site years requires that the observed variability exceeds these uncertainties.

Economic Evaluation of Ferric Carboxymaltose for the Management of Hemodialysis Patients with Iron Deficiency Anemia in Italy

Introduction

Patients with chronic kidney disease on hemodialysis (HD) are at high risk of developing both iron deficiency and iron deficiency anemia (IDA). The administration of intravenous iron therefore represents the standard of care for the management of anemia in this patient setting.

Methods

A retrospective cohort of 38 HD patients in Italy was analyzed to assess the clinical and economic implications of switching from intravenous ferric gluconate (FG) to ferric carboxymaltose (FCM) on achievement of adequate hemoglobin (Hb) values and iron balance. The total observational period for each patient was 12 months, 6 months before and 6 months after switching to iron FCM. The pharmacoeconomic analysis considered the hospital perspective and the consumption of iron, blood transfusions and erythropoiesis-stimulating agents (ESAs), including healthcare personnel time.

Results

Switching from FG to FCM in dialysis adult patients with IDA allows a cost reduction per patient/month in the range €14–46, considering the use of biosimilar ESA or originator ESA, respectively. The percentage of patients with Hb target values increased from 63% to 82%, considering the entire observation period. In addition, other clinical parameters (ferritin, transferrin saturation, erythropoietin resistance index) improved after switching from FG to FCM.

Conclusion

FCM in HD patients was shown to provide a favorable efficacy profile over FG, with a lower cost per patient, mainly driven by a consistent reduction of ESA consumption.

Funding

Vifor Pharma Italia Srl.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-019-01089-z) contains supplementary material, which is available to authorized users.

Economic Impact of Introducing the RTS,S Malaria Vaccine: Cost-Effectiveness and Budget Impact Analysis in 41 Countries

Background. Malaria is a major public health burden in sub-Saharan Africa. This study estimated the cost-effectiveness and budget impact of adding four-dose malaria vaccination in infants or children to existing interventions in 41 endemic countries in sub-Saharan Africa. Methods. A static Markov cohort model followed a simulated 2017 birth cohort (36.5 million children) for 15 years in 5-day cycles, comparing three strategies: child vaccination (doses at ages 6, 7.5, 9, and 27 months); infant vaccination (doses at ages 6, 10, and 14 weeks and 21 months); no malaria vaccination. The base-case analysis was conducted from the health system perspective with vaccine price assumed at USD5/dose and annual discounting of 3% for costs and disability-adjusted life-years (DALYs). Efficacy was based on the Phase III RTS,S clinical trial. Results. The model projected that 24.6 million children, or 26.2 million infants, would be vaccinated. Compared with no vaccination, child (infant) vaccination was projected to avert 16.8 million (16 million) cases of malaria and 113,000 (107,000) malaria deaths in the birth cohort over the 15-year period. The incremental cost-effectiveness ratio was USD200/DALY averted (USD225/DALY averted) for child (infant) vaccination, which represents 14% (17%) of the gross domestic product (GDP) per capita threshold. The estimated budget impact was overall larger for infant vaccination but mixed situations occurred across countries. Vaccine price, discount rate, and parasite prevalence had the largest effect on cost-effectiveness. Conclusions. Child vaccination with RTS,S would be more cost-effective than infant vaccination across countries. Adding RTS,S malaria vaccination to existing interventions would be cost-effective assuming one GDP per capita threshold for both child and infant vaccination in all examined countries except for 6 countries with lower transmission.

Distribution and budget of biogenic silica in the Yangtze Estuary and its adjacent sea

Field investigations of the Yangtze Estuary and its adjacent sea were carried out from July to August 2011. The distribution, source, transportation and transformation of biogenic silica (BSi) in suspended particulate matter (SPM) and core sediments were comprehensively investigated; dissolved silica (DSi) in pore water was also analyzed in this work. The budgets of reactive silica (RSi) and BSi in the East China Sea (ECS) were initially constructed on the basis of the above survey. The results indicated that the BSi distribution in this area was mainly affected by the input of the Yangtze River and Taiwan Warm Current, which was significantly correlated with SPM. The RSi flux input by rivers accounts for 17.6% of the total source of RSi in the ECS. Thus, these findings combined with the horizontal distribution of BSi in the Yangtze Estuary and its adjacent sea indicate that riverine input has a profound influence on the primary production of diatoms in the euphotic zone. Submarine groundwater exchange accounts for 22.3% of the DSi input, especially in the upwelling region, which will directly affect the euphotic nutrient structure. The DSi benthic flux from pore water to upper water exceeds riverine input by 3-fold, accounting for 11.5% of primary production in the ECS, which can alleviate the Si limiting effect caused by the decrease in DSi flux from the Yangtze runoff in recent years. Approximately 75.5% of BSi is dissolved and re-engaged in the ECS silicon cycle in the settlement process.

Benefit-cost analysis to estimate the payback time and the economic value of two Mycoplasma hyopneumoniae elimination methods in breeding herds

Mycoplasma hyopneumoniae (Mhyo) is generally accepted to be the most common porcine respiratory pathogen worldwide causing big economical losses in swine production by affecting pig's downstream performance. The objective of this study was to develop a partial budget model to determine the payback period and economic value of two Mhyo elimination protocols. Retrospective data recorded from 2004 to 2017 from 70 breeding herds that implemented herd closure or whole-herd medication protocol targeting Mhyo elimination. Close out data was used to estimate differences in downstream performance between Mhyo-negative and positive flows. Assuming a 5000 sows breed-to-finish operation producing 135,870 weaned pigs and 125,000 finishing pigs/year, the total cost for implementing Mhyo elimination was $112,100 using the herd closure protocol, and $185,700 for the medication protocol. Statistically differences (p < 0.05) in downstream performance were observed for ADG and mortality, but not for feed conversion rate. The parameters that accounts for the greatest benefits were related to the improvement in ADG, savings in antibiotic medication in growing pigs and improvement in feed conversion rate. The benefit of Mhyo elimination was $877,375 per farm per year, or $7.00 per pig marketed. The estimated project value after 1 year was $616,121 for the herd closure considering a probability of success of 83%, and $323,177 for the medication protocol for 58% chance of success. The project value reached the break-even point when the cost per sow was $145.64 for the herd closure and $101.78 for the medication protocol. The payback period was 2 months after the start of marketing Mhyo-negative pigs for the herd closure, and 7 months for the medication protocol adjusted for the probability of success for each protocol. The protocols described here can be easily applied with a good success rate and showing that the benefits obtained are greater than the costs of project failure. Even if the farm stayed negative only a year, the economic benefits downstream are worth the investment. This information may help producers and veterinarians on decision-making process to conduct a Mhyo elimination protocol in their herds.

Ventana ALK (D5F3) in the Detection of Patients Affected by Anaplastic Lymphoma Kinase-positive Non-Small-cell Lung Cancer: Clinical and Budget Effect

BACKGROUND

To ensure identification of anaplastic lymphoma kinase-positive (ALK⁺) patients, the Italian Drug Agency suggested a testing algorithm based on the use of fluorescence in situ hybridization (FISH) and/or immunohistochemistry. The aim was to evaluate the clinical and economic effects of adopting an immunohistochemical test (Ventana ALK D5F3) as an option for detecting ALK protein expression in advanced non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

A budget impact model was developed by adopting the Italian National Health Service (NHS) perspective and a 5-year period to compare 2 scenarios: the current use of D5F3 (28%; current scenario) and increased use of D5F3 (60%; alternative scenario). The testing cost and the number and cost of the identified ALK⁺ patients were evaluated.

RESULTS

A more extensive use of D5F3 in the alternative scenario showed a decrease in diagnostic costs of ∼€468,000 compared with current scenario when considering all advanced NSCLC patients. If these savings were allocated to test more NSCLC patients (75% vs. 53%), an incremental cost per identified ALK⁺ patient of €63 would be required, leading to an overall survival gain for the alternative scenario compared with the current scenario (32.4 vs. 27.1 months; relative increase, 20%).

CONCLUSION

The use of D5F3 would provide a cost savings for the NHS owing to a lower acquisition cost than FISH and a comparable detection rate. The savings could be reinvested to test a greater number of patients, leading to more efficient identification, use of targeted therapy, and improvement in clinical outcomes of ALK⁺ patients.

Financial management of large, multi-center trials in a challenging funding milieu

BACKGROUND

Randomized clinical trials that have public health implications but no or low potential for commercial gain are predominantly funded by governmental (e.g., National Institutes of Health (NIH)) and not-for-profit organizations. Our objective was to develop an alternative clinical trial site funding model for judicious allocation of declining public research funds.

METHODS

In the Vitamin D and Type 2 Diabetes (D2d) study, an NIH-supported, large clinical trial testing the effect of vitamin D supplementation on incident diabetes in 2423 participants at high risk for diabetes, a hybrid financial management model for supporting collaborating clinical sites was developed and applied. The funding model employed two reimbursement components: Core (for study start-up and partial efforts throughout the study, ~40% of the total site budget), invoiced by sites, and Performance-Based Payments (for successful enrollment of participants and completion of follow-up visits, ~60% of the total site budget), automatically issued to the sites by the Coordinating Center based on actual recruitment and visits conducted. Underperforming sites transitioned to Performance-Based Payments only.

RESULTS

Recruitment occurred from October 2013 through December 2016, requiring one additional year than the 2-year projection. Median enrollment at each site was 88 participants (range 29-318; 20 to 205% of the site target). At the end of year 1, study-wide recruitment was at 12% of the target (vs. 50% projected) and 12% of the total grant award was invested. The model constantly evaluated sites' needs and re-allocated resources to meet the study enrollment goal. If D2d had issued cost reimbursement subaward agreements and sites invoiced for their entire budget, 83% of the award would have been spent for all study activities over the first 4 years of the trial compared to 65% of the award spent (US$26M) under the hybrid model used by D2d.

CONCLUSIONS

It is feasible to foster a hybrid financial management approach to steward limited available public funds for research in a dynamic and consistent way that does not compromise the trial's scientific integrity and ensures conservation of funds to complete recruitment and continue to follow up participants.

Global analysis of agricultural soil denitrification in response to fertilizer nitrogen

Terrestrial soil denitrification is of great importance for closing the nitrogen (N) cycle, yet the current understanding of soil denitrification response to N fertilization remains uncertain. While there has been a focus on factors controlling N₂O fluxes from agricultural soils because of its global warming effect, much less is known about factors controlling total denitrification losses, yet these can be sufficiently large to affect N use efficiency. Here, we collated 353 observations from 74 papers and conducted a global-scale meta-analysis to explore the effects of N fertilization on agricultural soil denitrification (N₂O+N₂) where the acetylene inhibition technique was used. Relative to the control, N fertilization significantly increased soil denitrification by an average of 174%, although the magnitude of this increase differed significantly across environmental and soil conditions. Soil denitrification was more responsive to N fertilization in grasslands than in croplands. The changes in soil denitrification increased exponentially when the rates of synthetic N fertilizer application≤250kgNha^-1, but above this threshold, there were no further increases. The responses of soil denitrification to N fertilization were negatively correlated with soil clay content, C:N ratio, and bulk density. The comparable responses of soil N₂O emissions (165%) and denitrification to N fertilization resulted in a small insignificant decrease of the N₂O:N₂ ratio. Organic fertilizer applied with and without synthetic N fertilizer can contribute to lower N₂O emissions probably by facilitating the last step of soil denitrification to N₂ production. Taken together, we conclude that these findings can provide important insights on regulating soil denitrification, which might contribute to improvement of N use efficiency and elimination of its negative impacts in agro-ecosystems.

Grant Writing Tips for Translational Research

All investigators face the same challenge-the highly competitive nature of the grant review process. Innovation alone is not enough to ensure grant-supported funding. Applied clinical research requires a diverse, collaborative team of investigators with specialized skills, a supportive clinical research environment, and access to clinical material. Additionally, the lack of animal models for many diseases and ethical limitations prevent direct mechanistic experiments that are possible using in vitro systems or animal models. Therefore, specific granting mechanisms and program initiatives target translational research studies. This chapter provides grant writing tips and lists resources that may prove helpful for new investigators seeking research funding in support of translational research, biobanking, and research utilizing molecular biomarkers.

Changing Face of Family Planning Funding in Kenya: A Cross-Sectional Survey of Two Urban Counties

As international development partners reduce funding for family planning (FP) programs, the need to estimate the financial resources devoted to FP is becoming increasingly important both at all levels. This cross-sectional assessment examined the FP financing sources, agents, and expenditures in two counties of Kenya for fiscal years 2010/2011 and 2011/2012 to guide local decision-making on financial allocations. Data were collected through a participatory process. This involved stakeholder interviews, review of financial records and service statistics, and a survey of facilities offering FP services. Financing sources and agents were identified, and source amounts calculated. Types of FP provider organizations and the amounts spent by expenditure categories were identified. Overall, five financing sources and seven agents for FP were identified. Total two-year expenditures were KSh 307.8 M (US$ 3.62 M). The government's share of funding rose from 12% to 21% over the two years (p=0.029). In 2010/2011, the largest expense categories were administration, commodities, and labor; however, spending on commodities increased by 47% (p=0.042). This study provides local managers with FP financing and expenditure information for use in budget allocation decision-making. These analyses can be done routinely and replicated in other local counties or countries in a context of devolution.

Optimising the introduction of multiple childhood vaccines in Japan: A model proposing the introduction sequence achieving the highest health gains

BACKGROUND

Many countries struggle with the prioritisation of introducing new vaccines because of budget limitations and lack of focus on public health goals. A model has been developed that defines how specific health goals can be optimised through immunisation within vaccination budget constraints.

METHODS

Japan, as a country example, could introduce 4 new pediatric vaccines targeting influenza, rotavirus, pneumococcal disease and mumps with known burden of disease, vaccine efficacies and maximum achievable coverages. Operating under budget constraints, the Portfolio-model for the Management of Vaccines (PMV) identifies the optimal vaccine ranking and combination for achieving the maximum QALY gain over a period of 10 calendar years in children <5 years old. This vaccine strategy, of interest and helpful for a healthcare decision maker, is compared with an unranked vaccine selection process.

RESULTS

Results indicate that the maximum QALY gain with a fixed annual vaccination budget of 500 billion Japanese Yen over a 10-year period is 72,288 QALYs using the optimal sequence of vaccine introduction (mumps [1st], followed by influenza [2nd], rotavirus [3rd], and pneumococcal [4th]). With exactly the same budget but without vaccine ranking, the total QALY gain can be 20% lower.

CONCLUSION

The PMV model could be a helpful tool for decision makers in those environments with limited budget where vaccines have to be selected for trying to optimise specific health goals.

3. How comprehensive can we be in the economic assessment of vaccines?

In two previous papers we argued on current vaccines economic assessment not fully comprehensive when using the incremental cost-utility analysis normally applied for treatments. Many differences exist between vaccines and drug treatments making vaccines economic evaluation more cumbersome. Four challenges overwhelmingly present in vaccines assessment are less important for treatments: requirements for population, societal perspectives, budget impact evaluation, and time focused objectives (control or elimination). Based on this, economic analysis of vaccines may need to be presented to many different stakeholders with various evaluation preferences, in addition to the current stakeholders involved for drugs treatment assessment. Then, we may need a tool making the inventory of the different vaccines health economic assessment programmes more comprehensive. The cauliflower value toolbox has been developed with that aim, and its use is illustrated here with rotavirus vaccine. Given the broader perspectives for vaccine assessment, it provides better value and cost evaluations. Cost-benefit analysis may be the preferred economic assessment method when considering substitution from treatment to active medical prevention. Other economic evaluation methods can be selected (i.e. optimisation modelling, return on investment) when project prioritisation is the main focus considered and when stakeholders would like to influence the development of the healthcare programme.

Towards a more comprehensive approach for a total economic assessment of vaccines?: 1. The building blocks for a health economic assessment of vaccination

​Since we were born, we all take preventative actions to avoid unpredictable adverse conditions. Some actions are done automatically. Others require a conscious choice , either for personal or social benefit. A distinction can therefore be drawn between non-active and active prevention, and between individual and social prevention. Active prevention requires making a choice in time, effort, and cost. We call it an economic choice. Vaccines belong to the group of active and social prevention. Because a vaccination program is an economic social choice, how should it be valued, and what cost should we pay for? To date, the economic evaluations developed for treatment have been applied to vaccines. However, over 25 different characteristics differentiate vaccines from treatment. For example, the benefit of vaccination is measured at the population level not at the individual level, the main effect of prevention is societal and not an individual-based gain only, and the biggest hurdle to implement a new vaccine is the initial budget investment and not so much its estimated 'value for money'. This makes the current application of incremental cost-utility analysis difficult for vaccines for a comprehensive evaluation. New approaches may be needed to capture the full economic benefit of vaccines.​.

[Usefulness of the budget and the balanced scorecard in managing Primary Care Centres. Impact on staff motivation]

OBJECTIVE

To analyse the utility perceived by managers of centers of primary care about management tools (budget and balanced scorecard), together their impact on human resources motivation.

DESIGN

Qualitative study (case study) based on grounded theory performed between January and June 2014.

LOCATION

Units of Clinical Management of Primary Health (UGCAP) in Metropolitan Health Area of Seville, Spain.

PARTICIPANTS

UGCAP managers and Health Area (CEO) managers.

METHOD

Data were collected through 8 semi-structured interviews using non-probabilistic intentional sampling with representation and sufficiency criteria of discourse. Interviews were recorded, literally transcripted and analysis through in-vivo codes.

RESULTS

Both tools are fully implemented but differently used in primary care centers. Budget is perceived as a coercive management tool, which has been imposed for cost saving; however, it is scarcely adequate for day-by-day management. While balanced scorecard is a more flexible tool that allows identifying financial and welfare problems, budgeting limits heavily reduce the possibility of implementing adequate solutions. The policy of incentives is not adequate either, leading on de-motivation.

CONCLUSIONS

This study shows that budgeting restrictions have led to a significant reduction in autonomy of Spanish Primary Care centers. Management decision making is much centralised, also focused on cost saving over quality of healthcare. As a result, two needs emerge for the future: increasing centers' autonomy and improving staff commitment through training and professional development programs.

Inflammatory bowel disease: Efficient remission maintenance is crucial for cost containment

The inflammatory bowel diseases (IBD) are chronic incurable inflammatory disorders of the gut. Some 10% run a downhill course, requiring emergency medical support and often surgery; another small subset are monogenic, and, threatening pediatric patients, are the challenge of these days. The majority of the IBDs, however, are polygenic low-penetrance diseases, running a lifetime waxing-and-waning course. The prevalent trend is towards a slow worsening and steady cost increase. Each and all drugs of the available arsenal exhibit strengths and weaknesses: Mesalamines are chiefly effectively for mild-moderate colitis, and do not work in Crohn’s; steroids do not control some 40% of the ulcerative colitis cases, and are not indicated for Crohn’s; thiopurines are effective in the maintenance of the IBDs but do not prevent relapses on withdrawal; biologics are still being used empirically (not monitored) causing further increase of their cost over that of hospitalization. Against all these caveats, two simple rules still hold true: Strict adherence maintenance and avoidance of colitogenic drugs. This matter is expanded in this minireview.

The impact on women's health and the cervical cancer screening budget of primary HPV screening with dual-stain cytology triage in Belgium

Dual stain cytology, or "diagnostic cytology", offers a significant increase in sensitivity compared to cytology, with a slight decrease in specificity. This can reduce additional investigations like colposcopies, biopsies, and follow-up visits. Cervical cancer screening for women between 25 and 65 years of age with diagnostic cytology is estimated to reduce the incidence of cervical cancer by 36% and reduce annual cervical cancer mortalities by 40%. The reduced number of screening visits and the decrease in incidence and mortality will improve quality of life. In this article, a model was created to evaluate the cost-effectiveness of diagnostic cytology for Belgium. In this approach, precancerous cells are more likely to be immediately identified during the first screening visit. This reduces both the number and frequency of follow-up visits required. After two cycles (6 years), the prevalence of CIN and cervical cancer is decreased significantly in the screened population. At a population level, these shifts can reduce the screening budget by 21%, resulting in savings of 5.3 million euro a year in Belgium. Diagnostic cytology benefits all stakeholders involved in cervical cancer screening.

2. How is the economic assessment of vaccines performed today?

This paper describes how the economic assessment of vaccines is performed today. It discusses why it may be incomplete and explores potential approaches to adjust the analysis to be more comprehensive. Besides helping protect against serious disease, vaccines also help avoid mild disease episodes that may not receive medical attention but which have important societal consequences. They also benefit unvaccinated individuals by reducing disease transmission. Wider societal benefits may extend beyond a decrease in disease incidence, as lower transmission rates reduce the risk of epidemics, which in turn reduces the pressure on healthcare providers, and may improve the quality of care for patients with unrelated diseases. Vaccines also lower the use of antibiotics leading to less pressure on anti-microbial resistance. Conventional ICUA focuses on individual health benefits, like increased survival. Therefore, this approach may not adequately capture the wider vaccination benefits. We discuss differences between treatment and vaccine prevention in the economic assessment, and how ICUA has been adapted to cope with the inconsistencies. Although such adaptations may fulfil the demand of one specific stakeholder, they may not meet the needs of other stakeholders who operate at the societal level, such as ministries other than healthcare, employers, caregivers, and insurers.

Economic impact of onabotulinumtoxinA for overactive bladder with urinary incontinence in Europe

BACKGROUND

Overactive bladder (OAB) is a common condition that has a significant impact on patients' health-related quality-of-life and is associated with a substantial economic burden to healthcare systems. OnabotulinumtoxinA has a well-established efficacy and safety profile as a treatment for OAB; however, the economic impact of using onabotulinumtoxinA has not been well described.

METHODS

An economic model was developed to assess the budget impact associated with OAB treatment in France, Germany, Italy, Spain and the UK, using onabotulinumtoxinA alongside best supportive care (BSC)-comprising incontinence pads and/or anticholinergic use and/or clean intermittent catheterisation (CIC)-vs BSC alone. The model time horizon spanned 5 years, and included direct costs associated with treatment, BSC, and adverse events.

RESULTS

Per 100,000 patients in each country, the use of onabotulinumtoxinA resulted in estimated cost savings of €97,200 (Italy), €71,580 (Spain), and €19,710 (UK), and cost increases of €23,840 in France and €284,760 in Germany, largely due to day-case and inpatient administration, respectively. Projecting these results to the population of individuals aged 18 years and above gave national budget saving estimates of €9,924,790, €27,458,290, and €48,270,760, for the UK, Spain, and Italy, respectively, compared to cost increases of €12,160,020 and €196,086,530 for France and Germany, respectively. Anticholinergic treatment and incontinence pads were the largest contributors to overall spending on OAB management when onabotulinumtoxinA use was not increased, and remained so in four of five scenarios where onabotulinumtoxinA use was increased. This decreased resource use was equivalent to cost offsets ranging from €106,110 to €176,600 per 100,000 population.

CONCLUSIONS

In three of five countries investigated, the use of onabotulinumtoxinA, in addition to BSC, was shown to result in healthcare budget cost savings over 5 years. Scenario analyses showed increased costs in Germany and France were largely attributable to the treatment setting rather than onabotulinumtoxinA acquisition costs.

Planning and Budgeting for Nutrition Programs in Tanzania: Lessons Learned From the National Vitamin A Supplementation Program

BACKGROUND

Micronutrient deficiency in Tanzania is a significant public health problem, with vitamin A deficiency (VAD) affecting 34% of children aged 6 to 59 months. Since 2007, development partners have worked closely to advocate for the inclusion of twice-yearly vitamin A supplementation and deworming (VASD) activities with budgets at the subnational level, where funding and implementation occur. As part of the advocacy work, a VASD planning and budgeting tool (PBT) was developed and is used by district officials to justify allocation of funds. Helen Keller International (HKI) and the Tanzania Food and Nutrition Centre (TFNC) conduct reviews of VASD funds and health budgets annually in all districts to monitor the impact of advocacy efforts. This paper presents the findings of the fiscal year (FY) 2010 district budget annual review. The review was intended to answer the following questions regarding district-level funding: (1) how many funds were allocated to nutrition-specific activities in FY 2010? (2) how many funds were allocated specifically to twice-yearly VASD activities in FY 2010? and (3) how have VASD funding allocations changed over time?

METHODS

Budgets from all 133 districts in Tanzania were accessed, reviewed and documented to identify line item funds allocated for VASD and other nutrition activities in FY 2010. Retrospective data from prior annual reviews for VASD were used to track trends in funding. The data were collected using specific data forms and then transcribed into an excel spreadsheet for analysis.

RESULTS

The total funds allocated in Tanzania's districts in FY 2010 amounted to US$1.4 million of which 92% were for VASD. Allocations for VASD increased from US$0.387 million to US$1.3 million between FY 2005 and FY 2010. Twelve different nutrition activities were identified in budgets across the 133 districts. Despite the increased trend, the percentage of districts allocating sufficient funds to implement VAS (as defined by cost per child) was just 21%.

DISCUSSION

District-driven VAS funding in Tanzania continues to be allocated by districts consistently, although adequacy of funding is a concern. However, regular administrative data point to fairly high and consistent coverage rates for VAS across the country (over 80% over the last 10 years). Although this analysis may have omitted some nutrition-specific funding not identified in district budget data, it represents a reliable reflection of the nutrition funding landscape in FY 2010. For this year, total district nutrition allocations add up to only 2% of the amount needed to implement nutrition services at scale according to Tanzania's National Nutrition Strategy Implementation Plan.

CONCLUSION

VASD advocacy and planning support at the district level has succeeded in ensuring district allocations for the program. To promote sustainable implementation of other nutrition interventions in Tanzania, more funds must be allocated and guidance must be accompanied by tools that enable planning and budgeting at the district level.

A systematic approach to designing statistically powerful heteroscedastic 2 × 2 factorial studies while minimizing financial costs

Background

The 2 × 2 factorial design is widely used for assessing the existence of interaction and the extent of generalizability of two factors where each factor had only two levels. Accordingly, research problems associated with the main effects and interaction effects can be analyzed with the selected linear contrasts.

Methods

To correct for the potential heterogeneity of variance structure, the Welch-Satterthwaite test is commonly used as an alternative to the t test for detecting the substantive significance of a linear combination of mean effects. This study concerns the optimal allocation of group sizes for the Welch-Satterthwaite test in order to minimize the total cost while maintaining adequate power. The existing method suggests that the optimal ratio of sample sizes is proportional to the ratio of the population standard deviations divided by the square root of the ratio of the unit sampling costs. Instead, a systematic approach using optimization technique and screening search is presented to find the optimal solution.

Results

Numerical assessments revealed that the current allocation scheme generally does not give the optimal solution. Alternatively, the suggested approaches to power and sample size calculations give accurate and superior results under various treatment and cost configurations.

Conclusions

The proposed approach improves upon the current method in both its methodological soundness and overall performance. Supplementary algorithms are also developed to aid the usefulness and implementation of the recommended technique in planning 2 × 2 factorial designs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0214-3) contains supplementary material, which is available to authorized users.

FP/FORM Versus FP/SAL Within Clinical Practice: An Updated Budget Impact Analysis in Asthma

Introduction

Pressurized metered-dose inhalers (pMDI) such as fluticasone propionate and salmeterol (FP/SAL) are commonly used for the treatment of asthma in the UK. Previously, a budget impact analysis demonstrated that use of FP and formoterol fumarate (FP/FORM) pMDI as an alternative to FP/SAL pMDI, would be a cost-saving option for the UK National Health Service (NHS). This budget impact analysis aimed to update the existing analysis with prescription volume data and real-world evidence since the introduction of FP/FORM to the UK market.

Methods

Patient Data (IMS Information Solutions UK Ltd) moving annual total (MAT) August 2015 were used to ascertain the number of units of pMDI prescribed. Annual costs to the NHS in terms of drug, administration, monitoring and adverse event costs, were used to estimate the potential budget impact for FP/FORM and FP/SAL. Costs were calculated for current prescription volumes (12% FP/FORM, 88% FP/SAL), and for different prescription volume scenarios (FP/FORM at 0%, 25%, 50% and 100%). Real-world evidence and budget impact at a clinical commissioning group (CCG) level were also considered.

Results

Total annual costs per person year were less with FP/FORM (£625) than with FP/SAL (£734). Annual costs to the NHS based on the current prescription volumes and clinical trial data were estimated at £210.0M, however, based on real-world evidence, costs were estimated at £179.8M. For all scenarios with increased FP/FORM prescription volumes, the annual total costs to the NHS decreased. This was reflected at a CCG level.

Conclusion

The use of FP/FORM as an alternative to FP/SAL can result in cost savings for the NHS when assessing drug, administration, monitoring and adverse events costs. The inclusion of data released since the launch of FP/FORM within the budget impact analysis demonstrates that the potential cost savings to the NHS that were previously published are being translated to clinical practice.

Funding

Mundipharma, UK.

Simple randomized algorithms for online learning with kernels

In online learning with kernels, it is vital to control the size (budget) of the support set because of the curse of kernelization. In this paper, we propose two simple and effective stochastic strategies for controlling the budget. Both algorithms have an expected regret that is sublinear in the horizon. Experimental results on a number of benchmark data sets demonstrate encouraging performance in terms of both efficacy and efficiency.

Costs of Treatment after Renal Transplantation: Is it Worth to Pay More?

The primary aim of the study was to estimate costs of treatment for the first year after renal transplantation from the perspective of health insurance organizations in Iran. An Excel-based and a Monte Carlo model were developed to determine the treatment costs of current clinical practice in renal transplantation therapy (RTT). Inputs were derived from Ministry of Health and insurance organizations database, hospital and pharmacy records, clinical trials and local and international literature. According to the model, there were almost 17,000 patients receiving RTT in Iran, out of which about 2,200 patients underwent the operation within the study year (2011 - 2012; n = 2,200) The estimated first year total treatment cost after renal transplantation was almost $14,000,000. These costs corresponded to annual total cost per patient of almost $6500 for the payers. Renal transplantation therapy is almost fully reimbursed by government in Iran. However, regarding new expensive medicines, cost of medical expenditure is rapidly growing and becoming quite unaffordable for the government; therefore, out-of-pocket (OOP) payments are dramatically increasing over time. In order to improve reimbursement policy making under pressure of current budget constraints, the present study is providing decision makers with practical tools make it possible for them to easily compare budgetary impact of the current therapy strategy with the future financial consequences of purchasing newly proposed medicines. In other words having estimation of the current budget spending on RTT would help policy makers in making efficient resource allocation and decrease quite high OOP expenditures.