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The healthcare sector is ubiquitously plagued by workforce shortages in economies around the globe. The fragility of this structural shortage becomes apparent when external shocks, such as the COVID-19 pandemic, exacerbate the lack of workers in clinical practice. In this article, we summarize current trends in healthcare workforce development across the globe, review theoretical concepts of workforce shortages, and discuss policies to address them. In practice, developed countries often address workforce shortages with targeted migration policies. However, targeted workforce migration policies only intensify workforce shortages in low-and middle-income countries. Theoretical macroeconomic models suggest that supply shortages may result from too low wages, supply lagging behind demand, and social perception. Changes in the wage rate cannot sufficiently increase the supply of health professionals as scholars find inelastic wages for physicians and nurses. Nonpecuniary factors such as working conditions, job satisfaction, and intrinsic motivation are at least equally important as financial incentives. In conclusion, increased wages can only be part of a heterogeneous policy plan to address shortages. Migration and retirement levels of health professionals can temporarily mitigate workforce shortages but rarely change the underlying systemic issues. Increasing the number of places available in medical and nursing schools while also improving, both, financial and nonfinancial incentives for employees are long-term structural policy options., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: This study addresses the growing importance of health economics and pharmacoeconomics in preparing healthcare professionals for economic decision-making, particularly in China's evolving healthcare system. Despite their significance, these subjects are inconsistently included in health education in Southwest China, making it crucial to assess students' proficiency and educational needs., Methods: A cross-sectional study was conducted from July to October 2023, involving medical and pharmaceutical programs across universities in Sichuan, Chongqing, Guizhou, and Yunnan. Data on students' knowledge, attitudes, and proficiency were captured using a structured questionnaire. Advanced statistical methods, including descriptive analysis, ANOVA, regression analysis, PCA, and Spearman correlation heatmaps, were employed for data analysis using IBM SPSS and Python. The sample consisted of 781 students, with the survey facilitated via the Questionnaire Star platform., Results: The survey revealed moderate comprehension of health economics and pharmacoeconomics among 781 health-related students, with an average knowledge score of 2.9. The majority were pharmacy students (45.58%) and aged 21-24 years (65.81%) with a significant female majority (64.92%). Academic year significantly influenced understanding, while gender differences were minimal. Spearman correlation indicated a strong linkage (0.78) between Supply and Demand and Cost Effectiveness, with minimal correlations between knowledge and attitudes towards the educational importance of health economics. Multiple regression analysis highlighted the impact of gender and academic progression on students' comprehension of Supply and Demand concepts, as well as the influence of knowledge levels on their attitudes towards the importance of health economics education. PCA indicated the complex structure of knowledge and attitudes., Conclusions: The study found moderate knowledge levels in health economics among health professions students in Southwest China, with academic year affecting comprehension and minimal gender differences. Pharmacy students had higher proficiency in pharmaceutical-related areas, but gaps in complex topics like 'Economic Evaluation' highlight the need for targeted educational improvements to better prepare students for healthcare economic decision-making., (© 2024. The Author(s).)

Introduction: In a previously published randomised, placebo-controlled trial, 800 mg/day of pharmaceutical-grade chondroitin sulfate (CS) was shown to be superior to placebo in reducing pain and improving function over 6 months in patients with symptomatic knee osteoarthritis (OA). The aim of the current post hoc analyses was to evaluate the cost-effectiveness of CS compared with placebo in a European perspective using individual patient data from this clinical trial., Methods: Patients with knee OA randomised to CS or placebo were followed up at 1, 3 and 6 months. The algo-functional Lequesne index was used to derive the EuroQol Five-Dimension Five-Level (EQ-5D-5L) score based on a validated formula. The EQ-5D-5L scores at each time point were used to calculate the changes in quality-adjusted life years (QALYs) with the area under the curve method. Costs were assessed using the average price of CS in the countries where the original study took place and where CS is currently marketed. The costs of CS in three countries were then used (i.e. the Czech Republic, Italy and Switzerland). The incremental cost-effectiveness ratio (ICER) threshold for CS to be considered cost-effective was set at 91,870 EUR per QALY (equivalent to the usually recommended threshold of US $100,000). The study used an intention-to-treat population, i.e. patients who received one dose of the study drug, and imputed missing values using the basal observation carried forward method., Results: No significant differences in baseline characteristics were observed between the CS group (N = 199) and the placebo group (N = 205). The mean cost of CS for 6 months of treatment was 194.74 EUR. After 6 months of treatment, CS showed a mean ICER of 33,462 (95% CI 5130-61,794) EUR per QALY gained, indicating cost-effectiveness compared with placebo. The acceptability curve for cost-effectiveness shows that the CS treatment is likely to be cost-effective compared with placebo, with a 93% probability when the ceiling ratio is set at 91,870 EUR per QALY gained., Conclusions: These results highlight the role of CS as a cost-effective therapeutic option in the management of OA. However, further studies taking into account the use of other healthcare resources are warranted for a more complete understanding., (© 2024. The Author(s).)

Objectives: This study aimed to assess the productivity loss and cost due to maternal ill-health conditions and its associated factors throughout pregnancy in rural Sri Lanka., Design: A follow-up study of women registered in the Rajarata Pregnancy Cohort (RaPCo)., Setting: Anuradhapura district, Sri Lanka., Participants: 1573 pregnant women who were followed up from pregnancy identification to termination., Primary and Secondary Outcome Measures: The primary outcome measures of this study are productivity loss due to maternal ill-health conditions expressed by days/month and productivity cost due to maternal ill-health conditions expressed in monetary terms (US$)/month. Data were collected monthly, and all pregnant women were asked to report the leading cause of maternal ill-health condition and the associated loss due to absenteeism and presenteeism., Results: During the pregnancy follow-up, 3595 (81.5%) months had at least one episode of maternal ill-health condition. Of these, only 1729 (48.1%) episodes sought medical care. Assistance for lost routine work was reported in 1281 (35.6%) episodes. The absenteeism, presenteeism and gross and net productivity loss per month were 3.6, 4.5, 8.1 and 5.5 days/month, respectively. The corresponding productivity cost was US$15.26/month. Nausea and vomiting (NVP) reported the highest prevalence (n=1599, 44.5%) until the second month of the third trimester, presenteeism (5.5 days/month) and gross productivity loss (9.5 days/month). Pregnant women with vaginal bleeding reported the highest absenteeism (6.2 days/month) and net productivity loss (6.8 days/month). Pregnant women diagnosed with anaemia reported the highest productivity cost (US$26.98/month). Monthly household expenditure, poverty and receiving assistance were the associated factors of productivity loss (p<0.05)., Conclusion: Maternal ill-health conditions during pregnancy lead to productivity loss in rural Sri Lanka. NVP, vaginal bleeding and anaemia are the leading causes of productivity loss. Hence, controlling and preventing the leading causes are the recommended priorities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Analysing and evaluating how efficiently health resources are allocated to county-level Traditional Chinese Medicine (TCM) hospitals in Zhejiang Province, this study aims to provide empirical evidence for improving operational efficiency and optimising resource allocation in these hospitals., Design and Setting: The study employed a three-stage Data Envelopment Analysis (DEA) model to assess efficiency, using data from 68 county-level TCM hospitals. Four input and five output variables related to TCM services were selected for the analysis., Results: The first-stage DEA results indicated that in 2022, the technical efficiency (TE) of TCM hospitals in Zhejiang Province was 0.788, the pure technical efficiency (PTE) was 0.876 and the scale efficiency (SE) was 0.903. The classification of hospitals into four groups based on the bed size showed statistically significant differences in returns to scale (p<0.001). The Stochastic Frontier Analysis regression results were significant at the 1% level across four regressions, showing that environmental variables such as per capita GDP, population density and the number of hospitals impacted efficiency. In the third stage DEA, after adjusting the input variables, the TE, PTE and SE improved to 0.809, 0.833 and 0.917, respectively. The adjusted mean TE rankings by region were West (0.860) > East (0.844) > South (0.805) > North (0.796) > Central (0.731)., Conclusion: There is an imbalance between the inputs and outputs of county-level TCM hospitals. Each region must consider factors such as the local economy, population and medical service levels, along with the specific development characteristics of hospitals, to reasonably determine the scale of county-level TCM hospital construction. Emphasis should be placed on improving hospital management and technical capabilities, coordinating regional development, promoting the rational allocation and efficient use of TCM resources and enhancing the efficiency of resource allocation in county-level TCM hospitals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To explore the research trends and hotspots of health economics evaluations of patients with chronic fatigue syndrome., Methods: To explore the research trends and hotspots of health economics evaluations of chronic fatigue syndrome, 180 articles published between 1991 and 2024 were visualized and analyzed via CiteSpace 6.3 software. R3 and VOSviewer1.6.20 and R4.3.3. The content includes annual publication volume, journal distribution, author country, publishing organization, author collaboration, citation analysis, and keyword analysis in 7 aspects., Results: Fewer studies have evaluated the health economics of individuals with chronic fatigue syndrome in China and abroad, Chinese studies are especially rare, and research results in the UK are mostly found in other countries. Moreover, cooperation and linkages between institutions, as well as between authors, are not yet strong., Conclusion: The hotspot of health economics evaluation methods in this field is cost-effectiveness analysis, and the hotspot of diagnosis and treatment methods is cognitive‒behavioral therapy. We also found that chronic fatigue syndrome may also have a strong potential association with depression from the perspective of health economics. Health economic evaluations of multiple treatments should be conducted simultaneously to increase attention to this field and provide a reference basis for low-cost and high-quality diagnostic and treatment programs., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Wan et al.)

Introduction: An adequate health workforce (HWF) is essential to achieving the targets of the Sustainable Development Goals (SDG), including universal health coverage. However, weak HWF planning and constrained fiscal space for health, among other factors in the WHO Africa Region, has consistently resulted in underinvestment in HWF development, shortages of the HWF at the frontlines of service delivery and unemployment of qualified and trained health workers. This is further compounded by the ever-evolving disease burden and reduced access to essential health services along the continuum of health promotion, disease prevention, diagnostics, curative care, rehabilitation and palliative care., Methods: A stock and flow model based on HWF stock in 2022, age structure, graduation and migration was conducted to project the available stock by 2030. To estimate the gap between the projected stock and the need, a population needs-based modelling was conducted to forecast the HWF needs by 2030. These estimations were conducted for all 47 countries in the WHO African Region. Combining the stock projection and needs-based estimation, the modelling framework included the stock of health workers, the population's need for health services, the need for health workers and gap analysis expressed as a needs-based shortage of health workers., Results: The needs-based requirement for health workers in Africa was estimated to be 9.75 million in 2022, with an expected 21% increase to 11.8 million by 2030. The available health workers in 2022 covered 43% of the needs-based requirements and are anticipated to improve to 49% by 2030 if the current trajectory of training and education outputs is maintained. An increase of at least 40% in the stock of health workers between 2022 and 2030 is anticipated, but this increase would still leave a needs-based shortage of 6.1 million workers by 2030. Considering only the SDG 3.c.1 tracer occupations (medical doctors, nurses, midwives, pharmacists and dentists), the projected needs-based shortage is 5.3 million by 2030. In sensitivity analysis, the needs-based shortage is most amenable to the prevalence of diseases/risk factors and professional standards for service delivery CONCLUSIONS: The WHO African Region would need to more than double its 2022 HWF stock if the growing population's health needs are to be adequately addressed. The present analysis offers new prospects to better plan HWF efforts considering country-specific HWF structure, and the burden of disease., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Aims: The aim of this study is to examine the characteristics and quality of economic evaluations for reimbursed medical devices in Japan., Materials and Methods: A pragmatic review of cost-effectiveness evaluations (CEA) and other economic evaluations for medical devices reimbursed in Japan published between January 2010 and December 2023 was conducted using the PubMed (Medline), Japan Medical Abstracts Society (ICHUSHI Web), and the Cost-Effectiveness Analysis Registry of the Tufts Medical Center databases - as well as Google Scholar. Evaluations for devices assessed under the health technology assessment (HTA) system in Japan were also reviewed., Results: Thirty-nine published studies were included with 20 studies (51%) for devices used to treat cardiovascular conditions, 7 studies (18%) for devices used to treat neurological/neurovascular conditions and orthopedic conditions, respectively, and 5 studies (13%) for devices used to treat other types of conditions. The number of published studies for reimbursed medical devices increased from 2017. Nearly 60% of the studies were cost-utility analyses and many were cost-consequence analyses (26%). Although the quality of the studies conducted were good, lack of data was mentioned as a key limitation of nearly all studies - with limited data in general (33%), lack of long-term outcomes data (33%), and lack data for Japan (21%) being key issues. Moreover, lack of cost data was mentioned as a limitation for nearly half (49%) of studies., Limitations: As this was not a systematic literature review, some relevant studies may have been excluded. Moreover, some databases that are known to cover other journals were not used., Conclusions: Despite concerns about lack of sufficient outcomes data, good quality CEAs have been published for reimbursed devices in Japan. However, lack of data may still be an issue and the impact of the learning curve effect on cost-effectiveness may need to be considered more.

Introduction: Aid harmonisation is a key component of donor efforts to make aid more effective by improving coordination and simplifying and sharing information to avoid duplication. This study evaluates the harmonisation of health and humanitarian aid in Syria during acute humanitarian and health crises from 2011 to 2019., Methods: Data on humanitarian and health aid for Syria between 2011 and 2019 was collected from the Organisation for Economic Cooperation and Development's Creditor Reporting System to assess the harmonisation of aid. The data was linked to four key indicators of the conflict: the number of internally displaced persons; the number of people in need of humanitarian assistance; the number or frequency of internal movements (displacements) by individuals; and the decline in Syria's population between 2011 and 2019. This was compared with data from highly fragile states and developing countries. Four focus group discussions, four key informants' interviews and three consultations with humanitarian practitioners were also conducted., Results: The findings suggest that overall aid harmonisation did not occur and importantly did not correlate with increased humanitarian needs. During the first 5 years, humanitarian and health pooled funds (which endorse aid harmonisation) in Syria were nearly entirely absent, far less than those in developing countries and highly fragile states. However, from 2016 to 2019, a visible surge in humanitarian pooled funds indicated an increase in the harmonisation of donors' efforts largely influenced by adopting the Whole of Syria approach in 2015 as a positive result of the cross-border United Nation (UN) Security Council resolution in 2014., Conclusion: Harmonisation of aid within the Syrian crisis was found to have little correlation with the crisis parameters and population needs, instead aligning more with donor policies. Assessing fragmentation solely at the donor level is also insufficient. Aid effectiveness should be assessed with the inclusion of community engagement and aid beneficiary perspectives. Harmonisation mechanisms must be disentangled from international politics to improve aid effectiveness. In Syria, this study calls for finding and supporting alternative humanitarian coordination and funding mechanisms that are not dependent on the persistent limitations of the UN Security Council., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Global disparities in valvular surgery services exist. Cost-effectiveness analysis (CEA) and cost-utility analysis can be used to guide national investment decisions. This scoping review aims to synthesize economic evaluations for valvular surgery by income settings and provide recommendations., Methods: A systematic literature review identified primary CEAs or CUAs in English comparing surgical management strategies for valvular heart disease. MEDLINE, Embase, CINAHL, Web of Science, and Business Source Complete were searched using keywords "valvular surgery," "valve disease," "cost-effectiveness," and "cost-benefit analysis". Articles comparing outcomes or costs only were excluded. Search results were uploaded and screened on COVIDENCE. Variables from eligible articles were charted in a spreadsheet., Results: Twenty articles were eligible, six from low- and middle-income countries (LMICs) and 14 from high-income countries (HICs). In HICs, the top conditions were degenerative aortic valve disease (7/14) and mitral valve disease (4/14) compared to congenital (2/6) and rheumatic heart diseases (2/6) in LMICs. HICs evaluated new technologies and techniques, whereas LMICs compared different valve types or surgery versus no intervention. Most articles used published studies (12/20) or databases (7/20) to conduct their CEA and quality-adjusted life years was the most common effectiveness measure (12/20). Comparator interventions were cost-effective in all LMIC articles and in 8/14 for HICs., Conclusion: Economic evaluations are mostly conducted in HICs and for adult conditions. More analyses in LMICs are needed. This can be facilitated by maintaining databases, documenting costs, and implementing quality of life assessments., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: The relative efficacy of information provision versus financial incentives in improving primary care quality remains a critical, unresolved question. We investigated these two strategies in Catalonia's public primary care system from 2010 to 2019: an innovative online platform providing real-time quality indicator information and targeted economic incentives for achieving indicator goals., Methods: We conducted a comprehensive interrupted time series regression analysis on data from 272 primary care practices (5,628,080 patients). This analysis used linear regression models with Newey-West standard errors, and a sensitivity analysis including logit transformations to address ceiling effects. We evaluated 1) immediate post-intervention changes (step changes) in indicator results and inter-practice variability (coefficient of variation, CV), and 2) shifts in pre-intervention trends (slopes). We scrutinized 39 indicators after rigorous quality control: 23 novel (12 informed, 11 incentivized) and 16 derived from existing incentivized indicators. Robustness checks included 14 consistently incentivized and 10 non-intervened indicators. Overall, we assessed 63 indicators: 18 control, 13 follow-up, 9 quaternary prevention, 7 treatment, 7 diagnosis, 6 screening and 3 vaccination indicators., Findings: Informed indicators showed positive impacts in 75% (9/12) of cases, and incentivized indicators in 64% (7/11) of cases. Incentivized indicators displayed improvements in annual trends ranging from 6.66 to 1.25 percentage points, with step changes up to 8.87 percentage points. Information led to step changes ranging from 19.67 to 1.07 percentage points, along with trend improvements between 1.09 and 0.34 percentage points annually. Both interventions were associated with step reductions in variability (up to -0.18 CV reduction) and significant trend improvements. Derived indicators showed limited improvements in results or variability (31%, 5/16), with minor step increases up to 2.22 percentage points., Interpretation: Our findings reveal that information provision alone can match or even surpass the impact of financial incentives in improving care quality and reducing practice variability. This challenges conventional wisdom and offers a cost-effective, scalable approach to primary care quality enhancement, with far-reaching implications for global health policy., Funding: European Union, Horizon Europe., Competing Interests: The authors declare no competing interests., (© 2024 The Author(s).)

The objective of this study is to characterize how financial hardship related to oral health care (OHC) out-of-pocket (OOP) spending has been conceptualized, defined, and measured in the literature and to identify evidence gaps in this area. This scoping review follows Arksey and O'Malley's framework and synthesizes financial hardship from OHC concepts, methodologies, and evidence gaps. We searched Ovid-Medline, Ovid-Embase, PubMed, Web of Science, Scopus, EconLit, Business Source Premier, and the Cochrane Library. Gray literature was sourced from institutional websites (World Health Organization, United Nations, World Bank Group, Organisation for Economic Co-operation and Development, and governmental health agencies) as well as ProQuest Dissertations and Thesis Global. We used defined inclusion and exclusion criteria to select studies published between 2000 and 2023. Of the 1,876 records, 65 met our criteria. The studies conceptualized financial hardship as catastrophic spending, impoverishment, negative coping strategies, bankruptcy, financial burden, food insecurity, and personal financial hardship experience. We found heterogeneity in defining OHC OOP payments and services. Also, financial hardship was frequently measured as catastrophic health expenditure using cross-sectional designs and national household spending surveys from high-income and to a lesser extent lower-middle-income countries. We identify and discuss challenges in terms of conceptualizing financial hardship, study designs, and measurement instruments in the OHC context. Some of the common evidence gaps identified include studying the causal relationship in financial hardship from OHC, assessing the financial hardship and unmet dental needs due to cost relationship, and distinguishing the effect between pain/discomfort and esthetic/cosmetic dental treatments on financial hardship. Financial hardship in OHC needs further exploration and the use of consistent definitions as well must distinguish between treatments alleviating pain/discomfort from esthetic/cosmetic treatments. Our study is relevant for policy makers and researchers aiming to monitor financial protection of OOP payments on OHC in the wake of universal health coverage for oral health., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To evaluate whether having previously disenrolled from Medicare Advantage (MA) is associated with lower hazards of future MA enrollment., Data Sources and Study Setting: Secondary data from Medicare., Study Design: We examined beneficiaries with baseline FFS enrollment from 2017-2019 using a 20% sample of Medicare claims. Cox proportional hazard models were used to examine the association of prior MA enrollment (in the three years prior to baseline FFS enrollment) with MA re-enrollment, and whether this association is modified by Alzheimer's Disease and Related Dementias (ADRD), prior nursing home use, chronic illness, dual eligible status, and availability of MA plans and quality., Data Collection: Not applicable., Principal Findings: Overall, 3.3% of beneficiaries switched to MA annually. Of those with prior MA enrollment, MA switching percentages were 9.0%, 4.6%, and 6.8% for those whose most recent MA enrollments were 1, 2, and 3 years prior to their baseline FFS year. Comparatively, the switching percentages was 3.2% for those with no prior MA enrollment. The hazards of switching to MA were 2.73 (p < 0.001), 1.29 (p < 0.001), and 1.97 (p < 0.001) times greater than remaining in FFS for beneficiaries whose most recent MA enrollments were one, two, and three years prior to their baseline FFS year. Hazards of switching were generally similar between those with and without ADRD, stratified by recency in prior MA experience, except those with dual eligibility. Among those with ADRD, switching hazards were greatest for 3 years prior MA enrollees in counties with the fewest available (HR: 3.84, p < 0.001) and lowest-rated plans (HR: 4.02, p < 0.001)., Conclusions: Recency of switching from MA to FFS was the strongest predictor of a FFS-to-MA switch, identifying a population of beneficiaries who multiply switch regardless of health status or MA access. Future health policy considerations should more closely examine the vulnerabilities and long-term outcomes of this population., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Introduction: Measuring social value has always been a challenge for organizations that generate such value, including foundations, NGOs, social enterprises, and governmental entities. Often, the benefits of these initiatives are perceived as intangible or long-term, making them difficult to quantify. Assessing social value demonstrates the impact of investments and accountability to stakeholders.Healthcare organizations should be evaluated from a broad perspective, where the quality of healthcare services is an integral part of the social value with multiple beneficiaries.This study aims to determine the economic and social impact of Hospital Santa Marina on the Bizkaia (Basque Country) population in 2023, as well as to evaluate the evolution of the hospital's social value from 2018 to 2023., Materials and Methods: The study was conducted from the multifaceted perspective of social accounting (stakeholder theory), utilizing the Social Return on Investment (SROI) tool. The economic value of the hospital (both direct and indirect) and the hospital's specific social value were calculated based on areas identified by stakeholders. Subsequently, the hospital's integrated social value and socio-emotional value were determined., Results: The hospital contributed €34,696,178.20 to society in Direct and Indirect Market Social Value (SROI), and the Non-Market Social Value amounted to €119,758,230.71. This generated an integrated social value of the hospital of €154,454,408.91, which, considering the satisfaction index for the year 2023 was 0.9805, leads to a socio-emotional value of €211,998,238.76., Conclusions: Hospital Santa Marina generates significant economic value for the society, beyond its direct contribution to the population's health. These findings underscore the importance of adopting a broader perspective on health and highlight the role of healthcare institutions as drivers of sustainable development., (Copyright © 2024 FECA. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Cannabis-based medicinal products (CBMPs) are increasingly demonstrating effectiveness in treating a wide range of conditions, with a relatively high safety profile in clinical usage compared to other prescription pain medications and few contraindications. Consultation and other prescription-related costs are, at present, higher for CBMPs than for some other treatment options, leading to some concern around wider prescribing., Research Design and Methods: An early cost-effectiveness model was developed to estimate the impact of prescribing CBMPs alone and/or in addition to analgesics, physiotherapy, and cognitive behavioral therapy for chronic pain in the UK for 1 year., Results: Due to their comparative effectiveness, CBMPs were found to be cost saving. Various scenarios were model tested; in all scenarios where CBMPs decrease pain-level states, less resource use is required. Increased efficacy of 5% was conservatively assumed based on current Real-World Evidence. In this scenario, CBMPs were significantly more cost-effective, and as costs relating to the prescribing of these continue to fall, relative savings are predicted to increase., Conclusion: These findings highlight the substantial cost saving that CBMPs may represent for the treatment of chronic pain patients, and the benefits for healthcare providers as a treatment for this often hard-to-treat population.

Introduction: The number of adolescents seeking professional help for depression is increasing and, despite advances in treatment, large unmet treatment needs remain. In the current protocol, we describe the design and methodology of a randomised controlled trial (RCT) to evaluate the clinical efficacy of two forms of internet-delivered behavioural activation (I-BA), with and without therapist support, in reducing depressive symptoms, compared with treatment as usual (TAU). Secondary objectives include examining the 12-month maintenance of the treatment effects and conducting a health economic evaluation of the interventions., Methods and Analysis: In this single-blinded RCT, we aim to include 215 participants aged 13-17 years with mild to moderate depression who will be randomised (1:1:1 ratio) to 10 weeks of either therapist-guided or self-guided I-BA, or TAU provided by regular mental health clinics. Data will be collected at baseline, weekly for the initial 10 weeks, post-treatment and at 3 and 12-month follow-ups. The primary endpoint is the 3-month follow-up. The primary outcome is blinded clinician-rated severity of depressive symptoms, measured by the Children's Depression Rating Scale-Revised. Treatment response is defined as a score of 'Much improved' or 'Very much improved' on the Clinical Global Impression-Improvement Scale, administered at the primary endpoint. Outcome assessors will be blinded to treatment conditions at all assessment points. A health economic evaluation of I-BA will be performed, both in the short term (primary endpoint) and the long term (12-month follow-up)., Ethics and Dissemination: Ethical approval was obtained from the Swedish Ethical Review Authority in June 2021. The final participant was enrolled on 3 May 2024 and expected to reach the primary endpoint by November 2024. The results of this study will be disseminated through publication in peer-reviewed journals, presented at conferences and communicated to healthcare providers and the public., Trial Registration Number: NCT04977856., Competing Interests: Competing interests: DM-C receives royalties for contributing articles to UpToDate, outside the current work. DM-C and ES are part owners of Scandinavian E-Health AB. Scandinavian E-Health AB was not involved in the funding, design, interpretation of study results or writing of the manuscript., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The cost of implementation is typically not accounted for in published economic evaluations, which determine the relative value for money of health innovations and are important for allocating scarce resources. Despite key papers outlining relevant implementation costs, they continue to be under reported in the literature and often not considered in practice. This study sought to understand and outline current practices for capturing the costs associated with implementation efforts, with examples from the digital health setting., Methods: A qualitative study of semi-structured interviews with purposefully sampled experts in implementation science, health economics and/or digital health was conducted. The interview guide was informed by a literature review and was pilot tested. Interviews were digitally recorded and transcribed. A hybrid inductive/deductive framework analysis was conducted using thematic analysis to elicit key concepts related to the research question., Results: Interviews were conducted with sixteen participants with specialist expertise in implementation science (n = 8), health economics (n = 6), and/or digital health (n = 8). Five participants were experienced in more than one field. Four key themes were elicited from the data: difficulty identifying and collecting implementation cost data; variation in approaches for collecting implementation cost data; the value of implementation costs; and collaboration enables implementation costing. Broadly, while interviewees recognised implementation costs as important, only some costs were considered in practice likely due to the perceived ill-defined boundaries and inconsistencies in terminology. A variety of methods were used to collect and estimate implementation costs; the most frequent approach was staff time tracking. Multidisciplinary collaboration facilitated this process, but the burden of collecting the necessary data was also highlighted., Conclusions: In current practice, standardised methods are not commonly used for data collection or estimation of implementation costs. Improved data collection through standardised practices may support greater transparency and confidence in implementation cost estimates. Although participants had industry exposure, most were also academic researchers and findings may not be representative of non-academic industry settings., (© 2024. The Author(s).)

Aims: There is increasing concern over the mental distress of youth in recent years, which may impact mental healthcare utilisation. Here we aim to examine temporal patterns of mental healthcare expenditures in the Netherlands by age and sex in the period between 2015 and 2021., Methods: Comprehensive data from health insurers in the Netherlands at the 3-number postal code level were used for cluster weighted linear regressions to examine temporal patterns of mental healthcare expenditure by age group (18-34 vs 35-65). The same was done for medical specialist and general practitioner costs. Additionally, we examined interactions with gender, by adding the interaction between age, year and sex to the model., Results: Mental healthcare costs for younger adults (18-34) were higher than those for older adults (35-65) at all time points (β = 0.22, 95%-CI = 0.19; 0.25). Furthermore there was an increase in the strength of the association between younger age and mental healthcare costs from β = 0.22 (95%-CI = 0.19; 0.25) in 2015 to β = 0.37 (95%-CI = 0.35; 0.40) in 2021 ( p < 0.0001) and this was most evident in women ( p < 0.0001). Younger age was associated with lower general practitioner costs at all time points, but this association weakened over time. Younger age was also associated with lower medical specialist costs, which did not weaken over time., Conclusions: Young adults, particularly young women, account for an increasing share of mental healthcare expenditure in the Netherlands. This suggests that mental distress in young people is increasingly met by a response from the medical system. To mitigate this trend a public mental health approach is needed.

Objective: In high HIV-burden countries like Uganda, financing and resource allocation for HIV services have rapidly evolved. This study aimed to employ time-driven activity-based costing (TDABC) to examine the allocation of resources and associated costs for HIV care throughout the country., Design: A cross-sectional study., Setting: This study was conducted at 31 health facilities throughout Uganda: 16 level III health centres, 10 level IV health centres and 5 district hospitals., Participants: 1119 persons receiving HIV services in 2020., Methods: We conducted TDABC to quantify costs, resource consumption and duration of service provision associated with antiretroviral therapy, prevention of mother-to-child transmission, HIV counselling and testing (HCT), voluntary medical male circumcision (VMMC) and pre-exposure prophylaxis. We also quantified disparities in resource consumption according to client-level and facility-level characteristics to examine equity. Fixed-effects multivariable regression analyses were employed to inspect factors associated with service costs and provider-client interaction time., Results: The mean cost of services ranged from US$8.18 per visit for HCT to US$32.28 for VMMC. In terms of disparities, those in the Western region received more provider time during visits compared with other regions (35 more minutes, p<0.001); and those receiving care at private facilities received more provider time compared with public facilities (13 more minutes, p=0.02); and those at level IV health centres received more time compared with those at level III (12 more minutes, p=0.01). Absent consumables, services for older adults (US$2.28 higher, p=0.02), those with comorbidities (US$1.44 higher, p<0.001) and those living in the Western region (US$2.88 higher, p<0.001) were more expensive compared with younger adults, those without comorbidities and those in other regions, respectively. Inclusive of consumables, services were higher-cost for individuals in wealthier households (US$0.83 higher, p=0.03) and those visiting level IV health centres (US$3.41 higher, p=0.006) compared with level III., Conclusions: Costs and resources for HIV care vary widely throughout Uganda. This variation requires careful consideration: some sources of variation may be indicative of vertical and horizontal equity within the health system, while others may be suggestive of inequities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources., Objective: To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings., Methods: The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Six databases (PubMed, EMBASE, Global Health, Cochrane, Global Index Medicus, and Tuft's Cost-Effectiveness Registry) were searched in September 2023. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints., Results: Four hundred and sixty-eight unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in termination of resuscitation protocols, professional prehospital defibrillator use, and CPR training followed by the distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment., Conclusion: Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings., (© 2024. The Author(s).)

Introduction: The COVID-19 pandemic led to a decline in fertility rates worldwide. Although many regions have experienced a temporary drop in fertility rates with the spread of the infection, subsequent recovery has varied across countries. This study aimed to evaluate the impact of COVID-19 infection rates and regional sociodemographic factors on the recovery of fertility rates in Japan following the state of emergency., Methods: This study examined prefectural fertility data from before the COVID-19 pandemic to forecast fertility rates up to 2022 using a seasonal autoregressive integrated moving average model. A regression analysis was conducted on fertility rates during the first state of emergency and the subsequent recovery rate with respect to the number of new COVID-19 cases and sociodemographic factors specific to each prefecture., Results: During the first state of emergency, the monthly fertility rate decreased by an average of -13.8% (SD: 6.26, min: -28.78, max: 0.15) compared with the previous year. Over the following 22 months, the average fertility recovery rate was +2.31% (SD: 3.57; min: -8.55, max: 19.54). Multivariate analysis of the impact of the pandemic on fertility changes during the first emergency indicated a negative correlation between new COVID-19 cases per capita and the proportion of nuclear households. No significant correlation was found between fertility recovery rate and new COVID-19 cases or emergency duration. When classifying fertility rate fluctuation patterns before and after the emergency into four clusters, variations were noted in the proportion of the elderly population, marriage divorce rate and the number of internet searches related to pregnancy intentions across the clusters., Conclusions: No association was found between pregnancy intentions related to the spread of infection, such as the number of new cases and the fertility recovery rate following the first state of emergency. Differences in the patterns of decline and recovery during the pandemic were observed based on population composition and internet searches for infection and pregnancy across different prefectures., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: A significant burden of unmet pediatric surgical disease exists in low- and middle-income countries. We sought to assess the associations between the installation of a pediatric operating room (OR) and clinical and economic outcomes for families with children in Ethiopia., Methods: A retrospective cohort study was performed of children who underwent elective surgery in a tertiary-level Ethiopian public hospital, comparing patient outcomes before and after OR installation in August 2019. Clinical data were collected via chart review, and an inpatient economic survey was administered to patient caregivers. Interrupted time series analysis investigated trends in surgical volume over time. The relative economic benefit was determined by comparing the patients' household income to the monetary health benefit gained using the value of statistical life method., Results: One thousand one hundred and ninety-six patients were included from August 2018 to July 2022. Surgery averted 20,541 disability-adjusted life years (DALYs) cumulatively or 17 DALYs per patient. Monthly case volume and DALYs averted significantly increased postinstallation. The median annual household income of the economic survey responders (n = 339) was $1337 (IQR 669-2592). 27.7% (n = 94/339) lived in extreme poverty, and 41.3% (n = 140/339) experienced catastrophic healthcare expenditure. Net monetary health benefit was $29.3 million or $26,646 per patient. The ratio of net monetary health benefit to household annual income was 60:1., Conclusions: Installing a pediatric OR in a public Ethiopian hospital ensures increased access to surgery for those most impoverished in Ethiopia and improves equitable access to surgical care. Greater investment in expanding pediatric surgical infrastructure can help address global inequities in child health., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Assessing the methodological quality of economic evaluations (EEs) is crucial for evidence-based decision-making. The study aimed to evaluate EEs in restorative dentistry and endodontics, while also analyzing the scientific landscape of researchers and publications through co-authorship and citation network analysis providing an insight into the distribution of scientific expertise., Methodology: A systematic search for relevant articles from 2012 to 2022 was conducted using PubMed, Scopus, and EBSCO. The ten-point Drummond checklist was used to appraise the methodological quality of included studies. Bibliometric data for network analysis were extracted from the Dimensions database and visualized using VOSviewer software., Results: Of the 37 articles, 81.08% scored good, 16.21% average, and 2.7% poor on the methodological rating scale. Most of the included studies were in Q1 journals, with limited representation in Q2 and Q3 journals. Compliance was highest in Q2 journals (95%), followed by Q1 (88.36%), while it dropped to 40% for Q3 journals. Co-authorship analysis revealed a dense network of researchers, with Prof. Falk Schwendicke V. having a significant influence. Moreover, the Journal of Dentistry had the highest impact, followed by Journal of Endodontics and BMC Oral Health., Conclusions: Despite a diverse scientific landscape, participation from developing countries was limited emphasizing the need for inclusivity and diversity in the scientific network. While the quantity of good-quality studies was encouraging, the overall quality of evidence remains paramount for decision-making in healthcare policy and practice. Therefore, continuous efforts to improve methodological rigor and reporting practices are essential to contribute robust evidence., (© 2024. The Author(s).)

Aim: Estimate patient counts, treatment patterns and outcomes of a subset of patients with early breast cancer (EBC) presenting with hormone receptor positive, human epidermal growth factor receptor 2 negative, node positive features, who are at high-risk of recurrence, in Taiwan. Materials & methods: Data from Taiwan's National Health Insurance Research Database and Taiwan Cancer Registry from 1 January 2011 to 31 December 2020 were analyzed. Results: There were 4500 patients with high-risk EBC (10.4% of all patients with EBC) from 2012 to 2018, with an annual average incidence of 643 that increased over time. Five-year progression was 24.8% in patients with high-risk EBC and 8-year survival was low (69.6%). Conclusion: Patients with hormone receptor positive, human epidermal growth factor receptor 2 negative, node positive high-risk EBC clinical features are an increasing high-risk subset of all patients with EBC.

In the context of the Chinese government's advocacy for "Internal Circulation", ongoing reforms in medical insurance policies raise critical questions about whether the basic medical insurance system can stimulate resident consumption and enhance its quality. Based on five waves of panel data from the China Health and Retirement Longitudinal Survey (CHARLS), this paper analyzes the impact of medical insurance on the consumption scale and structure of middle-aged and older adult rural residents by using the time-varying difference-in-differences (time-varying DID) method. The findings indicate that the Urban-Rural Resident Basic Medical Insurance (URRBMI) effectively stimulates the consumption scale of rural middle-aged and older adult individuals, particularly enhancing non-food consumption, development-oriented spending, and hedonic consumption. This, in turn, optimizes the consumption structure and improves overall consumption quality. Notably, URRBMI significantly enhances the consumption scale and structure among rural middle-aged and older adult women, unmarried individuals, and residents in western China. These results suggest that URRBMI plays a crucial role in alleviating consumption inequality within rural areas and across different regions, providing a theoretical foundation for policy-making., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zhou and Ping.)

Aims: Exemplify the potential of using health economy modeling and simulations to support and optimize wound dressing purchasing decisions., Materials and Methods: We developed a Markov cost-effectiveness modeling framework fusing clinical and industry sources of healing and cost outcomes for evaluating dressings, focusing on polymeric membrane dressings compared to passive foam dressings without active inflammation modulation components. We calculated the wound care costs for patients with and without diabetes, as well as for infected and non-infected wounds, to illustrate the effectiveness of this model in supporting decision-making., Results: The model results demonstrated that polymeric membrane dressings reduce the cumulative treatment costs compared to passive foam dressings, due to fewer dressing changes and lower associated labor costs, regardless of the initial product price differences., Conclusion: Cost-effectiveness calculations should be performed in healthcare facilities to support purchasing decisions based on true cost analyses. Making purchasing decisions focusing on the dressing price alone may provide wrong estimates of the real cost differences., Competing Interests: Declaration of competing interest This work was partially supported by the Israeli Ministry of Science & Technology (Medical Devices Program Grant no. 3-17421, awarded to Professor Amit Gefen in 2020) and by an unrestricted educational grant from Ferris Mfg. Corp. (Fort Worth, TX, USA)., (Copyright © 2024 Tissue Viability Society / Society of Tissue Viability. Published by Elsevier Ltd. All rights reserved.)

Background: Cost-effectiveness evidence is a critical tool to support resource allocation decisions. There is growing recognition that the development of benefit packages for surgical care should be guided by such evidence, particularly in resource-constraint settings., Methods: We conducted a systematic review of evidence (Medline, Embase, Global Health, EconLit and grey literature) on the cost-effectiveness of surgery across low-income and middle-income countries published between January 2013 and January 2023. We included studies with minor and major therapeutic surgeries and minimally invasive intraluminal and endovascular interventions. We computed and compared the average cost-effectiveness ratios (ACERs) for different surgical interventions to the respective national gross domestic product per capita to determine cost-effectiveness and to common traditional public health interventions., Results: We identified 87 unique studies out of 20 070 articles screened. Studies spanned 23 countries, with China (n=20), Thailand (n=12), Brazil (n=8) and Iran (n=8) accounting for about 55% of the evidence. Overall, the median ACERs across procedure groups ranged from I$17/disability-adjusted life year (DALY) for laparotomies to I$170 186/DALY for bariatric surgeries. Most of the ACER estimates were classified as cost-effective (89%) or very cost-effective (76%). Low-complexity surgical interventions compared favourably to common public health interventions., Conclusion: These findings reinforce the growing body of evidence that investments in surgery are economically smart. There remains however paucity of high-quality evidence that would allow decision-makers to assess the comparative cost-effectiveness of surgery and to determine best buys across a wide range of specialties and interventions. A concerted effort is needed to advance the generation and utilisation of economic evidence in the drive towards scale-up of surgical care across low-income and middle-income countries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The use and value of artificial intelligence (AI)-driven tools and techniques are under investigation in detecting coronary artery disease (CAD). EchoGo Pro is a patented AI-driven stress echocardiography analysis system produced by Ultromics Ltd. (henceforth Ultromics) to support clinicians in detecting cardiac ischaemia and potential CAD. This manuscript presents the research protocol for a field study to independently evaluate the accuracy, acceptability, implementation barriers, users' experience and willingness to pay, cost-effectiveness and value of EchoGo Pro., Methods and Analysis: The 'Evaluating AI-driven stress echocardiography analysis system' (EASE) study is a mixed-method evaluation, which will be conducted in five work packages (WPs). In WP1, we will examine the diagnostic accuracy by comparing test reports generated by EchoGo Pro and three manual raters. In WP2, we will focus on interviewing clinicians, innovation/transformation staff, and patients within the National Health Service (NHS), and staff within Ultromics, to assess the acceptability of this technology. In this WP, we will determine convergence and divergence between EchoGo Pro recommendations and cardiologists' interpretations and will assess what profile of cases is linked with convergence and divergence between EchoGo Pro recommendations and cardiologists' interpretations and how these link to outcomes. In WP4, we will conduct a quantitative cross-sectional survey of trust in AI tools applied to cardiac care settings among clinicians, healthcare commissioners and the general public. Lastly, in WP5, we will estimate the cost of deploying the EchoGo Pro technology, cost-effectiveness and willingness to pay cardiologists, healthcare commissioners and the general public. The results of this evaluation will support evidence-informed decision-making around the widespread adoption of EchoGo Pro and similar technologies in the NHS and other health systems., Ethics Approval and Dissemination: This research has been approved by the NHS Health Research Authority (IRAS No: 315284) and the London South Bank University Ethics Panel (ETH2223-0164). Alongside journal publications, we will disseminate study methods and findings in conferences, seminars and social media. We will produce additional outputs in appropriate forms, for example, research summaries and policy briefs, for diverse audiences in NHS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: One million people in England and Wales experience sexual violence and abuse each year, with nearly half experiencing serious sexual offences; around 30,000 survivors access sexual assault referral centres., Objectives: This research was commissioned by National Institute for Health and Care Research to evaluate access, interventions and care pathways for survivors, especially those provided through sexual assault referral centres., Design, Setting, Participants: The sexual assault referral centres care pathway was investigated through six sub-studies. There were two Cochrane Reviews (4274 participants). Seventy-two providers and 5 survivors were interviewed at eight sites; the children and young people study involved 12 participants from two sexual assault referral centres. A cohort study involving three-wave data collection over 1 year (21 sites; 2602 service users screened, 337 recruited) used a multilevel modelling framework to explore risk factors for burden of post-traumatic stress disorder symptoms at baseline and change at 1 year. We analysed costs and outcomes and conducted a narrative analysis (41 survivors). We worked closely with survivors and prioritised the safety/welfare of participants and researchers., Results: Cochrane Reviews identified large effects from psychosocial interventions for post-traumatic stress disorder and depression. Sexual assault referral centres delivered a high-quality frontline service for survivors but groups experiencing domestic abuse and some ethnic and cultural minorities were under-represented. The qualitative research emphasised inter-agency collaboration for survivor benefit. The cohort study identified a risk 'triad' of adverse childhood experiences, poor mental health and economic deprivation, which was associated with baseline trauma burden. There were important improvements in trauma symptoms a year later. These improvements were unrelated to different sexual assault referral centre models. Costs and other outcomes were also similar across models. Harmful policing and justice practices/procedures were identified by 25% of participants. In this context, trauma-competent interviewing techniques, regular/timely updates and conveying case decisions with care signalled good practice., Limitations: The cohort study lacked a comparison group, reducing confidence in the finding that access to sexual assault referral centres explained the reduction observed in post-traumatic stress disorder., Conclusions and Future Work: Barriers to access call for concerted efforts to implement trauma-informed universal health services. The risk 'triad' underscores the value of holistic approaches to care at sexual assault referral centres and timely follow-on care. Poor mental health was the main barrier to service access beyond sexual assault referral centres. The persistence of trauma symptoms a year after accessing sexual assault referral centres signals urgent need for tackling counselling wait-lists, expanding support options and commitment to lifelong care. Multidisciplinary evaluation of sexual assault referral centres for better health provides a foundation for advancing trauma-informed practices in the context of sexual violence and abuse., Study Registration: This study is registered as ISRCTN30846825 https://doi.org/10.1186/ISRCTN30846825., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/117/04) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 35. See the NIHR Funding and Awards website for further award information.

Aim: To assess the cost-effectiveness of a digital diabetes prevention programme (d-DPP) compared with a diabetes prevention programme (DPP) for preventing type 2 diabetes (T2D) in individuals with prediabetes in the United States., Methods: A Markov cohort model was constructed, simulating a 10-year period starting at the age of 45 years, with a societal and healthcare sector perspective. The effectiveness of the d-DPP intervention was evaluated using a meta-analysis, with that of the DPP as the comparator. The initial cycle represented the treatment period, and transition probabilities for the post-treatment period were derived from a long-term lifestyle intervention meta-analysis. The onset of T2D complications was estimated using microsimulation. Quality-adjusted life years (QALYs) were calculated based on health utility measured by short form (SF)-12 scores, and a willingness-to-pay threshold of $100 000 per QALY gained was applied., Results: The d-DPP intervention resulted in cost savings of $3,672 from a societal perspective and $2,990 from a healthcare sector perspective and a gain of 0.08 QALYs compared with the DPP. The dropout rate was identified as a significant factor influencing the results. Probabilistic sensitivity analysis showed that the d-DPP intervention was preferred in 85.8% in the societal perspective and 85.2% in the healthcare sector perspective., Conclusions: The d-DPP is a cost-effective alternative to in-person lifestyle interventions for preventing the development of T2D among individuals with prediabetes in the United States., (© 2024 The Author(s). Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Background: Clostridioides difficile is the most common cause of healthcare-associated diarrhea. Research suggests that treating C. difficile infections (CDI) with fidaxomicin (FDX) is more effective than vancomycin (VAN), with potential cost savings. The objective was to calculate the budget impact of FDX treatment compared to VAN from a German payer perspective., Research Design and Methods: The analysis used real-world data of patients discharged from University Hospital Cologne between Jan-01-2018 and Dec-31-2019. We identified recurrent and non-recurrent CDI cases and calculated direct treatment costs based on G-DRG flat rates. To calculate average costs per treatment and the budget impact, recurrence probabilities for VAN and FDX were taken from published evidence (28-day and 90-day scenarios)., Results: Totally, 475 cases were analyzed, thereof 421 non-recurrent, causing mean costs of €32,901 per case (95% CI: 27.752-38.050). Thirty-two patients experienced a recurrence within 28 days, yielding mean costs of €10,952 (95% CI: 5.627-16.277) for their additional hospital stay. The resulting budget impact was €1,303 (95% CI: 670-1.937) in favor of FDX, ranging from €148.34 to €2,190.30 in scenario analyses., Conclusion: The analysis indicates FDX treatment can lead to cost savings compared to VAN. Future research should focus on specific patient groups, such as refractory CDI patients.

Study Objective: Identify changes and trends in the real value of Medicare payments for anesthesia services between 2000 and 2020 and how it may affect practices., Design: Retrospective analysis., Setting: We utilized the Physician/Supplier Procedure Summary (PSPS) datasets of Medicare Part B claims to identify high volume anesthesia services in 2020 with 20 years of data. The Consumer Price Index was used as a measure of inflation to adjust prices., Patients: The PSPS datasets contain summaries of all annual Medicare Part B claims and payment amounts by carrier and locality., Interventions: Patients receiving anesthesia services., Measurements: For each service, identified by Current Procedural Terminology (CPT) codes, we trended the average Medicare payment per procedure from 2000 to 2020 and calculated year to year changes and compound annual growth rate (CAGR). We also evaluated base and time units for each CPT code and the national Medicare anesthesia conversion factor (CF) for the same years., Main Results: The average Medicare payment in the study sample increased 20.1% from 2000 to 2020. After adjusting for inflation, the average Medicare payment per anesthesia service decreased by 20.8% over that period. The Medicare anesthesia CF increased 24.9% in the same period, and after adjusting for inflation, the real value of the CF decreased 16.9%. Average CAGR across the 20 anesthesia services was 0.88%, compared to the average annual inflation at 2.06%., Conclusions: Average Medicare payment for common anesthesia services after adjusting for inflation have decreased from 2000 to 2020, consistent with findings in other physician specialties. Understanding these trends is important for practice viability and suggests significant financial implications for anesthesia practices and hospitals if the trend were to continue., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Although overall health and social care expenditures among persons with dementia are larger than for other diseases, the resource and cost implications of a comorbid diagnosis of dementia in acute hospitals in the U.S. are largely unknown. We estimate the difference in inpatient outcomes between similar hospital admissions for patients with and without comorbid dementia (CD)., Methods: Inpatient admissions, from the U.S. National Inpatient Sample (2016-2019), were stratified according to hospital characteristics and primary diagnosis (using ICD-10-CM codes), and entropy balanced within strata according to patient and hospital characteristics to create two comparable groups of admissions for patients (aged 65 years or older) with and without CD (a non-primary diagnosis of dementia). Generalized linear regression modeling was then used to estimate differences in length of stay (LOS), cost, absolute mortality risk and number of procedures between these two groups., Results: The final sample consisted of 8,776,417 admissions, comprised of 1,013,879 admissions with and 7,762,538 without CD. CD was associated with on average 0.25 (95 % CI: 0.24-0.25) days longer LOS, 0.4 percentage points (CI: 0.37-0.42) higher absolute mortality risk, $1187 (CI: -1202 to -1171) lower inpatient costs and 0.21 (CI: -0.214 to -0.210) fewer procedures compared to similar patients without CD., Conclusion: Comorbid dementia is associated with longer LOS and higher mortality in acute hospitals but lower inpatient costs and fewer procedures. This highlights potential communication issues between dementia patients and hospital staff, with patients struggling to express their needs and staff lacking sufficient dementia training to address communication challenges., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: Chronic axial low back pain (CLBP) that is not responsive to medication management or physical therapy often requires significant clinical intervention. Several interventional pain management options exist, including a 60-day peripheral nerve stimulation (PNS) treatment. This economic evaluation investigated the potential for projected cost savings associated with prioritizing 60-day PNS treatment relative to a 'standard of care' (SOC) approach (where patients do not have access to 60-day PNS)., Methods: A decision tree (supervised machine learning) model tracked treatment progression across two hypothetical cohorts of US patients with CLBP in whom non-interventional options were ineffective (Cohort A: treatment starting with 60-day PNS followed by any additional interventional and surgical treatments versus Cohort B: standard of care interventional and surgical treatments without access to 60-day PNS). Treatment efficacy estimates were based on published success rates. Conditional on treatment failure, up to two additional interventions were considered within the 12-month time frame in both cohorts. SOC treatment options included epidural injection, radiofrequency ablation (RFA), basivertebral nerve ablation (BVNA), PNS permanent implant (PNS-PI), spinal cord stimulator (SCS) trial/implant, and spinal fusion surgery. Treatment choice probabilities in both cohort algorithms were based on clinician interviews. Costs were based on national Medicare reimbursement levels in the ambulatory surgery center (ASC) setting. Savings reflected the difference in projected costs between cohorts. A Monte Carlo simulation and sensitivity analyses were conducted to generate confidence intervals and identify important inputs., Results: The treatment algorithm which prioritized initial 60-day PNS treatment was projected to save $8056 (95% CI $6112-$9981) per patient during the first year of interventional treatment relative to the SOC approach., Conclusions: Use of the 60-day PNS treatment as an initial interventional treatment in patients with CLBP may result in significant savings for Medicare. Projected savings may be even larger for commercial payers covering non-Medicare patients., (© 2024. The Author(s).)

Introduction: Considering the prospects of increased prevalence and disability due to neck and low back pain, it is relevant to investigate the care processes adopted, to assist future public policies and decision-making for a better allocation of resources. Objective: the aim of this study was to estimate the costs arising from inpatient and outpatient care of individuals with Neck Pain (NP) and Low Back Pain (LBP) in Brazil, between 2010 and 2019., Methods: This is a cost-of-illness study from the perspective of the Brazilian public health system, based on health conditions with high prevalence (neck and low back pain). Data were presented descriptively using absolute and relative values., Results: Between 2010 and 2019, the health system spent more than $600 million (R$ 2.3 billion) to treat NP and LBP in adults, and LBP accounted for most of the expenses. Female had higher absolute expenses in inpatient care and in the outpatient system., Conclusion: Our study showed that the costs with NP and LBP in Brazil were considerable. Female patients had higher outpatient costs and male patients had higher hospitalization costs. Healthcare expenses were concentrated for individuals between 34 and 63 years of age.

Aim: Incorporating health-related quality of life (HRQoL) measures into health economic analyses can help to provide evidence to inform decisions about how to improve patient outcomes in the most cost-effective manner. The aim of this narrative review was to assess which HRQoL instruments have been used in economic evaluations of type 2 diabetes management including in Indigenous communities., Method: MEDLINE (Ovid), Embase (Ovid) and Cochrane were searched from inception to June 2022. Studies included patients with type 2 diabetes; economic evaluations, derived scores from direct questioning of individuals; and were in English. Records were assessed for bias using the JBI critical appraisal tools., Results: A total of 3737 records were identified, with 22 publications meeting the criteria for inclusion. Across those 22 articles, nine HRQoL instruments had been utilised. Generic tools were most frequently used to measure HRQoL, including EQ-5D (-3 L and -5 L) (n = 10, 38%); SF-12 (n = 5, 19%); and SF-36 (n = 4, 15%). Two tools addressing the specific stressors faced by people with type 2 diabetes were utilised: Problem Areas In Diabetes tool (n = 1, 4%) and Diabetes Distress Scale (n = 1, 4%). Two publications reported whether the study population included Indigenous peoples., Conclusion: A wide range of HRQoL instruments are used in economic evaluations of type 2 diabetes management, with the most frequent being varying forms of the EQ-5D. Few economic evaluations noted whether Indigenous peoples were featured in the study population. More research into HRQoL in people living with type 2 diabetes is urgently needed to improve evidence on effectiveness and cost-effectiveness of interventions., (© 2024 The Author(s). Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Exploring efficient and easily implementable prenatal screening strategies aims at birth defect prevention and control. However, there have been limited economic evaluations of non-invasive prenatal screening (NIPS) strategies in China. Furthermore, these studies were predominantly confined to local or geographically proximate provinces and lacked universality and representativeness. This study assesses the health economics of current prenatal screening strategies and NIPS as first-line screening programs, analyzing their efficacy to determine an optimal strategy. From the perspective of health economics, cost-effectiveness, cost-benefit, and single-factor sensitivity were conducted for five different screening strategies using a decision tree model. Among pregnant women aged < 35 years who underwent only one screening for foetal Down syndrome (DS), the detection rate, false positive rate and positive predictive value of NIPS for foetuses with DS were superior to those of the other four serological screening methods. Although applying NIPS as first-line screening method yields the highest efficacy and benefits, it currently lacks cost-effectiveness when compared to serological screening and sequential NIPS screening strategies., (© 2024. The Author(s).)

Background: The US Department of Veterans Affairs, Department of Defense (VA/DoD) clinical guidelines recommend extended-release naltrexone (XR-NTX) as a treatment option for moderate-to-severe alcohol use disorder (AUD); however, contemporary real-world outcomes related to this guideline are lacking. This retrospective, observational, descriptive study examined treatment patterns and healthcare resource use (HCRU) among veterans with an AUD diagnosis who initiated XR-NTX., Methods: Veterans with incident AUD who initiated XR-NTX between 8/2014 and 11/2018 were identified. Treatment patterns and HCRU were assessed during the 1-year baseline period before and following XR-NTX initiation (the index date)., Results: Of the 3665 VA patients (mean [SD] age: 46 [12.5] years; male: 89.7%; White: 76.9%) included in the study, time from AUD diagnosis to XR-NTX initiation was highly variable (mean [range]: 13.6 [0-50.5 months]). Patients received a mean [SD] of 6.8 [6.1] XR-NTX administrations; 44.4% received ⩾6. Mean [SD] time to XR-NTX discontinuation was 93.4 [75.7] days, and 31.3% of discontinuing patients resumed XR-NTX therapy. Of those who received other subsequent medications for AUD, 38.6% (acamprosate) to 47.8% (disulfiram) re-initiated XR-NTX. The proportion of patients with ⩾1 inpatient admissions decreased during follow-up compared with baseline (all-cause: 61.5% to 37.8%; AUD-related: 58.0%-35.4%); with a smaller decrease observed in emergency department (ED) visits. In contrast, more patients had ⩾1 outpatient visits during follow-up (all-cause: 97.5%-99.7%; AUD-related: 84.4%-92.7%). Compared with baseline, mean number of inpatient admissions and ED visits decreased during follow-up, while the number of outpatient visits increased for both all-cause and AUD-related care., Conclusions: Among VA patients with AUD who initiated XR-NTX, we observed reductions in all-cause and AUD-related acute care, and increases in outpatient care. This finding demonstrates a possible transition from acute, inpatient treatment to long-term, outpatient care that may reflect a reduction in disease severity. Additional research is warranted., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RG is an employee of Alkermes, Inc. JL, AKO and MAS and were employees of Alkermes, Inc., during the conduct of the study and may own stock in the company. SS, ES and AL are employees of Analysis Group, Inc., a consulting firm that received funding from the study’s sponsor to conduct this study. KW serves on the Scientific Advisory Board for Pear Therapeutics and is a member of the Alcohol Clinical Trials Initiative (ACTIVE) Workgroup, which has been supported previously, but not in the past 36 months, by Abbott/AbbVie, Amygdala Neurosciences, Arbor Pharmaceuticals, GSK, Indivior, Janssen, Lilly, Pfizer, and Schering Plough; but in the past 36 months, its activities were supported by Alkermes, Inc., Dicerna, Ethypharm, Lundbeck, Mitsubishi, and Otsuka. SL, LS and KD have no financial conflicts of interest to disclose., (© The Author(s) 2024.)

Objectives: This study investigates factors associated with use of real-world data (RWD) in economic modelling for single technology appraisals (STAs) of cancer drugs by the National Institute for Health and Care Excellence (NICE) to improve systematic understanding of the use of RWD., Methods: The data were extracted from STAs of cancer drugs, for which NICE issued guidance between January 2011 and December 2022 (n=267). Binary regression was used to test hypotheses concerning the greater or lesser use of RWD. Bonferroni-Holm correction was used to control error rates in multiple hypotheses tests. Several explanatory variables were considered in this analysis, including time (Time), incidence rate of disease (IR), availability of direct treatment comparison (AD), generalisability of trial data (GE), maturity of survival data in trial (MS) and previous technology recommendations by NICE (PR). The primary outcome variable was any use of RWD. Secondary outcome variables were specific uses of RWD in economic models., Results: AD had a statistical negative association with any use of RWD whereas no associations with non-parametric and parametric use of RWD were found. Time had several statistical associations with use of RWD (validating survival distributions for the intervention, estimating progression-free survival for the intervention, estimating overall survival for comparators and transition probabilities)., Conclusions: RWD were more likely to be used in economic modelling of cancer drugs when randomised controlled trials failed to provide relevant clinical information of the drug for appraisals, particularly in the absence of direct treatment comparisons. These results, based on analysis of data systematically collected from previous appraisals, suggest that uses of RWD were associated with data gaps in the economic modelling. While this result may support some of the claimed advantages of using RWD when evidence is absent, the question, the extent to which use of RWD in indirect treatment comparisons reduces uncertainty is still to be determined., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jiyeon Kang is supported by the Centre for Cancer Biomarkers, University of Bergen, funded by the Research Council of Norway grant number (223250). She also holds a ESRC (Economic and Social Research Council) postdoctoral fellowship. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Also, any fellowship or external contribution had no impacts on this paper. John Cairns is a diagnostic advisory committee member of the National Institute for Health and Care Excellence., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Familial hypercholesterolemia (FH) is a prevalent genetic disorder with global implications for severe cardiovascular diseases. Motivated by the growing recognition of the need for early diagnosis and treatment of FH to mitigate its severe consequences, alongside the gaps in understanding the economic implications and equity impacts of FH screening, this study aims to synthesize the economic evidence on the cost-effectiveness of FH screening and to analyze the impact of FH screening on health inequality., Methods: We conducted a systematic review on the economic evaluations of FH screening and extracted information from the included studies using a pre-determined form for evidence synthesis. We synthesized the cost-effectiveness components involving the calculation of synthesized incremental cost-effectiveness ratios (ICERs) and net health benefit (NHB) of different FH screening strategies. Additionally, we applied an aggregate distributional cost-effectiveness analysis (DCEA) to assess the impact of FH screening on health inequality., Results: Among the 19 studies included, over half utilized Markov models, and 84% concluded that FH screening was potentially cost-effective. Based on the synthesized evidence, cascade screening was likely to be cost-effective, with an ICER of $49,630 per quality-adjusted life year (QALY). The ICER for universal screening was $20,860 per QALY as per evidence synthesis. The aggregate DCEA for six eligible studies presented that the incremental equally distributed equivalent health (EDEH) exceeded the NHB. The difference between EDEH and NHB across the six studies were 325, 137, 556, 36, 50, and 31 QALYs, respectively, with an average positive difference of 189 QALYs., Conclusions: Our research offered valuable insights into the economic evaluations of FH screening strategies, highlighting significant heterogeneity in methods and outcomes across different contexts. Most studies indicated that FH screening is cost-effective and contributes to improving overall population health while potentially reducing health inequality. These findings offer implications that policies should promote the implementation of FH screening programs, particularly among younger population. Optimizing screening strategies based on economic evidence can help identify the most effective measures for improving health outcomes and maximizing cost-effectiveness., (© 2024. The Author(s).)

Objectives: To estimate the interaction between economic status (ES) and healthy lifestyle in long COVID among Chinese older people infected with SARS-CoV-2., Design: A cross-sectional study based on the Peking University Health Cohort in Anning, Yunnan., Setting: All primary health institutions in Anning, Yunnan Province, China, from April to May 2023., Participants: A total of 4804 people aged 60 and older infected with SARS-CoV-2 were included in this study., Primary and Secondary Outcome Measures: Long COVID was measured by participants' self-reported symptoms using structured questionnaires. ES was measured by last-month personal income, and participants' ES was defined as low if their income was below the per capita monthly income of local residents. Lifestyle score was equal to the number of healthy behaviours (including smoking, drinking, weight, exercise and diet) and grouped using the median score as the cut-off point. Univariate and multivariate logistic models were employed to estimate the association of ES with long COVID. Interaction between ES and lifestyle in long COVID was assessed by multiplicative interaction term., Results: We enrolled a total of 4804 participants infected with SARS-CoV-2, of whom 57.3% (2754 of 4804) had at least one long COVID symptom. Fatigue (1546, 56.1%), cough (1263, 45.9%) and muscle pain (880, 32.0%) were the top three common symptoms. Patients with low ES had a 48% (adjusted OR: 1.48; 95% CI 1.22, 1.82) increased risk of long COVID. A significant interaction was observed between ES and lifestyle (p value for interaction <0.001) in long COVID., Conclusion: The interaction between ES and healthy lifestyle in long COVID was prominent. Comprehensive strengthened economic support for patients recovering from COVID-19, especially for those with low healthy lifestyle, should be implemented to prevent and manage long COVID symptoms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The COVID-19 lockdowns had negative effects on children's and adults' mental and physical health. There is, however, a paucity of research that explores differences in health-related quality of life (HRQL) and well-being over time after the COVID-19 lockdowns had been lifted. Furlough during lockdowns, increases in unemployment, and the emerging cost-of-living crisis all put pressure on family finances, which could have a detrimental effect on HRQL and well-being. This study, part of the wider Active-6 study, explored how HRQL, capability well-being and family financial strain changed after the lockdowns, the relationship between these outcomes, and whether physical activity had any mediating effect on differences in HRQL and capability well-being., Methods: Cross-sectional data were collected in May-December 2021 (Wave 1) and January-July 2022 (Wave 2). Children (aged 10-11) and their parent/carer were recruited from 23 to 27 schools in each wave, respectively, and completed validated questionnaires measuring HRQL (adults - EQ-5D-5L, children - CHU9D), capability well-being (adults - ICECAP-A) and family financial strain (adults - Family Economic Strain Scale, FESS). Children also completed questions on capability well-being. Weekday minutes of moderate-to-vigorous physical activity (MVPA) were measured using accelerometers. Mixed-effects regression models, adjusted for gender, age group (adults only), IMD and highest household education, were used to explore differences in HRQL and capability well-being between waves. In addition, the moderating effect of financial strain and the mediating effect of MVPA on HRQL and capability well-being were explored., Results: Active-6 recruited 393 parent-child pairs in Wave 1 and 436 in Wave 2. There were no differences in HRQL (EQ-5D, CHU9D) and capability well-being (ICECAP-A) scores between waves, but financial strain was worse in Wave 2 compared to Wave 1 (FESS score difference 1.14 adjusted 95% CI 0.15 to 2.12). Increased financial strain was associated with lower (worse) EQ-5D-5L, CHU9D and ICECAP-A scores. There was no evidence of a mediating effect of MVPA., Limitations and Future Work: Pre-COVID-19 data on HRQL were not collected, so analysis was limited to post-lockdown only. Participating parents were predominantly female and participation was lower among lower socio-economic groups, limiting our ability to explore inequalities. Intervention planning to increase physical activity and health and well-being during the COVID-19 recovery should consider the financial strain families are experiencing and the negative implications of financial strain on HRQL., Conclusions: There were no differences in HRQL and capability well-being in children and adults after lockdowns lifted in 2021 and a year later in 2022. The results indicate increasing financial strain, which could reflect the UK's 'cost of living crisis'., Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131847.

Objective: This study compared the costs and nursing time associated with the delivery of continuous infusion of antibiotics via elastomeric infusion pumps (EIP) versus conventional intermittent infusion (CII) across different care pathways., Design: Retrospective real-world data informed a cost comparison analysis that compared costs and nursing hours between infusion of antibiotics via EIP versus CII across eight care pathways in inpatient or outpatient care during infection episodes. Real-world data were obtained from patients treated within a year with parenteral antimicrobial therapy in Päijät-Häme Region, Finland., Setting: Inpatient care with hospital admission and outpatient care at hospital at home in Päijät-Häme Region in Finland., Participants: 3778 patients with a total of 4214 infection episodes treated with intravenous antimicrobial therapy., Interventions: Eight treatment strategies with various combinations of EIP and CII administered in inpatient or outpatient care., Primary and Secondary Outcome Measures: Direct costs and nursing time., Results: Skin and soft tissue infections accounted for the highest number of episodes treated with EIP overall (30.8%; 74 out of 240 episodes) and in outpatient care specifically (53.3%; 128 out of 240 episodes). Compared with inpatient care costs with CII (€4590 per episode), treating skin and soft tissue infections in outpatient care with EIP or CII incurred only 24% (€1104) and 35% (€1620) of the costs, respectively. Across all treatment strategies and infections studied, the use of EIP consistently required less nursing time. The highest nursing time in the outpatient care was observed in sepsis episodes treated with CII (37 hours with CII vs 7 hours with EIP per episode)., Conclusion: Delivery of antimicrobial therapy using continuous infusions with EIP instead of CII can significantly decrease the nursing time and cost in both inpatient and outpatient care. For skin and soft tissue infections and sepsis, the utilisation of EIP is a cost-saving option in outpatient care compared with the use of CII., Competing Interests: Competing interests: TH, ML and EH received consulting fees paid directly to their employer by Baxter Healthcare SA. JS and TG are employees of Baxter Healthcare SA, and they did not participate in data capture nor data-analysis, nor data interpretation., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)