Travel Distance Between Participants in US Telemedicine Sessions With Estimates of Emissions Savings: Observational Study

BACKGROUND

Digital health and telemedicine are potentially important strategies to decrease health care's environmental impact and contribution to climate change by reducing transportation-related air pollution and greenhouse gas emissions. However, we currently lack robust national estimates of emissions savings attributable to telemedicine.

OBJECTIVE

This study aimed to (1) determine the travel distance between participants in US telemedicine sessions and (2) estimate the net reduction in carbon dioxide (CO2) emissions attributable to telemedicine in the United States, based on national observational data describing the geographical characteristics of telemedicine session participants.

METHODS

We conducted a retrospective observational study of telemedicine sessions in the United States between January 1, 2022, and February 21, 2023, on the doxy.me platform. Using Google Distance Matrix, we determined the median travel distance between participating providers and patients for a proportional sample of sessions. Further, based on the best available public data, we estimated the total annual emissions costs and savings attributable to telemedicine in the United States.

RESULTS

The median round trip travel distance between patients and providers was 49 (IQR 21-145) miles. The median CO2 emissions savings per telemedicine session was 20 (IQR 8-59) kg CO2). Accounting for the energy costs of telemedicine and US transportation patterns, among other factors, we estimate that the use of telemedicine in the United States during the years 2021-2022 resulted in approximate annual CO2 emissions savings of 1,443,800 metric tons.

CONCLUSIONS

These estimates of travel distance and telemedicine-associated CO2 emissions costs and savings, based on national data, indicate that telemedicine may be an important strategy in reducing the health care sector's carbon footprint.

Saving ambulance resources: a service evaluation of the identification of non-viable out-of-hospital cardiac arrest in London by advanced paramedic practitioners in critical care

Background

Advanced paramedic practitioners in critical care (APPCCs) are advanced clinical practitioners focused on the delivery of pre-hospital critical care. While working in an ambulance control room setting, APPCCs seek to identify emergency calls appropriate for operational APPCCs to attend. These would include out-of-hospital cardiac arrest (OHCA). Through interrogation of incoming emergency calls they are also able to identify OHCA calls where resuscitation may be futile. In these cases, and within a governance framework, they stand down multiple ambulance responders, leaving only the closest responding resource to attend, thereby 'saving resources' that can be re-directed to other waiting emergency calls. It is believed that this is the first initiative of this nature in the United Kingdom.

Methods

A three-year retrospective service evaluation of data was undertaken. The aim was to quantify the number of 'saved resources', including both double crewed ambulances (DCAs) and solo (single-person) responders, and furthermore to equate those savings into potential hours saved, using average known job cycle times (JCTs). Additionally, safety was assessed by searching all mandated incident reports for occasions where, despite cancellation of resources by an APPCC, resuscitation was commenced by the first response to scene.

Results

A total of 13,356 ambulance resources were saved. Of these, 6593 (49.4%) were DCAs and 6763 (50.6%) were solo responders. Using the average JCT for deceased patients of 104.8 minutes, the total time saving equated to 23,328.48 hours of work or 1944.04 12-hour shifts. When considering DCAs alone, the average JCT for obviously deceased patients was 110.9 minutes. This equates to 12,186.1 hours of work or 1015.5 12-hour shifts. A total of 15 incident reports were identified. All had been investigated, revealing appropriate decision making in cancelling ambulance resources. No patient harm was identified.

Conclusion

APPCCs working within a governance framework safely saved a significant number of ambulance resources over a three-year period. Perceived benefits include 'freeing up' DCA and solo responders, allowing them to be redirected to other emergency calls, leading to potential improvement in response times for patients waiting for an ambulance resource.

Costs of shoulder and elbow procedures are significantly reduced in ambulatory surgery centers compared to hospital outpatient departments

BACKGROUND

Recent literature has shown the advantages of outpatient surgery for many shoulder and elbow procedures, including cost savings with equivalent safety in appropriately selected patients. Two common settings for outpatient surgeries are ambulatory surgery centers (ASCs), which function as independent financial and administrative entities, or hospital outpatient departments (HOPDs), which are owned and operated by hospital systems. The purpose of this study was to compare shoulder and elbow surgery costs between ASCs and HOPDs.

METHODS

Publicly available data from 2022 provided by the Centers for Medicare & Medicaid Services (CMS) was accessed via the Medicare Procedure Price Lookup Tool. Current Procedural Terminology (CPT) codes were used to identify shoulder and elbow procedures approved for the outpatient setting by CMS. Procedures were grouped into arthroscopy, fracture, or miscellaneous. Total costs, facility fees, Medicare payments, patient payment (costs not covered by Medicare), and surgeon's fees were extracted. Descriptive statistics were used to calculate means and standard deviations. Cost differences were analyzed using Mann-Whitney U tests.

RESULTS

Fifty-seven CPT codes were identified. Arthroscopy procedures (n = 16) at ASCs had significantly lower total costs ($2667 ± $989 vs. $4899 ± $1917; P = .009), facility fees ($1974 ± $819 vs. $4206 ± $1753; P = .008), Medicare payments ($2133 ± $791 vs. $3919 ± $1534; P = .009), and patient payments ($533 ± $198 vs. $979 ± $383; P = .009) compared with HOPDs. Fracture procedures (n = 10) at ASCs had lower total costs ($7680 ± $3123 vs. $11,335 ± $3830; P = .049), facility fees ($6851 ± $3033 vs. $10,507 ± $3733; P = .047), and Medicare payments ($6143 ± $2499 vs. $9724 ± $3676; P = .049) compared with HOPDs, although patient payments were not significantly different ($1535 ± $625 vs. $1610 ± $160; P = .449). Miscellaneous procedures (n = 31) at ASCs had lower total costs ($4202 ± $2234 vs. $6985 ± $2917; P < .001), facility fees ($3348 ± $2059 vs. $6132 ± $2736; P < .001), Medicare payments ($3361 ± $1787 vs. $5675 ± $2635; P < .001), and patient payments ($840 ± $447 vs. $1309 ± $350; P < .001) compared with HOPDs. The combined cohort (n = 57) at ASCs had lower total costs ($4381 ± $2703 vs. $7163 ± $3534; P < .001), facility fees ($3577 ± $2570 vs. $6539.1 ± $3391; P < .001), Medicare payments ($3504 ± $2162 vs. $5892 ± $3206; P < .001), and patient payments ($875 ± $540 vs. $1269 ± $393; P < .001) compared with HOPDs.

CONCLUSION

Shoulder and elbow procedures performed at HOPDs for Medicare recipients were found to have average total cost increase of 164% compared with those performed at ASCs (184% savings for arthroscopy, 148% for fracture, and 166% for miscellaneous). ASC use conferred lower facility fees, patient payments, and Medicare payments. Policy efforts to incentivize migration of surgeries to ASCs may translate into substantial health care cost savings.

Comparative cost savings of biosimilar and dose rounding utilization in oncology care

INTRODUCTION

The exponential rise in cancer costs has led many centers to utilize dose rounding to the nearest vial size when the difference in dose is ≤10% to decrease costs. The recent approval of several biosimilar products has presented another opportunity to mitigate the rising costs of oncology care. Scarce information exists about the expected cost savings of combining dose rounding strategies (DRS) with biosimilar use (BU). We therefore assessed the cost savings of combining DRS and BU.

METHODS

Electronic health record data for two health systems in Rhode Island were used to identify patients who received ≥1 of trastuzumab, trastuzumab-anns, bevacizumab, or bevacizumab-awwb from October 1, 2015 to September 1, 2020. Costs were estimated using Medicare drug pricing. Multivariable generalized estimating equations adjusting for age, gender, presence of metastases, dosing weight, and dose administered were used to compare costs per dose between the four exposure groups: DRS + BU, DRS only, BU only, and neither DRS or BU.

RESULTS

A total of 1156 patients were administered 15,145 doses of drug. After covariate adjustment, average savings per dose was greatest in the DRS + BU group (vs. the neither DRS nor BU group); $331 for trastuzumab and $497 for bevacizumab.

CONCLUSIONS

Combining dose rounding with biosimilar substitution for trastuzumab and bevacizumab resulted in significant cost savings per dose and should be implemented by healthcare systems.

Improving health care efficiency one click at a time

Computers are an integral component of modern hospitals. Mouse clicks are currently inherent to this use of computers. However, mouse clicks are not instantaneous. These clicks may be associated with significant costs. Estimated costs associated with 10 additional clicks per day for 20 000 staff exceed AU$500 000 annually. Workflow modifications that increase clicks should weigh the potential benefits of such changes against these costs. Future investigation of strategies to reduce low-value clicks may provide an avenue for health care savings.

Increasing saltiness of salts (NaCl) using mid-infrared radiation to reduce the health hazards

Table salt, rock salt, and iodized salts (composed principally of NaCl) are commonly used in many areas, such as medicine, cooking, industry, or personal care. Common fried, salty, and spicy foods contain an excess of added salt, which has detrimental health effects, especially on the kidneys. Our research aims to enhance the inherent saltiness of these three salts, which would reduce intake and thereby minimize salt's health hazards. We invented a water-based 2-6 μm of Mid-Infrared Generating Atomizer (MIRGA), which, when applied to salts, caused changes in the salts' chemistry and enhanced saltiness, thus allowing the reduction of salt intake by 25%-30%. This easy-to-use technology did not show any side effects. MIRGA was found to have enhanced the saltiness, thus allowing the reduction of salt intake by 25%-30%. MIRGA is safe, portable, highly economical, unique in the mid-IR laser technology, and possesses vast research scope in other areas of food science.

How do hospital characteristics and ties relate to the uptake of second-generation biosimilars? A longitudinal analysis of Portuguese NHS hospitals, 2015-2021

BACKGROUND

There is limited evidence on within-country discrepancies in biosimilar uptake. This study analyzes differences in timing and diffusion of biosimilar uptake across Portuguese NHS hospitals and explores possible determinants.

RESEARCH DESIGN AND METHODS

We analyzed publicly accessible consumption data of originator biologic and biosimilar drugs for adalimumab, etanercept, infliximab, rituximab, and trastuzumab, by hospital and month for the years 2015-2021 (N = 9,467). We modeled the time to biosimilar adoption using survival regression models and the share of biosimilar consumption using generalized estimated equations with random hospital effects.

RESULTS

Academic hospitals were characterized by a quicker uptake of adalimumab and infliximab biosimilars but lower shares for other drugs. A higher total consumption of biologics was related to a lower share of biosimilar uptake. A stronger participation in randomized controlled trials was linked to higher biosimilar shares and quicker uptake, except for rituximab. If all NHS hospitals had biosimilar shares equal to the highest ones, potential annual savings could reach 13.9 million euros.

CONCLUSION

The findings suggest a need for capacity-building on biosimilar prescribing, including for doctors of academic hospitals and those working in settings where high biosimilar use would be expected.

Health and economic impact of subcutaneous allergen immunotherapy in patients with pollen-induced allergic rhinoconjunctivitis: real-word evidence from the Czech Republic

Background: The prevalence of allergic rhinoconjunctivitis (AR) has been increasing over the years, and allergen immunotherapy (AIT) remains the only disease-modifying treatment. However, cost-effectiveness data remain scarce. Methods: In this single-arm, noninterventional, prospective, multicenter study, we describe the effectiveness, safety and costs of subcutaneous AIT for pollen-induced allergic rhinoconjunctivitis. Results: Of 471 new AIT users, 317 completed three courses of treatment, and symptoms improved in 96%; no serious adverse reactions were reported. The cost of symptomatic medication decreased by 49% and the cost of unscheduled specialist visits decreased by 73%. Except for AIT administration, total healthcare costs decreased by 54% compared with the baseline pollen season without AIT. Conclusion: In clinical practice, subcutaneous AIT is an effective treatment generating savings on symptomatic medication and unscheduled consultations.

If you were a policymaker, which treatment would you disinvest? A participatory value evaluation on public preferences for active disinvestment of health care interventions in the Netherlands

INTRODUCTION

Currently, it is not known what attributes of health care interventions citizens consider important in disinvestment decision-making (i.e. decisions to discontinue reimbursement). Therefore, this study aims to investigate the preferences of citizens of the Netherlands toward the relative importance of attributes of health care interventions in the context of disinvestment.

METHODS

A participatory value evaluation (PVE) was conducted in April and May 2020. In this PVE, 1143 Dutch citizens were asked to save at least €100 million by selecting health care interventions for disinvestment from a list of eight unlabeled health care interventions, described solely with attributes. A portfolio choice model was used to analyze participants' choices.

RESULTS

Participants preferred to disinvest health care interventions resulting in smaller gains in quality of life and life expectancy that are provided to older patient groups. Portfolios (i.e. combinations of health care interventions) resulting in smaller savings were preferred for disinvestment over portfolios with larger savings.

CONCLUSION

The disinvestment of health care interventions resulting in smaller health gains and that are targeted at older patient groups is likely to receive most public support. By incorporating this information in the selection of candidate interventions for disinvestment and the communication on disinvestment decisions, policymakers may increase public support for disinvestment.

Motion state-dependent motor learning based on explicit visual feedback is quickly recalled, but is less stable than adaptation to physical perturbations

Recent studies have shown that adaptation to visual feedback perturbations during arm reaching movements involves implicit and explicit learning components. Evidence also suggests that explicit, intentional learning mechanisms are largely responsible for savings—a faster recalibration compared with initial training. However, the extent explicit learning mechanisms facilitate learning and early savings (i.e., the rapid recall of previous performance) for motion state-dependent learning is generally unknown. To address this question, we compared the early savings/recall achieved by two groups of human subjects. One experienced physical perturbations (a velocity-dependent force-field, vFF) to promote adaptation that is thought to be a largely implicit process. The second was only given visual feedback of the required force-velocity relationship; subjects moved in force channels and we provided visual feedback of the lateral force exerted during the movement, as well as the required force pattern based on the movement velocity. Thus, subjects were shown explicit information on the extent the applied temporal pattern of force matched the required velocity-dependent force profile if the force-field perturbation had been applied. After training, both groups experienced a decay and washout period, which was followed by a reexposure block to assess early savings/recall. Although decay was faster for the explicit visual feedback group, the single-trial recall was similar to the physical perturbation group. Thus, compared with visual feedback perturbations, conscious modification of motor output based on motion state-dependent feedback demonstrates rapid recall, but this adjustment is less stable than adaptation based on experiencing the multisensory errors that accompany physical perturbations.

NEW & NOTEWORTHY The extent explicit feedback facilitates motion state-dependent changes to motor output is largely unknown. Here, we examined motor adaptation for subjects that experienced physical perturbations and another that made adjustments based on explicit visual feedback information of the required force-velocity relationship. Our results suggest that adjustment of motor output can be based on explicit motion state-dependent information and demonstrates rapid recall, but this learning is less stable than adaptation based on physical perturbations to movement.

Competition between parallel sensorimotor learning systems

Sensorimotor learning is supported by at least two parallel systems: a strategic process that benefits from explicit knowledge and an implicit process that adapts subconsciously. How do these systems interact? Does one system's contributions suppress the other, or do they operate independently? Here, we illustrate that during reaching, implicit and explicit systems both learn from visual target errors. This shared error leads to competition such that an increase in the explicit system's response siphons away resources that are needed for implicit adaptation, thus reducing its learning. As a result, steady-state implicit learning can vary across experimental conditions, due to changes in strategy. Furthermore, strategies can mask changes in implicit learning properties, such as its error sensitivity. These ideas, however, become more complex in conditions where subjects adapt using multiple visual landmarks, a situation which introduces learning from sensory prediction errors in addition to target errors. These two types of implicit errors can oppose each other, leading to another type of competition. Thus, during sensorimotor adaptation, implicit and explicit learning systems compete for a common resource: error.

Individual Differences in Sensorimotor Adaptation Are Conserved Over Time and Across Force-Field Tasks

Sensorimotor adaptation enables the nervous system to modify actions for different conditions and environments. Many studies have investigated factors that influence adaptation at the group level. There is growing recognition that individuals vary in their ability to adapt motor skills and that a better understanding of individual differences in adaptation may inform how motor skills are taught and rehabilitated. Here we examined individual differences in the adaptation of upper-limb reaching movements. We quantified the extent to which participants adapted their movements to a velocity-dependent force field during an initial session, at 24 h, and again 1-week later. Participants (n = 28) displayed savings, which was expressed as greater initial adaptation when re-exposed to the force field. Individual differences in adaptation across various stages of the experiment displayed weak-strong reliability, such that individuals who adapted to a greater extent in the initial session tended to do so when re-exposed to the force field. Our second experiment investigated if individual differences in adaptation are also present when participants adapt to different force fields or a force field and visuomotor rotation. Separate groups of participants adapted to position- and velocity-dependent force fields (Experiment 2a; n = 20) or a velocity-dependent force field and visuomotor rotation in a single session (Experiment 2b; n = 20). Participants who adapted to a greater extent to velocity-dependent forces tended to show a greater extent of adaptation when exposed to position-dependent forces. In contrast, correlations were weak between various stages of adaptation to the force-field and visuomotor rotation. Collectively, our study reveals individual differences in adaptation that are reliable across repeated exposure to the same force field and present when adapting to different force fields.

Younger and Late Middle-Aged Adults Exhibit Different Patterns of Cognitive-Motor Interference During Locomotor Adaptation, With No Disruption of Savings

It has been proposed that motor adaptation and subsequent savings (or faster relearning) of an adapted movement pattern are mediated by cognitive processes. Here, we evaluated the pattern of cognitive-motor interference that emerges when young and late middle-aged adults perform an executive working memory task during locomotor adaptation. We also asked if this interferes with savings of a newly learned walking pattern, as has been suggested by a study of reaching adaptation. We studied split-belt treadmill adaptation and savings in young (21 ± 2 y/o) and late middle-aged (56 ± 6 y/o) adults with or without a secondary 2-back task during adaptation. We found that young adults showed similar performance on the 2-back task during baseline and adaptation, suggesting no effect of the dual-task on cognitive performance; however, dual-tasking interfered with adaptation over the first few steps. Conversely, dual-tasking caused a decrement in cognitive performance in late middle-aged adults with no effect on adaptation. To determine if this effect was specific to adaptation, we also evaluated dual-task interference in late middle-aged adults that dual-tasked while walking in a complex environment that did not induce motor adaptation. This group exhibited less cognitive-motor interference than late middle-aged adults who dual-tasked during adaptation. Savings was unaffected by dual-tasking in both young and late middle-aged adults, which may indicate different underlying mechanisms for savings of reaching and walking. Collectively, our findings reveal an age-dependent effect of cognitive-motor interference during dual-task locomotor adaptation and no effect of dual-tasking on savings, regardless of age. Young adults maintain cognitive performance and show a mild decrement in locomotor adaptation, while late middle-aged adults adapt locomotion at the expense of cognitive performance.

Monoclonal Antibodies against SARS-CoV-2: Potential Game-Changer Still Underused

Even several months after the start of a massive vaccination campaign against COVID-19, mortality and hospital admission are still high in many countries. Monoclonal antibodies against SARS-CoV-2 are the ideal complement to vaccination in infected subjects who are at high risk for progression to severe disease. Based on data of the Italian Ministry of Health, in the period April-August 2021, monoclonal antibodies were prescribed to 6322 patients. In the same period, 70,022 patients over 70 years old became infected with SARS-CoV-2. Even considering that all monoclonal antibodies were prescribed to this category of patients, we calculated that only 9% of these subjects received the treatment. Moreover, using efficacy data provided by clinal trials, we estimated the potential benefit in terms of reduction of hospital admissions and deaths. Considering utilisation of monoclonal antibodies in half infected patients over 70 years, we estimated that hospital admissions and deaths might have been reduced by 7666 and 3507, respectively. Finally, we calculated the economic benefit of monoclonal use. In the same scenario (50% use of monoclonal antibodies to patients over 70), we estimated potential savings of USD 117,410,105. In conclusion, monoclonal antibodies were used in a small proportion of patients over 70 in Italy. A more extensive use might have resulted in a marked decrease in hospital admissions, deaths and in conspicuous saving for the health system.

Savings in Human Force Field Learning Supported by Feedback Adaptation

Savings have been described as the ability of healthy humans to relearn a previously acquired motor skill faster than the first time, which in the context of motor adaptation suggests that the learning rate in the brain could be adjusted when a perturbation is recognized. Alternatively, it has been argued that apparent savings were the consequence of a distinct process that instead of reflecting a change in the learning rate, revealed an explicit re-aiming strategy. Based on recent evidence that feedback adaptation may be central to both planning and control, we hypothesized that this component could genuinely accelerate relearning in human adaptation to force fields (FFs) during reaching. Consistent with our hypothesis, we observed that on re-exposure to a previously learned FF, the very first movement performed by healthy volunteers in the relearning context was better adapted to the external disturbance, and this occurred without any anticipation or cognitive strategy because the relearning session was started unexpectedly. We conclude that feedback adaptation is a medium by which the nervous system can genuinely accelerate learning across movements.

Sensitivity to error during visuomotor adaptation is similarly modulated by abrupt, gradual and random perturbation schedules

It has been suggested that sensorimotor adaptation involves at least two processes (i.e., fast and slow) that differ in retention and error sensitivity. Previous work has shown that repeated exposure to an abrupt force field perturbation results in greater error sensitivity for both the fast and slow processes. While this implies that the faster relearning is associated with increased error sensitivity, it remains unclear what aspects of prior experience modulate error sensitivity. In the present study, we manipulated the initial training using different perturbation schedules, thought to differentially affect fast and slow learning processes based on error magnitude, and then observed what effect prior learning had on subsequent adaptation. During initial training of a visuomotor rotation task, we exposed three groups of participants to either an abrupt, a gradual, or a random perturbation schedule. During a testing session, all three groups were subsequently exposed to an abrupt perturbation schedule. Comparing the two sessions of the control group who experienced repetition of the same perturbation, we found an increased error sensitivity for both processes. We found that the error sensitivity was increased for both the fast and slow processes, with no reliable changes in the retention, for both the gradual and structural learning groups when compared to the first session of the control group. We discuss the findings in the context of how fast and slow learning processes respond to a history of errors.

Using Fresh Starts to Nudge Increased Retirement Savings

We conducted a field experiment to study the effect of framing future moments in time as new beginnings (or "fresh starts"). University employees (N=6,082) received mailings with an opportunity to choose between increasing their contributions to a savings plan immediately or at a specified future time point. Framing the future time point in relation to a fresh start date (e.g., the recipient's birthday, the first day of spring) increased the likelihood that the mailing recipient chose to increase contributions at that future time point without decreasing their likelihood of increasing contributions immediately. Overall, fresh start framing increased retirement plan contributions in the eight months following the mailing. Our findings represent the first experimental demonstration of the benefits of fresh start framing in a consequential field setting.

Real-World Six-Year National Cost-Minimization Analysis of IncobotulinumtoxinA and OnabotulinumtoxinA in the VA/DoD Healthcare Systems

Purpose

This study sought to perform a real-world, long-term cost-minimization analysis for incobotulinumtoxinA (Xeomin^®) versus onabotulinumtoxinA (Botox^®), given the established non-inferiority when utilized at similar doses.

Methods

The Department of Veterans Affairs (VA) and Department of Defense (DoD) national healthcare systems were included in this analysis. Real-world purchase data for incobotulinumtoxinA were used to estimate the direct drug costs between calendar years 2014 and 2019. Publicly available federal pharmaceutical prices (Federal Supply Schedule and Big 4) were used. The primary outcome was the difference in total direct costs nationally for incobotulinumtoxinA (real-world) versus having hypothetically utilized onabotulinumtoxinA (projected) for similar utilization. Sites utilizing ≥100 vials (of 100 Unit equivalents) of incobotulinumtoxinA annually were categorized as “major adopters”. IncobotulinumtoxinA 50 Unit vials were assumed to be an alternative to a 100 Unit vial of onabotulinumtoxinA for 50% of such vial purchases in the base case scenario to account for differences in wastage.

Results

Over the six-year study time frame, 156 sites (76.8%) utilized incobotulinumtoxinA of the 203 total VA healthcare systems and DoD medical centers. Of these sites, 67 were major adopters for at least one year, with a mean of 3.4 years spent as a major adopter over the study period. Average annual savings per major adopter was $105,782. IncobotulinumtoxinA costs for all VA/DoD sites was $46.39 million for the six-year period versus a projected $71.92 million onabotulinumtoxinA cost—a total savings of $25.53 million (35.5% relative reduction). Approximately, 82.8% of savings stemmed from lower drug acquisition cost ($21.14 million) and 17.2% of savings ($4.39 million) was related to reduced wastage. It was estimated that a total of 9958 extra onabotulinumtoxinA 100 Unit vials would have been wasted during the six-year period, translating to the need for a 5.9% increase in vial purchases versus incobotulinumtoxinA.

Conclusion

Meaningful cost savings were realized related to incobotulinumtoxinA adoption over a long-term time frame in the VA/DoD healthcare systems.

Policies to Encourage the Use of Biosimilars in European Countries and Their Potential Impact on Pharmaceutical Expenditure

Introduction: Biosimilar medicines are considered promising alternatives to new biologicals with high price tags. The extent of savings resulting from biosimilar use depends on their price and uptake, which are largely shaped by pricing, reimbursement, and demand-side policies. This article informs about different policy measures employed by European countries to design the biologicals market and explores potential savings from the increased use of biosimilar medicines in Germany. Methods: Policy measures that target the price and uptake of biosimilar medicines were identified based on a prefilled questionnaire survey with public authorities in 16 European countries, who were the members of the Pharmaceutical Pricing and Reimbursement Information network (July 2020). Potential savings that could have been generated in Germany if different measures identified in the surveyed countries had been implemented were calculated for six publicly funded biological molecules. Price data of the Pharma Price Information service and German consumption data for 2018 were used for the calculation of five scenarios. Results: Several countries use a price link policy, setting the biosimilar price as a percentage of the price of the reference biological. Also lowering the price of the reference biological upon market entry of a biosimilar is less frequently used. While tendering of biosimilar medicines in the inpatient setting is the norm, it is rarely employed for biosimilars in outpatient use. Reference price systems and INN prescribing of medicines are the commonly used policy measures in the off-patent market, but some countries define exemptions for biologicals. Substituting biosimilars at the pharmacy level is rather an exception. Potential savings in Germany ranged from 5% (simple price link) to 55% (prices at the level of other countries) for the six studied molecules. Conclusion: Despite some differences, there are discernible tendencies across European countries with regard to their applications of certain policy measures targeting the price and uptake of biosimilar medicines. The potential for savings of some of these policies was clearly demonstrated. Monitoring and evaluation of these rather recent measures is key for obtaining a more comprehensive picture of their impact.

Budget Impact Analysis of Biosimilar Products in Spain in the Period 2009-2019

Since the first biosimilar medicine, Omnitrope^® (active substance somatropin) was approved in 2006, 53 biosimilars have been authorized in Spain. We estimate the budget impact of biosimilars in Spain from the perspective of the National Health System (NHS) over the period between 2009 and 2019. Drug acquisition costs considering commercial discounts at public procurement procedures (hospital tenders) and uptake data for both originator and biosimilar as actual units consumed by the NHS were the two variables considered. Two scenarios were compared: a scenario where no biosimilars are available and the biosimilar scenario where biosimilars are effectively marketed. All molecules exposed to biosimilar competition during this period were included in the analysis. The robustness of the model was tested by conducting multiple sensitivity analyses. From the payer perspective, it is estimated that the savings produced by the adoption of biosimilars would reach EUR 2306 million over 11 years corresponding to the cumulative savings from all biosimilars. Three molecules (infliximab, somatropin and epoetin) account for 60% of the savings. This study provides the first estimation of the financial impact of biosimilars in Spain, considering both the effect of discounts that manufacturers give to hospitals and the growing market share of biosimilars. We estimate that in our last year of data, 2019, the savings derived from the use of biosimilars relative total pharmaceutical spending in Spain is 3.92%. Although more research is needed, our evidence supports the case that biosimilars represent a great opportunity to the sustainability of the NHS through rationalizing pharmaceutical spending and that the full potential of biosimilar-savings has not been achieved yet, as there is a high variability in biosimilar uptake across autonomous regions.

Human Papillomavirus (HPV) Health Savings as an Alternative Solution: HPV Vaccination Behavior in Adolescents

OBJECTIVE

This study aimed to measure the effects of reproductive health savings (tabungan kesehatan reproduksi, Takespro) on human papillomavirus (HPV) vaccine initiation program and the quality of the decision making to get vaccinated, as measured by knowledge, attitudes, beliefs, and self-efficacy toward HPV vaccination.

METHODS

This quasi-experimental study was conducted on 128 students randomly allocated to intervention and control groups. This research was conducted in junior high schools. The intervention group received the health education "Takespro HPV" intervention through videos and booklets for 6 months at school. Participants in the control group received usual care from the school. Data were collected using a questionnaire of knowledge, attitudes, beliefs, and self-efficacy about HPV vaccination modified by researchers based on previous research and tested for validity and reliability. Data were analyzed using Mann-Whitney test and independent t-test.

RESULTS

A total of 40 participants were actively enrolled in the intervention group, and 88 were passively enrolled in the control group. The health education that was part of the Takespro HPV intervention improved the knowledge (p < 0.05) and self-efficacy (p < 0.05) of the intervention group compared with the control group. The attitude and belief variables showed no significant difference (p > 0.05). Forty students exhibited the health reproduction savings behavior at schools. However, the savings amount was insufficient to get HPV vaccination at the initiation phase.

CONCLUSION

"Takespro" HPV intervention can be considered an alternative to increasing the coverage of HPV vaccination in adolescents in Yogyakarta.
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Improving livelihoods and gender equitable attitudes of street-connected young people in Eldoret, Kenya: Results from a pilot evidence-based intervention

Street-connected young people (SCY) in Eldoret, Kenya, experience substantial gender inequities, economic marginalization and are highly vulnerable to acquiring HIV. This study sought to explain and explore how participation in a pilot-adapted evidence-based intervention, Stepping Stones and Creating Futures, integrated with matched savings, changed SCY's economic resources, livelihoods and gender equitable attitudes. We piloted our adapted intervention using a convergent mixed-methods design measuring outcomes pre- and post-intervention with 80 SCY in four age- and gender-stratified groups of 20 participants per group (young women aged 16-19 years and 20-24 years, young men aged 16-19 years and 20-24 years). The pilot occurred at MTRH-Rafiki Centre for Excellence in Adolescent Health in Eldoret, Kenya, from September 2017 to January 2018. Through street outreach, Peer Facilitators created four age- and gender-stratified sampling lists of SCY whom met the eligibility criteria and whom indicated their interest in participating in the intervention during outreach sessions. Simple random sampling was used to select eligible participants who indicated their interest in participating in the intervention. The adapted intervention, Stepping Stones ya Mshefa na Kujijenga Kimaisha, included 24 sessions that occurred over 14 weeks, focused on sexual and reproductive health, gender norms in society, livelihoods and included a matched-savings programme conditional on attendance. The primary outcome of interest was gender equitable attitudes measured using the Gender Equitable Men scale and secondary outcomes included economic resources and livelihoods. Participants had a significant change in gender equitable attitudes from pre- to post-intervention from 43 (IQR 38-48) to 47 (IQR 42-51) (p < .001). Quantitatively and qualitatively participants reported increases in daily earnings, changes in street involvement, housing and livelihood activities. Overall, this study demonstrated that the adapted programme might be effective at changing gender equitable attitudes and improving livelihood circumstances for SCY in Kenya.

The effects of a spaceflight analog with elevated CO2 on sensorimotor adaptation

Aboard the International Space Station (ISS), astronauts must adapt to altered vestibular and somatosensory inputs due to microgravity. Sensorimotor adaptation on Earth is often studied with a task that introduces visuomotor conflict. Retention of the adaptation process, known as savings, can be measured when subjects are exposed to the same adaptive task multiple times. It is unclear how adaptation demands found on the ISS might interfere with the ability to adapt to other sensory conflict at the same time. In the present study, we investigated the impact of 30 days' head-down tilt bed rest combined with elevated carbon dioxide (HDBR + CO₂) as a spaceflight analog on sensorimotor adaptation. Eleven subjects used a joystick to move a cursor to targets presented on a computer screen under veridical cursor feedback and 45° rotated feedback. During this NASA campaign, five individuals presented with optic disk edema, a sign of spaceflight-associated neuro-ocular syndrome (SANS). Thus, we also performed post hoc exploratory analyses between subgroups who did and did not show signs of SANS. HDBR + CO₂ had some impact on sensorimotor adaptation, with a lack of savings across the whole group. SANS individuals showed larger, more persistent after-effects, suggesting a shift from relying on cognitive to more implicit processing of adaptive behaviors. Overall, these findings suggest that HDBR + CO₂ alters the way in which individuals engage in sensorimotor processing. These findings have important implications for missions and mission training, which require individuals to adapt to altered sensory inputs over long periods in space.NEW & NOTEWORTHY This is the first bed rest campaign examining sensorimotor adaptation and savings in response to the combined effect of HDBR + CO2 and to observe signs of spaceflight-associated neuro-ocular syndrome (SANS) in HDBR participants. Our findings suggest that HDBR + CO2 alters the way that individuals engage in sensorimotor processing. Individuals who developed signs of SANS seem to rely more on implicit rather than cognitive processing of adaptive behaviors than subjects who did not present signs of SANS.

Cost Effectiveness of Sample Pooling to Test for SARS-CoV-2

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Budget Impact Analysis of Switching to Rituximab's Biosimilar in Rheumatology and Cancer in 13 Countries Within the Middle East and North Africa

Introduction

Biosimilars of monoclonal antibodies are being rapidly developed and approved by public health regulatory authorities worldwide. These biosimilars are expected to bring significant budgetary savings to national governments and consequently increase patients' accessibility to biological therapy. Rituximab has been used extensively for the treatment of cancer and rheumatoid disorders over the past two decades. New biosimilars of Rituximab have been developed and introduced into clinical practice. We have analyzed the budgetary impact and savings outcome of introducing Rituximab's biosimilar into 13 countries within the Middle East and North Africa through the implementation of a budget impact analysis model.

Methods

Our model was based on a 1-year full uptake and switch scenario of the Rituximab's biosimilar CT-P10. The model calculated the total number of patients based on the total national consumption of Rituximab per country. Accordingly, the model produced savings per each indication which were translated into the additional number of patients that would be permitted access to Rituximab's therapy as a result of these savings.

Results

In our modeling scenario, the total projected savings that will result from the uptake of Rituximab's biosimilar within the MENA region were estimated to be 46.59 million dollars. The cumulative savings in all 13 countries would allow access of Rituximab's therapy for a total of 6589 patients which is equivalent to a 14% increase in the number of patients benefiting from Rituximab's therapy.

Conclusion

The introduction of Rituximab's biosimilar within the Middle East and North Africa region is associated with significant budgetary savings that will allow public national health authorities to reinvest such economic gains either in expanding access to Rituximab therapy or other costly lifesaving biologicals.

Potential Cost-Savings From the Use of the Biosimilars in Slovakia

Objectives: To analyse the market shares of biosimilars in Slovakia and to calculate the potential cost-savings from the use of biosimilars in Slovakia based on two different data sources. Methods: National reimbursement lists from the Czech Republic, Hungary, Poland and Slovakia were used for analyzing the availability of biosimilars with public funding. In addition, the reimbursement dossiers of biosimilars, the justifications of reimbursement decisions by the Slovak Ministry of Health, and final reimbursement decrees, which are published on the webpage of the Slovak Ministry of Health, were utilized for this study. Reimbursement decisions regarding biosimilars by the Slovak Ministry of Health from 2006 to August 2019 were considered and the detailed utilization of biosimilars in 2018 was analyzed based on data from the State Institute for Drug Control. The study was validated based on data from the Slovak National Health Information Center. Results: Fifty four biosimilars were approved by the European Medicines Agency (EMA) in August 2019. Of the total group of licensed biosimilars on the market, 29 biosimilars (54%) were available in the Czech Republic, 28 biosimilars (52%) were available in Poland, and 27 biosimilars (50%) were available in Hungary and 24 biosimilars (44%) were available in Slovakia. Our analysis, based on the data provided by distributors of medicinal products to the State Institute for Drug Control, revealed that the health fund in Slovakia could have saved 35 to 50 million euros per year if biosimilars with marketing authorisations had been available on the Slovak market. The calculations assumed a 25-35% price decrease against the original biological medical products, and that there would be no increase in the utilization of biosimilars in Slovakia. Conclusions: To achieve significant improvement in patient access to biosimilars in Slovakia, a top-down approach establishing targets and quotas for the procurement of biosimilars should be applied.

Effectiveness and Economic Evaluation of Hospital-Outreach Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Objective

Hospital-outreach pulmonary rehabilitation (PR) can improve health status and reduce health-care utilization by patients with chronic obstructive pulmonary disease (COPD). However, its long-term effects and costs versus benefits are still not clear. This study was conducted to develop, deliver, and evaluate the effects and monetary savings of a hospital-outreach PR program for patients with COPD.

Methods

A randomized controlled trial was conducted. Patients with COPD (n=208) were randomly assigned to the hospital-outreach PR program (treatment) or treatment as usual (control). The treatment group received a 3-month intensive intervention, including supervised physical exercise, smoking cessation, self-management education, and psychosocial support, followed by long-term access to a nurse through telephone follow-up and home visits up to 24 months. The control group received routine care, including discharge education and a self-management education brochure. Main outcomes were collected at 3, 6, 12, and 24 -months postrandomization. Primary outcomes included health-care utilization (ie, readmission rates, times, and days, and emergency department visits) and medical costs. Secondary outcomes included lung function (ie, FEV1, FEV1% predicted, FVC), dyspnea (mMCR), exercise capacity (6MWD), impact on quality of life (CAT), and self-management (CSMS).

Results

At the end of 24 months, 85 (81.7%) in the treatment group and 89 (85.6%) in the control group had completed the whole program. Compared with the control group, patients in the treatment group had lower readmission rates, times, and days at 6 and 12 months and during 12-24 months. Regarding costs during the 2 years, the program achieved CN¥3,655.94 medical  savings per patient per year, and every ¥1 spent on the program led to ¥3.29 insavings. Patients in the treatment group achieved improvements in FEV1, FEV1% predicted, exercise capacity, and self-management. It also achieved relief of dyspnea symptoms and improvement in COPD's impact on quality of life.

Conclusion

The hospital-outreach PR program for patients with COPD achieved reductions in health-care utilization, monetary savings, and improvements in patient health outcomes. The effects of the program were sustained for at least 2 years.

Trial Registration

This trial was registered at the Chinese Clinical Trial Registry (ChiCTR-TRC-14005108).

Which Early Withdrawal Penalty Attracts the Most Deposits to a Commitment Savings Account?

Previous research has shown that some people voluntarily use commitment contracts that restrict their own choice sets. We study how people divide money between two accounts: a liquid account that permits unrestricted withdrawals and a commitment account that is randomly assigned in a between-subject design to have either a 10% early withdrawal penalty, or a 20% early withdrawal penalty, or not to allow early withdrawals at all (i.e., an infinite penalty). When the liquid account and the commitment account pay the same interest rate, higher early-withdrawal penalties attract more commitment account deposits. This pattern is predicted by the hypothesis that some participants are partially- or fully-sophisticated present-biased agents. Such agents perceive that higher penalties generate greater scope for commitment by disincentivizing (penalized) early withdrawals. The experiment also shows that when the commitment account pays a higher interest rate than the liquid account, the positive empirical slope relating penalties and commitment deposits is flattened, suggesting that naïve present-biased agents or agents with standard exponential discounting are also in our sample. Across all of our experimental treatments, higher early withdrawal penalties on the commitment account sometimes increase and never reduce allocations to the commitment account.

Task Errors Drive Memories That Improve Sensorimotor Adaptation

Traditional views of sensorimotor adaptation (i.e., adaptation of movements to perturbed sensory feedback) emphasize the role of automatic, implicit correction of sensory prediction errors. However, latent memories formed during sensorimotor adaptation, manifest as improved relearning (e.g., savings), have recently been attributed to strategic corrections of task errors (failures to achieve task goals). To dissociate contributions of task errors and sensory prediction errors to latent sensorimotor memories, we perturbed target locations to remove or enforce task errors during learning and/or test, with male/female human participants. Adaptation improved after learning in all conditions where participants were permitted to correct task errors, and did not improve whenever we prevented correction of task errors. Thus, previous correction of task errors was both necessary and sufficient to improve adaptation. In contrast, a history of sensory prediction errors was neither sufficient nor obligatory for improved adaptation. Limiting movement preparation time showed that the latent memories driven by learning to correct task errors take at least two forms: a time-consuming but flexible component, and a rapidly expressible, inflexible component. The results provide strong support for the idea that movement corrections driven by a failure to successfully achieve movement goals underpin motor memories that manifest as savings. Such persistent memories are not exclusively mediated by time-consuming strategic processes but also comprise a rapidly expressible but inflexible component. The distinct characteristics of these putative processes suggest dissociable underlying mechanisms, and imply that identification of the neural basis for adaptation and savings will require methods that allow such dissociations.SIGNIFICANCE STATEMENT Latent motor memories formed during sensorimotor adaptation manifest as improved adaptation when sensorimotor perturbations are reencountered. Conflicting theories suggest that this "savings" is underpinned by different mechanisms, including a memory of successful actions, a memory of errors, or an aiming strategy to correct task errors. Here we show that learning to correct task errors is sufficient to show improved subsequent adaptation with respect to naive performance, even when tested in the absence of task errors. In contrast, a history of sensory prediction errors is neither sufficient nor obligatory for improved adaptation. Finally, we show that latent sensorimotor memories driven by task errors comprise at least two distinct components: a time-consuming, flexible component, and a rapidly expressible, inflexible component.

Framing Flexible Spending Accounts: A Large-Scale Field Experiment on Communicating the Return on Medical Savings Accounts

Tax-preferred health savings devices such as Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) offer employees potentially valuable financial instruments for directing pre-tax earnings to eligible medical expenses. Despite their increasing popularity as an employee benefit, however, there is little causal evidence around individual demand for these accounts. This paper seeks to address this gap in the literature, reporting on a randomized controlled field experiment conducted with over 11,000 U. S federal employees in 2017 in order to evaluate the effectiveness of targeted messages designed to increase FSA contributions. Our results suggest that the provision of basic information about FSAs delivered via an emailed employee newsletter did not affect the likelihood of contribution or the contribution level. The addition of statements about the absolute returns or relative returns offered by the accounts similarly had no significant effects, and these null effects are observed despite relatively high email open rates. We discuss explanations for the null results and the policy implications of findings from what appears to be the first health economics experiment analyzing tax incentives around health care savings.

Modeling the potential impact of abuse-deterrent opioids on medical resource utilization

Objectives: To extend a previously published manuscript on a model for estimating potential avoided medical events and cost savings in the US associated with the introduction of extended-release abuse-deterrent opioids and incorporate new methods of evaluating abuse deterrence using human abuse potential studies. Methods: A model was developed to estimate reductions in abuse-related events and annual savings in the US. Model inputs included: opioid abuse prevalence, abuse-deterrent opioid cost and effectiveness at deterring abuse, and opioid abuse-related events and costs. Direct (medical and drug) and indirect (work loss) cost savings (2017 US$) and abuse-related events were estimated assuming the replacement of the entire extended-release opioid market (brand and generic) by brand abuse-deterrent opioids. Results: Replacing the extended-release opioid market with abuse-deterrent opioids is estimated to lower annual abuse-related medical events by ∼13-31% (e.g. 78,000-186,000 emergency department visits) and lower annual medical costs by ∼$640 M-$1,538 M, depending on the abuse-deterrent technology (physical/chemical barrier or agonist/antagonist). Replacement of extended-release oxycodone with extended-release abuse-deterrent oxycodone is associated with the largest amount of cost savings and highest number of avoided medical events, followed by replacing extended-release morphine with an extended-release abuse-deterrent opioid. Replacement of transdermal fentanyl is associated with the smallest amount of cost savings and lowest number of avoided medical events. Conclusion: Agonist/antagonist abuse-deterrent opioid technology is associated with higher annual medical cost savings and more avoided events than physical/chemical barrier technology. Total net savings are dependent upon the abuse-deterrent opioid price relative to non-abuse-deterrent opioids.

Systematic investment in the delivery of guideline-coherent therapy reduces mortality and overall costs in patients with ST-elevation myocardial infarction: Results from the Stent for Life economic model for Romania, Portugal, Basque Country and Kemerovo region

AIMS

The Stent for Life initiative aims at the reduction of mortality in patients with ST-elevation myocardial infarction by enhancing timely access to primary percutaneous coronary intervention. To assess the associated health and socioeconomic impact, the Stent for Life economic project was launched and applied to four model regions: Romania, Portugal, the Basque Country in Spain, and the Kemerovo region in the Russian Federation.

METHODS AND RESULTS

The Stent for Life economic model is based on a decision tree that incorporates primary percutaneous coronary intervention rates and mortality. Healthcare costs and indirect costs caused by loss of productivity were estimated. A baseline scenario simulating the status quo was compared to the Stent for Life scenario which integrated changes initiated by the Stent for Life programme. In the four model regions, primary percutaneous coronary intervention numbers rose substantially between 29-303%, while ST-elevation myocardial infarction mortality was reduced between 3-10%. Healthcare costs increased by 8% to 70%. Indirect cost savings ranged from 2-7%. Net societal costs were reduced in all model regions by 2-4%.

CONCLUSION

The joint effort of the Stent for Life initiative and their local partners successfully saves lives. Moreover, the increase in healthcare costs was outweighed by indirect cost savings, leading to a net cost reduction in all four model regions. These findings demonstrate that systematic investments to improve the access of ST-elevation myocardial infarction patients to guideline-coherent therapy is beneficial, not only for the individual, but also for the society at large.

Retirement Savings Model Tested With Brazilian Private Health Care Workers

Retirement is one of the most serious challenges facing Brazil currently, considering the rapid pace of population aging, growing social inequalities, and the difficulty that Brazilians have in planning for their financial future. The number of studies on psychosocial factors in retirement is limited. The aim of this cross-sectional study is to determine Brazilian health workers' perceptions about financial planning for retirement, based on studies by Hershey and Mowen (2000). In this study, retirement saving - the dependent variable - is highlighted by the use of a model with the following antecedents: parental influence, retirement goal clarity and retirement planning activity level. The goals of the study were to establish mediating and moderating relationships as an innovative approach to the original model. Data was gathered from 319 workers at a private hospital in the municipality of Niterói, Rio de Janeiro (Brazil) who filled out a questionnaire concerning their saving behaviors and antecedents. Results indicated a model in which goal clarity mediated the relationship between parental influence and retirement saving, and retirement activity was observed to influence the level of retirement saving. The findings confirmed the complexities of financial planning for retirement, and emphasized important factors, such as parental advice starting in childhood and the effect of this advice on goal clarity. The results also pointed to the role of individual responsibility in the process, which depended on establishing a plan for activities. In addition to parental advice, an educational approach can contribute encouraging saving behaviors and helping retirees achieve financial security in retirement.

The 24-h savings of adaptation to novel movement dynamics initially reflects the recall of previous performance

Humans rapidly adapt reaching movements in response to perturbations (e.g., manipulations of movement dynamics or visual feedback). Following a break, when reexposed to the same perturbation, subjects demonstrate savings, a faster learning rate compared with the time course of initial training. Although this has been well studied, there are open questions on the extent early savings reflects the rapid recall of previous performance. To address this question, we examined how the properties of initial training (duration and final adaptive state) influence initial single-trial adaptation to force-field perturbations when training sessions were separated by 24 h. There were two main groups that were distinct based on the presence or absence of a washout period at the end of day 1 (with washout vs. without washout). We also varied the training duration on day 1 (15, 30, 90, or 160 training trials), resulting in 8 subgroups of subjects. We show that single-trial adaptation on day 2 scaled with training duration, even for similar asymptotic levels of learning on day 1 of training. Interestingly, the temporal force profile following the first perturbation on day 2 matched that at the end of day 1 for the longest training duration group that did not complete the washout. This correspondence persisted but was significantly lower for shorter training durations and the washout subject groups. Collectively, the results suggest that the adaptation observed very early in reexposure results from the rapid recall of the previously learned motor recalibration but is highly dependent on the initial training duration and final adaptive state.NEW & NOTEWORTHY The extent initial readaptation reflects the recall of previous motor performance is largely unknown. We examined early single-trial force-field adaptation on the second day of training and distinguished initial retention from recall. We found that the single-trial adaptation following the 24-h break matched that at the end of the first day, but this recall was modified by the training duration and final level of learning on the first day of training.

Interactions between motor exploration and reinforcement learning

Motor exploration, a trial-and-error process in search for better motor outcomes, is known to serve a critical role in motor learning. This is particularly relevant during reinforcement learning, where actions leading to a successful outcome are reinforced while unsuccessful actions are avoided. Although early on motor exploration is beneficial to finding the correct solution, maintaining high levels of exploration later in the learning process might be deleterious. Whether and how the level of exploration changes over the course of reinforcement learning, however, remains poorly understood. Here we evaluated temporal changes in motor exploration while healthy participants learned a reinforcement-based motor task. We defined exploration as the magnitude of trial-to-trial change in movements as a function of whether the preceding trial resulted in success or failure. Participants were required to find the optimal finger-pointing direction using binary feedback of success or failure. We found that the magnitude of exploration gradually increased over time when participants were learning the task. Conversely, exploration remained low in participants who were unable to correctly adjust their pointing direction. Interestingly, exploration remained elevated when participants underwent a second training session, which was associated with faster relearning. These results indicate that the motor system may flexibly upregulate the extent of exploration during reinforcement learning as if acquiring a specific strategy to facilitate subsequent learning. Also, our findings showed that exploration affects reinforcement learning and vice versa, indicating an interactive relationship between them. Reinforcement-based tasks could be used as primers to increase exploratory behavior leading to more efficient subsequent learning.NEW & NOTEWORTHY Motor exploration, the ability to search for the correct actions, is critical to learning motor skills. Despite this, whether and how the level of exploration changes over the course of training remains poorly understood. We showed that exploration increased and remained high throughout training of a reinforcement-based motor task. Interestingly, elevated exploration persisted and facilitated subsequent learning. These results suggest that the motor system upregulates exploration as if learning a strategy to facilitate subsequent learning.

Accelerated redevelopment of vocal skills is preceded by lasting reorganization of the song motor circuitry

Complex motor skills take considerable time and practice to learn. Without continued practice the level of skill performance quickly degrades, posing a problem for the timely utilization of skilled motor behaviors. Here we quantified the recurring development of vocal motor skills and the accompanying changes in synaptic connectivity in the brain of a songbird, while manipulating skill performance by consecutively administrating and withdrawing testosterone. We demonstrate that a songbird with prior singing experience can significantly accelerate the re-acquisition of vocal performance. We further demonstrate that an increase in vocal performance is accompanied by a pronounced synaptic pruning in the forebrain vocal motor area HVC, a reduction that is not reversed when birds stop singing. These results provide evidence that lasting synaptic changes in the motor circuitry are associated with the savings of motor skills, enabling a rapid recovery of motor performance under environmental time constraints.

Both fast and slow learning processes contribute to savings following sensorimotor adaptation

Recent work suggests that the rate of learning in sensorimotor adaptation is likely not fixed, but rather can change based on previous experience. One example is savings, a commonly observed phenomenon whereby the relearning of a motor skill is faster than the initial learning. Sensorimotor adaptation is thought to be driven by sensory prediction errors, which are the result of a mismatch between predicted and actual sensory consequences. It has been proposed that during motor adaptation the generation of sensory prediction errors engages two processes (fast and slow) that differ in learning and retention rates. We tested the idea that a history of errors would influence both the fast and slow processes during savings. Participants were asked to perform the same force field adaptation task twice in succession. We found that adaptation to the force field a second time led to increases in estimated learning rates for both fast and slow processes. While it has been proposed that savings is explained by an increase in learning rate for the fast process, here we observed that the slow process also contributes to savings. Our work suggests that fast and slow adaptation processes are both responsive to a history of error and both contribute to savings. NEW & NOTEWORTHY We studied the underlying mechanisms of savings during motor adaptation. Using a two-state model to represent fast and slow processes that contribute to motor adaptation, we found that a history of error modulates performance in both processes. While previous research has attributed savings to only changes in the fast process, we demonstrated that an increase in both processes is needed to account for the measured behavioral data.

Expanding Understanding of Community Health Worker Programs: A Cross-Sectional Survey on the Work, Satisfaction, and Livelihoods of CHWs in Madagascar

With health worker shortages in rural areas, community health workers (CHWs) are instrumental to the sustainability of primary health care and to the ability to meet health needs. Identifying appropriate operational models and incentive structures is an important element of long-term success. This article reports on CHWs’ work demands and affective response to their volunteer work within the broader context of their livelihoods in Madagascar. A cross-sectional survey of 874 CHWs, called Agents de Santé Communautaire (ACs), from 14 districts across 5 regions was conducted in June 2015. Only 44% of ACs had cash savings. Subsistence farming was the main livelihood strategy; ninety-two percent of ACs were food insecure and 89% had experienced a shock in the past year. Overall, 77% of ACs financed commodity resupply through sales of health products and 18% from their personal savings; stock-outs at point of supply and financial and time constraints were the main reported challenges in getting health products. The average satisfaction score with AC work was 3 out of 4. This assessment from Madagascar helps unveil a more comprehensive view of the reality of CHWs’ lives. Managers need to take into account the potential implications of the demands of CHW work on already precarious livelihoods.

Movement and perception recalibrate differently across multiple days of locomotor learning

Learning a new movement through error-based adaptation leads to recalibration of movement and altered perception of that movement. Although presumed to be closely related, the relationship between adaptation-based motor and perceptual changes is not well understood. Here we investigated the changes in motor behavior and leg speed perception over 5 days of split-belt treadmill adaptation. We specifically wanted to know if changes in the perceptual domain would demonstrate savings-like behavior (i.e., less recalibration with more practice) and if these changes would parallel the savings observed in the motor domain. We found that the recalibration of leg speed perception decreased across days of training, indicating savings-like behavior in this domain. However, we observed that the magnitude of savings across days was different between motor and perceptual domains. These findings suggest a degree of independence between the motor and perceptual processes that occur with locomotor adaptation. NEW & NOTEWORTHY Error-based adaptation learning drives changes in movement and perception of movement. Are these changes across domains linked or simply coincidental? Here, we studied changes in movement and perception across 5 days of repeated locomotor adaptation. Savings-like behavior in the motor and perceptual domains developed with different magnitudes and over different timescales, leading us to conclude that motor and perceptual processes operate at least somewhat independently during locomotor adaptation.

Neural predictors of sensorimotor adaptation rate and savings

In this study, we investigate whether individual variability in the rate of visuomotor adaptation and multiday savings is associated with differences in regional gray matter volume and resting-state functional connectivity. Thirty-four participants performed a manual adaptation task during two separate test sessions, on average 9 days apart. Functional connectivity strength between sensorimotor, dorsal cingulate, and temporoparietal regions of the brain was found to predict the rate of learning during the early phase of the adaptation task. In contrast, default mode network connectivity strength was found to predict both the rate of learning during the late adaptation phase and savings. As for structural predictors, greater gray matter volume in temporoparietal and occipital regions predicted faster early learning, whereas greater gray matter volume in superior posterior regions of the cerebellum predicted faster late learning. These findings suggest that the offline neural predictors of early adaptation may facilitate the cognitive aspects of sensorimotor adaptation, supported by the involvement of temporoparietal and cingulate networks. The offline neural predictors of late adaptation and savings, including the default mode network and the cerebellum, likely support the storage and modification of newly acquired sensorimotor representations.

Impact of prior errors on visuomotor adaptation and savings: experimental considerations and clinical implications

The motor system retains learning from visuomotor adaptation tasks in the form of "savings" to enable faster readaptation to similar perturbations in the future. Leow et al. (J Neurophysiol 116: 1603-1614, 2016) suggest that the experience of prior errors during relearning is necessary for savings while repetition of prior actions may not be sufficient. These findings provide novel insight into factors that contribute to visuomotor adaptation and can be applied to future experimental and clinical research.

Multi-day Adaptation and Savings in Manual and Locomotor Tasks

Using an individual differences approach, we evaluated whether manual and locomotor adaptation are associated in terms of adaptation and savings across days, and whether they rely on shared underlying mechanisms involving visuospatial working memory or visual field dependence. Participants performed a manual and a locomotor adaptation task during 4 separate test sessions over a 3-month period. Reliable adaptation and savings were observed for both tasks. It was further found that higher visuospatial working memory performance and lower visual field dependence scores were associated with faster learning in the manual and locomotor tasks, respectively. Moreover, adaptation rates were correlated between the 2 tasks in the final test session, suggesting that people may gradually be learning something generalizable about the adaptation process.

Should Governments Invest More in Nudging?

Governments are increasingly adopting behavioral science techniques for changing individual behavior in pursuit of policy objectives. The types of “nudge” interventions that governments are now adopting alter people’s decisions without coercion or significant changes to economic incentives. We calculated ratios of impact to cost for nudge interventions and for traditional policy tools, such as tax incentives and other financial inducements, and we found that nudge interventions often compare favorably with traditional interventions. We conclude that nudging is a valuable approach that should be used more often in conjunction with traditional policies, but more calculations are needed to determine the relative effectiveness of nudging.

Impact of savings groups on the lives of the poor

Savings-led microfinance programs operate in poor rural communities in developing countries to establish groups that save and then lend out the accumulated savings to each other. Nonprofit organizations train villagers to create and lead these groups. In a clustered randomized evaluation spanning three African countries (Ghana, Malawi, and Uganda), we find that the promotion of these community-based microfinance groups leads to an improvement in household business outcomes and women's empowerment. However, we do not find evidence of impacts on average consumption or other livelihoods.

Cost analysis of adolescent idiopathic scoliosis surgery: early discharge decreases hospital costs much less than intraoperative variables under the control of the surgeon

BACKGROUND

Spinal fusion surgery for the treatment of adolescent idiopathic scoliosis (AIS) is increasing. Health systems and surgeons are decreasing hospital length of stay (LOS) to decrease costs. The purpose of this study was to review the contribution of an accelerated discharge protocol on the total cost of a single episode of care related to the surgical treatment of AIS at a single institution.

METHODS

A retrospective cost analysis was performed over an 18-month period, from January 2014 through June 2015, before and after the institution of an accelerated discharge program. Patients treated surgically with ICD-9 code 737.30 (Idiopathic Scoliosis) were reviewed. Itemized costs and LOS were analyzed collectively and by surgeon before and after the accelerated discharge protocol.

RESULTS

Eighty AIS patients were treated surgically. The accelerated discharge program significantly reduced average LOS from 4.2 days in 2014 to 3.3 days during the first 6 months of 2015 (P≤0.05). There were no increases in complications. There was a 9% decrease in the total average costs per episode of care. A weighted average, a relative average change in costs, and an average cost savings per case were calculated for 12 different categories. Average Surgical Services and Nursing costs decreased during the study period while all other costs increased. The accelerated discharge program did not directly contribute significantly to this decrease in costs. Greatest cost reduction was associated with average bone graft and pedicle screw cost, with an overall 8.5% reduction in pedicle screw use and a 58% reduction in bone graft costs.

CONCLUSIONS

Intraoperative variables under the direct control of the surgeon contribute much more to cost reduction than an accelerated discharge program for surgically treated AIS patients.

Supply-side and demand-side policies for biosimilars: an overview in 10 European member states

This study aimed to provide an overview of biosimilar policies in 10 EU MSs. Methods: Ten EU MS pharmaceutical markets (Belgium, France, Germany, Greece, Hungary, Italy, Poland, Spain, Sweden, and the UK) were selected. A comprehensive literature review was performed to identify supply-side and demand-side policies in place in the selected countries. Results: Supply-side policies for biosimilars commonly include price linkage, price re-evaluation, and tendering; the use of internal or external reference pricing varies between countries; health technology assessment is conducted in six countries. Regarding demand-side policies, pharmaceutical prescription budgets or quotas and monitoring of prescriptions (with potential financial incentives or penalties) are in place in eight and in seven countries respectively. Switching is generally allowed, but is solely the physician's responsibility. Automatic substitution is not recommended, or even forbidden, in most EU MSs. Prescription conditions or guidelines that apply to biosimilars are established in nearly all surveyed EU MSs. Conclusions: Important heterogeneity in policies on biosimilars was seen between (and even within) selected countries, which may partly explain variations in biosimilar uptake. Supply-side policies targeting price have been reported to limit biosimilar penetration in the long term, despite short-term savings, while demand-side policies are considered to positively impact uptake.

Right prefrontal cortex transcranial direct current stimulation enhances multi-day savings in sensorimotor adaptation

We have previously reported that visuospatial working memory performance and magnitude of activation in the right dorsolateral prefrontal cortex predict the rate of visuomotor adaptation. Recent behavioral studies suggest that sensorimotor savings, or faster relearning on second exposure to a task, are due to recall of these early, strategic components of adaptation. In the present study we applied anodal transcranial direct current stimulation to right or left prefrontal cortex or left motor cortex. We found that all groups adapted dart throwing movements while wearing prism lenses at the same rate as subjects receiving sham stimulation on day 1 On test day 2, which was conducted a few days later, the right prefrontal and left motor cortex groups adapted faster than the sham group. Moreover, only the right prefrontal group exhibited greater savings, expressed as a greater difference between day 1 and day 2 errors, compared with sham stimulation. These findings support the hypothesis that the right prefrontal cortex contributes to sensorimotor adaptation and savings.

NEW & NOTEWORTHY

We have previously reported that visuospatial working memory performance and magnitude of activation in the right dorsolateral prefrontal cortex predict the rate of manual visuomotor adaptation. Sensorimotor savings, or faster adaptation to a previously experienced perturbation, has been recently linked to cognitive processes. We show that facilitating the right prefrontal cortex with anodal transcranial direct current stimulation enhances sensorimotor savings compared with sham stimulation.

Savings for visuomotor adaptation require prior history of error, not prior repetition of successful actions

When we move, perturbations to our body or the environment can elicit discrepancies between predicted and actual outcomes. We readily adapt movements to compensate for such discrepancies, and the retention of this learning is evident as savings, or faster readaptation to a previously encountered perturbation. The mechanistic processes contributing to savings, or even the necessary conditions for savings, are not fully understood. One theory suggests that savings requires increased sensitivity to previously experienced errors: when perturbations evoke a sequence of correlated errors, we increase our sensitivity to the errors experienced, which subsequently improves error correction (Herzfeld et al. 2014). An alternative theory suggests that a memory of actions is necessary for savings: when an action becomes associated with successful target acquisition through repetition, that action is more rapidly retrieved at subsequent learning (Huang et al. 2011). In the present study, to better understand the necessary conditions for savings, we tested how savings is affected by prior experience of similar errors and prior repetition of the action required to eliminate errors using a factorial design. Prior experience of errors induced by a visuomotor rotation in the savings block was either prevented at initial learning by gradually removing an oppositely signed perturbation or enforced by abruptly removing the perturbation. Prior repetition of the action required to eliminate errors in the savings block was either deprived or enforced by manipulating target location in preceding trials. The data suggest that prior experience of errors is both necessary and sufficient for savings, whereas prior repetition of a successful action is neither necessary nor sufficient for savings.

Ownership of individual retirement accounts - an empirical analysis based on SHARE

This paper examines the household retirement saving decisions in what concerns to the ownership of Individual Retirement Accounts (IRAs) in eight European Union (EU) countries. IRAs are more and more seen as an alternative to public pension benefits, which are decreasing. Therefore, understanding the enrolment in IRAs, both the socio-economic factors and over time, is most important. Detailed empirical analysis of the factors that might influence the ownership of IRAs is presented based on Survey of Health Ageing and Retirement in Europe (SHARE), using data from Wave 2 (2006-2007) and Wave 4 (2010-2011). Further, to analyse the impact of legal retirement age in the ownership of IRAs, two subsamples are considered: people aged between 50 and 64 years old (50-64 years) and people aged 65 or over (≥ 65 years). The results suggest that age, years of education, income and ownership of dwelling influence positively and significantly household saving, while number of children, marital status and risk aversion have a negative effect. Marital status and income are not statistically significant for retired people. Policy implications are derived.

Economic and health implications from earlier detection of HIV infection in the United Kingdom

Purpose

To model the budget and survival impact of implementing interventions to increase the proportion of HIV infections detected early in a given UK population.

Patients and methods

A Microsoft Excel decision model was designed to generate a set of outcomes for a defined population. Survival was modeled on the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) study extrapolated to a 5-year horizon as a constant hazard. Hazard rates were specific to age, sex, and whether detection was early or late. The primary outcomes for each year up to 5 years were: annual costs, numbers of infected cases, hospital admissions, and surviving cases. Three locations in the UK were chosen to model outcomes across a range of HIV prevalence areas: Lambeth, Southwark, and Lewisham (LSL), Greater Manchester Cluster (GMC), and Kent and Medway (K&M).

Results

In LSL, the projected cumulative cost savings over 5 years were £3,210,206 or £5,290,206 when including the value of the 104 life-years saved. Savings were insensitive to transmission rates, but sensitive in direct proportion to the percentage shift from late to early detection. In GMC, savings were in a similar proportion to LSL, but the magnitude was smaller, as a consequence of the lower base-case HIV prevalence. In K&M, with a smaller population and lower HIV prevalence than GMC, savings were commensurately smaller (£733,202 cumulatively over 5 years).

Conclusion

The results strengthen the rationale for implementing increased testing in high prevalence areas. However, in areas of low prevalence, it is unlikely that costs will be returned over a 5-year period.