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PurposeWe aimed to estimate health state utility values (HSUVs) for the key health states found in opioid use disorder (OUD) cost-effectiveness models in the published literature.MethodsData obtained from six trials representing 1,777 individuals with OUD. We implemented mapping algorithms to harmonize data from different measures of quality of life (the SF-12 Versions 1 and 2 and the EQ-5D-3 L). We performed a regression analysis to quantify the relationship between HSUVs and the following variables: days of extra-medical opioid use in the past 30 days, injecting behaviors, treatment with medications for OUD, HIV status, and age. A secondary analysis explored the impact of opioid withdrawal symptoms.ResultsThere were statistically significant reductions in HSUVs associated with extra-medical opioid use (-0.002 (95% CI [-0.003,-0.0001]) to -0.003 (95% CI [-0.005,-0.002]) per additional day of heroin or other opiate use, respectively), drug injecting compared to not injecting (-0.043 (95% CI [-0.079,-0.006])), HIV-positive diagnosis compared to no diagnosis (-0.074 (95% CI [-0.143,-0.005])), and age (-0.001 per year (95% CI [-0.003,-0.0002])). Parameters associated with medications for OUD treatment were not statistically significant after controlling for extra-medical opioid use (0.0131 (95% CI [-0.0479,0.0769])), in line with prior studies. The secondary analysis revealed that withdrawal symptoms are a fundamental driver of HSUVs, with predictions of 0.817 (95% CI [0.768, 0.858]), 0.705 (95% CI [0.607, 0.786]), and 0.367 (95% CI [0.180, 0.575]) for moderate, severe, and worst level of symptoms, respectively.ConclusionWe observed HSUVs for OUD that were higher than those from previous studies that had been conducted without input from people living with the condition.

BACKGROUND AND OBJECTIVE: Half of patients with gastroesophageal reflux disease (GERD) experience persistent symptoms while on proton pump inhibitors (PPIs), thus driving efforts to develop novel adjunctive therapies for PPI-refractory GERD. An economic analysis was performed to establish at what cost and efficacy such potential medications are likely to become cost effective in clinical practice. METHODS: A Markov decision model was used to examine a hypothetical cohort of patients being evaluated for PPI-refractory GERD in the USA. The model compared 3 strategies: (1) usual care (i.e., upfront diagnostic testing with upper endoscopy ± ambulatory pH testing); (2) use of a PPI-adjunctive therapy after positive ambulatory pH testing; and (3) empiric use of a PPI-adjunctive therapy (i.e., diagnostic testing only after failing empiric treatment). The primary outcome was incremental cost per quality-adjusted life year (QALY) gained (third-party payer perspective) over a 10-year time horizon using a willingness to pay threshold of $100,000/QALY. RESULTS: In two-way sensitivity analyses varying the cost and effectiveness of the PPI-adjunctive therapy, most combinations revealed that use of the medication after positive pH testing was the most cost-effective approach. Empiric treatment was the preferred strategy only when the therapy was highly efficacious (≥ 87.5% response rate) and low cost (≤ $109/month). Use of PPI-adjunctive treatments were not cost effective when the cost exceeded $1150/month. CONCLUSION: Use of PPI-adjunctive therapies in those with persistent GERD symptoms may become cost effective when guided by ambulatory pH tests. These data can guide investigators, industry, and payers as they develop, validate, and price new treatments for PPI-refractory GERD.

BackgroundProject Orbis is a global initiative that aims to streamline regulatory review processes across international regulators in the USA, Canada, Australia, UK, Israel, Brazil, Singapore, and Switzerland to bring promising cancer drugs to patients earlier. We explored the clinical benefit, time to regulatory approval and health technology assessment recommendations, reimbursement outcomes, and monthly treatment prices of cancer drugs reviewed through this initiative.MethodsFor this retrospective, comparative analysis, we identified cancer drug approvals reviewed through Project Orbis in the USA, Canada, and the UK between May 1, 2019, and Nov 1, 2023. Approvals of cancer drugs reviewed Project Orbis were extracted from the Food and Drug Administration (FDA) Oncology Centre of Excellence and all other FDA approvals from the Drugs@FDA database. The co-primary outcomes were time of regulatory review, time from regulatory approval to health technology assessment recommendation (England, Scotland, and Canada), reimbursement outcomes, clinical benefit (defined as median gains in progression-free survival and overall survival) between cancer drug approvals reviewed by Project Orbis and other FDA approval processes, and monthly treatment prices. The Wilcoxon rank-sum and Fisher's Exact tests were used to examine statistical significance between approvals reviewed through Project Orbis and other FDA approvals during the same period.FindingsBetween May 1, 2019 and Nov 1, 2023, 81 (33%) of 244 cancer drugs approved by the FDA were reviewed through Project Orbis. The median overall survival gains were 4·1 months (IQR 3·3-5·1) compared with 2·7 months (2·1-3·9) for other FDA approvals. Similarly, progression-free survival gains were 2·6 months (IQR 1·7-4·9) for Project Orbis compared with 2·6 months (0·6-5·1) for other FDA approvals. Neither overall survival (p=0·11) nor progression-free survival (p=0·44) gains were significantly different between the two cohorts of approvals. Of the 14 UK Medicines and Healthcare products Regulatory Agency (MHRA) approvals reviewed by the Scottish Medicines Consortium (SMC), the agency gave positive recommendations for all 14 (100%). Of the 15 MHRA approvals reviewed by the National Institute for Health and Care Excellence (NICE), the agency gave positive recommendations for six (40%). Of the 49 approvals reviewed by the Canadian Agency for Drugs and Technologies in Health (CADTH), the agency conditionally recommended 44 (90%). The time between regulatory approval to NICE recommendation increased from a median of 137 days (IQR 102-172) in 2021 to 302 days (184-483) in 2023, SMC recommendation increased from 185 days (in 2021 for one drug only) to 368 days (IQR 313-476) in 2023, and CADTH decision increased from 97 days (in 2020 for one drug only) to 202 days (IQR 153-304) in 2023. The median monthly price of approvals reviewed through Project Orbis was US$20 000 per month (IQR 13 000-37 000).InterpretationClinical outcomes of Project Orbis were no different than other FDA approvals during the same time, and access, after a successful health technology assessment, was considerably delayed or absent, raising questions about whether Project Orbis participation translates into faster patient access to medicines with high clinical benefit and sustainable costs. Although future challenges might benefit from regulatory harmonisation, the advantages are currently unclear.FundingNone.

This viewpoint discusses cost-effectiveness estimates for EtranaDez, a gene therapy for hemophilia B, using the Institute for Clinical and Economic Reviews (ICER) framework for single and short-term therapies (SSTs). EtranaDez offers long-term benefits from a single administration, in contrast to the high costs and frequent dosing required by current factor IX prophylaxis. However, the projected gains in health from EtranaDez are small relative to the cost implications of the therapy, and consequently, how the cost offsets associated with EtranaDez are counted has a substantial impact on assessing its cost-effectiveness. Strategies for assessing cost offsets used in the ICER SST framework include a 50/50 cost-sharing model between the health care system and the manufacturer and a cap of $150,000 annually on health care cost offsets. Results from the standard full cost-offset analysis as reported by ICER depicted EtranaDez as a dominant therapy with substantial cost savings compared with factor IX prophylaxis. However, while considering the ICER SST framework, particularly the $150,000 annual cap scenario, the cost-effectiveness was significantly reduced. The incremental cost-effectiveness ratio varied notably between these scenarios, challenging the conventional perception of value of gene therapy in health care. These cost-sharing scenarios highlight the potential of the ICER SST framework to help curtail inefficient health care spending. In cases in which the cost of existing treatment is exceedingly high, the application of such frameworks would improve efficiency in resource allocation, fostering a balance between incentives for innovation and economic sustainability in managed care systems.

BACKGROUND: Mental, neurological, and substance abuse (MNS) disorders describe a range of conditions that affect the brain and cause distress or functional impairment. In the Middle East and North Africa (MENA), MNS disorders make up 10.88 percent of the burden of disease as measured in disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) is one of the main providers of mental health services and one of the largest contributors to mental health research in the region. Within the past decade, mental health resources and services has increased. METHODS: We employ a needs-based workforce estimate as a planning exercise to arrive at the total number of psychiatrists, nurses, and psychosocial care providers needed to meet the epidemiological need of mental health conditions of the population of KSA. Estimates for a potential mental health workforce gap were calculated using five steps: Step 1-Quantify target population for priority mental health conditions. Step 2-Identify number of expected cases per year. Step 3-Set target service coverage for each condition. Step 4-Estimate cost-effective health care service resource utilization for each condition. Step 5-Estimate service resources needed for each condition. RESULTS: The planning exercise indicates an epidemiologic need for a total of 17,100 full-time-equivalent (FTE) health care providers to treat priority MNS disorders. KSA appears to have a need-based shortage of 10,400 health workers to treat mental disorders. A total of 100 psychiatrists, 5700 nurses, and 4500 psychosocial care providers would be additionally needed (that is, above and beyond current levels) to address the priority mental health conditions. The shortfall is particularly severe for nurses and psychosocial workers who make up 98.9 percent of the shortfall. This shortage is substantial when compared to other high-income countries. Overall, the workforce needed to treat MNS conditions translates to 49.2 health workers per 100,000 population. CONCLUSION: Challenges to addressing the shortfall are Saudi specific which includes awareness of cultural customs and norms in the medical setting. These challenges are compounded by the lack of Saudi nationals in the mental health workforce. Saudi nationals make up 29.5 percent of the physician workforce and 38.8 percent of the nursing workforce. Policymakers and planners supplement this shortfall with non-Saudi providers, who must be mindful of Saudi-specific cultural considerations. Potential solutions to reducing the shortfall of mental health care workers includes nurse task shifting and training of general practitioners to screen for, and treat, a subset of MNS disorders.

BACKGROUND: Eculizumab and efgartigimod were approved to treat anti-acetylcholine receptor antibody-positive generalized myasthenia gravis (anti-AChR Ab-positive gMG). These relatively new biological treatments provide a more rapid onset of action and improved efficacy compared with conventional immunosuppressive treatments, but at a higher cost. OBJECTIVE: To assess the cost-effectiveness of eculizumab and, separately, efgartigimod, each added to conventional therapy vs conventional therapy alone, among patients with refractory anti-AChR Ab-positive gMG and those with anti-AChR Ab-positive gMG, respectively. METHODS: A Markov model with 4 health states was developed, evaluating costs and utility with a 4-week cycle length and lifetime time horizon from a health care system perspective and a modified societal perspective including productivity losses from patients and caregiver burden. Model inputs were informed by key clinical trials and relevant publications identified from targeted literature reviews, and drug costs were identified from Micromedex Red Book. Costs and outcomes were discounted at 3% per year. Incremental cost-effectiveness ratios (ICERs; cost per quality-adjusted life-year [QALY] gained) were calculated for each comparison. RESULTS: Among the corresponding populations, lifetime costs and QALYs, respectively, for eculizumab were $5,515,000 and 11.85, and for conventional therapy, $308,000 and 10.29, resulting in an ICER of $3,338,000/QALY gained. For efgartigimod, lifetime costs and QALYs, respectively, were $6,773,000 and 13.22, and for conventional therapy, $322,000 and 9.98, yielding an ICER of $1,987,000/QALY gained. After applying indirect costs in a modified societal perspective, the ICERs were reduced to $3,310,000/QALY gained for eculizumab and $1,959,000/QALY gained for efgartigimod. CONCLUSIONS: Eculizumab and efgartigimod are rapidly acting and effective treatments for myasthenia gravis. However, at their current price, both therapies greatly exceeded common cost-effectiveness thresholds, likely limiting patient access to these therapies.

OBJECTIVE: Nursing home residents may be particularly vulnerable to coronavirus disease 2019 (COVID-19). Therefore, a question is when and how often nursing homes should test staff for COVID-19 and how this may change as severe acute respiratory coronavirus virus 2 (SARS-CoV-2) evolves. DESIGN: We developed an agent-based model representing a typical nursing home, COVID-19 spread, and its health and economic outcomes to determine the clinical and economic value of various screening and isolation strategies and how it may change under various circumstances. RESULTS: Under winter 2023-2024 SARS-CoV-2 omicron variant conditions, symptom-based antigen testing averted 4.5 COVID-19 cases compared to no testing, saving $191 in direct medical costs. Testing implementation costs far outweighed these savings, resulting in net costs of $990 from the Centers for Medicare & Medicaid Services perspective, $1,545 from the third-party payer perspective, and $57,155 from the societal perspective. Testing did not return sufficient positive health effects to make it cost-effective [$50,000 per quality-adjusted life-year (QALY) threshold], but it exceeded this threshold in ≥59% of simulation trials. Testing remained cost-ineffective when routinely testing staff and varying face mask compliance, vaccine efficacy, and booster coverage. However, all antigen testing strategies became cost-effective (≤$31,906 per QALY) or cost saving (saving ≤$18,372) when the severe outcome risk was ≥3 times higher than that of current omicron variants. CONCLUSIONS: SARS-CoV-2 testing costs outweighed benefits under winter 2023-2024 conditions; however, testing became cost-effective with increasingly severe clinical outcomes. Cost-effectiveness can change as the epidemic evolves because it depends on clinical severity and other intervention use. Thus, nursing home administrators and policy makers should monitor and evaluate viral virulence and other interventions over time.

OBJECTIVE: Implantable loop recorders (ILRs) are increasingly used for long-term rhythm monitoring after ischaemic and cryptogenic stroke, with the goal of detecting atrial fibrillation (AF) and subsequent initiation of oral anticoagulation to reduce risk of adverse clinical outcomes. There is a need to determine the effectiveness of different rhythm monitoring strategies in this context. METHODS: We conducted a retrospective cohort analysis of individuals with commercial and Medicare Advantage insurance in Optum Labs Data Warehouse who had incident ischaemic or cryptogenic stroke and no prior cardiovascular implantable electronic device from 1 January 2016 to 30 June 2021. Patients were stratified by rhythm monitoring strategy: ILR, long-term continuous external cardiac monitor (>48 hours to 30 days) or Holter monitor (≤48 hours). The primary outcome was risk-adjusted all-cause mortality at 12 months. Secondary outcomes included new diagnosis of AF and oral anticoagulation, bleeding, and costs. RESULTS: Among 48 901 patients with ischaemic or cryptogenic stroke, 9235 received an ILR, 29 103 long-term continuous external monitor and 10 563 Holter monitor only. Mean age was 69.9 (SD 11.9) years and 53.5% were female. During the 12-month follow-up period, patients who received ILRs compared with those who received long-term continuous external monitors had a higher odds of new diagnosis of AF and oral anticoagulant initiation (adjusted OR 2.27, 95% CI 2.09 to 2.48). Compared with patients who received long-term continuous external monitors, those who received ILRs had similar 12-month mortality (HR 1.00; 95% CI 0.89 to 1.12), with approximately $13 000 higher costs at baseline (including monitor cost) and $2500 higher costs during 12-month follow-up. CONCLUSIONS: In this large real-world study of patients with ischaemic or cryptogenic stroke, ILR placement resulted in more diagnosis of AF and initiation of oral anticoagulation, but no difference in mortality compared with long-term continuous external monitors.

UNLABELLED: Continuous tobacco use in patients with cancer is linked to substantial healthcare costs due to increased risks and complications, whereas quitting smoking leads to improved treatment outcomes and cost reductions. Addressing the need for empirical evidence on the economic impact of smoking cessation, this study examined the association between smoking cessation and healthcare cost utilization among a sample of 930 patients with cancer treated at The University of Texas MD Anderson Cancer Centers Tobacco Research and Treatment Program (TRTP). Applying conditional quantile regression and propensity scores to address confounding, our findings revealed that abstinence achieved through the TRTP significantly reduced the median cost during a 3-month period post-quitting by $1,095 [β = -$1,095, P = 0.007, 95% confidence interval (CI), = (-$1,886 to -$304)]. Sensitivity analysis corroborated these conclusions, showing a pronounced cost reduction when outlier data were excluded. The long-term accrued cost savings from smoking cessation could potentially offset the cost of participation in the TRTP program, underscoring its cost effectiveness. An important implication of this study is that by reducing smoking rates, healthcare systems can more efficiently allocate resources, enhance patient health outcomes, and lessen the overall cancer burden. PREVENTION RELEVANCE: This study emphasizes the dual impact of smoking cessation programs in patients with cancer: quitting smoking and reducing healthcare costs. It highlights the importance of integrating cessation programs into cancer prevention strategies, ensuring both individual health benefits and broader, system-wide economic efficiencies. See related Spotlight, p. 197.

BACKGROUND: Audit and Feedback (A&F) interventions based on quality indicators have been shown to lead to significant improvements in compliance with evidence-based care including de-adoption of low-value practices (LVPs). Our primary aim was to evaluate the cost-effectiveness of adding a hypothetical A&F module targeting LVPs for trauma admissions to an existing quality assurance intervention targeting high-value care and risk-adjusted outcomes. A secondary aim was to assess how certain A&F characteristics might influence its cost-effectiveness. METHODS: We conducted a cost-effectiveness analysis using a probabilistic static decision analytic model in the Québec trauma care continuum. We considered the Québec Ministry of Health perspective. Our economic evaluation compared a hypothetical scenario in which the A&F module targeting LVPs is implemented in a Canadian provincial trauma quality assurance program to a status quo scenario in which the A&F module is not implemented. In scenarios analyses we assessed the impact of A&F characteristics on its cost-effectiveness. Results are presented in terms of incremental costs per LVP avoided. RESULTS: Results suggest that the implementation of A&F module (Cost = $1,480,850; Number of LVPs = 6,005) is associated with higher costs and higher effectiveness compared to status quo (Cost = $1,124,661; Number of LVPs = 8,228). The A&F module would cost $160 per LVP avoided compared to status quo. The A&F module becomes more cost-effective with the addition of facilitation visits; more frequent evaluation; and when only high-volume trauma centers are considered. CONCLUSION: A&F module targeting LVPs is associated with higher costs and higher effectiveness than status quo and has the potential to be cost-effective if the decision-makers willingness-to-pay is at least $160 per LVP avoided. This likely represents an underestimate of true ICER due to underestimated costs or missed opportunity costs. Results suggest that virtual facilitation visits, frequent evaluation, and implementing the module in high-volume centers can improve cost-effectiveness.

HighlightsWe illustrate the steps involved in carrying out cost-effectiveness analysis using net benefit regressions with possibly censored demo data by providing step-by-step guidance and code applied to a data set.We demonstrate the importance of these new methods by illustrating how naïve methods for handling censoring can lead to biased cost-effectiveness results.

BACKGROUND: Cost-effectiveness analysis of HIV self-testing using patient-level data from a randomized clinical trial can inform HIV prevention funding decisions. Cost-effectiveness analysis using net-benefit regression addresses the sampling uncertainty in the trial data and the variability of policymakers willingness to pay (WTP). METHODS: We used published data from a 12-month longitudinal randomized clinical trial that enrolled 2665 men who had sex with men randomly assigned to the self-testing arm (participants receiving self-test kits) and control arm (participants receiving standard-of-care), and the self-testing arm identified 48 additional new HIV cases. We used net-benefit regression to investigate the cost-effectiveness of an HIV self-testing intervention, which compared the incremental cost per new HIV diagnosis with policymakers WTP thresholds. We addressed the uncertainties in estimating the incremental cost and the policymakers WTP per new diagnosis through the incremental net-benefit (INB) regression and cost-effectiveness acceptability curve (CEAC) analyses. RESULTS: From the health care providers perspective, the INB analysis showed a positive net benefit of HIV self-testing compared with standard-of-care when policymakers WTP per new HIV diagnosis was $9365 (95% confidence interval: $5700 to $25,500) or higher. The CEAC showed that the probability of HIV self-testing being cost-effective compared with standard-of-care was 58% and >99% at a WTP of $10 000 and $50 000 per new HIV diagnosis, respectively. CONCLUSION: The INB and CEAC analyses suggest that HIV self-testing has the potential to be cost-effective for relatively low values of policymakers WTP.

IntroductionIn high-burden settings, low-complexity screening tests for tuberculosis (TB) could expand the reach of community-based case-finding efforts. The potential costs and cost-effectiveness of approaches incorporating these tests are poorly understood.MethodsWe developed a microsimulation model assessing 3 approaches to community-based case-finding in hypothetical populations (India-, South Africa-, The Philippines-, Uganda-, and Vietnam-like settings) with TB prevalence 4 times that of national estimates: (1) screening with a point-of-care C-reactive protein (CRP) test, (2) screening with a more sensitive "Hypothetical Screening test" (95% sensitive for Xpert Ultra-positive TB, 70% specificity; equipment/labor costs similar to Xpert Ultra, but using a $2 cartridge) followed by sputum Xpert Ultra if positive, or (3) testing all individuals with sputum Xpert Ultra. Costs are expressed in 2023 US dollars and include treatment costs.ResultsUniversal Xpert Ultra was estimated to cost a mean $4.0 million (95% uncertainty range: $3.5 to $4.6 million) and avert 3200 (2600 to 3900) TB-related disability-adjusted life years (DALYs) per 100 000 people screened ($670 [The Philippines] to $2000 [Vietnam] per DALY averted). CRP was projected to cost $550 (The Philippines) to $1500 (Vietnam) per DALY averted but with 44% fewer DALYs averted. The Hypothetical Screening test showed minimal benefit compared to universal Xpert Ultra, but if specificity were improved to 95% and per-test cost to $4.5 (all-inclusive), this strategy could cost $390 (The Philippines) to $940 (Vietnam) per DALY averted.ConclusionsScreening tests can meaningfully improve the cost-effectiveness of community-based case-finding for TB but only if they are sensitive, specific, and inexpensive.

BackgroundRecently-updated global guidelines for cervical cancer screening incorporated new technologies-most significantly, the inclusion of HPV DNA detection as a primary screening test-but leave many implementation decisions at countries' discretion. We sought to develop recommendations for Malawi as a test case since it has the second-highest cervical cancer burden globally and high HIV prevalence. We incorporated updated epidemiologic data, the full range of ablation methods recommended, and a more nuanced representation of how HIV status intersects with cervical cancer risk and exposure to screening to model outcomes of different approaches to screening.MethodsUsing a Markov model, we estimate the relative health outcomes and costs of different approaches to cervical cancer screening among Malawian women. The model was parameterized using published data, and focused on comparing "triage" approaches-i.e., lesion treatment (cryotherapy or thermocoagulation) at differing frequencies and varying by HIV status. Health outcomes were quality-adjusted life years (QALYs) and deaths averted. The model was built using TreeAge Pro software.ResultsThermocoagulation was more cost-effective than cryotherapy at all screening frequencies. Screening women once per decade would avert substantially more deaths than screening only once per lifetime, at relatively little additional cost. Moreover, at this frequency, it would be advisable to ensure that all women who screen positive receive treatment (rather than investing in further increases in screening frequency): for a similar gain in QALYs, it would cost more than four times as much to implement once-per-5 years screening with only 50% of women treated versus once-per-decade screening with 100% of women treated. Stratified screening schedules by HIV status was found to be an optimal approach.ConclusionsThese results add new evidence about cost-effective approaches to cervical cancer screening in low-income countries. At relatively infrequent screening intervals, if resources are limited, it would be more cost-effective to invest in scaling up thermocoagulation for treatment before increasing the recommended screening frequency. In Malawi or countries in a similar stage of the HIV epidemic, a stratified approach that prioritizes more frequent screening for women living with HIV may be more cost-effective than population-wide recommendations that are HIV status neutral.

Thermosensation, the ability to detect and estimate temperature, is an evolutionarily conserved process that is essential for survival. Thermosensing is impaired in various pain syndromes, resulting in thermal allodynia, the perception of an innocuous temperature as painful, or thermal hyperalgesia, an exacerbated perception of a painful thermal stimulus. Several behavioral assays exist to study thermosensation and thermal pain in rodents, however, most rely on reflexive withdrawal responses or the subjective quantification of spontaneous nocifensive behaviors. Here, we created a new apparatus, the thermal escape box, which can be attached to temperature-controlled plates and used to assess temperature-dependent effort-based decision-making. The apparatus consists of a light chamber with an opening that fits around temperature-controlled plates, and a small entryway into a dark chamber. A mouse must choose to stay in a brightly lit aversive area or traverse the plates to escape to the enclosed dark chamber. We quantified escape latencies of adult C57Bl/6 mice at different plate temperatures from video recordings and found they were significantly longer at 5 °C, 18 °C, and 52 °C, compared to 30 °C, a mouses preferred ambient temperature. Differences in escape latencies were abolished in male Trpm8-/- mice and in male Trpv1-/- animals. Finally, we show that chronic constriction injury procedures or oxaliplatin treatement significantly increased escape latencies at cold temperatures compared to controls, the later of which was prevented by the analgesic meloxicam. This demonstrates the utility of this assay in detecting cold pain. Collectively, our study has identified a new and effective tool that uses cost-benefit valuations to study thermosensation and thermal pain.

To address the issues of node interaction power overrun and high carbon emissions that may arise during distributed optimization in multi‐energy parks (MEPs), this paper proposes a distributed low‐carbon and economic operation method for multi‐energy parks based on a cloud platform that considers network transmission capacity.The proposed method achieves maximun profit by designing a two layer collaborative architecture for distributed optimization operations. At the top level, cloud platform services are utilized to build a model for checking network transport capacity and carbon emission quotas, optimizing network node over‐limit inspection. The bottom layer constructs a distributed optimization model for multi‐energy complementation in each park, taking into account the information privacy and individual interests of each multi‐energy park. An improved alternating direction multiplier method (ADMM) is proposed to effectively solve the two‐layer framework. The case studies show that the distributed optimization method under cloud platform services proposed in this paper can achieve maximum revenue for integrated energy service provider while ensuring the safe operation of multi‐energy parks, and reasonably allocate the benefits of collaborative operation among various parks while promoting carbon emission reduction. [ABSTRACT FROM AUTHOR]

Purpose: Surgical site infections (SSIs) following spine surgery are associated with morbidity and resource utilization. Applying prophylactic closed-incisional negative pressure wound therapy (ciNPWT) during posterior instrumented fusion has mixed results in reducing rates of wound complications and SSI. We evaluated the clinical efficacy and potential cost-savings associated with ciNPWT in high-risk patients receiving posterior instrumented spinal fusion. Methods: We retrospectively reviewed patients receiving posterior instrumented spinal fusion for any surgical indication between July 1, 2017 and December 31, 2019, and compared rates of wound dehiscence, SSI, and reoperation for wound complications between standard surgical dressings and ciNPWT. Surgical dressing selection was based on the senior author's assessment of infection risk factors. Results: A total of 229 patients (n = 85 standard surgical dressings, n = 144 ciNPWT) were included. The ciNPWT group had significantly more risk factors for wound-related complications, including older age (61.8 vs. 58.5 years, p = 0.042), diabetes mellitus (36.8% vs. 23.5%, p = 0.037), more instrumented levels (5.6 vs. 3.9, p < 0.0001), estimated blood loss (1298 vs. 998 mL, p = 0.036), and deformity was the predominant operative indication (29.9% vs. 17.7%, p = 0.040). Prophylactic ciNPWT was associated with significantly lower rates of wound dehiscence (21.5% vs. 34.1%, p = 0.036) and SSI (8.3% vs. 21.2%, p = 0.005). Number needed to treat with ciNPWT to prevent one SSI was 8 patients. The cost of preventing one SSI was $4,560. Cost-benefit analysis demonstrated a potential mean savings of $21,662 per operative SSI prevented and $270,775 per 100 patients undergoing posterior instrumented fusion with ciNPWT. Conclusions: Prophylactic ciNPWT use is a cost-effective means of reducing rates of wound dehiscence and SSI following posterior instrumented fusion. Previous presentations: An abstract from this work was presented as an oral presentation at the 2023 CNS Annual Meeting in Washington, DC. [ABSTRACT FROM AUTHOR]

Societal Impact Statement Summary Intercropping techniques like the Three Sisters, where maize, beans, and squash are grown in an intermixed arrangement, have sustained communities in the Americas for thousands of years and continue to be practiced around the world. In collaboration with the Catawba Indian Nation, we assessed the yield and labor demands required when farming with Three Sisters versus monoculture arrangements. Our results illustrate how farmers could use different planting strategies depending on their priorities (e.g., maximizing yield) and available resources (e.g., conserving land, seeds, or labor). Studies like these can help inform food sovereignty programs and support cultural initiatives in Native communities. Many Native American communities have historically grown maize, beans, and squash in polyculture as the Three Sisters because of the reciprocal ecological benefits the species provide each other and the surrounding environment. For instance, archaeological remains indicate that the Catawba Indian Nation had grown the Three Sisters for hundreds of years before experiencing the expansion of the colonial market economy, a smallpox epidemic, and the drastic loss of land. To support the Catawba Indian Nation's food sovereignty and traditional ecological knowledge initiatives, we assess the yield and labor demands of growing their traditional variety of maize, beans, and squash plants in the Three Sisters planting design versus in monoculture conditions. While total maize yield was highest in monoculture, plants grew larger, had higher survival, and produced greater yield per plant and per unit area of land in the Three Sisters. Squash yield was highest in monoculture. Trellising bean plants in monoculture required the most labor, and altogether, yield per hour of labor was higher in monoculture than in the Three Sisters. Ultimately, the most appropriate farming strategy for the Catawba Indian Nation to use will depend on their priorities (e.g., maximizing the production of one species versus all species). We discuss the challenges managers of small farms face when considering traditional versus modern agricultural methods and describe how a respectful partnership between the Catawba Nation and Davidson College expanded and enhanced the outcomes of this study. [ABSTRACT FROM AUTHOR]

ABSTRACT Asymptomatic lymphocytosis poses a common challenge in haematology. Immunophenotyping can establish whether a clonal population is present, but it is expensive and the benefit of diagnosing asymptomatic patients is unproven. This study aimed to establish data to guide the use of immunophenotyping. We analysed the proportion of lymphocytosis in full blood count (FBC) samples across a five‐year period within a large UK National Health Service (NHS) trust. Persistent lymphocytosis was present in 0.18% (437/242678) of repeat community samples. Of samples sent for immunophenotyping, 743/784 (95%) with a lymphocyte count > 10 × 109/L had a clonal population, compared to 223/1696 (14%) with a lymphocyte count < 5 × 109/L. We followed up a longitudinal cohort of asymptomatic patients with clonal lymphocytosis to determine how many required treatment. The minority (11/46) of patients needed treatment within 9 years of follow‐up. Of patients needing treatment, 10/11 (91%) had a presenting lymphocyte count > 10 × 109/L. In all cases, treatment was initiated when the patient became symptomatic. We propose a lymphocyte count threshold of > 10 × 109/L for referral and immunophenotyping in patients with asymptomatic lymphocytosis. This approach aims to balance safety and cost‐effectiveness and reflects uncertainty in the value of diagnosis for asymptomatic patients. [ABSTRACT FROM AUTHOR]

Medical imaging plays a pivotal role in diagnostic medicine with technologies like Magnetic Resonance Imagining (MRI), Computed Tomography (CT), Positron Emission Tomography (PET), and ultrasound scans being widely used to assist radiologists and medical experts in reaching concrete diagnosis. Given the recent massive uplift in the storage and processing capabilities of computers, and the publicly available big data, Artificial Intelligence (AI) has also started contributing to improving diagnostic radiology. Edge computing devices and handheld gadgets can serve as useful tools to process medical data in remote areas with limited network and computational resources. In this research, the capabilities of multiple platforms are evaluated for the real-time deployment of diagnostic tools. MRI classification and segmentation applications developed in previous studies are used for testing the performance using different hardware and software configurations. Cost–benefit analysis is carried out using a workstation with a NVIDIA Graphics Processing Unit (GPU), Jetson Xavier NX, Raspberry Pi 4B, and Android phone, using MATLAB, Python, and Android Studio. The mean computational times for the classification app on the PC, Jetson Xavier NX, and Raspberry Pi are 1.2074, 3.7627, and 3.4747 s, respectively. On the low-cost Android phone, this time is observed to be 0.1068 s using the Dynamic Range Quantized TFLite version of the baseline model, with slight degradation in accuracy. For the segmentation app, the times are 1.8241, 5.2641, 6.2162, and 3.2023 s, respectively, when using JPEG inputs. The Jetson Xavier NX and Android phone stand out as the best platforms due to their compact size, fast inference times, and affordability. [ABSTRACT FROM AUTHOR]

Purpose: This pilot study evaluated the cost–benefit of research-based Treatment Foster Care Oregon (TFCO) as an alternative treatment setting to residential care for children in the Illinois child welfare system. Methods: Using secondary analysis of child welfare administrative data, this study observed, for 2 years, 52 children enrolled in TFCO and 67 children who were eligible for TFCO but remained in or entered residential care. Results: Over the 2-year period, the average daily cost of care for children in TFCO was $249, compared to $320 for children in residential care, resulting in cost-savings of $51,058 per child and an overall net benefit of $94,294 per child. Conclusions: The promising cost–benefit evidence of TFCO as implemented in a state child welfare system has implications on social work services and placement decision-making, and system capacity in scaling up short-term therapeutic foster homes for children who might otherwise languish in residential care. [ABSTRACT FROM AUTHOR]

For public interest advocates engaged on issues of worker health and safety and environmental protections, regulatory cost–benefit analysis has long been seen as an obstacle to meaningful progress. In November 2023, the Biden administration overhauled Circular A-4, which provides guidance to agencies on how to perform cost–benefit analyses for their rules. The reforms seek to make cost–benefit analysis less biased against worker safety, public health, environmental, and other protective safeguards. As such, the new version of Circular A-4 offers important new levers to agencies to justify more stringent protections. By extension, those in the public interest community can use agency implementation of the new Circular A-4 as part of their advocacy efforts for specific rules they are tracking. This article seeks to support this tactic by providing a roadmap for advocates on how to incorporate into their comments critiques of agencies' cost–benefit analyses based on the Circular A-4 revisions. [ABSTRACT FROM AUTHOR]

A cost–benefit analysis of air pollution reduction measures in maritime transport systems can support the sustainability commitments of the industry and validate the related economic incentives. However, a systematic cost–benefit analysis approach has not yet been framed, as data availability and resources are limited. This study explores an alternative cost–benefit estimate approach to reduce air pollution in shipping based on a broad review and applies it to a case study regarding the domestic emission controls of Xiamen shipping. The results show that switching to a fuel with a maximum allowable fuel sulphur content of 1.5% to 0.5% for cargo ships and other vessels leads to more than nine times the external benefits to costs, while switching to a fuel with less than 0.5% sulphur content may lead to below-cost external benefits; the benefits/cost ratio based on shore power is 3.14. The proposed approach contributes to estimating not only the input costs but also their external benefits to fit the externality of sustainability actions. In the future, more site-specific factors and parameters and more case studies are recommended to improve the research reliability and accuracy as well as enrich the knowledge base for shipping sustainability development. [ABSTRACT FROM AUTHOR]

Given that e-commerce is an essential way to improve the efficiency of resource allocation and boost economic growth in the era of digital technology, China has launched the national e-commerce demonstration city (NEDC) pilot project to enhance the application and extension of e-commerce. This study aims to explore the effect of the NEDC pilot policy on economic growth. Based on data sources from 285 prefecture-level cities in China from 2005 to 2021, this study assesses the effect of the NEDC pilot policy on economic growth by applying the staggered difference-in-differences (DID) method with the two-way fixed effects (TWFE) model. In addition, this study investigates the issues of heterogeneity, mediating effects, and cost–benefit of the NEDC pilot policy. The major results of this study are as follows: (1) Compared to non-demonstration cities, the implementation of the NEDC pilot policy resulted in a 4.1% increase in GDP in demonstration cities. Moreover, this boosting effect is particularly significant in prefecture-level cities associated with a high level of digital technology application; however, this positive effect disappears in prefecture-level cities with a high degree of local government intervention. (2) Decreasing transaction costs, increasing business opportunities, and reducing labor misallocation are the main mediating channels for the impact of the NEDC pilot policy on economic growth, implying that the NEDC pilot policy has played an important role in reducing information asymmetry, transaction links, and resource misallocation. (3) The benefits of the NEDC pilot policy exceed its costs as revealed by the fact that the pilot policy has dramatically increased the ratio of GDP to network costs, electricity consumption costs, and labor costs. This study recommends that when strengthening the application of e-commerce, it is essential to reduce excessive government intervention and enhance e-commerce support measures to ensure the role of e-commerce in facilitating economic growth. [ABSTRACT FROM AUTHOR]

Cellulose nanofiber (CNF) has attracted a lot of attention because it has the potential to improve the physical and mechanical properties of various nanocomposites. CNF is produced by a number of chemical processes, with bleaching being a crucial step for increasing CNF yield. To better comprehend the delignification process, kinetic studies are therefore crucial. In the present study, a first-order kinetic model was used to explore the kinetics of delignification and lignin solubilisation process. The activation energy of bleaching process was found to be 18.14 kJ/mol. The delignification rate constant (kL) for bleaching process was found to be 0.864 h − 1 at 70 °C. Under experimental conditions, the activation enthalpy and entropy were varied from 15.04 to 15.45 kJ/mol and 121.45 to 122.65 J/Mol/K respectively. In the present investigation, Δ G ∗ was found to be negative (− 39.33 to − 45.19 kJ/mol), which indicates that the reaction is spontaneous. Colloidal behaviour studies of CNF are crucial to determine the most effective CNF application since CNF is often treated in aqueous dispersion before being utilised in a particular application. CNF dispersion was found to be stable at pH 13 in the current investigation. CNF has an average hydrodynamic diameter (Di) of 169 nm and a zeta potential of − 24.2 mV at pH 13. Derjaguin–Landau–Verwey–Overbeek (DLVO) theory successfully explained the observed behaviour of CNF dispersion. To make CNF production cost-effective, a comprehensive cost–benefit analysis of the entire process is required. The purity of CNF obtained from Imperata cylindrica was 94.36%, with a sellable cost of 117.74 INR (1.55 $) per mg. [ABSTRACT FROM AUTHOR]

With the impact and cost of continued river degradation and climate changeinduced extreme rainfall and floods, there is growing urgency to achieve and maintain good river health to meet global sustainable development goals. Upscaling and working with nature-based solutions at regional, catchment and fluvial corridor scales is critical. One way to achieve this is to work within a recovery-enhanced approach to river rehabilitation, incorporating processes of geomorphic and vegetative recovery to build fluvial corridors in areas where they have become fragmented. Geomorphologically-informed cost-benefit analysis has not previously been applied in a riverine or riparian context, at the catchment or regional scale needed. We applied Marxan in a novel manner to undertake the first cost-benefit analysis for geomorphologically-informed rehabilitation of river systems. We estimated that to rehabilitate 75,500 km of streams in coastal catchments of NSW will cost $8.2 billion, comparing favourably to recent single flood event insurance losses, and projected future losses. We developed Marxan scenarios based on three broad approaches to river management: ad hoc and reactive, working with recovery and corridors, across current and future time periods. We found there are considerable current and flow-on future financial and non-financial benefits, and lower initial total and per-hectare rehabilitation costs, by fully adopting working with recovery or corridors approaches and moving away from the ad hoc and reactive approaches which dominate current practice. Implementing targeted rehabilitation based on a rolling sequence over time of corridors scenarios provides optimal holistic solutions to improve geomorphic condition and enhance recovery potential at landscape-scale. Our study demonstrates the use of Marxan as an accessible tool to address prioritisation complexity, and to run and cost landscape-scale rehabilitation scenarios over time. Our study also demonstrates the positive offsite feedbacks that occur through multiplier effects, as recovery occurs, and corridors are built. Geomorphologically-informed decision making becomes more robust, transparent, cost-effective, consistent across catchments, and adaptive to local situations and evolving river management priorities. [ABSTRACT FROM AUTHOR]

Ultra‐high voltage (UHV) converter stations are critical nodes in power grids. This paper proposes a probabilistic framework for assessing and mitigating the seismic risk of UHV converter station systems to enhance the seismic performance of the grid. First, a Bayesian network model for the system functionality of UHV converter stations was established based on the enumeration of equipment failure scenarios. Conditional probability tables (CPTs) were used to represent the causal relationship among subsystems and system functionality. Inference calculations were conducted using Bayes' theorem. Then, the definition of system seismic loss risk distribution was proposed to assess the seismic risk of the system over its entire lifespan. The feasibility of this framework was validated using a specific UHV converter station, yielding analytical solutions for the probability distribution of system functionality and seismic vulnerability curves. Additionally, the cost‐effectiveness of several risk mitigation strategies was assessed. A cost‐benefit analysis was performed from the perspectives of both the expected loss of a single earthquake and the life‐cycle cost. The framework comprehensively considered the constraints imposed by series, parallel, and bypass control devices on the system's functionality. It was revealed that the seismic loss risk for UHV converter stations exhibits a characteristic of low probability but high loss. [ABSTRACT FROM AUTHOR]

Background: Australia's clinical trials sector is highly productive with continued sector investment needed to enhance research impact. Generating economic evidence alongside trials has the potential to facilitate the implementation of trial results into practice. Ascertaining the use of health economic evaluations alongside clinical trials can assist in determining whether clinical trials fully realize and operationalize their potential to change policy and practice. The aims of this study were to ascertain the uptake of health economic evaluations alongside Australian-led clinical trials and explore associations between uptake and trial characteristics. Methods: This observational study comprised a descriptive analysis of clinical trials registries, a cross-sectional survey of Australian Clinical Trials Alliance (ACTA) networks, and a subgroup analysis of completed acute care trials. Descriptive analyses of trial registrations were conducted, with logistic regressions used to identify predictors of proposing and subsequently publishing a health economic evaluation alongside acute care trials. Results: Few randomized Australian-led clinical trials (11% of 9251) and ACTA network trials (43% of 227) proposed a health economic evaluation. In the subgroup analysis, 22% of the 324 acute care trials and 53% of the 38 ACTA network acute care trials proposed a health economic evaluation. Acute care trials funded by government bodies were significantly more likely to propose and publish a health economic evaluation than those funded by hospitals, universities, and other funders, after adjusting for phase, registration year, primary sponsor type, and comparator. Conclusions: Current uptake of health economic evaluations alongside Australian-led clinical trials is low, with uptake higher among the subset of ACTA network trials. This is despite economic evidence playing an increasingly prominent role in health system management, as well as rising health expenditure, limited budgets, and competing demands. There is significant opportunity to embed health economic evaluations alongside clinical trials, particularly phase 3 trials, to increase research outputs and optimize research translation. Investing in clinical trial networks that support funding for a health economist or a health economic evaluation may be an effective strategy to increase the uptake of health economic evaluations alongside trials. [ABSTRACT FROM AUTHOR]

Introduction: Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described. Objective: We aimed to compare the costs of eOBCS and mastectomy. Methods: We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included. Results: Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416. Conclusion: eOBCS is associated with a lower cost than mastectomy and had a low conversion rate to mastectomy. [ABSTRACT FROM AUTHOR]

Summary: Distributed cache systems are utilized to enhance I/O performance between computing applications and storage systems. However, the traditional file access predictors employed in these cache systems are only suitable for workloads with simple file access patterns, rendering them inadequate for the complex access patterns found in big data computing scenarios. In this article, we propose a file access predictor (DFAP) based on WaveNet, which has exhibited promising results in file access tasks when compared to other baseline models. Cache systems are often constrained by limited cache space due to cost, cluster size, and other factors. In big data scenarios, cached data and prefetched data often compete for limited space. To address this issue, we introduce a cache prefetching algorithm (CBAP) for cache systems, which is based on cost‐benefit analysis to improve cache utilization. Furthermore, we implement a novel file prefetching framework on Alluxio, which accelerates computing jobs by up to 18%. [ABSTRACT FROM AUTHOR]

Background: The use of acetaminophen in the perioperative period has emerged as an attractive option for providing safer and cost‐effective analgesia in children. Aims: The primary aim of our project was to increase the use of acetaminophen (both oral and intravenous) in the perioperative period from a baseline of 39.5% to 50% for all surgical patients within 24 months. The secondary aim was to increase the use of enteral acetaminophen from 10% to 52.5% during the same period. Methods: A multidisciplinary team was formed, and model for improvement was chosen as the QI methodology. The primary measure was the total percentage of surgical patients receiving any form of perioperative acetaminophen, while our secondary measure was the percentage use of oral acetaminophen administration. We also tracked the average maximum PACU (Post Anesthesia Care Unit) pain scores and the percentage of patients receiving IV opioids. Multiple interventions were conducted, including education, increasing the availability of acetaminophen, and optimizing the electronic medical record (EMR). Monthly data was collected using an automated report in the EMR. Results: We successfully achieved our goal, increasing the use of acetaminophen from 39.5% to 70% within four months. Despite some fluctuations, by the end of 24 months, we not only met but surpassed our goal, with 63% of patients receiving perioperative acetaminophen. Similarly, the usage of oral acetaminophen increased from a baseline of 10% to 78%. Our average maximum PACU pain scores improved from 5.4 to 5.2, and the percentage of patients receiving rescue opioids decreased from 15.4 to 13.1. Conclusion: We successfully achieved and sustained our goals of improving acetaminophen use for our surgical patients without worsening pain scores or worsening use of intravenous opioids. Future directions include further refining our strategies and exploring additional opportunities to optimize pain management in pediatric perioperative settings. [ABSTRACT FROM AUTHOR]

This research aims to investigate euthanasia, the act of terminating the lives of humans and certain animals due to their poor living conditions. This study explores euthanasia within the framework of sustainability, including environmental, economic, and social aspects. To achieve this, euthanasia is examined through a cost-benefit analysis using a management accounting approach, considering its implications across the economic, environmental, and social dimensions of sustainability. Data for this study were estimated by the authors. Income and cost factors related to the presence or absence of euthanasia were identified within the economic, environmental, and social realms of sustainability, followed by a comprehensive cost-benefit analysis. It is important to note that the purpose of this analysis is not to advocate for specific decisions but rather to present a nuanced understanding of the issue and invite the reader’s perspective. The cost-benefit analysis showed that the monetary costs and income, as well as the influence of non-monetary factors, may fluctuate depending on the medical specifics of the case and the dynamics of the patient’s family profile. [ABSTRACT FROM AUTHOR]

Mesopelagic fish represent an opportunity for fishing companies and food production, but their exploitation carries substantial environmental risks related to these populations' role in the oceanic carbon pump. We assess the economic viability of mesopelagic fishing from a private economic perspective, focusing on costs and revenues accruing to the fishing industry, and a public economic perspective, considering impacts on society at large, notably climate change. We develop a stylized model, which we apply to four pelagic trawling fleets in the European Union. We find that a mesopelagic fishery operated with current excess capacity in the four fleets considered is profitable from a private perspective, but the climate impacts potentially outweigh the private economic benefits. This implies that strict governance arrangements are needed to safeguard the sustainability of the mesopelagic zone. Considering long-term dynamics, we explore potential natural limits to an expanding mesopelagic fishery. First, a growing fishery will reduce biomass level, affecting profitability. Second, an increase in mesopelagic production may lower the price, also limiting potential for expansion. For the time being, however, it is unlikely that the fishery will reach a scale level where such feedbacks can be expected, making effective governance arrangements even more crucial. [ABSTRACT FROM AUTHOR]

Effective mitigation of climate change requires a robust set of policy interventions. Existing policy appraisal frameworks and approaches impact the design and choice of these policy options. However, their application to transformative climate policy can present several shortcomings. In light of criticism around current appraisal methods, we review the climate policy appraisal landscape and interview policy experts in three major emerging economies: Brazil, China and India. Little research has been done on the perception, approach, and practice of policy appraisal in these countries, even though they will have a significant impact on global progress to mitigate climate change. We find that policy appraisal in Brazil, China, and India is supported by guidelines, but the detail and implementation of those guidelines vary significantly. Cost–benefit analysis (CBA) is the prevailing decision-making framework in both Brazil and India whereas multi-criteria analysis is the dominant framework in China. Practitioners appear to understand CBA and its limitations well but also value its usability and the perception of robustness. Across all countries, political considerations can outweigh appraisal findings; respondents suggested this can be negative, in the sense that appraisal results are sometimes ignored, but can also be positive in the sense that other objectives are considered. Existing approaches present several limitations, particularly regarding transformational change, which could hamper progress to formulate and implement effective climate and energy policy. Key policy insights: Guidelines that standardize the appraisal process are considered better for accountability and therefore increase the influence of appraisal in policymaking. The choice of approach affects the appraisal outcome. The type of policy and its intended aims should inform the method of appraisal used. Climate policies are often transformational in nature. As such, their outcomes can be very uncertain. More efforts are needed to integrate these considerations of uncertainty into appraisal frameworks. More computational models that consider system feedbacks and uncertainty are needed to robustly analyse the impacts of transformative policies. [ABSTRACT FROM AUTHOR]

Numerous studies have found that people's reservation prices for selling things they possess are roughly twice what others who don't possess those things would be willing to pay to acquire them. This finding, which behavioral economists call loss aversion, prompts an important policy question: If losses weigh twice as heavily as gains, should the cost-benefit principle be modified to recommend taking only those actions whose benefits are at least twice as large as their costs? Here, I argue that this would be misguided. Although losses do indeed loom disproportionately large, both in prospect and in the immediate aftermath of having experienced them, people generally adapt to them much more quickly and completely than they had anticipated. Once people take an action, its benefits quickly become part of their endowments, causing its perceived value to rise accordingly. But adaptation affects the costs of the action in the opposite direction. Even costs that seemed genuinely daunting in prospect are generally seen as much less so once people have had an opportunity to adapt to them. To say that loss aversion creates a powerful status-quo bias is thus descriptive but, by all indications, maladaptive. [ABSTRACT FROM AUTHOR]

High percentage of global electrical power production today comes from steam plants. Thus, improving performance of such plants is crucial to minimize its environmental effects and achieve operational economy. This project aim is to study several aspects of plants operation such as pollution, safety, health, economy and dangerous incidents during operation. Thereby, assessment may be conducted through specific rating factor as death rate (DR); greenhouse emissions (CO2EQV); capacity factor (CF); generating efficiency (η); reliability (Rbt); cost; availability; global production (Prd) & consumption rates (Econs). These rating factors were applied to all types of energy sources to evaluate its safety & cleanliness (DR & CO2EQV); reliability at maximum power at specific time (CF & Rbt); generation efficiency to maintain acceptable cost and power losses control (η & Cost); examining finally each source availability to insure continuous operation under regular global production (Prd) & consumption rates (Econs). As a result, the percentage contribution of each energy source showed that fossil fuels are the dirtiest & most dangerous, while both renewable and nuclear are safe & clean. As for DR factor, coal contribution is 47.5% while less than 1% for nuclear, wind and solar. Likewise, (CO2EQV) showed similar outcome in this respect. In addition, the higher the efficiency (%) the lower the operating cost (USc/kWh). Consequently, results showed that poor rating for solar (8.7c/kWh) & wind (5.1c/kWh) which is due to their low generation rate in comparison to cost effective nuclear (2.4c/kWh), hydro (2.2c/kWh) and NG (2.2c/kWh) power generation process. In conclusion, energy sources were grouped as nonrenewable (fossil fuel), renewable and nuclear. Whereby linking all risk factors, favors renewable and nuclear sources while nonrenewable gave environmental damaging effects in most rating aspect. [ABSTRACT FROM AUTHOR]

With the increasing challenges facing the logistics industry, especially in meeting the growing demand for distribution efficiency and accuracy, the use of modern technology to optimize logistics distribution routes has become a key issue. This study explores the application of artificial intelligence (AI) and Internet of Things (IoT) technologies in the optimization of logistics distribution routes. The research first focused on collecting and processing logistics related data, including historical delivery records, real-time traffic data, and cargo tracking information. Then, by building optimization models based on AI and IoT technologies, the study explores the potential of these technologies to improve logistics distribution efficiency and reduce costs. In addition, through cost-benefit analysis and discussion of challenge coping strategies, this study not only verified the effectiveness of the proposed scheme in theory, but also demonstrated its feasibility in practical application. Finally, the study presents implications for industry practice and recommendations for future research, emphasizing the importance of continuous technology evaluation and adaptation to market changes. [ABSTRACT FROM AUTHOR]

Background: Chuna manual therapy (CMT), a Korean manual therapy technique predominantly used for treating low back pain (LBP) and related disorders, lacks well-conceived research focusing on its comparative effectiveness, safety, and economic evaluation, particularly with respect to complex CMT with established CMT diagnostic algorithms. This study aims to illustrate a protocol for a randomized clinical study for comparative effectiveness and cost-effectiveness of complex CMT with simple CMT and usual care. Methods: This is a protocol for a three-armed, multicenter, assessor-blinded, pragmatic, randomized controlled trial study. A total of 81 patients suffering from non-acute LBP with pelvic biomechanical lesions (PBL), characterized by a pain duration of at least two weeks and a Numeric Rating Scale (NRS) score of 5 or higher, will be recruited from two Korean medicine hospitals. These participants will be randomly assigned to one of three groups: complex CMT plus usual care (UC; n = 27), simple CMT plus UC (n = 27), or UC groups (n = 27). They will undergo treatment for 4 weeks, and follow-up assessments will be performed 8 weeks after treatment completion. The primary outcome will be the NRS score of LBP, and secondary outcomes will include the Oswestry Disability Index, Patient Global Impression of Change, credibility and expectancy questionnaire, three-dimensional posture analysis indicators, quality of life assessment, economic evaluation, and safety assessments. Discussion: This will be the first study to assess the comparative effectiveness, safety, and cost-effectiveness of complex CMT compared to UC and simple/complex CMT in patients with LBP and PBL. We will also analyze useful diagnostic methods to help in clinical practice for CMT diagnosis. Trial registration: Clinical Research Information Service (CRIS), KCT0009210. Registered on February 28, 2024. [ABSTRACT FROM AUTHOR]

The chemical industry, a cornerstone of the global economy essential for modern life, has raised significant concerns due to its unique nature. Chemical technologies often require high energy inputs, involving ecotoxic reagents thus assessing risks from an economic standpoint becomes complex. While the economic aspects of chemical technologies have been discussed and economic tools have been used to inform investment decisions in this field, many fundamental issues remain unexplored, such as the clear definition of chemical technology economics and the reasons for its importance. The primary contribution of this article is to synthesize insights into these fundamental issues and propose pathways for future research in chemical technology economics. This review is divided into two sections: the first provides an overview of the significance of economic factors in chemical technologies, and the second explores the fundamentals of economics and their application to chemical technology considerations. Our research underscores that economic theories significantly influence the profile of chemical technologies, viewing the chemical sector as a dual asset. First, the sector has a unique opportunity to lead the way in promoting sustainable economic development, and second, it can adopt economic behaviors that align with environmental and societal needs. [ABSTRACT FROM AUTHOR]

This study is a cost-benefit analysis examining an urban district's partial school nurse coverage conversion to full-time coverage. Through a partnership with a health care system, the district received funding, resulting in the hiring of full-time nurses to cover all K-8 elementary schools. Researchers compared the cost of nursing services to the savings in teacher, secretary, principal, and parent productivity, reduced medical procedure costs, and grants nurses managed. The year before implementing additional nurses, the return on investment (ROI) to the community for nursing services was calculated to be $1.59 for every dollar invested in schools with full-time coverage and $1.29 for schools with partial coverage. After implementing full-time nurses in each school, there was an ROI of $1.50 during the 2015–2016 school year, $1.64 for 2016–2017, and $1.67 for 2017–2018. The analysis provides evidence that full-time coverage could result in a positive ROI for schools and the community. [ABSTRACT FROM AUTHOR]

In this paper, we conduct a cost-benefit analysis (CBA) of five alternative management strategies for red deer in Denmark: free harvest, trophy hunting, maximum harvest and two cases for natural demographic population compositions. To capture the outcome under each strategy we use a biological sex- and age-structured population model. The net benefit function includes meat values, recreational values, browsing damage costs and traffic damage costs and these values and costs are assumed to differ for the various sex and age classes of red deer. We show that the maximum harvest strategy leads to a reasonably high positive total net benefit, while the free harvest strategy yields a small positive net benefit. On the other hand, the trophy hunting strategy generates a high negative net benefit, while small negative net benefits are obtained under the two strategies for natural demographic population compositions. [ABSTRACT FROM AUTHOR]

Purpose: This paper aims to examine prospective graduate students' attitudes toward educational loan borrowing in an experimental setting. Design/methodology/approach: Participants were randomly assigned to two treatment groups and one control group. Subjects in experimental group 1 received financial education: a short online course on the economic viability of getting a master's degree and how to finance it with a graduate student loan, while subjects in experimental group 2 received financial education along with information on the availability bias. Findings: Relying on a control group in the assessment of financial literacy education intervention impacts, this research finds positive causal treatment effects on individuals' attitudes toward debt-financed graduate education. In comparison to the control group, experimental subjects perceived the possibility of going into debt with a graduate loan to complete a master's degree as less stressful and worrying. Practical implications: This study has important educational policy implications to prevent students from stopping investing in human capital by perceiving educational loan debt as something stressful or worrying. The results can help potential (and current) grad students develop a feasible financial plan for graduate school by encouraging higher education institutions to implement educational loan information and financial education into university seminar courses for better graduate student loan decision-making. Originality/value: Student attitudes toward debt have been analyzed in the context of higher education, but only a few researchers internationally have used an experimental design to study personal financial decision-making. [ABSTRACT FROM AUTHOR]

Forests are both an irreplaceable natural resource and a vital economic asset for all humankind. Based on the data of counties in mainland China from 2007 to 2020, the article explores the direct impact and spatial spillover effects of the policy implementation on the economic growth of counties with the help of the forest city pilot policy and the policy evaluation model. The results reveal that policy implementation can have a positive economic growth effect on the pilot counties, which, in turn, can significantly increase the size of the county's GDP, the level of GDP per capita, and the total amount of nighttime lighting brightness. The implementation of forest city construction can bring about 2.74% of total GDP size, about 2.63% of per capita GDP development level, and about 7.25% of nighttime light brightness to the county on average. Cost–benefit analysis also indicates that forest city construction can bring about a comprehensive economic benefit of approximately CNY 686.453 million (approximately USD 96.82 million) to the counties. The rapid improvement in labor productivity, significant influx of high-end factors, and continuous expansion of market potential are important mechanisms through which policy implementation promotes economic growth in pilot counties. While promoting economic growth in the pilot counties, forest city construction can also have positive spatial spillover effects on neighboring areas in the pilot counties. Furthermore, when the deficits in atmospheric vapor pressure and annual evapotranspiration are used as instrumental variables for forest city construction, the empirical estimates are not significantly altered. In the process of building forest cities, county governments should be wary of issues such as the high cost of forest maintenance. This study provides a Chinese model and policy reference for other countries and regions in the world to deal with the relationship between forest city construction and county economic growth. [ABSTRACT FROM AUTHOR]

The primary objectives of transportation system development in European countries include improving transport efficiency, enhancing national economic competitiveness, and promoting sustainable mobility. A key aspect of achieving these goals is the evaluation of transport externalities, particularly external accident costs, which is critical for ensuring the economic and social sustainability of road transport development. This study comprehensively evaluates external road accident costs and proposes an innovative approach to internalizing these costs through a cost–benefit analysis (CBA). By integrating these external costs into CBA, policymakers can better understand the societal impact of road safety investments, allowing for more informed decisions regarding measures to reduce road accidents and fatalities. This paper also explores the role of specific safety investments, such as installing vehicle restrain systems (VRS), buffers, and terminals on the national road network, as well as installing speed cameras, in reducing accidents and mitigating external costs. The findings highlight road safety measures' importance in enhancing economic efficiency and social well-being, providing a solid foundation for the sustainable and efficient development of transportation systems. [ABSTRACT FROM AUTHOR]

This paper investigates the economic feasibility and benefits of introducing genetically modified (GM) crops into Lebanon's agricultural sector. The methodology combines a rigorous cost–benefit analysis with qualitative insights from local farmers and agricultural scientists to ensure relevance to Lebanon's unique agricultural context. Through this study, we identified tomatoes and potatoes as the most suitable crops for GM implementation. The findings indicate that GM tomatoes could increase net income by USD 10,000 per hectare in the short term and USD 50,000 over five years. These economic benefits are primarily driven by higher yields and reduced pesticide costs. This study emphasizes the necessity of a holistic approach, including financial support, infrastructure development, farmer education, and robust market access strategies, to maximize the potential of GM crops. This research provides a strategic framework for leveraging GM technology to address Lebanon's agricultural challenges, promoting sustainable practices, enhancing food security, and ensuring long-term economic stability. By integrating local context and stakeholder perspectives, this paper offers a unique and actionable pathway for successful GM crop implementation in Lebanon. [ABSTRACT FROM AUTHOR]