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Contemporary data on the availability, cost and affordability of essential medicines for chronic respiratory diseases (CRDs) across low-income and middle-income countries (LMICs) are missing, despite most people with CRDs living in LMICs. Cross-sectional data for seven CRD medicines in pharmacies, healthcare facilities and central medicine stores were collected from 60 LMICs in 2022-2023. Medicines for symptomatic relief were widely available and affordable, while preventative treatments varied widely in cost, were less available and largely unaffordable. There is an urgent need to address these issues if the Sustainable Development Goal 3 is to be achieved for people with asthma by 2030., Competing Interests: Competing interests: KM reports advisory board fees from AstraZeneca and GlaxoSmithKline., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Importance: Chronic lower respiratory disease (CLRD) is the fourth leading cause of death in the United States, which imposes a considerable burden on individuals, families, and societies. The association between county-level health disparity and CLRD outcomes in New York state needs investigation., Objective: To evaluate the associations of CLRD outcomes with county-level health disparities in New York state., Design, Setting, and Participants: In this cross-sectional study, CLRD age-adjusted hospitalization for 2016 and mortality rates from 2014 to 2016 were obtained from the New York state Community Health Indicator Reports provided by the New York state Department of Health. County Health Rankings were used to evaluate various health factors to provide a summary z score for each county representing the county health status and how that county ranks in the state. Data analysis was performed from November 2020 to March 2021., Main Outcomes and Measures: The main outcomes were age-adjusted hospitalization and mortality rates for CLRD. The z score was calculated from the County Health Rankings, which includes subindicators of health behaviors, clinical care, social and economic factors, and physical environment. Pearson r and linear regression models were estimated., Results: During the study, 60 335 discharges were documented as CLRD hospitalizations in 2016 and 20 612 people died from CLRD from 2014 to 2016 in New York state. After adjusting for age, the CLRD hospitalization rate was 27.6 per 10 000 population, and the mortality rate was 28.9 per 100 000 population. Among 62 counties, Bronx had the highest hospitalization rate (64.7 per 10 000 population) whereas Hamilton had the lowest hospitalization rate (6.6 per 10 000 population). Mortality rates ranged from 17.4 per 100 000 population in Kings to 62.9 per 100 000 population in Allegany. County Health Rankings indicated Nassau had the lowest z score (the healthiest), at -1.17, but Bronx had the highest z score (the least healthy), at 1.43, for overall health factors in 2018. An increase of 1 point in social and economic factors z score was associated with an increase of 17.6 hospitalizations per 10 000 population (β = 17.61 [95% CI, 10.36 to 24.87]; P < .001). A 1-point increase in health behaviors z score was associated with an increase of 41.4 deaths per 100 000 population (β = 41.42 [95% CI, 29.88 to 52.97]; P < .001)., Conclusions and Relevance: In this cross-sectional study, CLRD outcomes were significantly associated with county-level health disparities in New York state. These findings suggest that public health interventions and resources aimed at improving CLRD outcomes should be tailored and prioritized in health disadvantaged areas.

Background: Many impoverished communities in South Africa (SA) simultaneously face multiple preventable socioenvironmental hazards associated with elevated burdens of ill health. One such hazard is failure to institute effective buffer zones between human settlements and point sources of pollution such as airports and industrial zones., Objectives: To gather information on living conditions, housing quality and health status in two poor communities in the SA coastal industrial city of Port Elizabeth., Methods: The study was undertaken in Walmer Township, situated in close proximity to Port Elizabeth International Airport, and Wells Estate, which borders two industrial sites. Approximately 120 households were randomly selected from each study site. Following written informed consent, information on the neighbourhood environment and housing conditions was collected through administration of a structured questionnaire., Results: The two study sites were similar in respect of household language, income, education, high levels of debt servicing and high reliance on social grants. Relative to Walmer Township, higher levels of indoor dust and bad odours in the neighbourhood were reported in Wells Estate, as were higher rates of selected respiratory ill-health symptoms. Upper respiratory tract symptoms were significantly associated with reports of high levels of indoor dust, while lower respiratory tract symptoms were significantly associated with low income, overcrowding, and having a young child in the household., Conclusions: The study highlights a scenario of a triple environmental hazard to health in the study communities: (i) poverty; (ii) poor-quality housing; and (iii) lack of an effective buffer zone between the study communities and local point sources of pollution. Respiratory ill-health conditions were significantly associated with poverty, household composition and living conditions.

Laparoscopic hemihepatectomy (LHH) may offer advantages over open hemihepatectomy (OHH) in blood loss, recovery, and hospital stay. The aim of this study is to evaluate our recent experience performing hemihepatectomy and compare complications and costs up to 90 days following laparoscopic versus open procedures. Retrospective evaluation of patients undergoing hemihepatectomy at our center 01/2010-12/2018 was performed. Patient, tumor, and surgical characteristics; 90-day complications; and costs were analyzed. Inverse probability of treatment weighting (IPTW) was used to balance covariates. A total of 141 hemihepatectomies were included: 96 OHH and 45 LHH. While operative times were longer for LHH, blood loss and transfusions were less. At 90 days, there were similar rates of liver-specific and surgical complications but fewer medical complications following LHH. Medical complications that arose with greater frequency following OHH were primarily pulmonary complications and urinary and central venous catheter infections. Complications at 90 days were lower following LHH (Clavien-Dindo grade ≥ III OHH 23%, LHH 11%, p = 0.130; Comprehensive Complication Index OHH 20.0 ± 16.1, LHH 10.9 ± 14.2, p = 0.001). While operating costs were higher, costs for hospital stay and readmissions were lower with LHH. Patients undergoing LHH experience a significant reduction in postoperative medical complications and costs, resulting in 90-day cost equity compared with OHH.

Prevalence data of respiratory diseases (RDs) in Central Asia (CA) and Russia are contrasting. To inform future research needs and assist government and clinical policy on RDs, an up-to-date overview is required. We aimed to review the prevalence and economic burden of RDs in CA and Russia. PubMed and EMBASE databases were searched for studies that reported prevalence and/or economic burden of RDs (asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, interstitial lung diseases (ILD), lung cancer, pulmonary hypertension, and tuberculosis (TB)) in CA (Kyrgyzstan, Uzbekistan, Tajikistan, Kazakhstan, and Turkmenistan) and Russia. A total of 25 articles (RD prevalence: 18; economics: 7) were included. The majority ( n = 12), mostly from Russia, reported on TB. TB prevalence declined over the last 20 years, to less than 100 per 100,000 across Russia and CA, yet in those, multidrug-resistant tuberculosis (MDR-TB) was alarming high (newly treated: 19-26%, previously treated: 60-70%). COPD, asthma (2-15%) and ILD (0.006%) prevalence was only reported for Russia and Kazakhstan. No studies on cystic fibrosis, lung cancer and pulmonary hypertension were found. TB costs varied between US$400 (Tajikistan) and US$900 (Russia) for drug-susceptible TB to ≥US$10,000 for MDR-TB (Russia). Non-TB data were scarce and inconsistent. Especially in CA, more research into the prevalence and burden of RDs is needed.

Aims: To examine the impact of perioperative inhaled corticosteroids (ICS) on length-of-stay (LOS) and costs among patients receiving high-respiratory-risk surgeries. Methods: Adult patients who underwent high-respiratory-risk surgeries in 2015 were identified in the Tianjin Urban Employee Basic Medical Insurance database. Patients were grouped into ICS or non-ICS cohorts according to whether they received ICS during the perioperative period of the index hospitalization. Propensity Score Matching was performed to create matched pairs between two cohorts. The impact of perioperative ICS on LOS and direct medical costs was estimated by negative binomial model and generalized liner model. Results: Eight hundred and twenty-one hospital stays with high-respiratory-risk were selected in the ICS cohort and another 821 stays in the non-ICS cohort were matched. The mean LOS was 13.0 (±0.3) days in the ICS cohort, which was significantly lower than the matched non-ICS cohort. Patients with thorax and ear-nose-throat surgeries had a significant decrease in LOS in the ICS cohort compared to the non-ICS cohort, with a mean decrease of 5.5 and 1.1 days, respectively. In adjusted analyses, perioperative ICS treatment was associated with shorter LOS, lower total, and respiratory-related costs (reductions of 10.1%, 7%, and 5.3%, respectively) after controlling for demographic, clinical, and hospital characteristics. Limitations: Some respiratory risk factors such as living behavior and environment were unable to be captured and respiratory-related costs might be underestimated, limited by claim data. Lastly, caution should be taken when generalizing the results to other populations, as only patients with moderate-to-severe surgeries on the thorax and above were selected in this study. Conclusions: Perioperative ICS treatment was associated with decreased LOS and lower costs for patients undergoing high-respiratory-risk surgeries in China.

Objectives: To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses., Methods: We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models., Results: Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference -0.3; 95% confidence interval: -1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (-4.6; 95% confidence interval: -7.5 to -1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status., Conclusions: We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians "do more" for hospitalized children who are not UTD., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Hofstetter previously received research support from Pfizer Independent Grants for Learning and Change; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Bovine respiratory disease (BRD) is a multifactorial disease that is estimated to affect 22% of preweaned dairy calves in the United States and is a leading cause of preweaning mortality in dairy calves. Overall cost of calfhood BRD is reflected in both the immediate cost of treating the disease as well as lifetime decrease in production and increased likelihood of affected cattle leaving the herd before their second calving. The goal of this paper was to develop an estimate of the cost of BRD based on longitudinal treatment data from a study of BRD with a cohort of 11,470 preweaned dairy calves in California. Additionally, a cost-benefit analysis was performed for 2 different preventative measures for BRD, an increase of 0.47 L of milk per day for all calves or vaccination of all dams with a modified live BRD vaccine, using differing assumptions about birth rate and number of calves raised per year. Average short-term cost of BRD per affected calf was $42.15, including the use of anti-inflammatory medications in the treatment protocols across all management conditions. The cost of treating BRD in calves appears to have increased in recent years and is greater than costs presented in previous studies. A cost-benefit analysis examined different herd scenarios for a range of cumulative incidences of BRD from 3 to 25%. Increasing milk fed was financially beneficial in all scenarios above a 3% cumulative incidence of BRD. Use of a modified live vaccine in dams during pregnancy, examining only its value as a form of BRD prevention in the calves raised on the farm, was financially beneficial only if the cumulative incidence of BRD exceeded 10 to 15% depending on the herd size and whether the dairy farm was raising any bull calves. The cost-benefit analysis, under the conditions studied, suggests that producers with high rates of BRD may benefit financially from implementing preventative measures, whereas these preventative measures may not be cost effective to implement on dairy farms with very low cumulative incidences of BRD. The long-term costs of calfhood BRD on lifetime productivity were not factored into these calculations, and the reduction in disease may be associated with additional cost savings and an improvement in calf welfare and herd life., (Copyright © 2020 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Objectives: To identify distinctive patterns of respiratory-related health services use (HSU) between birth and 3 years of age, and to examine associated symptom and risk profiles., Methods: This study included 729 mother and child pairs enrolled in the Toronto site of the Canadian Healthy Infant Longitudinal Development study in 2009-2012; they were linked to Ontario health administrative databases (2009-2016). A model-based cluster analysis was performed to identify distinct groups of children who followed a similar pattern of respiratory-related HSU between birth and 3 years of age, regarding hospitalization, emergency department (ED) and physician office visits for respiratory conditions and total health care costs (2016 Canadian dollars)., Results: The majority (estimated cluster weight = 0.905) showed a pattern of low and stable respiratory care use (low HSU) while the remainder (weight = 0.095) showed a pattern of high use (high HSU). From 0 to 3 years of age, the low- and high-HSU groups differed in mean trajectories of total health care costs ($783 per 6 months decreased to $114, vs $1796 to $177, respectively). Compared to low-HSU, the high-HSU group was associated with a constant risk of hospitalizations, early high ED utilization and physician visits for respiratory problems. The two groups differed significantly in the timing of wheezing (late onset in low-HSU vs early in high-HSU) and future total costs (stable vs increased)., Conclusions: One in ten children had high respiratory care use in early life. Such information can help identify high-risk young children in a large population, monitor their long-term health, and inform resource allocation., (© 2019 Wiley Periodicals, Inc.)

Objective: To compare the economic impact of high-dose trivalent (HD) versus standard-dose trivalent (SD) influenza vaccination on direct medical costs for cardio-respiratory hospitalizations in adults aged 65 years or older enrolled in the United States (US) Veteran's Health Administration (VHA)., Methods: Leveraging a relative vaccine effectiveness study of HD versus SD over five respiratory seasons (2010/11 through 2014/15), we collected cost data for healthcare provided to the same study population both at VHA and through Medicare services. Our economic assessment compared the costs of vaccination and hospital care for patients experiencing acute cardio-vascular or respiratory illness., Results: We analyzed 3.5 million SD and 158,636 HD person-seasons. The average cost of HD and SD vaccination was $23.48 (95% CI: $21.29 - $25.85) and $12.21 (95% CI: $11.49 - $13.00) per recipient, respectively, while the hospitalization rates for cardio-respiratory disease in HD and SD recipients were 0.114 (95% CI: 0.108-0.121) and 0.132 (95% CI: 0.132-0.133) per person-season, respectively. Attributing the average cost per hospitalization of $11,796 (95% CI: $11,685 - $11,907) to the difference in hospitalization rates, we estimated savings attributable to HD to be $202 (95% CI: $115 - $280) per vaccinated recipient., Conclusions: For the five-season period of 2010/11 through 2014/15, HD influenza vaccination was associated with net cost savings due to fewer hospitalizations, and therefore lower direct medical costs, for cardio-respiratory disease as compared to SD influenza vaccination in the senior US VHA population., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The concentrations of particulate matter with aerodynamic diameters less than 2.5 µm (PM 2.5 ) and 10 µm (PM 10 ) is a widespread concern and has been demonstrated for 103 countries. During the past few years, the exposure-response function (ERf) has been widely used to estimate the health effects of air pollution. However, past studies are either based on the cost-of-illness or the willingness-to-pay approach, and therefore, either do not cover intangible costs or costs due to the absence of work. To address this limitation, a hybrid health effect and economic loss model is developed in this study. This novel approach is applied to a sample of environmental and cost data in China. First, the ERf is used to link PM 2.5 concentrations to health endpoints of chronic mortality, acute mortality, respiratory hospital admission, cardiovascular hospital admission, outpatient visits-internal medicine, outpatient visits-pediatrics, asthma attack, acute bronchitis, and chronic bronchitis. Second, the health effect of PM 2.5 is monetized into the economic loss. The mean economic loss due to PM 2.5 was much heavier in the North than the South of China. Furthermore, the empirical results from 76 cities in China show that the health effects and economic losses were over 4.98 million cases and 382.30 billion-yuan in 2014 and decreased dramatically compared with those in 2013.

Background: Transcutaneous electric acupoint stimulation (TEAS) has shown benefits when used peri-operatively. However, the role of numbers of areas with acupoint stimulation is still unclear. Therefore, we report the protocol of a randomized controlled trial of using TEAS in elderly patients subjected to gastrointestinal surgery, and comparing dual-acupoint and single-acupoint stimulation., Methods/design: A multicenter, randomized, controlled, three-arm design, large-scale trial is currently undergoing in four hospitals in China. Three hundred and forty-five participants are randomly assigned to three groups in a 1:1:1 ratio, receiving dual-acupoint TEAS, single-acupoint TEAS, and no stimulation, respectively. The primary outcome is incidence of pulmonary complications at 30 days after surgery. The secondary outcomes include the incidence of pulmonary complications at 3 days after surgery; the all-cause mortality within 30 days and 1 year after surgery; admission to the intensive care unit (ICU) and length of ICU stay within 30 days after surgery; the length of postoperative hospital stay; and medical costs during hospitalization after surgery., Discussion: The result of this trial (which will be available in September 2019) will confirm whether TEAS before and during anesthesia could alleviate the postoperative pulmonary complications after gastrointestinal surgery in elderly patients, and whether dual-acupoint stimulation is more effective than single-acupoint stimulation., Trials Registrations: ClinicalTrials.gov, ID: NCT03230045 . Registered on 10 July 2017.

China is in a critical stage of ambient air quality management after global attention on pollution in its cities. Industrial development and urbanization have led to alarming levels of air pollution with serious health hazards in densely populated cities. The quantification of cause-specific PM 2.5 -related health impacts and corresponding economic loss estimation is crucial for control policies on ambient PM 2.5 levels. Based on ground-level direct measurements of PM 2.5 concentrations in 338 Chinese cities for the year 2016, this study estimates cause-specific mortality using integrated exposure-response (IER) model, non-linear power law (NLP) model and log-linear (LL) model followed by morbidity assessment using log-linear model. The willingness to pay (WTP) and cost of illness (COI) methods have been used for PM 2.5 -attributed economic loss assessment. In 2016 in China, the annual PM 2.5 concentration ranged between 10 and 157 μg/m 3 and 78.79% of the total population was exposed to >35 μg/m 3 PM 2.5 concentration. Subsequently, the national PM 2.5 -attributable mortality was 0.964 (95% CI: 0.447, 1.355) million (LL: 1.258 million and NPL: 0.770 million), about 9.98% of total reported deaths in China. Additionally, the total respiratory disease and cardiovascular disease-specific hospital admission morbidity were 0.605 million and 0.364 million. Estimated chronic bronchitis, asthma and emergency hospital admission morbidity were 0.986, 1.0 and 0.117 million respectively. Simultaneously, the PM 2.5 exposure caused the economic loss of 101.39 billion US$, which is 0.91% of the national GDP in 2016. This study, for the first time, highlights the discrepancies associated with the three commonly used methodologies applied for cause-specific mortality assessment. Mortality and morbidity results of this study would provide a measurable assessment of 338 cities to the provincial and national policymakers of China for intensifying their efforts on air quality improvement., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: For the pilot phase of an integrative pediatric program, we defined inpatient treatment algorithms for bronchiolitis, asthma and pneumonia, using medications and nursing techniques from anthroposophic medicine (AM). Parents could choose AM treatment as add-on to conventional care., Material and Methods: To evaluate the 18-month pilot phase, parents of AM users were asked to complete the Client Satisfaction Questionnaire (CSQ-8) and a questionnaire on the AM treatment. Staff feedback was obtained through an open-ended questionnaire. Economic data for project set-up, medications and insurance reimbursements were collected., Results: A total of 351 children with bronchiolitis, asthma and pneumonia were hospitalized. Of these, 137 children (39%) received AM treatment, with use increasing over time. 52 parents completed the questionnaire. Mean CSQ-8 score was 29.77 (95% CI 29.04-30.5) which is high in literature comparison. 96% of parents were mostly or very satisfied with AM; 96% considered AM as somewhat or very helpful for their child; 94% considered they learnt skills to better care for their child. The staff questionnaire revealed positive points about enlarged care offer, closer contact with the child, more relaxed children and greater role for parents; weak points included insufficient knowledge of AM and additional nursing time needed. Cost for staff training and medications were nearly compensated by AM related insurance reimbursements., Conclusions: Introduction of anthroposophic treatments were well-accepted and led to high parent satisfaction. Additional insurance reimbursements outweighed costs. The program has now been expanded into a center for integrative pediatrics., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: This study sought to evaluate the impact of an interdisciplinary care model for pediatric aerodigestive patients in terms of efficiency, risk exposure, and cost., Methods: Patients meeting a standard clinical inclusion definition were studied before and after implementation of the aerodigestive program., Results: Aerodigestive patients seen in the interdisciplinary clinic structure achieved a reduction in time to diagnosis (6 vs 150 days) with fewer required specialist consultations (5 vs 11) as compared to those seen in the same institution prior. Post-implementation patients also experienced a significant reduction in risk, with fewer radiation exposures (2 vs 4) and fewer anesthetic episodes (1 vs 2). Total cost associated with the diagnostic evaluation was significantly reduced from a median of $10,374 to $6055., Conclusion: This is the first study to utilize a pre-post cohort to evaluate the reduction in diagnostic time, risk exposure, and cost attributable to the reorganization of existing resources into an interdisciplinary care model. This suggests that such a model yields improvements in care quality and value for aerodigestive patients, and likely for other pediatric patients with chronic complex conditions., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Human protection policies require favorable risk-benefit judgments prior to launch of clinical trials. For phase I and II trials, evidence for such judgment often stems from preclinical efficacy studies (PCESs). We undertook a systematic investigation of application materials (investigator brochures [IBs]) presented for ethics review for phase I and II trials to assess the content and properties of PCESs contained in them. Using a sample of 109 IBs most recently approved at 3 institutional review boards based at German Medical Faculties between the years 2010-2016, we identified 708 unique PCESs. We then rated all identified PCESs for their reporting on study elements that help to address validity threats, whether they referenced published reports, and the direction of their results. Altogether, the 109 IBs reported on 708 PCESs. Less than 5% of all PCESs described elements essential for reducing validity threats such as randomization, sample size calculation, and blinded outcome assessment. For most PCESs (89%), no reference to a published report was provided. Only 6% of all PCESs reported an outcome demonstrating no effect. For the majority of IBs (82%), all PCESs were described as reporting positive findings. Our results show that most IBs for phase I/II studies did not allow evaluators to systematically appraise the strength of the supporting preclinical findings. The very rare reporting of PCESs that demonstrated no effect raises concerns about potential design or reporting biases. Poor PCES design and reporting thwart risk-benefit evaluation during ethical review of phase I/II studies.

Diabetes is associated with a significant burden globally. The costs of diabetes-related hospitalizations are unknown in most developing countries. The aim of this study was to estimate the total number and economic burden of hospitalizations attributable to diabetes mellitus (DM) and its complications in adults from the perspective of the Brazilian Public Health System in 2014. Data sources included the National Health Survey (NHS) and National database of Hospitalizations (SIH). We considered diabetes, its microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications (coronary heart disease, cerebrovascular disease, and peripheral arterial disease), respiratory and urinary tract infections, as well as selected cancers. Assuming that DM patients are hospitalized for these conditions more frequently that non-DM individuals, we estimated the etiological fraction of each condition related to DM, using the attributable risk methodology. We present number, average cost per case, and overall costs of hospitalizations attributable to DM in Brazil in 2014, stratified by condition, state of the country, gender and age group. In 2014, a total of 313,273 hospitalizations due to diabetes in adults were reported in Brazil (4.6% of total adult hospitalization), totaling (international dollar) Int$264.9 million. The average cost of an adult hospitalization due to diabetes was Int$845, 19% higher than hospitalization without DM. Hospitalizations due to cardiovascular diseases related to diabetes accounted for the higher proportion of costs (47.9%), followed by microvascular complications (25.4%) and DM per se (18.1%). Understanding the costs of diabetes and its major complications is crucial to raise awareness and to support the decision-making process on policy implementation, also allowing the assessment of prevention and control strategies., Competing Interests: The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Care coordination programs are important in caring for medically complex pediatric patients, particularly for children with special health care needs. This study is a retrospective financial analysis of a hospital-based care coordination program involving one procedural subgroup of children with special health care needs: those receiving pediatric tracheostomy. Hospital records were reviewed for patients who received a tracheostomy at a large Midwestern U.S. hospital from 1999 through 2015. The population was divided into two subgroups: patients who received a tracheostomy before the development of a care coordination program and patients who received a tracheostomy after enrollment in the care coordination program. Patient records were reviewed for length of stay, readmissions related to respiratory and tracheostomy management, and total hospital charges. Enrollment in a care coordination program for the pediatric tracheostomy patient resulted in a decrease in mean length of stay and reduced hospital charges and a slight increase in readmissions. Further analysis using larger sample sizes and multiple centers is necessary to determine whether such outcomes are the direct result of enrollment in a care coordination program., (Copyright © 2017 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Objective: Hospital-based data reveal that children who have secondhand smoke exposure (SHSe) experience severe respiratory illnesses and greater resource utilization. Our objective was to assess the relationship between SHSe and illness severity/resource utilization among children presenting to the pediatric emergency department (PED) with three common respiratory conditions-asthma, bronchiolitis, and pneumonia., Methods: A retrospective review of a yearlong consecutive sample of PED patients with SHSe status documentation and asthma, bronchiolitis, or pneumonia diagnoses was performed. PED illness severity/resource utilization variables included triage categorization, initial oxygen saturation, evaluation/testing (influenza A & B, respiratory syncytial virus, chest X-ray), procedures/interventions performed (supplemental oxygen, suctioning, intubation), medications administered, and disposition. Logistic and linear regression models were conducted to determine differences in each diagnosis group while controlling for sociodemographics, medical history, seasonality, and insurance type., Results: There were 3,229 children with documentation of SHSe status and an asthma (41%), bronchiolitis (36%), or pneumonia (23%) diagnosis. Across diagnosis groups, approximately 1/4 had positive documentation of SHSe. Asthmatic children with SHSe were more likely to receive corticosteroids (odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.19, 2.44) and/or magnesium sulfate (OR = 1.66, 95% CI = 1.14, 2.40). Children with SHSe and bronchiolitis were more likely to receive racemic epinephrine (OR = 2.48, 95% CI = 1.21, 5.08), have a chest X-ray (OR = 1.36, 95% CI = 1.00, 1.85), and/or be admitted (OR = 1.46, 95% CI = 1.09, 1.95). No differences in illness severity/resource utilization were identified for children with pneumonia., Conclusions: SHS-exposed children with asthma or bronchiolitis have greater illness severity/resource utilization. Our findings highlight the importance of SHSe assessment, cessation, and research efforts in the PED setting.

Background: The main objective of this article is to estimate the global cost related to the use of the two drugs (associated drugs, specialist visits, hospital admissions, plasma drug monitoring)., Methods: The drug prescriptions were extracted from the Information System of the Pharmaceutical Prescriptions of the Marche Region for each ATC code in the years 2008-2012 and the number of patients per year and other outcomes measure were obtained., Results: 13,574 patients were treated with theophylline and 19,426 patients with doxophylline. The number of patients treated was approximately 5,000 per year. Co-prescription with other drugs, use of corticosteroids, mean number of visits and hospital admissions (per 100 patients) were lower for doxophylline vs theophylline (1.55vs5.50, 0.3vs0.7, 2.05vs3.73 and 1.57vs3.3 respectively). The annual mean cost per patient was €187.4 for those treated with doxophylline and €513.5 for theophylline., Conclusions: In our study, doxophylline resulted to be associated with a reduction of the overall cost.

National estimates of the health and economic burdens of exposure to ambient fine particulate matter (PM 2.5 ) in India reveal substantial impacts. This information, often lacking at the local level, can justify and drive mitigation interventions. Here, we assess the health and economic gains resulting from attainment of WHO guidelines for PM 2.5 concentrations - including interim target 2 (IT-2), interim target 3 (IT-3), and the WHO air quality guideline (AQG) - in Nagpur district to inform policy decision making for mitigation. We conducted a detailed assessment of concentrations of PM 2.5 in 9 areas, covering urban, peri-urban and rural environments, from February 2013 to June 2014. We used a combination of hazard and survival analyses based on the life table method to calculate attributed annual number of premature deaths and disability-adjusted life years (DALYs) for five health outcomes linked to PM 2.5 exposure: acute lower respiratory infection for children <5years, ischemic heart disease, chronic obstructive pulmonary disease, stroke and lung cancer in adults ≥25years. We used GBD 2013 data on deaths and DALYs for these diseases. We calculated averted deaths, DALYs and economic loss resulting from planned reductions in average PM 2.5 concentration from current level to IT-2, IT-3 and AQG by the years 2023, 2033 and 2043, respectively. The economic cost for premature mortality was estimated as the product of attributed deaths and value of statistical life for India, while morbidity was assumed to be 10% of the mortality cost. The annual average PM 2.5 concentration in Nagpur district is 34±17μgm -3 and results in 3.3 (95% confidence interval [CI]: 2.6, 4.2) thousand premature deaths and 91 (95% CI: 68, 116) thousand DALYs in 2013 with economic loss of USD 2.2 (95% CI: 1.7, 2.8) billion in that year. It is estimated that interventions that achieve IT-2, IT-3 and AQG by 2023, 2033 and 2043, would avert, respectively, 15, 30 and 36%, of the attributed health and economic loss in those years, translating into an impressively large health and economic gain. To achieve this, we recommend an exposure-integrated source reduction approach., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Local tumour ablation (LTA) may yield better perioperative outcomes than partial nephrectomy (PN), however the impact of each treatment on perioperative mortality and health care expenditures is unknown. The aim of the study was to compare mortality, morbidity and health care expenditures between LTA and PN., Patients and Methods: A population-based assessment of 2471 patients with cT1a kidney cancer treated with either LTA or PN, between 2000 and 2009, in the SEER-Medicare database was performed. After propensity score matching, 30-day mortality, overall and specific complication rates, length of stay, readmission rates and health care expenditures according to LTA or PN were estimated. Multivariable logistic and linear models addressed the effect of each specific LTA approach on overall complication rates, length of stay, readmission rates and health care expenditures., Results: The 30-day mortality was <2% after either LTA or PN (OR 2.27, p = 0.2). The overall complication rate was 21% after LTA and 40% after PN (OR 0.38, p < 0.001). Blood transfusions, infection/sepsis, wound infections, respiratory complications, gastrointestinal complications, acute kidney injury, and accidental puncture or laceration/foreign body left during procedure rates resulted lower after LTA relative to PN (all p < 0.05). Similarly, length of stay and health care expenditures resulted lower after LTA relative to PN (all p < 0.05). Conversely, readmission rate was not significantly different in LTA relative to PN (p = 0.1)., Conclusions: Despite similar perioperative mortality, LTA is associated with lower complications rate, shorter length of stay and lower health care expenditure relative to PN., (Copyright © 2016 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Introduction: Influenza presents additional burdens for children with chronic respiratory conditions. Influenza vaccinations may reduce complications, yet approximately half of children remain unprotected. Evidence supports integration of text and e-mail into multicomponent strategies to increase influenza vaccination rates among children with chronic respiratory conditions., Methods: A single text and e-mail message was sent to those with enabled preferences in the patient portal. A follow-up survey assessed aspects of message receipt. Surveys were completed without collection of demographics., Results: A total of 3,206 messages were successfully delivered. Surveys were initiated by 107 recipients. Frequency analysis showed that text and e-mail messages were preferred forms of communication. A statistically significant relationship was found between receiving a message and receiving an influenza vaccination (p = .027)., Discussion: Text and e-mail messaging are cost effective and well received, and they can be easily integrated into existing systems. These methods are translatable across populations and can convey various types of messages., (Copyright © 2016 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Background : The Asia-Pacific Economic Cooperation (APEC) meeting was held from 5 November to 11 November 2014 in Beijing, and comprehensive emission control measures were implemented. The efficiency of these measures on particulate matter-related health impacts and economic cost need to be evaluated. Methods : The influences of emission control measures during APEC on particulate matter were evaluated, and health economic effects were assessed. Results : Average concentrations of PM 2.5 and PM 10 during APEC were reduced by 57.0%, and 50.6% respectively, compared with pre-APEC period. However, the concentrations of particulate matter rebounded after APEC. Compared with the pre-APEC and post-APEC periods, the estimated number of deaths caused by non-accidental, cardiovascular and respiratory diseases that could be attributed to PM 2.5 and PM 10 during the APEC were the lowest. The economic cost associated with mortality caused by PM 2.5 and PM 10 during the APEC were reduced by (61.3% and 66.6%) and (50.3% and 60.8%) respectively, compared with pre-APEC and post-APEC. Conclusions : The emission control measures were effective in improving short term air quality and reducing health risks and medical expenses during 2014 APEC, but more efforts is needed for long term and continuous air quality improvement and health protection., Competing Interests: The authors declare no conflict of interest.

Background: Almost 70% of hospital admissions for Medicare beneficiaries originate in the emergency department (ED). Research suggests that some of these patients' needs may be better met through home-based care options after evaluation and treatment in the ED., Objective: We sought to estimate Medicare cost savings resulting from using the Home Health benefit to provide treatment, when appropriate, as an alternative to inpatient admission from the ED., Methods: This is a prospective study of patients admitted from the ED. A survey tool was used to query both emergency physicians (EPs) and patient medical record data to identify potential candidates and treatments for home-based care alternatives. Patient preferences were also surveyed. Cost savings were estimated by developing a model of Medicare Home Health to serve as a counterpart to the actual hospital-based care., Results: EPs identified 40% of the admitted patients included in the study as candidates for home-based care. The top three major diagnostic categories included diseases and disorders of the respiratory system, digestive system, and skin. Services included intravenous hydration, intravenous antibiotics, and laboratory testing. The average estimated cost savings between the Medicare inpatient reimbursement and the Home Health counterpart was approximately $4000. Of the candidate patients surveyed, 79% indicated a preference for home-based care after treatment in the ED., Conclusions: Some Medicare beneficiaries could be referred to Home Health from the ED with a concomitant reduction in Medicare expenditures. Additional studies are needed to compare outcomes, develop the logistical pathways, and analyze infrastructure costs and incentives to enable Medicare Home Health options from the ED., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess characteristics associated with health care spending trends among child high resource users in Medicaid., Methods: This retrospective analysis included 48 743 children ages 1 to 18 years continuously enrolled from 2009-2013 in 10 state Medicaid programs (Truven MarketScan Medicaid Database) also in the top 5% of all health care spending in 2010. Using multivariable regression, associations were assessed between baseline demographic, clinical, and health services characteristics (using 2009-2010 data) with subsequent health care spending (ie, transiently, intermittently, persistently high) from 2011-2013., Results: High spending from 2011-2013 was transient for 54.2%, persistent for 32.9%, and intermittent for 12.9%. Regarding demographic characteristics, the highest likelihood of persistent versus transient spending occurred in children aged 13 to 18 years versus 1 to 2 years in 2010 (odds ratio [OR], 3.0 [95% confidence interval (CI), 2.7-3.4]). Regarding clinical characteristics, the highest likelihoods were in children with ≥6 chronic conditions (OR, 4.8 [95% CI, 3.5-6.6]), a respiratory complex chronic condition (OR, 2.5 [95% CI, 2.2-2.8]), or a neuromuscular complex chronic condition (OR, 2.3 [95% CI, 2.2-2.5]). Hospitalization and emergency department (ED) use in 2010 were associated with a decreased likelihood of persistent spending in 2011-2013 (hospitalization OR, 0.7 [95% CI, 0.7-0.7]); ED OR, 0.8 [95% CI, 0.8-0.8])., Conclusions: Most children with high spending in Medicaid are without persistently high spending in subsequent years. Adolescent age, multiple chronic conditions, and certain complex chronic conditions increased the likelihood of persistently high spending; hospital and ED use decreased it. These data may help inform the development of new models of care and financing to optimize health and save resources in children with high resource use., (Copyright © 2016 by the American Academy of Pediatrics.)

Background: Since the global financial crisis, UK NHS spending has reduced considerably. Respiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Under the remit of 'prudent healthcare' championed by the Welsh Health Minister, a Programme Budgeting Marginal Analysis (PBMA) of the North Wales respiratory care pathway was conducted., Methods: A PBMA panel of directors of medicines management, therapies finance, planning, public health and healthcare professionals used electronic voting to establish criteria for decision-making and vote on candidate interventions in which to disinvest and invest., Results: A sum of £86.9 million was spent on respiratory care in 2012-13. Following extensive discussion of 13 proposed candidate interventions facilitated by a chairperson, 4 candidates received recommendations to disinvest, 7 to invest and 2 to maintain current activity. Marginal analysis prioritized mucolytics and high antibiotic prescribing as areas for disinvestment, and medicines waste management and pulmonary rehabilitation for investment., Conclusions: This exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and investment decisions. Initial progress has begun with communication from the Medical Director in relation to the disinvestment in mucolytics prescribing and possible redirection of funding options being explored., (© The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health.)

Introduction: People with traumatic spinal cord injury (SCI) face complex challenges in their care, recovery and life. Secondary conditions can develop to involve many body systems and can impact health, function, quality of life, and community participation. These secondary conditions can be costly, and many are preventable. The aim of this study was to describe the type and direct costs of secondary conditions requiring readmission to hospital, or visit to an emergency department (ED), within the first two years following traumatic spinal cord injury (SCI)., Methods: A retrospective cohort study using population-level linked data from hospital ED and admission datasets was undertaken in Victoria, Australia. The incidence and direct treatment costs of readmission to hospital and ED visit within 2-years post-injury for secondary conditions related to SCI were measured for the 356 persons with traumatic SCI with a date of injury from 2008 to 2011., Results: Of the 356 cases, 141 (40%) experienced 366 (median 2, range 1-11) readmissions to hospital for secondary conditions. 95 (27%) visited an ED at least once, within two years of injury for a secondary condition. The cost of hospital readmissions was AUD$5,553,004 and AUD$87,790 for ED visits. The mean±SD cost was AUD$15,172±$20,957 per readmission and AUD$670±$198 per ED visit. Urological conditions (e.g. urinary tract infection) were most common, followed by pressure areas/ulcers for readmissions, and fractures in the ED., Conclusions: Hospitalisation for complications within two years of traumatic SCI was common and costly in Victoria, Australia. Improved bladder and pressure area management could result in substantial morbidity and cost savings following SCI., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Growth in the elderly population has increased both the demand for health services and healthcare expenses, with relevant consequences for economic stability. The current study aimed to analyze the morbidity profile and hospital expenses with elderly patients in relation to socioeconomic and demographic conditions in Paraná State, Brazil, from 2008 to 2012, applying principal components analysis and groupings. Regions with higher and lower economic and human development showed high prevalence of hospitalizations and costs pertaining to the circulatory and respiratory systems and cardiac diseases for males and females. In regions with intermediary development, diseases of the nervous system in men and of the circulatory system in women had the highest morbidity and hospital expenses. Thus, measures for prevention and health promotion in this elderly population should be targeted to regional investigations.

Context and Objective: Exposure to air pollutants is one of the factors responsible for hospitalizations due to respiratory diseases. The objective here was to estimate the effect of exposure to particulate matter (such as PM2.5) on hospitalizations due to certain respiratory diseases among residents in Volta Redonda (RJ)., Design and Setting: Ecological time series study using data from Volta Redonda (RJ)., Methods: Data on hospital admissions among residents of Volta Redonda (RJ), between January 1, 2012, and December 31, 2012, due to pneumonia, acute bronchitis, bronchiolitis and asthma, were analyzed. Daily data on PM2.5 concentrations were estimated through the CCATT-BRAMS model. The generalized additive Poisson regression model was used, taking the daily number of hospitalizations to be the dependent variable and the PM2.5 concentration to be the independent variable, with adjustment for temperature, relative humidity, seasonality and day of the week, and using lags of zero to seven days. Excess hospitalization and its cost were calculated in accordance with increases in PM2.5 concentration of 5 µg/m3., Results: There were 752 hospitalizations in 2012; the average concentration of PM2.5 was 17.2 µg/m3; the effects of exposure were significant at lag 2 (RR = 1.017), lag 5 (RR = 1.022) and lag 7 (RR = 1,020). A decrease in PM2.5 concentration of 5 µg/m3 could reduce admissions by up to 76 cases, with a decrease in spending of R$ 84,000 a year., Conclusion: The findings from this study provide support for implementing public health policies in this municipality, which is an important steelmaking center.

Unlabelled: Burdens of poverty are often compounded by respiratory problems. This study aimed to identify the support needs and intervention preferences for low-income families facing this challenge., Design and Methods: Interviews were conducted in two Canadian provinces with low-income children/adolescents (n=32) diagnosed with respiratory health problems and their parents or family caregiver (n=37)., Results: These vulnerable children and parents described non-supportive interactions with some health service providers and inadequate information. They reported isolation and support deficits, exacerbated by limited resources and health restrictions. Children/adolescents felt isolated and excluded and wanted to connect with peers. Group or dyadic level support, delivered by peers and health professionals, was desired. The importance of logistics to enhance accessibility and appeal of group or dyadic support interventions was clearly identified., Conclusions: The findings of this study reveal that low-income children and their families encounter challenges to accessing support and to utilizing support resources., Practice Implications: Partnerships with low-income children/adolescents and family caregivers in provision of education and social support can combat isolation and ignorance. Reducing inequities for this high risk population could be achieved by providing support from experienced peers, in combination with health professional guidance, and knowledge about pulmonary health., (Copyright © 2016. Published by Elsevier Inc.)

Background: Infectious disease burden estimates provided by a composite health measure give a balanced view of the true impact of a disease on a population, allowing the relative impact of diseases that differ in severity and mortality to be monitored over time. This article presents the first national disease burden estimates for a comprehensive set of 32 infectious diseases in the Netherlands., Methods and Findings: The average annual disease burden was computed for the period 2007-2011 for selected infectious diseases in the Netherlands using the disability-adjusted life years (DALY) measure. The pathogen- and incidence-based approach was adopted to quantify the burden due to both morbidity and premature mortality associated with all short and long-term consequences of infection. Natural history models, disease progression probabilities, disability weights, and other parameters were adapted from previous research. Annual incidence was obtained from statutory notification and other surveillance systems, which was corrected for under-ascertainment and under-reporting. The highest average annual disease burden was estimated for invasive pneumococcal disease (9444 DALYs/year; 95% uncertainty interval [UI]: 8911-9961) and influenza (8670 DALYs/year; 95% UI: 8468-8874), which represents 16% and 15% of the total burden of all 32 diseases, respectively. The remaining 30 diseases ranked by number of DALYs/year from high to low were: HIV infection, legionellosis, toxoplasmosis, chlamydia, campylobacteriosis, pertussis, tuberculosis, hepatitis C infection, Q fever, norovirus infection, salmonellosis, gonorrhoea, invasive meningococcal disease, hepatitis B infection, invasive Haemophilus influenzae infection, shigellosis, listeriosis, giardiasis, hepatitis A infection, infection with STEC O157, measles, cryptosporidiosis, syphilis, rabies, variant Creutzfeldt-Jakob disease, tetanus, mumps, rubella, diphtheria, and poliomyelitis. The very low burden for the latter five diseases can be attributed to the National Immunisation Programme. The average disease burden per individual varied from 0.2 (95% UI: 0.1-0.4) DALYs per 100 infections for giardiasis, to 5081 and 3581 (95% UI: 3540-3611) DALYs per 100 infections for rabies and variant Creutzfeldt-Jakob disease, respectively., Conclusions: For guiding and supporting public health policy decisions regarding the prioritisation of interventions and preventive measures, estimates of disease burden and the comparison of burden between diseases can be informative. Although the collection of disease-specific parameters and estimation of incidence is a process subject to continuous improvement, the current study established a baseline for assessing the impact of future public health initiatives.

Introduction: Chronic diseases are associated with productivity loss costs due to sickness absence. It is not always clear, however, which chronic diseases in particular are involved with how many sickness days and associated costs., Objective: To determine the prevalence, additional days of sickness absence, and associated costs of chronic diseases among the Dutch working population from 2007 to 2011., Methods: Prevalence of chronic diseases and additional days of sickness absence were derived from the Netherlands Working Conditions Survey (NWCS) from 2007 to 2011. The cost of each sickness absence day was based on linked personal income data. We used multiple regression analysis to derive the unconfounded additional days of sickness absence due to each chronic disease., Results: Annually, approximately 37 % of the Dutch working population reported some type of chronic physical or psychological disease. No clinically relevant changes in prevalence of specific chronic diseases were observed in the studied period, nor in the number of additional sickness absence days or associated costs. The national financial burden due to sickness absence associated with chronic musculoskeletal disorders amounted to €1.3 billion annually., Conclusions: Chronic diseases result in substantial productivity loss due to sickness absence. Given the ageing population, the proposed increase in the state pension age and an increase in sedentary lifestyle and obesity, the prevalence of chronic diseases may be expected to rise. Coordinated efforts to maintain and improve the health of the working population are necessary to minimize socioeconomic consequences.

Severe health risks caused by PM10 (particulate matter with an aerodynamic diameter ≤10 μm) pollution have induced inevitable economic losses and have rendered pressure on the sustainable development of society as a whole. In China, with the "Polluters Pay Principle", polluters should pay for the pollution they have caused, but how much they should pay remains an intractable problem for policy makers. This paper integrated an epidemiological exposure-response model with economics methods, including the Amended Human Capital (AHC) approach and the Cost of Illness (COI) method, to value the economic loss of PM10-related health risks in 16 districts and also 4 functional zones in Beijing from 2008 to 2012. The results show that from 2008 to 2012 the estimated annual deaths caused by PM10 in Beijing are around 56,000, 58,000, 63,000, 61,000 and 59,000, respectively, while the economic losses related to health damage increased from around 23 to 31 billion dollars that PM10 polluters should pay for pollution victims between 2008 and 2012. It is illustrated that not only PM10 concentration but also many other social economic factors influence PM10-related health economic losses, which makes health economic losses show a time lag discrepancy compared with the decline of PM10 concentration. In conclusion, health economic loss evaluation is imperative in the pollution indemnity system establishment and should be considered for the urban planning and policy making to control the burgeoning PM10 health economic loss.

Thoracic ultrasound (TUS) evolved in the last ten years as the method of choice for evaluating pleural abnormalities and for guiding lung procedures. TUS can "see" almost all structures in the chest, including thoracic wall, pleura, pleural space, the heart, the great vessels and the peripheral layers of the lungs. However, there is still a great need to develop TUS services in respiratory departments in Romania. To facilitate this development we reviewed the literature and selected what we considered to be essential practical information for the beginner in TUS, including technique, normal findings, and common abnormalities. Moreover, we describe here a step-by-step scanning technique for chest physicians. Our aim is to raise awareness of TUS. Because TUS is rapid, accurate, noninvasive and can be applied in any ward, we recommend facilitating the training of all junior respiratory doctors in this technique, as it is likely to improve patient experience, clinical effectiveness and to reduce costs with chest radiographs or CT scans in the future.

Background: Despite the burden of acute respiratory illnesses (ARI) among Aboriginal and Torres Strait Islander children being a substantial cause of childhood morbidity and associated costs to families, communities and the health system, data on disease burden in urban children are lacking. Consequently evidence-based decision-making, data management guidelines, health resourcing for primary health care services and prevention strategies are lacking. This study aims to comprehensively describe the epidemiology, impact and outcomes of ARI in urban Aboriginal and Torres Strait Islander children (hereafter referred to as Indigenous) in the greater Brisbane area., Methods/design: An ongoing prospective cohort study of Indigenous children aged less than five years registered with a primary health care service in Northern Brisbane, Queensland, Australia. Children are recruited at time of presentation to the service for any reason. Demographic, epidemiological, risk factor, microbiological, economic and clinical data are collected at enrolment. Enrolled children are followed for 12 months during which time ARI events, changes in child characteristics over time and monthly nasal swabs are collected. Children who develop an ARI with cough as a symptom during the study period are more intensely followed-up for 28 (±3) days including weekly nasal swabs and parent completed cough diary cards. Children with persistent cough at day 28 post-ARI are reviewed by a paediatrician., Discussion: Our study will be one of the first to comprehensively evaluate the natural history, epidemiology, aetiology, economic impact and outcomes of ARIs in this population. The results will inform studies for the development of evidence-based guidelines to improve the early detection, prevention and management of chronic cough and setting of priorities in children during and after ARI., Trial Registration: Australia New Zealand Clinical Trial Registry Registration Number: 12614001214628 . Registered 18 November 2014.

Unlabelled: In this United States-focused analysis we use outputs from two general circulation models (GCMs) driven by different greenhouse gas forcing scenarios as inputs to regional climate and chemical transport models to investigate potential changes in near-term U.S. air quality due to climate change. We conduct multiyear simulations to account for interannual variability and characterize the near-term influence of a changing climate on tropospheric ozone-related health impacts near the year 2030, which is a policy-relevant time frame that is subject to fewer uncertainties than other approaches employed in the literature. We adopt a 2030 emissions inventory that accounts for fully implementing anthropogenic emissions controls required by federal, state, and/or local policies, which is projected to strongly influence future ozone levels. We quantify a comprehensive suite of ozone-related mortality and morbidity impacts including emergency department visits, hospital admissions, acute respiratory symptoms, and lost school days, and estimate the economic value of these impacts. Both GCMs project average daily maximum temperature to increase by 1-4°C and 1-5 ppb increases in daily 8-hr maximum ozone at 2030, though each climate scenario produces ozone levels that vary greatly over space and time. We estimate tens to thousands of additional ozone-related premature deaths and illnesses per year for these two scenarios and calculate an economic burden of these health outcomes of hundreds of millions to tens of billions of U.S. dollars (2010$)., Implications: Near-term changes to the climate have the potential to greatly affect ground-level ozone. Using a 2030 emission inventory with regional climate fields downscaled from two general circulation models, we project mean temperature increases of 1 to 4°C and climate-driven mean daily 8-hr maximum ozone increases of 1-5 ppb, though each climate scenario produces ozone levels that vary significantly over space and time. These increased ozone levels are estimated to result in tens to thousands of ozone-related premature deaths and illnesses per year and an economic burden of hundreds of millions to tens of billions of U.S. dollars (2010$).

Objective: The World Health Organization (WHO) reports that nonsmokers experience disease and death due to secondhand smoke (SHS) exposure in the home. We estimated the total excess burden and costs to society due to SHS exposure in U.S. public housing., Methods: We quantified the public health burden for outcomes causally related to SHS exposure for nationally representative never-smoking residents in U.S. public housing using (1) WHO-recommended health outcomes and methodology, (2) publicly available and other large databases, and (3) published estimates of morbidity and mortality rates. We used published estimates of direct medical and nonmedical care costs and the value of productivity losses to estimate SHS-related societal costs for disease and death. We estimated the public health and economic burden for two serum cotinine limits of detection (LODs): 0.05 nanograms per milliliter (ng/mL) and 0.015 ng/mL., Results: In 2011, an estimated 37,791 never-smoking child and adult U.S. public housing residents experienced illness and death due to SHS exposure at home based on an LOD=0.05 ng/mL (50,967 residents at LOD=0.015 ng/mL). Costs incurred by society for these illnesses and deaths totaled $183 million (LOD=0.05 ng/mL) and $267 million (LOD=0.015 ng/mL) annually. Of the total costs, direct costs (medical and nonmedical) accounted for $128 million and $176 million for LOD=0.05 ng/mL and LOD=0.015 ng/mL, respectively. Medical care accounted for the majority of direct costs-$110 million at LOD=0.05 ng/mL and $153 million at LOD=0.015 ng/mL. Adverse respiratory health outcomes accounted for approximately one-half (56% at LOD=0.05 ng/mL and 52% at LOD=0.015 ng/mL) of total societal costs., Conclusion: Implementing smoke-free policies in all U.S. public housing could save lives and decrease SHS-related morbidity and mortality in never-smoking residents, resulting in annual societal savings of $183 million at LOD=0.05 ng/mL and $267 million at LOD=0.015 ng/mL.

The development and commercialization of drugs for rare diseases, termed 'orphan drugs', has historically been economically unattractive. However, because of the introduction of legislation that provides financial and regulatory incentives for the development of orphan drugs, new developments are making their way through the regulatory approval processes. Unfortunately, delays in availability of new drugs for treating rare disease continue to persist. This paper reviews the approach of several regulatory jurisdictions to orphan drugs in an effort to determine their relative effectiveness in providing patient access. Generally speaking, regulatory authorities across jurisdictions have recognized the need to enhance timely access to safe, effective treatment for patients with rare diseases and have been able to shift the approval timelines for access to new care. The greater impediment to orphan drug access appears to be funding, particularly in publicly sponsored health-care systems. Redundancies in federal and provincial reviews of orphan drugs can result in significant delays in access to new drugs. Clearly, more must be done to accelerate access to the treatments so desperately needed by patients. Public payers must be held accountable for their process and decisions--especially for rare disease therapies., (© 2015 Asian Pacific Society of Respirology.)

Background: Knowledge of the excess hospital costs and prolonged length of stay attributable to perioperative respiratory event (PRE) in pediatric anesthesia is useful for hospital planning. In this study, we compared costs (excess hospital costs and indirect costs) and length of hospital stay between children who had PRE and did not have PRE for noncardiac surgery at a tertiary care hospital in southern Thailand., Methods: A prospective matched cohort study was conducted in children aged <15 years who underwent general anesthesia between November 2012 and December 2013 at Songklanagarind Hospital. PRE children were matched with no PRE children (1:1) using a random selection procedure on outpatients/inpatients, type of surgery, surgical charge (baht), ASA physical status, age difference <9 years, and difference in time of surgery <6 months. Primary end points were excess hospital costs and number of days hospitalized after surgery. Number of days hospitalized after surgery, excess hospital costs and indirect costs regarding transportation, and income loss of parents between groups were compared using Wilcoxon signed rank test. Any hospital stay after surgery between groups was compared using McNemar χ test. A hurdle model was used to predict any hospital stay and number of days hospitalized after surgery. Multiple mixed-effects linear regression was used to identify predictors of adjusted excess hospital costs and indirect costs., Results: A total 430 children were included (215 matched pairs). More PRE children required hospital stay after surgery (81% vs 72%, P = 0.004), and PRE children had a longer number of days hospitalized after surgery (median [interquartile ranges]: 1 [1-3.5] vs 1 [0-2]; P < 0.001) and incurred higher excess costs (P < 0.001) but not indirect costs (P = 0.23). In multivariate analysis, PRE was a significant predictor for hospital stay after surgery (odds ratio, 2.56; 95% confidence interval, 1.23-5.31), longer hospitalization (count ratio, 2.10 [1.31-3.35]), higher excess costs (cost ratio, 1.30 [1.12-1.53]), and indirect cost (cost ratio, 1.58 [1.20-2.08]) after adjusting for patient and anesthesia characteristics. Universal coverage (74%) was associated with 35% and 64% higher excess cost compared with the Comptroller General's Department (17%) and self-pay (7%), respectively (P = 0.003)., Conclusions: The effects of PRE in pediatric anesthesia were hospital stay after surgery, 2 times longer hospitalization, 30% higher excess hospital costs, and 58% higher indirect cost among outpatients. Hospital policy to efficiently manage hospital beds and compensatory budget should be developed.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Age and smoking are common risk factors for COPD and other illnesses, often leading COPD patients to demonstrate multiple coexisting comorbidities. COPD exacerbations and comorbidities contribute to the overall severity in individual patients. Clinical trials investigating the treatment of COPD routinely exclude patients with multiple comorbidities or advanced age. Clinical practice guidelines for a specific disease do not usually address comorbidities in their recommendations. However, the management and the medical intervention in COPD patients with comorbidities need a holistic approach that is not clearly established worldwide. This holistic approach should include the specific burden of each comorbidity in the COPD severity classification scale. Further, the pharmacological and nonpharmacological management should also include optimal interventions and risk factor modifications simultaneously for all diseases. All health care specialists in COPD management need to work together with professionals specialized in the management of the other major chronic diseases in order to provide a multidisciplinary approach to COPD patients with multiple diseases. In this review, we focus on the major comorbidities that affect COPD patients. We present an overview of the problems faced, the reasons and risk factors for the most commonly encountered comorbidities, and the burden on health care costs. We also provide a rationale for approaching the therapeutic options of the COPD patient afflicted by comorbidity.