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Objectives: The purpose of this study was to assess the feasibility of the adoption of a machine learning (ML) algorithm in support of the investment decisions regarding high cost medical devices based on available clinical and epidemiological evidence. Methods: Following a literature search, the set of epidemiological and clinical need predictors was established. Both the data from The Central Statistical Office and The National Health Fund were used. An evolutionary algorithm (EA) model was developed to obtain the prediction of the need for CT scanners across local counties in Poland (hypothetical scenario). The comparison between the historical allocation and the scenario developed by the EA model based on epidemiological and clinical need predictors was established. Only counties with available CT scanners were included in the study. Results: In total, over 4 million CT scan procedures performed across 130 counties in Poland between 2015 and 2019 were used to develop the EA model. There were 39 cases of agreement between historical data and hypothetical scenarios. In 58 cases, the EA model indicated the need for a lower number of CT scanners than the historical data. A greater number of CT procedures required compared with historical use was predicted for 22 counties. The remaining 11 cases were inconclusive. Conclusions: Machine learning techniques might be successfully applied to support the optimal allocation of limited healthcare resources. Firstly, they enable automatization of health policy making utilising historical, epidemiological, and clinical data. Secondly, they introduce flexibility and transparency thanks to the adoption of ML to investment decisions in the healthcare sector as well.

Objectives We assessed the effects of 3 new elementary school–based health centers (SBHCs) in disparate Georgia communities—predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural—on asthma case management among children insured by Medicaid/Children’s Health Insurance Program (CHIP). Methods We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child–school year. Results We found an increase of about 19 ( P = .01) to 33 ( P < .001) percentage points in the probability of having ≥3 asthma-related visits per child–school year and an increase of about 22 ( P = .003) to 24 ( P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 ( P = .01) to 29 ( P < .001) percentage-point increase in receipt of asthma-control medication and a 15 ( P = .03) to 30 ( P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC. Conclusion Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

The impact of chronic diseases on labour force participation is not frequently examined or considered as part of cost-of-illness studies. The aim of this study was to determine the impact of chronic diseases on labour force participation among South African women. This study included 6126 women from the 2016 South African Demographic and Health Survey. Labour force participation/employment was the outcome variable. Data were analyzed in percentage and multivariable binary logistic regression. Results showed that approximately 28.7% of women participated in the labour force and about 5.0% had diabetes. The prevalence of diabetes among women who are not in the labour force was 5.5%, whereas those in the labour force reported 3.8% prevalence of diabetes. The diabetic women had 35% reduction in labour force participation when compared with non-diabetic women (aOR = 0.65; 95% CI: 0.48 to 0.89). Geographical region was associated with labour force participation. Rural women and those currently in union/living with a man had 35% (aOR = 0.65; 95% CI: 0.56 to 0.76) and 27% (aOR = 0.73; 95% CI: 0.64 to 0.85) reduction in labour force participation, respectively, when compared with their urban and single counterparts. The findings of this study revealed that diabetes was significantly associated with reduction in labour force participation among women.

ObjectivesTo examine how sales of sexual and reproductive health (SRH) products varied among pharmacies in Kenya using administrative data, leveraging natural variation in the COVID-19 pandemic and accompanying policy restrictions between 2019 and 2021.Design and settingEcological study of pharmacies in Kenya.Participants761 pharmacies using the Maisha Meds product inventory management system (capturing 572 916 products sold).OutcomesSales quantity, price and revenue of SRH products sold per pharmacy per week.ResultsCOVID-19 deaths were associated with a -2.97% (95% CI -3.82%, -2.11%) decrease in sales quantity, a 1.09% (95% CI 0.44%, 1.72%) increase in sales price and a -1.89% (-1.00%, -2.79%) decrease in revenues per pharmacy per week. Results were similar when considering new COVID-19 cases (per 1000) and the Average Policy Stringency Index. Results differed substantially between individual SRH products-a large decrease in sales quantity in pregnancy tests, injectables and emergency contraception, a modest decrease in condoms and no change in oral contraception. Sales price increases were similarly varied; four of the five most sold products were revenue neutral.ConclusionsWe found a robust negative association between SRH sales at pharmacies in Kenya and COVID-19 reported cases, deaths and policy restriction. Although our data cannot definitively point to reduced access, existing evidence from Kenya regarding unchanged fertility intentions, increases in unintended pregnancies and reported reasons for non-use of contraceptives during COVID-19 suggests a prominent role of reduced access. While policymakers may have a role in sustaining access, their role may be limited by broader macroeconomic problems, such as global supply chain disruptions and inflation, during supply shocks.

Purpose For many low- and middle-income countries (LMICs), breast cancer (BC) screening based on mammography is not a viable option. Clinical breast examination (CBE) may represent a pragmatic and cost-effective alternative. This paper examines the cost-effectiveness of CBE screening programme among a patient group for whom its cost-effectiveness is likely to be least evident (HER2-positive patients) and discuss the wider implications for BC screening in LMICs. Methods A Markov model was used to examine clinical and economic outcomes over a life-time horizon from the patient, public payer, and healthcare sector perspective. HER2-positive patients entered the model at either disease-free survival or metastatic BC state. The downstaging effect of CBE determined the starting probabilities in the no-screening and screening scenarios. The model used a monthly cycle length, with half-cycle correction. Costs and outcomes were discounted at 1.5% annually. Results Compared with no-screening, the cost-effectiveness ratio (ICER) per quality-adjusted life-year gained for the CBE screening programme was $1801, $2381, and $4179 from three mentioned perspectives, respectively. The finding of cost-effectiveness remained robust to a range of sensitivity analyses. The parameters to which ICERs are most sensitive are average age of cohorts, reduction in proportion of metastatic patients at diagnosis, cost of CBE, and BC detection rate of the programme. Conclusion For HER2-positive patients and compared with no-screening, CBE screening programme in Vietnam is cost-effective from all investigated perspectives. CBE is a ‘good value’ intervention and should be considered for implementation throughout Vietnam as well as in LMICs where mammography is not feasible.

Background The COVID-19 pandemic has caused changes that disrupted the status quo of society. As a result, the level of conflict in community pharmacy has increased significantly. With existing conflict research more focused on the management of conflict, it is important to direct attention towards understanding the nature of conflict. This understanding will allow for informed resources to be developed to guide practice, decreasing the occurrence of and negative effects of conflict. Objective This research explored experiences of pharmacists working in community pharmacies, to identify the occurrence and nature of conflicts which may have been motivated by changes resulting directly or indirectly from the COVID-19 pandemic, to provide directions for future research into the nature of conflict. Method Person-to-person semi-structured telephone interviews were conducted. Transcripts were analysed using inductive reasoning to identify themes. Results Thirteen pharmacists agreed to participate in this study and 9 were interviewed. Analysis revealed 7 themes that described the causes, contributors, management, outcome, and essence of experienced conflict. A model that incorporated existing theory and themes derived from this study was developed to facilitate understanding of the nature of conflict in community pharmacy during the COVID-19 pandemic. Conclusion Conflict in community pharmacy settings follows a defined model with multiple interrelated themes. Guidance from this model may assist pharmacists in reducing occurrences of dysfunctional conflicts during their practice.

Rationale & Objective Longer and more frequent hemodialysis sessions are associated with both benefits and harms. However, their relative importance to patients and how they influence acceptability for patients have not been quantified. Study Design Discrete-choice experiment in which a scenario followed by 12 treatment choice sets were presented to patients in conjunction with varying information about the clinical impact of the treatments offered. Setting and Participants Patients with kidney failure treated with maintenance dialysis for ≥1 year in 5 UK kidney centers. Predictors Length and frequency of hemodialysis sessions, and their prior reported associations with survival, quality of life, need for fluid restriction, hospitalization, and vascular access complications. Outcomes Selection of longer (4.5hr) or more frequent hemodialysis (4 sessions per week) regimens versus remaining on 3 sessions per week with session lengths of 4 hours. Analytical Approach Multinomial mixed effects logistic regression estimating the relative influence of different levels of the predictors on the selection of longer and more frequent dialysis, controlling for patient demographic characteristics. Results Among 183 prevalent in-centre haemodialysis patients (mean 4.7 years on dialysis, mean age of 63.7 years), 38.3% (70/183) always chose to remain on regimens of 3 sessions per week with session duration of 4 hours. Depicted associations of increasing survival and quality of life, reduced need for fluid restriction, and avoiding additional access complications were all significantly associated with choosing longer or more frequent treatment regimes. Younger age, fatigue, previous experience of vascular access complications, absence of heart failure, and shorter travel time to dialysis centers were associated with preference for 4 sessions per week. Patients expressed willingness to trade up to 2 years of life to avoid regimens of 4 sessions per week or access complications. After applying estimated treatment benefits and harms from existing literature, the fully adjusted model revealed that 27.1% would choose longer regimens delivered 3 times per week and 34.3% would choose 4hrs 4 times per week. Analogous estimates for younger fatigued patients living near their unit were 23.5% and 62.5%, respectively. Limitations Estimates were based on stated preferences rather than observed behaviors. Predicted acceptance of regimens was derived from data on treatment benefits and harms largely sourced from observational studies. Conclusions Predicted acceptance of longer and more frequent HD regimens substantially exceeds their use in current clinical practice. These findings underscore the need for robust data on clinical effectiveness of these more intensive regimens and more extensive consideration of patient choice in the selection of dialysis regimens.

IntroductionFood insecurity is a critical issue that refers to a lack of access to adequate food to support a healthy and active lifestyle. This problem has wide-reaching effects and can negatively impact health, education, and overall well-being. Addressing food insecurity requires a multifaceted approach that involves the efforts of governments, organizations, and individuals to ensure access to a balanced and nutritious diet for all.MethodsThe aim of this study is to shed light on macro-level models and evaluate food insecurity risk in international comparisons. We considered six criteria to evaluate food insecurity risk in terms of health expenditure, gross domestic product (GDP) per capita, and GDP growth rate among 14 Organisation for Economic Co-operation and Development (OECD) countries. We developed a modeling approach in three stages to compare food insecurity risk and discussed the reasons for the rankings of the countries based on the model results.ResultsAccording to our findings, the United States has the lowest food insecurity risk, while Colombia has the highest. The results suggest that economic factors, such as GDP per capita and GDP growth rate, play a significant role in food insecurity risk. The study highlights the importance of addressing economic disparities and promoting economic growth to reduce food insecurity.DiscussionThis study provides insights into the relationship between food insecurity and economic factors, indicating that addressing economic disparities and promoting economic growth can reduce food insecurity. Future research using similar models to link economic outcomes with important health components such as nutrition and physical activity could provide a foundation for policy development.

Peer reviewed: True, INTRODUCTION: This research investigates how community-led organisations' (CLOs') use of assets-based approaches improves health and well-being, and how that might be different in different contexts. Assets-based approaches involve 'doing with' rather than 'doing to' and bring people in communities together to achieve positive change using their own knowledge, skills and experience. Some studies have shown that such approaches can have a positive effect on health and well-being. However, research is limited, and we know little about which approaches lead to which outcomes and how different contexts might affect success. METHODS AND ANALYSIS: Using a realist approach, we will work with 15 CLOs based in disadvantaged communities in England, Scotland and Northern Ireland. A realist synthesis of review papers, and a policy analysis in different contexts, precedes qualitative interviews and workshops with stakeholders, to find out how CLOs' programmes work and identify existing data. We will explore participants' experiences through: a Q methodology study; participatory photography workshops; qualitative interviews and measure outcomes using a longitudinal survey, with 225 CLO participants, to assess impact for people who connect with the CLOs. An economic analysis will estimate costs and benefits to participants, for different contexts and mechanisms. A 'Lived Experience Panel' of people connected with our CLOs as participants or volunteers, will ensure the appropriateness of the research, interpretation and reporting of findings. ETHICS AND DISSEMINATION: This project, research tools and consent processes have been approved by the Glasgow Caledonian University School of Health and Life Sciences Ethics Committee, and affirmed by Ethics Committees at Bournemouth University, Queen's University Belfast and the University of East London. Common Health Assets does not involve any National Health Service sites, staff or patients.Findings will be presented through social media, project website, blogs, policy briefings, journal articles, conferences and visually in short digital stories, and photographic exhibitions.

Introduction Real-world data reporting healthcare resource utilisation and costs associated with end-of-life care for patients with chronic kidney disease (CKD) are limited. We examined length of hospitalisation and costs associated with end-of-life inpatient encounters using retrospective data from DISCOVER CKD. Methods Data on inpatient encounters for patients with CKD aged ≥ 18 years between January 2016 and March 2020 were extracted from the US Premier Hospital Database. Encounters ending in death were identified and grouped by reason for the encounter, using the International Classification of Diseases, Tenth Revision, and by their insurance coverage. Encounters were evaluated overall and stratified according to cardiovascular (CV), kidney failure and infection-related reasons, and by their coverage by commercial, Medicaid, Medicare or other insurers. Length of hospitalisation and total costs were calculated for encounters. Results Among 237,734 encounters ending in death, the mean [standard deviation (SD)] age was 74.2 (12.4) years, and 45.3% of patients were female. In total, 25,118, 4210 and 76,307 encounters were classified as relating to CV reasons, kidney failure and infection, respectively. Among all encounters, the mean (SD) length of hospitalisation ranged from 9.1 (11.2) (Medicare) to 12.8 (18.4) (Medicaid) days. Across insurers, encounters related to kidney failure were associated with the longest hospitalisations compared with CV and infection [mean range (days): 10.7–15.9 vs. 7.5–10.5 and 8.7–12.7, respectively]. The median [interquartile range (IQR)] total cost of any inpatient encounter was $17,057 ($8040–35,873). Kidney failure-related encounters had higher costs compared with CV and infection [median (IQR), $18,469 ($8673–38,315) vs. $17,503 ($7766–39,693) and $16,403 ($7762–34,910), respectively]. Medicaid-covered encounters had the highest costs of all insurers [median (IQR), $16,189 ($7725–33,443)]. Conclusions Among patients with CKD, end-of-life encounters were most frequently related to infection. Encounters relating to kidney failure incurred the highest costs. Trial registration ClinicalTrials.gov identifier: NCT04034992. Graphical Abstract Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-02010-3.

Health state utility values (HSUVs) are a key input in health economic modeling, but HSUVs of people with osteoarthritis (OA)-related conditions have not been systematically reviewed and meta-analyzed. Our objective was to systematically review and meta-analyze the HSUVs for people with OA.Searches within health economic/biomedical databases were performed to identify eligible studies reporting OA-related HSUVs. Data on study design, participant characteristics, affected OA joint sites, treatment type, HSUV elicitation method, considered health states, and the reported HSUVs were extracted. HSUVs for people with knee, hip, and mixed OA in pre- and posttreatment populations were meta-analyzed using random effects models.A total of 151 studies were included in the systematic review, and 88 in meta-analyses. Of 151 studies, 56% were conducted in Europe, 75% were in people with knee and/or hip OA, and 79% were based on the EuroQoL 5-dimension instrument. The pooled mean baseline HSUVs for knee OA core interventions, medication, injection, and primary surgery treatments were 0.64 (95% confidence interval [95% CI] 0.61-0.66), 0.56 (95% CI 0.45-0.68), 0.58 (95% CI 0.50-0.66), and 0.52 (95% CI 0.49-0.55), respectively. These were 0.71 (95% CI 0.59-0.84) for hip OA core interventions and 0.52 (95% CI 0.49-0.56) for hip OA primary surgery. For all knee OA treatments and hip OA primary surgery, pooled HSUVs were significantly higher in the post- than the pretreatment populations.This study provides a comprehensive summary of OA-related HSUVs and generates an HSUV database for people with different affected OA joint sites undergoing different treatments to guide HSUV choices in future health economic modeling of OA interventions.

Background and Aims: My Diabetes My Way (MDMW) is Scotland’s interactive website and mobile app for people with diabetes and their caregivers. It contains multimedia resources for diabetes education and offers access to electronic personal health records. This study aims to assess the cost-utility of MDMW compared with routine diabetes care in people with type 2 diabetes who do not use insulin. Materials and Methods: Analysis used the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model 2. Clinical parameters of MDMW users (n = 2576) were compared with a matched cohort of individuals receiving routine care alone (n = 11 628). Matching criteria: age, diabetes duration, sex, and socioeconomic status. Impact on life expectancy, quality-adjusted life years (QALYs), and costs of treatment and complications were simulated over ten years, including a 10% sensitivity analysis. Results: MDMW cohort: 1670 (64.8%) men; average age 64.3 years; duration of diabetes 5.5 years. 906 (35.2%) women: average age 61.6 years; duration 4.7 years. The cumulative mean QALY (95% CI) gain: 0.054 (0.044-0.062) years. Mean difference in cost: –£118.72 (–£150.16 to –£54.16) over ten years. Increasing MDMW costs (10%): –£50.49 (–£82.24-£14.14). Decreasing MDMW costs (10%): –£186.95 (–£218.53 to –£122.51). Conclusions: MDMW is “dominant” over usual care (cost-saving and life improving) in supporting self-management in people with type 2 diabetes not treated with insulin. Wider use may result in significant cost savings through delay or reduction of long-term complications and improved QALYs in Scotland and other countries. MDMW may be among the most cost-effective interventions currently available to support diabetes.

Key content Continuing financial constraints on the UK’s National Health Service means the need for clinicians to provide high-quality care in a cost-effective way has never been greater. While the medical education system equips doctors with skills to provide safe clinical care, it should also provide an understanding of healthcare costs and cost-effectiveness analysis. Value-based care is becoming a key paradigm in women’s health services, where clinicians must employ strategies for delivering value, rationalising costs and capitalising on the use of emerging technologies. The calculation of value of an intervention for providers and service users may differ; care must be taken to ensure this concept is adapted for, and not imposed on healthcare systems. Engaging trainees in systems transformation and embedding the concepts of ‘do no financial harm’ are essential to ensure sustainable healthcare services. Learning Objectives To understand the principles of value-based health care. To highlight the importance of adopting ‘cost-conscious’ care within daily clinical practice. To learn the differences between ‘cost’, ‘charge’, ‘price’ and ‘reimbursement. To encourage developing value-based competencies for future medical workforce through utilising out of programme placements and digital resources. Ethical Issues The ethical obligation of clinicians to consider cost may encompass justice and equity. However, the impact of practicing value-based health care is yet to be evaluated.

STUDY OBJECTIVES: To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on health care utilization among a nationally representative and sample of older adults with multiple morbidities and pre-existing cardiovascular disease and subsequently diagnosed with obstructive sleep apnea in the United States. METHODS: Our data source was a random 5% sample of Medicare administrative claims data. All participants (n = 1,921) were of age ≥ 65 years, diagnosed with cardiovascular disease and obstructive sleep apnea, and subsequently began treatment with CPAP between 2009–2013. Based on the number of CPAP machine charges, individuals were categorized as low, partial, or high adherers (ie, < 4, 4–12, and > 12 CPAP charges, respectively). The impact of CPAP adherence status on health care utilization was assessed across multiple points of service, including outpatient encounters, inpatient stays, emergency department visits, and prescription fills over 24 months following CPAP initiation. RESULTS: Significant differences in demographic and comorbid disease characteristics were observed between low adherers (n = 377), partial adherers (n = 236), and high adherers (n = 1,308). After adjusting for covariates and relative to low adherers, high adherers demonstrated reduced inpatient visits (hazard ratio 0.75; 95% confidence interval 0.57, 0.97). CONCLUSIONS: In this nationally representative sample of older Medicare beneficiaries with multiple morbidities and relative to low adherers, high adherers demonstrated reduced inpatient utilization. CITATION: Wickwire EM, Bailey MD, Somers VK, et al. CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease. J Clin Sleep Med. 2022;18(1):39–45.

Background The provision of equitable and affordable health care has become increasingly challenging as advanced technology is introduced, particularly in developing countries. We explored the hypothesis that focused, small-scale mini–public-private partnerships have a potential role in providing equitable and affordable access to advanced technology for the benefit of all patients in developing nations, particularly middle-income countries. Methods A clinician-led financial plan was developed at the University of Malaya to create the Centre for Image Guidance and Minimally Invasive Therapy (CIGMIT) to provide an integrated platform for high-end care for Malaysian patients of all ages, both public and private, requiring complex neurosurgical and spinal procedures and stereotactic and intensity-modulated radiotherapy. The challenges faced during development of the plan were documented together with an audit of patient throughput and analyses of financial risk and return. Results CIGMIT opened in 2015. Patient throughput, both public and private, progressively increased in all facilities. In 2015–2019, 37,724 patients used the Centre’s facilities. CIGMIT has become progressively more profitable for the University of Malaya, the public and private hospitals, and the investor. CIGMIT has weathered the challenges posed by coronavirus disease 19. Conclusions Focused, small-scale mini–public-private partnerships have a potential role in providing advanced technology for the benefit of patients in developing nations, particularly middle-income countries, subject to an approach that balances equity of access between public and private health care systems with fair reward.

Health state utilities (HSU) data collected in real-world evidence studies are at risk of bias. Although numerous guidance documents are available, practical advice to avoid bias in HSU studies is limited. Thus, the objective of this article was to develop a concise toolbox intended for investigators seeking to collect HSU in a real-world setting. The proposed toolbox builds on existing guidance and provides practical steps to help investigators perform good quality research. The toolbox aims at increasing the credibility of HSU data for future reimbursement decision making.

Durable cell and gene therapies potentially transform patient lives, but payers fear unsustainable costs arising from the more than 1000 therapies in the development pipeline. A novel multi-module Markov chain Monte Carlo-based model projects product-indication approvals, treated patients, and product revenues. We estimate a mean 63.5 (54-74 5th to 95th percentile range) cumulative US product-indication approvals through 2030, with a mean 93000 patients treated in 2030 generating a mean US$24.4 billion (US$17.0B-35.0B, US$73.0B extreme) list price product revenues not including ancillary medical costs or cost offsets. Thus, the likely dozens of durable cell and gene therapies developed through 2030 are unlikely to threaten US health system financial sustainability.

ObjectivesEconomic evaluations of interventions for people with mental–physical multimorbidity, including a depressive disorder, are sparse. This study examines whether such interventions in adults are cost-effective.DesignA systematic review.Data sourcesMEDLINE, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Scopus, Web of Science and NHS EED databases were searched until 5 March 2022.Eligibility criteriaWe included studies involving people aged ≥18 with two or more chronic conditions (one being a depressive disorder). Economic evaluation studies that compared costs and outcomes of interventions were included, and those that assessed only costs or effects were excluded.Data extraction and synthesisTwo authors independently assessed risk of bias in included studies using recommended checklists. A narrative analysis of the characteristics and results by type of intervention and levels of healthcare provision was conducted.ResultsA total of 19 studies, all undertaken in high-income countries, met inclusion criteria. Four intervention types were reported: collaborative care, self-management, telephone-based and antidepressant treatment. Most (14 of 19) interventions were implemented at the organisational level and were potentially cost-effective, particularly, the collaborative care for people with depressive disorder and diabetes, comorbid major depression and cancer and depression and multiple long-term conditions. Cost-effectiveness ranged from £206 per quality-adjusted life year (QALY) for collaborative care programmes for older adults with diabetes and depression at primary care clinics (USA) to £79 723 per QALY for combining collaborative care with improved opportunistic screening for adults with depressive disorder and diabetes (England). Conclusions on cost-effectiveness were constrained by methodological aspects of the included studies: choice of perspectives, time horizon and costing methods.ConclusionsEconomic evaluations of interventions to manage multimorbidity with a depressive disorder are non-existent in low-income and middle-income countries. The design and reporting of future economic evaluations must improve to provide robust conclusions.PROSPERO registration numberCRD42022302036.

Peer reviewed: True, Acknowledgements: We would like to thank Professor Jennifer Whitty, Honorary Professorial Fellow at Norwich Medical School, and Senior Research Scientist at Evidera for her role in designing the research programme this review belongs to, and guiding development of the original protocol., Background: The extraordinarily high prevalence of treatment-resistant depression (TRD), coupled with its high economic burden to both healthcare systems and society, underscore how critical it is that resources are managed optimally to address the significant challenge it presents. Objective: To review the literature on economic evaluation in TRD systematically, with the aim of informing future studies by identifying key challenges specific to the area, and highlighting good practices. Methods: A systematic literature search across seven electronic databases was conducted to identify both within-trial and model-based economic evaluations in TRD. Quality of reporting and study design was assessed using the Consensus Health Economic Criteria (CHEC). A narrative synthesis was conducted. Results: We identified 31 evaluations, including 11 conducted alongside a clinical trial and 20 model-based evaluations. There was considerable heterogeneity in the definition of treatment-resistant depression, although with a trend for more recent studies to use a definition of inadequate response to two or more antidepressive treatments. A broad range of interventions were considered, including non-pharmacological neuromodulation, pharmacological, psychological, and service-level interventions. Study quality as assessed by CHEC was generally high. Frequently poorly reported items related to discussion of ethical and distributional issues, and model validation. Most evaluations considered comparable core clinical outcomes – encompassing remission, response, and relapse. There was good agreement on the definitions and thresholds for these outcomes, and a relatively small pool of outcome measures were used. Resource criteria used to inform the estimation of direct costs, were reasonably uniform. Predominantly, however, there was a high level of heterogeneity in terms of evaluation design and sophistication, quality of evidence used (particularly health state utility data), time horizon, population considered, and cost perspective. Conclusion: Economic evidence for interventions in TRD is underdeveloped, particularly so for service-level interventions. Where evidence does exist, it is hampered by inconsistency in study design, methodological quality, and availability of high quality long-term outcomes evidence. This review identifies a number of key considerations and challenges for the design of future economic evaluations. Recommendations for research and suggestions for good practice are made. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=259848&VersionID=1542096, identifier CRD42021259848.

Peer reviewed: True, Acknowledgements: We are grateful for the invaluable contribution provided by patient representatives. HW is funded by The Urology Foundation and Pan London Cancer Alliance (Royal Marsden Partners, North Central London Cancer Alliance, North East London Cancer Alliance, South East London Cancer Alliance and the NIHR BRCs). VK receives funding from Prostate Cancer UK and the John Black Charitable Foundation. GDS and IAM are supported by the NIHR Cambridge Biomedical Research Centre (BRC-1215-20014) and GDS by the Cancer Research UK Cambridge Centre [C9685/A25177]. EP is supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart’s Health NHS Trust. Mark Emberton receives research support from the United Kingdom’s National Institute of Health Research (NIHR) UCLH / UCL Biomedical Research Centre. He was conferred NIHR Senior Investigator Status in 2015. MGBT receives research funding from NIHR, St Peter’s Trust, Royal Free Charity, RCS, Facing up 2 Kidney Cancer and Kidney Cancer UK. The views expressed are those of the authors and not necessarily those of the funders., INTRODUCTION: The incidence of renal tumours is increasing and anatomic imaging cannot reliably distinguish benign tumours from renal cell carcinoma. Up to 30% of renal tumours are benign, with oncocytomas the most common type. Biopsy has not been routinely adopted in many centres due to concerns surrounding non-diagnostic rate, bleeding and tumour seeding. As a result, benign masses are often unnecessarily surgically resected. 99mTc-sestamibi SPECT/CT has shown high diagnostic accuracy for benign renal oncocytomas and other oncocytic renal neoplasms of low malignant potential in single-centre studies. The primary aim of MULTI-MIBI is to assess feasibility of a multicentre study of 99mTc-sestamibi SPECT/CT against a reference standard of histopathology from surgical resection or biopsy. Secondary aims of the study include obtaining estimates of 99mTc-sestamibi SPECT/CT sensitivity and specificity and to inform the design and conduct of a future definitive trial. METHODS AND ANALYSIS: A feasibility prospective multicentre study of participants with indeterminate, clinical T1 renal tumours to undergo 99mTc-sestamibi SPECT/CT (index test) compared with histopathology from biopsy or surgical resection (reference test). Interpretation of the index and reference tests will be blinded to the results of the other. Recruitment rate as well as estimates of sensitivity, specificity, positive and negative predictive value will be reported. Semistructured interviews with patients and clinicians will provide qualitative data to inform onward trial design and delivery. Training materials for 99mTc-sestamibi SPECT/CT interpretation will be developed, assessed and optimised. Early health economic modelling using a decision analytic approach for different diagnostic strategies will be performed to understand the potential cost-effectiveness of 99mTc-sestamibi SPECT/CT. ETHICS AND DISSEMINATION: Ethical approval has been granted (UK HRA REC 20/YH/0279) protocol V.5.0 dated 21/6/2022. Study outputs will be presented and published nationally and internationally. TRIAL REGISTRATION NUMBER: ISRCTN12572202.

This paper seeks to evaluate the cost-effectiveness of integrating social care into healthcare approaches. Specifically, it is a scoping review presenting comprehensive findings on social care integration compiled by analyzing discrete instances of integration.

Résumé La mesure du coût de la maladie se positionne au cœur des préoccupations actuelles des structures hospitalières. D'où la nécessité de recourir à des outils de contrôle de gestion adaptés pour mesurer la performance des hôpitaux. Ainsi, l'objectif principal de cette étude est d'examiner la faisabilité de l'Activity-Based-Costing (ABC) pour estimer le coût global d'une pathologie complexe et lourde comme le cancer du sein, en fonction du processus de prise en charge au CHU Hassan II de Fès, au Maroc. Compte tenu des choix méthodologiques relatifs au calcul des coûts dans une approche de type pharmaco-économique, une attention particulière a été portée au découpage du circuit de dispensation des produits pharmaceutiques afin d’estimer de point de vue de l’hôpital, le coût réel global et enfin déterminer son impact sur le budget alloué à la pharmacie, et ce, pour une durée de 3 ans. La prise en charge du cancer du sein représente, selon les résultats obtenus, un coût global de : 93 736 530,44 MAD, avec une moyenne de : 40 247,54 MAD par patiente pour 2329 cas durant les 3 années. Par conséquent, les dépenses liées à la prise en charge du cancer du sein représentent à elles seules environ 14% du budget global de la pharmacie. La mise en œuvre de cette étude nous permet de réfléchir à la situation actuelle et future en termes d'allocation des ressources, elle nous donnera donc la possibilité de générer des normes relatives à ce que devrait être le coût de production qui pourrait par la suite servir d'indicateur pour mesurer la performance des services de soins. Mots clés : Pharmaco-économie, produits pharmaceutiques, Activity-Based-Costing ABC, cancer du sein. Abstract Measuring the cost of illness is a critical issue for healthcare organizations nowadays. Therefore, it is necessary to measure the performance of hospitals using the right management control instruments. The objective of this study is to evaluate the feasibility of the ABC (Activity-Based-Costing) method, according to the care pathways of the Hassan II University Hospital in Fez, Morocco, in order to calculate the global cost of a complicated and serious disease such as breast cancer. Given the methodological choices adopted in the pharmaco-economic cost approach, particular attention was given to the pharmaceutical chain of care in order to estimate the real global cost from the viewpoint of the hospital and to finally determine its impact on the budget allocated to the pharmacy. This study was conducted over a three-year period, with a view to optimizing expenditures and budget control. The research revealed that the global cost of treating breast cancer is 93736,530.44 MAD, with an average of 40,247.54 MAD per patient throughout the 2329 cases over three years. Therefore, this means that the cost of breast cancer management requires about 14% of the total pharmacy budget. The implementation of this study provides a reflection on the current and future status of resources allocation, allowing the creation of some norms regarding the cost of production, which could later be used as an indicator to evaluate the performance of health services. Keywords: Health economics; Pharmaceutical spending; ABC method; Breast cancer.

The COVID-19 pandemic has impacted individuals, healthcare systems and economies in unprecedented ways. Health systems are focused on properly managing and delivering routine healthcare services, while developing strategies to control COVID-19. In addition, it is necessary to strengthen the infrastructure for the possible increase in the epidemic. All of this complicates the process of governments setting health and public policy. It is thought that governments need studies conducted from the perspective of health economics in order to determine the right policies at the right time. In this article, the COVID-19 pandemic is evaluated in terms of supply, demand, cost, economic evaluation, and inequalities, which are the main issues of health economics. In the article, first of all, the double-sided effect of COVID-19 on healthcare demand is emphasized. Then, the effects of COVID-19 on supply were examined through primary care providers, hospitals and emergency services. Information about the cost of COVID-19 disease was given and the importance of economic evaluation studies for resource use during the pandemic period was emphasized. Finally, it was mentioned about the health inequalities during the pandemic period and the need for improvement. Preventing and treating COVID-19 has high costs. In order to make the right decisions at the right time, policy makers need economic evaluation studies that evaluate the health consequences and costs of potential treatments together. In extraordinary situations such as a pandemic, evidence-based decisions prevent wasting valuable time and resources. In addition, the pandemic has brought to the agenda the issue of improving the health inequalities existing in health systems., COVID-19 salgını bireyleri, sağlık hizmetleri sistemlerini ve ekonomilerini benzeri görülmemiş şekilde etkilemiştir. Sağlık sistemleri, bir yandan COVID-19'u kontrol etme stratejileri geliştirilirken, diğer yandan rutin sağlık hizmetlerini doğru bir şekilde yönetip, sunmaya odaklanmıştır. Ayrıca olası salgın artışına yönelik olarak altyapının güçlendirilmesi de gerekmektedir. Bütün bunlar, hükümetlerin sağlık ve kamu politikalarını belirleme sürecini karmaşıklaştırmaktadır. Hükümetlerin doğru zamanda, doğru politikalar belirleyebilmesi için sağlık ekonomisi bakış açısıyla yapılmış çalışmalara ihtiyacı olduğu düşünülmektedir. Bu makalede, COVID-19 pandemisi, sağlık ekonomisinin temel konuları olan arz, talep, maliyet, ekonomik değerlendirme ve eşitsizlikler açısından değerlendirilmektedir. Makalede, öncelikle COVID-19’un sağlık hizmeti talebine olan çift yönlü etkisi üzerinde durulmuştur. Ardından COVID-19’un arz üzerindeki etkileri, birinci basamak hizmet sunucuları, hastaneler ve acil servisler üzerinden incelenmiştir. COVID-19 hastalığının maliyeti ile ilgili bilgiler verilmiş ve pandemi döneminde ekonomik değerlendirme çalışmalarının kaynak kullanımı için önemi vurgulanmıştır. Son olarak da pandemi dönemindeki sağlık eşitsizliklerinden ve iyileştirilmesi gerektiğinden bahsedilmiştir. COVID-19'u önlemenin ve tedavi etmenin yüksek maliyetleri bulunmaktadır. Doğru zamanda, doğru kararlar alabilmek için politika belirleyicilerinin, potansiyel tedavilerin sağlık sonuçları ile maliyetlerini bir arada değerlendiren ekonomik değerlendirme çalışmalarına ihtiyaçları vardır. Pandemi gibi olağanüstü durumlarda, kanıta dayalı alınan kararlar, kıymetli olan zamanın ve kaynakların boşa harcanmasını önlemektedir. Ayrıca pandemi, sağlık sistemlerinde mevcut olan sağlık eşitsizliklerinin iyileştirilmesi konusunun gündeme gelmesini sağlamıştır.

As medical errors can have significant negative effects on patients’ health and the costs of health systems, there is substantial interest in understanding causes of error for developing prevention interventions (Van Den Bos et al., 2011; Keers et al., 2013). Interdisciplinary research on decision making under uncertainty found that medical errors can occur because of physicians using heuristics that employ a practical method that is not guaranteed to be optimal or rational (Aberegg et al., 2005; Berner & Graber, 2008; Payne & Crowley, 2008; Neumann et al., 2011; Saposnik et al., 2017). While observational studies have suggested that physicians tend to follow the prescription and therapeutic recommendation of colleagues rather than making their own informed decision (Yang et al., 2014; Saposnik et al., 2017), experimental investigations are needed to assess to what extent recommendations by colleagues influence physicians’ decision making. This planned study aims to examine in a web-based experiment with 500 primary care physicians whether they follow incorrect recommendations given by their peers. In the experiment, the recommendation can come from a fellow physician or a consultant. The study will constitute an important step toward understanding the role of social information in prescribing errors. It will be the first study to use an experimental design to investigate the effects of social influences on physicians’ prescribing decisions. While the study will be performed in the primary care setting and focus on prescription behaviour, future studies can use the study design as a starting point to assess herding-like behaviour in different medical contexts and with different samples. The findings of the study could also have practical ethical and legal implications if herding-like behaviour is observed.

Peer reviewed: True, OBJECTIVES: To determine if a newer design of total knee replacement (TKR) (Journey II BCS) produces superior patient-reported outcomes scores and biomechanical outcomes than the older, more established design (Genesis II). SETTING: Patients were recruited from an NHS University Hospital between July 2018 and October 2019 with surgery at two sites. Biomechanical and functional capacity measurements were at a University Movement and Exercise Laboratory. PARTICIPANTS: 80 participants undergoing single-stage TKR. INTERVENTIONS: Patients were randomised to receive either the Journey II BCS (JII-BCS) or Genesis II TKR. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was the Oxford Knee Score (OKS), at 6 months. Secondary outcomes were: OKS Activity and Participation Questionnaire, EQ-5D-5L and UCLA Activity scores, Timed Up and Go Test, 6 min walk test, lower limb kinematics and lower limb muscle activity during walking and balance. RESULTS: This study found no difference in the OKS between groups. The OKS scores for the JII-BCS and Genesis II groups were mean (SD) 42.97 (5.21) and 43.13 (5.20) respectively, adjusted effect size 0.35 (-2.01,2.71) p=0.771In secondary outcome measures, the Genesis II group demonstrated a significantly greater walking range-of-movement (50.62 (7.33) vs 46.07 (7.71) degrees, adjusted effect size, 3.14 (0.61,5.68) p=0.02) and higher peak knee flexion angular velocity during walking (mean (SD) 307.69 (38.96) vs 330.38 (41.40) degrees/second, adjusted effect size was 21.75 (4.54,38.96), p=0.01) and better postural control (smaller resultant centre of path length) during quiet standing than the JII-BCS group (mean (SD) 158.14 (65.40) vs 235.48 (176.94) mm, adjusted effect size, 59.91 (-105.98, -13.85) p=0.01.). CONCLUSIONS: In this study population, the findings do not support the hypothesis that the Journey II BCS produces a better outcome than the Genesis II for the primary outcome of the OKS at 6 months after surgery. TRIAL REGISTRATION NUMBER: ISRCTN32315753.

Technical report for the Sheffield Tobacco Policy Model

A Protocol for a mixed method systematic review. This review aims to synthesise the challenges in workforce planning for genomic medicine. This will inform workforce planners in clinical, managerial, and commissioning roles, ensuring we have the right workforce, with the right skills, in the right place.

Policymakers need to invest in interventions to reduce obesity in the face of increasing obesity-related health and social care resource demands. The variation in economic modelling suggests that there is no consensus about the most appropriate approach to take, which may undermine confidence in current estimates of intervention cost-effectiveness and the development of future interventions. The aim of this study is to identify and critically appraise the economic models used recently to evaluate the long-term cost-effectiveness of policies or interventions to prevent or reduce overweight and obesity. This study will provide an evidence base for making recommendations for improving economic modelling.

Haemochromatosis is one of the most common autosomal recessive disorders amongst populations of northern European ancestry. It is a condition characterised by iron overload, which, if untreated, contributes to morbidity and mortality. As diagnosis is often delayed owing to the non-specific nature of early symptoms, population screening programs have been suggested to reduce the consequential burden of disease. To date, a paucity of robust health economic evidence regarding haemochromatosis screening has been cited as a key barrier to the establishment of such programs internationally. This thesis investigates and generates health economic evidence for haemochromatosis and related interventions, with a focus on population screening programs. Chapter 1 presents a general overview of haemochromatosis and health economic concepts pertinent to this thesis. Chapter 2 presents a systematic review of all health economic evidence regarding haemochromatosis screening and related interventions. Most of the evidence identified in the review related to population screening programs. The economic methodologies employed and the quality of epidemiologic evidence incorporated into these models were flawed in most studies, reducing their validity and generalizability. The gaps in current knowledge that were identified in this review guided the subsequent direction of this thesis. The systematic review did not identify any robust health state utility value data for haemochromatosis. Whilst four studies included in the review incorporated utility values into cost-effectiveness models, these were set at unrealistically high levels, with no description of the source of these provided. Chapter 3 aimed to robustly quantify the quality of life burden associated with haemochromatosis by measuring health state utility values. A national, online survey of people with haemochromatosis was conducted, which allowed for calculation of utilities for different categories of severity of haemochromatosis. These utility values, which provide insight into the quality of life impacts of haemochromatosis, were incorporated into the population screening model. In the absence of published literature quantifying the economic burden associated with haemochromatosis, a national cost of illness study was undertaken, and is reported in Chapter 4. Costs were estimated from the patient, government and societal perspectives, with societal costs extrapolated to the Australian population. These costs are the first to be published that quantify the economic burden of haemochromatosis. Whilst Chapters 3 and 4 provide information on the size of the burden associated with haemochromatosis, Chapter 6 identifies strategies to address this. Chapter 5 provides a detailed description of the construction and validation of the health economic model for screening for haemochromatosis. A state-transition Markov model using probabilistic decision analysis was constructed and validated for the Australian adult population of northern European ancestry. Chapter 6 presents the results generated from the health economics model. The target populations were males aged 30 years and females aged 45 years, both of northern European ancestry, and neonates irrespective of ancestry. Three population screening strategies (genotyping with a blood sample, genotyping with a buccal sample, sequential screening with two consecutive iron studies and confirmatory HFE genotyping) were modelled for adults and one for neonates (HFE genotyping). The current status quo was the comparator, which comprises a combination of cascade and opportunistic screening. From the government perspective, genotyping with a blood sample was the most cost-effective approach for males; for females, sequential screening was considered to be the most cost-effective. For male and female neonates, screening was associated with cost savings and increased effectiveness, thereby dominating the current status quo. This thesis presents a range of studies that were conducted to address the substantial knowledge gaps identified in the systematic review. Both the health state utility data and cost of illness data can be used to populate future health economic models regarding haemochromatosis interventions. The results of the modelling work provide medical and reimbursement decision-makers with robust data when considering future resource allocation decisions pertaining to screening for haemochromatosis.

Nowadays, very safe and effective antiretrovirals (ARVs) are available for people living with Human immunodeficiency virus (HIV). However, approximately 9.4 million people living with HIV (PLWH) are not adherent to therapy. During my Ph.D. journey, I explored PLWH-reported barriers and facilitators to adherence and developed pharmacist interventions to improve the health outcomes of PLWH. Findings of the dissertation found that pharmacists’ education and counseling sessions improved adherence to ARV, immunity, and viral load suppression. Pharmacists improved antiretroviral stewardship by reviewing medication prescribed, monitoring drug interactions, preventing adverse drug reactions, and improving the quality of life of PLWH.

To study the causal effect of the 1994 Finnish Sugar tax using NFBC 1966 and 1986 cohort data

This location provides the supplementary materials for the above paper.

Objective: In the context of growing financial pressures on health budgets, cost‐effective prevention strategies are needed to address the burden from non‐communicable disease in Australia. We explored how decision makers use economic evidence to inform such investment and how such evidence generated can more effectively meet the needs of end users. Methods: Thematic analysis of in‐depth interviews with 15 high level stakeholders (Treasury, state health departments and the insurance industry), supplemented by documentary analysis. Results: Types of prevention approaches and economic evidence relevant to decision makers differed by organisational perspective. Capacity building in understanding economic evaluations and research evidence that addresses the differing criteria for investment used by different organisations is needed. The task of determining investment priorities in disease prevention comes with significant challenges including ideological barriers, delayed outcome measures, and implementation uncertainties. Conclusions and Implications for public health: Promoting the greater use of economic evidence in prevention requires more work on two fronts: tailoring the methods used by economists to better match the organisational imperatives of end users; and promoting greater consideration of broader societal and health sector perspectives among end users. This will require significant infrastructure development, monitoring and evaluation, stronger national leadership and a greater emphasis on evidence coproduction.

Healthcare costs are rising globally. A shared ambition to use healthcare resources as effectively as possible requires healthcare reform based on value and cost-effectiveness. However, little scientific research has been done in the emergency department context. This project aims to perform a scoping review of the existing literature addressing value and cost-effectiveness of emergency department services.

Despite being in poorer health, disadvantaged groups generally have lower use of primary healthcare than other Australians. Disparities in primary healthcare use can lead to higher use of relatively more costly acute services and contribute to, or exacerbate pre-existing, health inequalities. This thesis provides an overview on unequal use of healthcare by disadvantaged groups and explores how the relative importance of different supply- and demand-side factors influence healthcare use among priority populations; namely, sexual and gender diverse populations, Indigenous peoples, and people with mental illness and disability. This thesis makes an important contribution to the understanding of how different strategies can be implemented to improve healthcare use and health outcomes among some of Australia’s most vulnerable populations.

This systematic review aims to summarize and evaluate the evidence regarding possible differences in performance (or quality) indicators of breast cancer screening through systematic (organized) breast cancer screening programs compared with opportunistic breast cancer screening.

Access to high-cost innovative medications is a challenge in many countries. Patient access scheme (PAS) implementation is believed to alleviate the financial constraints. We assessed stakeholder views as the uptake of PAS in Malaysia was poor due to a lack of data infrastructure, expertise, administrative mechanisms, and trust. We explored hypothetical PAS to assess its affordability in Malaysia for a rare and major disease. One scheme was found to be cost-effective and affordable for rare diseases. However, caution is needed in major illnesses as the net budget impact is exorbitant. PAS can be used with caution till other suitable reimbursement methods are available.

This project will determine the impact of ACOs on disparities in health outcomes and Medicare spending, and the heterogeneity of impact across ACOs, using difference-in-differences (DD) analyses of Medicare claims data from 2010 to 2020.

This research project aims to summarize the published evidence regarding the cost-effectiveness of systematic (organized) breast cancer screening compared to no screening or opportunistic (non-systematic) screening and to estimate the potential budget impact of breast cancer screening in the Canton of Zurich, Switzerland.

Trade agreements in the 21st century have evolved to include provisions that increasingly intrude into sectors previously the domain of governments alone. The potential for unintended consequences for the health sector arising from these agreements is poorly understood. This study explored the potential implications for the nursing workforce in Australia of select provisions of trade agreements using, as an example, the ‘Comprehensive and Progressive Agreement for Trans-Pacific Partnership'.

Food safety is important to prevent foodborne illnesses that can negatively affect public health and the economy. Preventative measures can be taken by government agencies, food-related workers, and consumers to reduce the occurrence of such illnesses. This paper examines the impact of government policies on food safety from the perspective of consumers, restaurant employees and employers, and food processing workers. The first essay explores how food safety recalls affect consumer behavior. The second essay studies the impact of minimum wage policies on service quality in the restaurant industry. The third essay investigates the effect of minimum wage policies on product food safety in the meat and poultry processing industry.

Content analysis of checklists assessing the quality of economic evaluations.

Scoping review to identify and characterize the available instruments or tools developed to assess the quality of economic analyses in health.

While many Indigenous eye health services within high-income nations, such as Australia, have value from a health needs and performance benchmark perspective, it is unclear whether these services have undergone comprehensive economic evaluations. With this in mind, we will conduct the first known review on this topic, aiming to identify the number and type of economic evaluations performed and to summarise the reported economic impact of specific services. This can guide policymakers and clinicians in their decisions to support and/or implement services which have been evaluated. We also aim to appraise the methodological quality of these evaluations and identify knowledge gaps in the area – both of which can inform future research.

This thesis uses mathematical models to provide evidence to guide efforts to eliminate hepatitis B as a public health threat. My work first investigates alternate approaches to deliver hepatitis B birth dose vaccine in low-and middle-income countries, and demonstrates the feasibility, acceptability, safety, importance and cost-effectiveness of their use. Secondly, to promote investment towards elimination, I investigate impact of hepatitis B mortality on global productivity. If nothing was to change, globally US$820 billion would be lost between 2022-2050; but if investment enabled elimination targets to be met by 2030, it would yield returns of US$110 billion by 2050.

Reducing the carbon footprint in critical care requires data and costs for key healthcare inputs specific to critical care and robust methods to include and analyze these data in economic evaluations. Yet, a comprehensive review of how environmental impact data are incorporated into health economic evaluations in critical care has yet to be conducted. The purpose of this scoping review is to synthesize available literature on whether and how environmental impact is considered in health economic evaluations of critical care.

Do healthcare providers pick their patients? This paper uses patient-level administrative data on skilled nursing facilities in California to estimate a structural model of selective admission practices in the nursing home industry. I exploit within-facility covariation between occupancy and admitted patient characteristics to distinguish admission patterns attributable to selective admission practices from those attributable to heterogeneous patient preferences. In spite of anti-discrimination laws, I find strong evidence of selective admission practices that disproportionately harm Medicaid-eligible patients with lengthy anticipated stays. Counterfactual simulations show that enforcing a prohibition on selective admissions would increase access for these residents at the cost of crowding out short-stay non-Medicaid patients from their preferred facilities. I simulate two additional policies intended to mitigate selective admissions: raising the Medicaid reimbursement rate and expanding capacity. I find the latter to be less costly and more effective than the former.

This is a registration of a protocol for a scoping review on strategies for training and involving laypeople in health technology assessment.

\\(Background:\\) Obesity is not only a major health concern, it is an economic problem. The current rates of obesity (defined as body mass index (BMI) ‚Äöv¢‚Ä¢ 30 kg/m\\(^¬¨‚â§\\)) are epidemic and severe obesity (defined as BMI ‚Äöv¢‚Ä¢ 35 kg/m\\(^¬¨‚â§\\)) is increasing more rapidly than obesity. Treatments for overweight and obesity include dietary therapy, exercise/behavioural interventions, weight loss medications and bariatric surgery. Bariatric surgery is considered the most efficacious intervention for severe and resistant obesity. This PhD thesis titled 'The Health Economics of Obesity and Bariatric Surgery' is an important part of a comprehensive, mixed-methods and multi-disciplinary Australian National Health and Medical Research Council (NHMRC) partnership project regarding bariatric surgery as a treatment option for obesity, within the State of Tasmania (Australia), nationally, and internationally. Key health economic evidence gaps were initially identified in the development of the successful NHMRC partnership project grant proposal. \\(Aims:\\) As a health economist within the NHMRC partnership project team, the principal aims of my PhD research were to: provide critical baseline analyses of the key themes and evidence gaps regarding the health economic reporting of bariatric surgery, locally, nationally and internationally; address key evidence gaps regarding the physical and psychosocial domains of health-related quality of life from the time of waitlisting for bariatric surgery; establish the multi-attribute utility instrument that preferentially captures the physical and psychosocial health-related quality of life of people waiting for, or who have undergone bariatric surgery; use qualitative research methods to investigate bariatric surgery patients' experiences to identify and prioritise health economic impacts of bariatric surgery that are typically excluded from existing studies, or not provided with sufficient priority; and develop a strategic research alliance with our Tasmanian State Government project partner to investigate the resource use and costs of obesity and bariatric surgery to the Tasmanian public hospital system. \\(Methods:\\) This thesis adopted a mixed-methods approach within real-world policy settings, consistent with a call for health economists to implement mixed-methods and policy-relevant research that is embedded in, and derived from real-world policy settings. First, validated guidelines and methodologies were followed in the systematic selection and analyses of the published literature regarding the health economic evaluation of bariatric surgery. The findings of this comprehensive systematic review informed the methods of the remainder of the thesis (Chapter 2). Second, the vastly different EQ-5D-5L and AQoL-8D multi-attribute utility instruments were systematically selected to investigate health state utility valuations (both instruments) and individual and super dimension scores (AQoL-8D only) in two cohorts of bariatric surgery patients. Patients who had received bariatric surgery many years previously in the private healthcare system (cross-sectional - Chapter 3) and patients who were publicly waitlisted for their surgery for many years and then operated on as part of a government policy decision to reduce waiting lists (longitudinal - Chapters 4 and 5) were studied. Third, qualitative research methods were used to investigate bariatric surgery patients' 'lived' experiences to identify and prioritise health economic impacts of bariatric surgery that are typically excluded from existing studies (Chapters 6 and 7). Fourth, a strategic research alliance with the critical health and project partner was adopted to construct and analyse a Tasmanian public hospital resource use and cost database about publicly-waitlisted patients before and after their primary bariatric surgery and surgical sequelae (Chapter 8). \\(Thesis\\) \\(outline\\) \\(and\\) \\(summary\\) \\(of\\) \\(key\\) \\(results:\\) Chapter 1 presents a general introduction of the health and economic burden of the obesity epidemic and bariatric surgery as a treatment option, and health economic concepts pertinent to this thesis. Chapter 2 provides a published comprehensive systematic review of the health economic evaluation of bariatric surgery. Evidence gaps identified in the systematic review informed the direction of the subsequent PhD projects of this thesis, part of the work program for the NHMRC partnership project, and some of the future directions for research beyond this thesis. Among other things, this study found that only 13% of included studies adopted a broader societal perspective, the cost of complications and reoperations for bariatric surgery were not included in one-third of studies and when they were included conservative estimates were generally adopted, out-of-pocket costs were largely ignored, the EQ-5D suite of multi-attribute utility instruments was prevalent in the health economic evaluation of bariatric surgery, and that only one study investigated publicly waitlisted patients. The study's quality appraisalagainst the Consolidated Health Economic Evaluation Reporting Standards checklist found heterogeneous approaches, inconsistent quality and key evidence gaps in the health economic reporting of bariatric surgery. Chapters 3, 4 and 5 present the first integrated published suite of health-related quality of life studies for the bariatric surgery study population that systematically selected two markedly different multi-attribute utility instruments, namely the EQ-5D-5L (Chapter 2 established the EQ-5D-5L was the internationally prevalent instrument in the economic evaluation of bariatric surgery) and the AQoL-8D (based on psychometric principles and testing). Importantly, the two instruments were used and compared for two different cohorts of bariatric surgery patients. Chapter 3 provides the first head-to-head comparison of the EQ-5D-5L and AQoL-8D for a cross-sectional cohort of patients who had received bariatric surgery in the private healthcare sector many years previously (median (interquartile range) 5 (3-8) years). Chapter 3 found that psychosocial health was a key driver for the study population and that the AQoL-8D preferentially captured and assessed their psychosocial health. This study also explored the international dominance of the EQ-5D in the clinical and economic evaluation literature and the paper recommended that the choice of multi-attribute utility instrument should be influenced by the innate sensitivities of the instrument to the relevant domains of heath for the particular study population. Chapters 4 and 5 were the first studies to use the EQ-5D-5L and AQoL-8D for a unique cohort of long-term and severely obese publicly waitlisted patients who then received bariatric surgery due to a public policy decision to reduce waiting lists. Chapter 2 identified that only one health economic study investigated the impact of waiting for bariatric surgery. A key finding of these studies was that the preoperative AQoL-8D health state utility valuation for this increasingly prevalent subgroup of bariatric surgery patients was less than those of people with cancer or heart disease. Even 3 months, and then 1 year after bariatric surgery, long-term publicly waitlisted patients recorded significant and clinically meaningful health-related quality of life improvements. This result suggested that long-waiting patients should not be 'written-off' by healthcare decision makers: they can still realise significant improvements in health-related quality of life outcomes when ultimately treated, and this should be factored into patient prioritisation decisions. Chapters 4 and 5 also investigated the emerging literature regarding the predictive capabilities of multi-attribute utility instruments in patient-centred bariatric care. Chapters 6 and 7 present studies that harness the unique advantages of qualitative research methods to improve our practice in health economics. The inspiration for the method of these studies was partly directed by the systematic review (Chapter 2) that identified the limited scope of costs and consequences for most health economic evaluations of bariatric surgery. Additionally, there has been a call for health economists to effectively integrate combinations of qualitative and quantitative methods into their research toolkit to enrich their research methodologies and therefore improve their practice in health economic study design, data gathering and analysis, reporting and ultimately research translation. These studies listened to patients' stories and key themes were identified inductively through a dialogue between the qualitative focus group data and pre-existing economic theory (perspective; externalities; emotional capital; information asymmetry). Published Chapter 6 identified the concept of emotional capital as a 'potentiator' for human capital where participants described life-changing desires to be productive and participate in their communities postoperatively. Two-thirds of the focus group participants accessed private healthcare for bariatric surgery and some of these participants experienced substantial economic burden to do so. Chapter 7 presents a second health economics study that implemented qualitative research methods. The inspiration for this study was that a key market failure in healthcare is information asymmetry. However, in the information-age, bariatric surgery patients may be more empowered in their negotiated relationship with healthcare providers through demand-induced supply. This study found a divergence between the pre- and postoperative information drivers. Psychosocial or socio-emotional drivers informed the sources and types of information that were important to participants preoperatively. The study also found that information sources relevant to participants preoperatively (e.g. family and friends, and the I...