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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jenvman.2007.05.002 Byline: Jane V. Hall (a), Victor Brajer (a), Frederick W. Lurmann (b) Keywords: Air pollution; Health effects; Control strategies; Economic costs; Benefit maximization Abstract: Many regions worldwide are experiencing rapid urbanization, and often along with growth in the local economy and population comes worsening air quality. Such regions typically find that addressing the additional challenge of polluted air is difficult. This paper reports the results of an assessment of the present health and related economic costs of poor air quality in the San Joaquin Valley of California. Further, it suggests how such assessments can support strategies to pursue pollution reductions that offer the largest near-term gains, by rigorously modeling the associations between pollution levels, demographic groups, and recognized adverse health effects. Author Affiliation: (a) Department of Economics, California State University, 800 N. State College Blvd., Fullerton, CA 92834, USA (b) Sonoma Technology, Inc., 1360 Redwood Way, Suite C., Petaluma, CA 94954, USA Article History: Received 3 August 2006; Revised 2 February 2007; Accepted 5 May 2007

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jhealeco.2005.09.002 Byline: Jane Hall (a), Denzil G. Fiebig (a)(b), Madeleine T. King (a), Ishrat Hossain (a), Jordan J. Louviere (a)(c) Keywords: Genetic testing; Screening; Discrete choice experiments; Stated preferences; Mixed logit Abstract: This study explores factors that influence participation in genetic testing programs and the acceptance of multiple tests. Tay Sachs and cystic fibrosis are both genetically determined recessive disorders with differing severity, treatment availability, and prevalence in different population groups. We used a discrete choice experiment with a general community and an Ashkenazi Jewish sample; data were analysed using multinomial logit with random coefficients. Although Jewish respondents were more likely to be tested, both groups seem to be making very similar tradeoffs across attributes when they make genetic testing choices. Author Affiliation: (a) Centre for Health Economics Research and Evaluation (CHERE), University of Technology, Sydney, PO Box 123 Broadway, NSW 2007, Australia (b) School of Economics, University of New South Wales, Australia (c) School of Marketing, University of Technology, Sydney, Australia Article History: Received 14 January 2005; Revised 13 May 2005; Accepted 19 September 2005

An overview of health program evaluation methods, and the rationale for the use of stated preference discrete choice modelling (SPDCM) techniques is provided. The use of SPDCM to deal with these issues is well accepted in marketing, transport, and environmental economics.

Metal and organic pollutants are prominent marine contaminants that disperse widely throughout the environment. Some contaminants biomagnify, leaving long-lived apex predators such as cetaceans at risk of toxicity. Various tissues collected post-mortem from 16 Ziphiidae individuals that stranded on the New South Wales (NSW) coast, Australia, over ∼15 years were investigated for 16 metals/metalloids and 33 organic contaminants. Polychlorinated biphenyls (PCBs) and Dichlorodiphenyltrichloroethanes (DDTs) were commonly detected in blubber and liver tissues. Mercury, cadmium and silver exceeded reported toxicity thresholds in several individuals. The liver tissue of a Mesoplodon layardii specimen had the highest mercury (386 mg/kg dry weight). Liver tissue of a Mesoplodon grayi specimen had the highest silver concentration (19.7 mg/kg dry weight), and the highest cadmium concentration was in Ziphius cavirostris kidney (478 mg/kg dry weight). This study provides important new information for rare Ziphiidae species globally. [Display omitted] • PCBs and DDXs most commonly detected organic contaminants • Elevated mercury, cadmium and silver in several whales • Mercury to selenium toxicity ratios exceeded 1:1 in some individuals • Some of the highest silver concentrations reported in Southern Hemisphere cetaceans [ABSTRACT FROM AUTHOR]

An article by Alexander Tabarrok on the concept of health insurance to cover the findings of genetics testing was analyzed. Two factors to be considered are whether employers are liable for discrimination when they subject applicants for genetic testing and the utility function of genetic testing. While genetic testing is used to determine future risk, the information derived can lead to a change in health status. It was suggested that further studies on the benefits and costs of insurance for genetic testing should be undertaken.

The study attempts to clarify the definitions, uses and interrelationship of justice, equity and access when applied to health care. Procedural justice is admitted to assume that an objective position be adopted. However, many modern philosophers no longer share this view and this shift in philosophical thought and the presence of different competing theories of justice must be recognized. Distribution of health is accepted to be critical to individuals and health care policy maker but other concerns such as distribution of information regarding availability of services and distribution of access to services must still be considered.

Study Objective: We describe the current US emergency medicine workforce in terms of clinician type and examine rural and urban emergency medicine workforce differences.Methods: Using the 2014 Medicare Public Use Files, we performed a cross-sectional study of all clinicians receiving reimbursement for evaluation and management (E/M) services (levels 1 to 5) to Medicare fee-for-service Part B beneficiaries in the emergency department. Providers were defined as emergency physicians, nonemergency physicians, or advanced practice providers, corresponding with the Medicare Public Use Files data set. The primary outcome was the number of clinicians providing greater than 10 E/M claims tabulated as a distinct encounter. Urbanicity data were obtained from the National Bureau of Economic Research.Results: Of 58,641 unique emergency medicine clinicians, 35,856 (61.1%) were classified as emergency physicians, 8,397 (14.3%) as nonemergency physicians, and 14,360 (24.5%) as advanced practice providers. Among nonemergency physicians categorized as emergency medicine clinicians, family practice and internal medicine predominated (41.7% and 19.9%, respectively). Among advanced practice providers, physician assistants (68.4%) and nurse practitioners (31.5%) predominated. A total of 58,565 emergency medicine clinicians were mapped to 2,291 US counties or equivalents. Urban counties had a higher proportion of emergency physicians (63.9%) compared with rural counties (44.8%); 27.1% of counties had no emergency medicine clinicians and 41.4% of counties had no emergency physicians reimbursed by Medicare fee-for-service Part B.Conclusion: This work establishes a new baseline estimate of the emergency care workforce, encompassing nearly 60,000 emergency medicine clinicians, of whom fewer than 2 in 3 were emergency physicians. Notable differences exist in the type of clinician staffing of emergency care between urban and rural communities. [ABSTRACT FROM AUTHOR]

Objectives To examine contemporary trends in end-of-life cancer care and geographic variation of end-of-life care aggressiveness among Medicare beneficiaries. Materials and Methods Using the Surveillance, Epidemiology, and End Results—Medicare data, we identified 132,051 beneficiaries who died as a result of cancer in 2006–2011. Aggressiveness of end-of-life care was measured by chemotherapy received within 14 days of death, > 1 emergency department (ED) visit within 30 days of death, > 1 hospitalization within 30 days of death, ≥ 1 intensive care unit (ICU) admission within 30 days of death, in-hospital death, or hospice enrollment ≤ 3 days before death. Using hierarchical generalized linear models, we assessed potentially aggressive end-of-life care adjusting for patient demographics, tumor characteristics, and hospital referral region (HRR)-level market factors. Results The proportion of beneficiaries receiving at least one potentially aggressive end-of-life intervention increased from 48.6% in 2006 to 50.5% in 2011 ( P < .001). From 2006 to 2011, increases were apparent in repeated hospitalization (14.1% vs. 14.8%; P = .01), repeated ED visits (34.3% vs. 36.6%; P < .001), ICU admissions (16.2% vs. 21.3%; P < .001), and late hospice enrollment (11.2% vs. 12.9%; P < .001), whereas in-hospital death declined (23.5% vs. 20.9%; P < .001). End-of-life chemotherapy use (4.4% vs. 4.5%) did not change significantly over time ( P = .12). The use of potentially aggressive end-of-life care varied substantially across HRRs, ranging from 40.3% to 58.3%. Few HRRs had a decrease in aggressive end-of-life care during the study period. Conclusions Despite growing focus on providing appropriate end-of-life care, there has not been an improvement in aggressive end-of-life cancer care in the Medicare program. [ABSTRACT FROM AUTHOR]

Objectives The 21-gene recurrence score (RS) assay helps guide adjuvant chemotherapy use for patients with breast cancer, and is predicted to reduce overall chemotherapy use. Little is known about recent patterns of testing in the Medicare program and the impact of testing on chemotherapy use as a function of patient age. Materials and Methods We conducted a national claims—based study of Medicare beneficiaries age ≥ 66 years. We assessed trends in assay use (using multivariable regression), adjuvant chemotherapy use, and associated expenditures, for all patients and for two age strata: age 66–74 years and 75–94 years. Geographic variations in assay adoption and regional-level correlation between assay and chemotherapy use were measured. Results We identified 132,222 women who underwent breast surgery from 2008–2011. Assay use increased from 9.0% to 17.2% from 2008–2011 (p < .001), but chemotherapy use remained stable at 12.5% (p = .49). In younger patients, assay use increased from 14.3% to 23.7% (p < .001), while chemotherapy use decreased from 18.2% to 16.2% (p < .001). In older patients, assay use increased from 4.1% to 9.9% (p < .001), while chemotherapy use remained stable at 6.8% (p = .67). Mean per-beneficiary expenditures for testing and chemotherapy increased from $2030 to $2430 (p < .001). Regions with increased assay adoption were not more likely to reduce chemotherapy. Conclusion Despite increased RS testing for both younger and older Medicare patients, there has only been a modest decrease in chemotherapy use for younger patients and no change for older patients, resulting in an overall increase in costs associated with gene expression profiling. [ABSTRACT FROM AUTHOR]

Summary Background and Objective In the context of predictions of future shortages of nurses, retaining new graduate nurses in the nursing workforce is essential to ensure sufficient nurses in the future. This paper investigates the links between satisfaction with nursing education and job satisfaction, and job dissatisfaction and intentions to leave a nursing job. Design and Data Sources It uses survey data from a cohort study of nursing students recruited through two Australian universities and followed after graduation and workforce entry. Method Structural equation modeling (SEM) was used to simultaneously estimate the impact of educational satisfaction (work preparation component) on job satisfaction and the impact of job satisfaction on the expectation of leaving the current job. Results Two job satisfaction sub-scales were identified: 1) work environment satisfaction and 2) work hours and wages satisfaction. Work preparation satisfaction was significantly and positively associated with both job satisfaction scales but only work environment satisfaction was significantly associated with the expectation to stay in the job; a one standard deviation increase in work environment satisfaction was associated with a 13.5 percentage point reduction in the probability of expecting to leave. The estimated effect of satisfaction with education on expecting to leave, occurring indirectly through job satisfaction, was small (reducing the probability by less than 3 percentage points for a 1 point increase in work preparation satisfaction). Participating in a graduate transition program had the largest effect, reducing the probability of expecting to leave by 26 percentage points, on average. Conclusions The study results suggest policies which focus on improving satisfaction with the work environment would be more effective at retaining nurses early in their career than improvements to conditions such as work hours and wages. Investment in new graduate transition programs would potentially have the largest impact on retention. [ABSTRACT FROM AUTHOR]

Summary: Background: Attrition rates among young and newly registered nurses are high; the capacity of nurse education programmes to prepare nurses for their professional role and the extent to which they are supported during the transition from student to registered nurse may be important factors. Objectives: This paper examines nursing student and recent graduate satisfaction with their education, focusing on their preparation for work. Design: A descriptive cohort design was used, combining qualitative and quantitative methods to measure and interpret satisfaction. Setting: Two Australian universities, one urban and one regional. Participants: 530 undergraduate nursing students and recent graduates from the Bachelor of Nursing programmes at the two universities. Methods: Data were collected via an online survey. Satisfaction with the programmes was measured with closed format questions covering different aspects of the programmes and a single open ended question. Responses were compared between older and younger respondents and between graduates and students at different stages of the programme. Results: Older students were more dissatisfied than younger students with the amount and type of training and their preparation for nursing work. First year students reported the highest levels of satisfaction, and third year students the lowest. The majority of graduates and third year students thought that the programme only partly prepared them for work in nursing. The free text comments particularly highlighted concerns with the amount and quality of clinical education. Conclusions: Programmes need to take account of the learning requirements of students to maximise the integration of theory and skill development in hospital environments with limited staffing and resources. The clinical environment and support received impact on the quality of learning and satisfaction of student nurses. Students who are dissatisfied with their educational and clinical experiences may choose to change their career direction. [Copyright &y& Elsevier]

Abstract: Health is an important factor in the capacity of family and friends (informal carers) to continue providing care for palliative care patients at home. This study investigates associations between the health-related quality of life (HRQOL) of current informal carers and characteristics of the carers and their caregiving situation, in a sample of Australian carers of palliative care patients. The cross-sectional study used the Short Form-36 Health Survey to measure HRQOL. It found carers to have better physical health and worse mental health than the general population. Of 178 carers, 35% reported their health to be worse than it was one year ago. Multiple regression analyses found that the HRQOL of carers whose health had deteriorated in the previous year was associated with the patient''s care needs but not the carer''s time input, unlike the carers reporting stable health. Clinicians caring for palliative care patients should be alert to the potential health impairments of informal carers and ensure that they are adequately supported in their caregiving role and have access to appropriate treatment and preventive health care. [Copyright &y& Elsevier]

Abstract: In the United Kingdom, as with other European countries, land-based emissions of NO x and SO2 have fallen significantly over the last few decades. SO2 emissions fell from a peak of 3185GgS in 1970 to 344GgS in 2005 and are forecast by business-as-usual emissions scenarios to fall to 172Gg by 2020. NO x emissions were at a maximum of 951GgN in 1970 and fell to 378 by 2005 with a further decrease to 243GgN forecast by 2020. These large changes in emissions have not been matched by emissions changes for NH3 which decreased from 315GgN in 1990 to 259 in 2005 and are forecast to fall to 222 by 2020. The Fine Resolution Atmospheric Multi-pollutant Exchange model (FRAME) has been applied to model the spatial distribution of sulphur and nitrogen deposition over the United Kingdom during a 15-year time period (1990–2005) and compared with measured deposition of sulphate, nitrate and ammonium from the national monitoring network. Wet deposition of nitrogen and sulphur was found to decrease more slowly than the emissions reductions rate. This is attributed to a number of factors including increases in emissions from international shipping and changing rates of atmospheric oxidation. The modelled time series was extended to a 50-year period from 1970 to 2020. The modelled deposition of SO x , NO y and NH x to the UK was found to fall by 87%, 52% and 25% during this period. The percentage area of sensitive habitats in the United Kingdom for which critical loads are exceeded is estimated to fall from 85% in 1970 to 37% in 2020 for acidic deposition and from 73% to 49% for nutrient nitrogen deposition. The significant reduction in land emissions of SO2 and NO x focuses further attention in controlling emissions from international shipping. Future policies to control emissions of ammonia from agriculture will be required to effect further significant reductions in nitrogen deposition. [Copyright &y& Elsevier]

Abstract: Hall J, Swinkels A, Briddon J, McCabe CS. Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease? A systematic review and meta-analysis of randomized controlled trials. Objective: To evaluate the literature on the effectiveness of aquatic exercise in relieving pain in adults with neurologic or musculoskeletal disease. Data Sources: A systematic literature search of 14 databases was examined for research on aquatic exercise over the period January 1980 to June 2006. Study Selection: Randomized controlled trials (RCTs) that included adults with neurologic or musculoskeletal disease, pain as an outcome measure, and exercise in water were included. Data Extraction: Information on the participants, interventions, and outcomes was extracted from the included studies. Quality appraisal was assessed using the Scottish Intercollegiate Guidelines Network criteria for RCTs. Data Synthesis: Nineteen studies met the inclusion criteria; 8 were of moderate to low risk of bias, and 5 of these had data suitable for meta-analyses. This showed that aquatic exercise has a small posttreatment effect in relieving pain compared with no treatment (P=.04; standardized mean difference [SMD], −.17; 95% confidence interval [CI], −.33 to −.01), but it is not possible to draw a firm conclusion because of the lack of consistency of evidence across studies. Comparable pain-relieving effects were found between aquatic and land-based exercise (P=.56; SMD=.11; 95% CI, −.27 to .50). Conclusions: There is sound evidence that there are no differences in pain-relieving effects between aquatic and land exercise. Compared with no treatment, aquatic exercise has a small pain-relieving effect; however, the small number of good-quality studies and inconsistency of results means that insufficient evidence limits firm conclusions. Future studies should aim for focused research questions on specific aquatic exercise techniques, using robust methodologic designs and detailed reporting of temperature, depth, and care setting. [Copyright &y& Elsevier]

Abstract: It is generally accepted that uncertainty should be taken into account in environmental assessments and the subsequent decision-making. This paper undertakes an uncertainty assessment for acidity and nutrient nitrogen critical loads and their exceedances, which is important in determining national and international policy on the emissions of acidifying air pollutants. This is the first time such an analysis has been done for the UK at the national scale. In this paper we illustrate the process and issues with reference to “managed coniferous woodland”, one of a number of habitat types for which critical loads are calculated. Again using coniferous woodland as an example Monte Carlo analysis showed that the uncertainties in the national critical loads varied between 14 and 29%. Policy makers are however primarily concerned with whether the critical load is exceeded and therefore the uncertainty in exceedance is also estimated. Again using coniferous woodland as an example, Monte Carlo analysis showed that for acidity, it was uncertain whether the critical load was exceeded or not for the majority of the coniferous woodland habitat. For nutrient nitrogen, most of the habitat had a very high probability of exceedance. [Copyright &y& Elsevier]

Abstract: Critical loads have been used at both the national and international scale in negotiations of protocols controlling the emissions of sulphur and nitrogen. Further, reductions in these pollutants have increasingly high costs; hence, quantifying the uncertainties in the calculation of critical loads and their exceedances has become increasingly important. The UK uses mass balance modelling techniques to calculate steady-state acidity and nutrient nitrogen critical loads for woodland habitats. The calculation uses data from a wide range of sources and the accuracy of the critical loads are influenced by the accuracy of the input data sets. This paper aims to quantify the uncertainties in the data used. A comparison of the uncertainties derived for UK data and those calculated by other European countries reveals a wide range in the estimates of uncertainty and in the methods used to derive them. Possible reasons for these differences are the different methods used to estimate the uncertainty, the scale at which the uncertainty was assessed and underlying methodological differences. Transparency in the way the uncertainties are derived are necessary for communication between scientists and decision makers. [Copyright &y& Elsevier]

Abstract: Critical loads and exceedances have been used as the basis for negotiation of the Gothenburg Protocol and the National Emissions Ceilings Directive to reduce emissions of sulphur and nitrogen across Europe. Since emissions have already been significantly reduced, the associated cost of further emission reductions is high. In order to define future abatement strategies, policy makers therefore need to understand uncertainties associated with critical load exceedances and interpret them accordingly. Deterministic methods of presenting critical load exceedance, which treat the critical load concept as a set criterion, are well established. Spatially explicit uncertainties in deposition estimates for Wales have recently become available and new ways of presenting information on critical load exceedance are now possible. We explore the utility of partial distributions and inverse cumulative distributions of exceedance data, probability of exceedance and cumulative distribution function by habitat, using Wales as a case study. [Copyright &y& Elsevier]

Background: Although there have been a number of economic evaluations of cardiac rehabilitation after acute myocardial infarction (AMI), none has considered only low-risk patients or control groups with no rehabilitation at all. Methods: An economic evaluation was included in a randomised controlled trial of patients following uncomplicated AMI. Eligible patients were randomised to return to normal activities after 6 weeks of standard rehabilitation (REHAB, n = 70) or to early return to normal activities 2 weeks after AMI with no formal rehabilitation (ERNA, n = 72). Outcomes were assessed weekly for 6 weeks, then 3, 6 and 12 months post-AMI. Outcomes included four quality of life (QOL) measures (physical abilities, distress, usual/social activities, self-care) and four measures of return to normal activities (paid and unpaid return to any work and to pre-AMI level of work). Statistical analysis included repeated-measures regression (QOL outcomes) and survival analysis (work outcomes). Results: There were no statistically significant differences between the two groups in any of the outcomes measured or in the use of other health services. The net cost that could be saved by the health service by targeting rehabilitation to high-risk patients was approximately $300 (Australian, 1999) per low-risk patient. Conclusions: Early return to normal activities without formal rehabilitation is cost-effective for low-risk patients. (Heart, Lung and Circulation 2002; 11: 10-18). [ABSTRACT FROM AUTHOR]

Although health technology assessment (HTA) is intended to provide policymakers with objective information, the likelihood that a health decision-maker (HDM) will use this information is associated with their knowledge, role and perception of the HTA process. In Ghana, policymakers are working towards formalising the use of HTA, but HDM knowledge of and attitude towards HTA are not known. Between March and May 2016, we conducted in-depth interviews and used inductive thematic analysis to explore Ghanaian HDMs (n = 23) and researchers' (n = 4) perceptions of and barriers to HTA and identify ways to promote HTA. We compare our findings with those reported in previous studies conducted in low-and-middle-income countries. Common themes were that resources, political and cultural factors act as barriers to HTA use. Recommendations made in previous studies which were also identified in this study included the need for the development of both human and data capacity, allocating funds to HTA and stakeholder involvement in HTA processes. Specific recommendations made by Ghanaian HDMs and researchers in this study focused on the establishment of an HTA body: its location, the constitution of the appraisal team, the type of evidence to appraise and who makes the final decision. The findings provide important information in the context of current planning to institutionalise HTA in Ghana. Addressing the identified barriers will enable policymakers to maximise the chances of realising the expected benefits of HTA, as participants who are potential producers and end-users are likely to use what they have contributed to. • As with other LMIC, decision-makers in Ghana have limited knowledge about HTA. • The identified barriers to HTA were resources, political and cultural issues. • To promote the use of HTA the identified barriers need addressing. • Decision-makers were positive about implementing HTA and identified areas of use. [ABSTRACT FROM AUTHOR]

Current discussions on controlling emissions of atmospheric nitrogenpollutants in Europe are adopting a multi-pollutant, multi-effect strategy where acidification, eutrophication and the effects of photochemical oxidants are all taken into account. Parallel activities by both the Convention on Long Range Transboundary Air Pollution (ratifiedby 42 governments of the 55 countries in the UNECE area) and the EU are making use of the critical loads approach and integrated assessment models to arrive at cost optimized scenarios for environmental protection. Critical loads and critical levels are used to define the thresholds for effects; as these are usually difficult to attain they are being used to set intermediate target objectives. A number of different methods for setting such targets, the so-called 'gap closures' are being investigated. While the basis for estimating critical loadsand levels has been extensively researched, collection of the necessary data and the development of methods continue to evolve. Current discussions on international agreements for emission reductions are based upon the best available information, but this has limitations which are often difficult to build into the decision making process. It is to be expected that any currently derived results will be an interim and very approximate solution for the problems resulting from pollutant emissions. Further steps will require better information on impacts and probably alternative approaches to the critical loads concept as it currently stands. [ABSTRACT FROM AUTHOR]

Equity is one of the key goals of universal healthcare coverage (UHC). Achieving this goal does not just depend on the presence of UHC, but also on its design and organisation. In Australia, out-of-hospital medical services are provided by private physicians in a market where fees are unregulated. This makes an interesting case to study equity. Using data from the Australian National Health Survey of 2014–15, we distinguish between the probability of any visit and the number of visits conditional on having any visit to analyse income-related inequity in general practitioner (GP) and specialist visits. We apply the horizontal inequity approach to measure the extent of inequity, and the decomposition method to explain the factors accounting for inequity. Our results show a small pro-rich inequity in the probability of any GP visit, but the distribution of conditional GP visits was concentrated among the poor. Inequity in the probability of any specialist visit was pro-rich. However, there was almost no inequity in conditional specialist visits. We find holding a concession card explained pro-poor inequity while income, education, and private health insurance contributed to pro-rich inequity in specialist visits. Although Australia has a universal health insurance system, there is unequal use (adjusted for health need) of physician services by socioeconomic status. This has implications for insurance design in other countries. • We find pro-rich inequity in the probability of GP and specialist visits in Australia. • Conditional GP visits was pro-poor, but no inequity in conditional specialist visits. • Contribution of concession card to inequity in physician visits was pro-poor. • Income, education, and private health insurance contributed to pro-rich inequity. • Our results has implications for insurance design in other developed countries. [ABSTRACT FROM AUTHOR]

Understanding whether high healthcare costs for individuals persist over time is critical for the development of policies that aim to reduce the prevalence of high cost patients. And while high healthcare costs will occur in any given year based on the prevalence of certain morbidities and acute conditions, a large random component of the distribution means that it is rarely the same people driving the bulk of healthcare expenditures. Using administrative data for over 250,000 Australian residents for the years between 2006 and 2011, we analyse the persistence of high annual healthcare costs. We examine the prevalence of high cost persistence in this sample, and then, we use endogenous switching models to identify the morbidity groups that are related with high cost persistence. These models also measure cases of cost amplification that are associated with a history of high cost healthcare. This analysis uses data from multiple categories of healthcare, specifically medical services, pharmaceuticals and admitted patient care. While there is a relatively low number of patients with persistent high cost (approximately 3% of the sample), this group accounted for 19% of aggregate expenditure. Pharmaceuticals were the most persistently high cost category of healthcare with 5% of the sample accounting for 32% of aggregate pharmaceutical expenditure. The morbidities associated with notable cost amplifications are morbidities that are hard to prevent or involve escalations of adverse health states that are difficult to avert. This casts doubt on whether broad policies can reduce the prevalence of individuals with persistently high healthcare costs. [ABSTRACT FROM AUTHOR]

The large increases in reactive nitrogen (N) deposition in developed countries since the Industrial Revolution have had a marked impact on ecosystem functioning, including declining species richness, shifts in species composition, and increased N leaching. A potential mitigation of these harmful effects is the action of N as a fertiliser, which, through increasing primary productivity (and subsequently, organic matter production), has the potential to increase ecosystem carbon (C) storage. Here we report the response of an upland heath to 10 years of experimental N addition. We find large increases in plant and soil C and N pools, with N-driven C sequestration rates in the range of 13–138 kg C kg − 1 . These rates are higher than those previously found in forest and lowland heath, mainly due to higher C sequestration in the litter layer. C sequestration is highest at lower N treatments (10, 20, and 40 kg N ha − 1 yr − 1 above ambient), with evidence of saturation at the highest N treatment, reflecting a physiologically aged Calluna vulgaris ( Calluna ) canopy. To maintain these rates of sequestration, the Calluna canopy should be managed to maximise it's time in the building phase. Scaling our results across UK heathlands, this equates to an additional 0.77 Mt CO2e per annum extra C sequestered into plant litter and the top 15 cm of heathland soil as a result of N deposition. The bulk of this is found in the litter and organic soil horizons that hold an average of 23% and 54% of soil C, respectively. This additional C represents around 0.44% of UK annual anthropogenic GHG emissions. When considered in the context of falling biodiversity and altered species composition in heathland, policy focus should remain on reducing N emissions. [ABSTRACT FROM AUTHOR]

Introduction: Opioid use disorder (OUD) and related comorbid conditions are highly prevalent among patients presenting to emergency department (ED) settings. Research has developed few comprehensive disease management strategies for at-risk patients presenting to the ED that both decrease illicit opioid use and improve initiation and retention in medication treatment for OUD (MOUD).Methods: The research team conducted a pilot pragmatic clinical trial that randomized 40 patients presenting to a single ED to a collaborative care intervention (n = 20) versus usual care control (n = 20) conditions. Interviewers blinded to patient intervention and control group status followed-up with participants at 1, 3, and 6 months after presentation to the ED. The 3-month Emergency Department Longitudinal Integrated Care (ED-LINC) collaborative care intervention for patients at risk for OUD included: 1) a Brief Negotiated Interview at bedside, 2) overdose education and facilitation of MOUD, 3) longitudinal proactive care management, 4) utilization of the statewide health information exchange platform for 24/7 tracking of recurrent ED utilization, and 5) weekly caseload supervision that incorporated measurement-based care treatment assessment with stepped-up care for patients with recalcitrant symptoms.Results: Overall, the ED-LINC intervention was feasibly delivered and acceptable to patients. The pilot study achieved >80% follow-up rates at 1, 3, and 6 months. In adjusted longitudinal mixed model regression analyses, no statistically significant differences existed in days of opioid use over the past 30 days for ED-LINC intervention patients when compared to patients receiving usual care (incidence-rate ratio (IRR) 1.50, 95% CI 0.54-4.16). The unadjusted mean number of days of illicit opioid use decreased at the 1-month and 3-month follow-up time points for both groups. ED-LINC intervention patients had increased rates of MOUD initiation compared to control patients (50% versus 30%); intervention versus control comparisons did not achieve statistical significance, although power to detect significant differences in the pilot was limited.Conclusions: The ED-LINC intervention for patients with OUD can be feasibly implemented and warrants testing in larger scale, adequately powered randomized pragmatic clinical trial investigations.Clinicaltrials: gov NCT03699085. [ABSTRACT FROM AUTHOR]

Abstract: Integrated assessment modelling has evolved to support policy development in relation to air pollutants and greenhouse gases by providing integrated simulation tools able to produce quick and realistic representations of emission scenarios and their environmental impacts without the need to re-run complex atmospheric dispersion models. The UK Integrated Assessment Model (UKIAM) has been developed to investigate strategies for reducing UK emissions by bringing together information on projected UK emissions of SO2, NOx, NH3, PM10 and PM2.5, atmospheric dispersion, criteria for protection of ecosystems, urban air quality and human health, and data on potential abatement measures to reduce emissions, which may subsequently be linked to associated analyses of costs and benefits. We describe the multi-scale model structure ranging from continental to roadside, UK emission sources, atmospheric dispersion of emissions, implementation of abatement measures, integration with European-scale modelling, and environmental impacts. The model generates outputs from a national perspective which are used to evaluate alternative strategies in relation to emissions, deposition patterns, air quality metrics and ecosystem critical load exceedance. We present a selection of scenarios in relation to the 2020 Business-As-Usual projections and identify potential further reductions beyond those currently being planned. [Copyright &y& Elsevier]