Surveillance for ocular hypertension: An evidence synthesis and economic evaluation

OBJECTIVES: To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways.

DESIGN: A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model.

SETTING: Primary and secondary care.

PARTICIPANTS: Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences).

INTERVENTIONS: We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community.

MAIN OUTCOME MEASURES: Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs).

RESULTS: The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence.

LIMITATIONS: Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates.

CONCLUSIONS: For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment.

FUNDING: The National Institute for Health Research Health Technology Assessment Programme.

D3.1 Benefits Analysis of the Initial Operational Cruiser-Feeder Concept

The REsearch on a CRuiser Enabled Air Transport Environment (RECREATE) project is considers the introduction and airworthiness of cruiser-feeder operations for civil aircraft. Cruiser-feeder operations are investigated as a promising pioneering idea for the air transport of the future. The soundness of the concept of cruiser-feeder operations for civil aircraft can be understood, taking air-to-air refueling operations as an example. For this example, a comprehensive estimate of the benefits can be made, which shows a fuel burn reduction potential and a CO2 emission reduction of 31% for a typical 6000 nautical miles flight with a payload of 250 passengers. This reduction potential is known to be large by any standard. The top level objective of the RECREATE project is to demonstrate on a preliminary design level that cruiser-feeder operations (as a concept to reduce fuel burn and CO2 emission levels) can be shown to comply with the airworthiness requirements for civil aircraft. The underlying Scientific and Technological (S&T) objectives are to determine and study airworthy operational concepts for cruiser-feeder operations, and to derive and quantify benefits in terms of CO2 emission reduction but also other benefits.

Work Package (WP) 3 has the objective to substantiate the assumed benefits of the cruiser/feeder operations through refined analysis and simulation. In this report, initial benefits evaluation of the initial RECREATE cruiser/feeder concepts is presented. The benefits analysis is conducted in delta mode, i.e. comparison is made with a baseline system. Since comparing different aircraft and air transport systems is never a trivial task, appropriate measures and metrics are defined and selected first. Non-dimensional parameters are defined and values for the baseline system derived.

The impact of cruiser/feeder operations such as air-to-air refueling are studied with respect to fuel-burn (or carbon-dioxide), noise and congestion. For this purpose, traffic simulations have been conducted.
Cruiser/feeder operations will have an impact on dispatch reliability as well. An initial assessment of the effect on dispatch reliability has been made and is reported.

Finally, a considerable effort has been made to create the infrastructure for economic delta analysis of the cruiser/feeder concept of operation. First results of the cost analysis have been obtained.

Implications of nanotechnology for the agri-food industry: Opportunities, benefits and risks

Nanotechnology has emerged as a technological advancement that could develop and transform the entire agri-food sector, with the potential to increase agricultural productivity, food security and economic growth for industries. Though as still a relatively new concept there are concerns over its safety, regulation and acceptance by the industry and consumers. This review set out to address the implications of nanotechnology for the agri-food industry by examining the potential benefits, risks and opportunities. Existing scientific gaps in knowledge are believed to be a prohibitive factor in addition to uncertainties in the level of awareness and attitudes towards the use of nanotechnology by the industry.

Challenging the SD benefits attributed to sport Mega-Events hosting

Sport Mega-event hosting faces opposition that is manifested with different intensity during the different phases of the event, from its inception as an idea to its delivery and legacy. Some Social Movements Organisations (SMOs) have acted as indefatigable monitors of the Sustainable Development (SD) dimension of sporting events in general and, in some of the most recent sport mega-events, in particular the Olympics, they have served as important advisors and facilitators. Nevertheless, in many cases we see enthusiastic supporters turning to vehemently challenging whatever positives have been associated with hosting the event. In addition, there is opposition to sport Mega-events in their entirety. That type of opposition tends to employ a holistic prism that manages to identify multiple interconnected negative aspects of hosting a sport mega-event and incorporate them into an anti-systemic discourse. It is important to bear in mind that irrespective of many proclamations to the opposite as far as megas are concerned (projects and/or events), a number of studies have demonstrated that citizen participation and democratic accountability in decision-making have been notoriously absent. After all, the idea of citizen participation in the planning of sport mega-event is essentially the public response to a plan conceived by others. There were, of course, some notable cases of democratic consultation at the early stages of bidding to host a sport mega-event but these more democratic approaches resulted in the failure of the bid (for e.g. Toronto 1996). The knowledge of this by the groups that initiated the hosting idea and the bidding process has led to discouraging in depth public consultation that may fit perfectly to the democratic process but not to the tight schedules of associated projects completion. That produces ‘autocracy against which opposition may arise’ (Hiller, 2000, p. 198). It is this democratic deficit that has led to important instances of social contestation and protest mobilizations by citizen groups as well as the more regular corps of social activists. From a perspective borrowed from the sociology of protest and social movements, sport mega-events hosting can operate as an issue that stimulates protest activities by an existing protest milieu and new actors as well as an important mobilizing resource. In fact, some scholars have also argued that the Olympic Games were an important frame for the transnational activism that was marked by anti-globalization protest in Seattle in 1999 (Cottrell & Nelson, 201; Lenskyj, 2008). In addition, it’s important not to lose sight of other acts dissent that take place in relatively close proximity, about a year before the event when most infrastructural and societal changes brought by hosting the event and impact start to become apparent by the host communities, like the rioting of August 2011 in the London Olympic Boroughs and the 2012 riots of June 2013 in Sao Paulo and other Brazilian cities. This paper starts by outlining the SD claims made in the bidding to host the summer Olympic Games by five prospective hosts (Sydney; Athens; Beijing; London and Rio) proceeds towards examining the opposition and challenges that was manifested in relation to these claims. In Particular it provides an assessment of protest-events over the aforementioned different phases of sport mega-events hosting. A different picture emerges for each of the host nation that is partly explained by local, national and global configuration of protest politics. Whereas the post-event legacy of the first two hosts of the Games can be assessed and that way see the validity of claims made by challengers in the other phases, in the other three cases, the implementation of Olympic Games Impact (OGI) studies offers the tool for discussing the post-event phase for Beijing and London and engage in a speculative exercise for the case of Rio. Judging by available findings, the paper concludes that the SD aspiration made in the bid documents are unlikely to be met and social contestation based on the same issues is likely to increase due to the current global economic crisis and BRICS, like China and Brazil, having entered the process of becoming global economic hegemons.

Reserve from wind power potential in system economic loading

The growth of wind power in some power systems is hampered by the system requirement for emergency reserve to cover loss of the biggest infeed. The study demonstrates that reserve provision from the wind sector itself has economic and operational benefits. A heuristic algorithm has been developed that can model the relevant aspects of emergency reserve provision in a system with both thermal and wind generations. The proposed algorithm is first validated by comparing its performance with established economic scheduling methods applied to a representative power system. The algorithm is then used to demonstrate the economic benefit of reserve provision from the wind sector. It is shown that such provision reduces wind energy curtailment and thermal unit ramping. Finally, it is shown that a wind sector capable of providing emergency reserve can expand economically beyond the capacity limit that would otherwise apply.

Long-Term Economic Model for Allocation of FACTS Devices in Restructured Power System Integrated Wind Generation

This study proposes an approach to optimally allocate multiple types of flexible AC transmission system (FACTS) devices in market-based power systems with wind generation. The main objective is to maximise profit by minimising device investment cost, and the system's operating cost considering both normal conditions and possible contingencies. The proposed method accurately evaluates the long-term costs and benefits gained by FACTS devices (FDs) installation to solve a large-scale optimisation problem. The objective implies maximising social welfare as well as minimising compensations paid for generation re-scheduling and load shedding. Many technical operation constraints and uncertainties are included in problem formulation. The overall problem is solved using both particle swarm optimisations for attaining optimal FDs allocation as main problem and optimal power flow as sub-optimisation problem. The effectiveness of the proposed approach is demonstrated on modified IEEE 14-bus test system and IEEE 118-bus test system.

Techno-Economic and Life Cycle Assessment on Lignocellulosic Biomass Thermochemical Conversion Technologies: A Review

Bioenergy derived from biomass provides a promising energy alternative and can reduce the greenhouse gas (GHG) emissions generated from fossil fuels. Biomass-based thermochemical conversion technologies have been acknowledged as apt options to convert bioresources into bioenergy; this bioenergy includes electricity, heat, and fuels/chemicals in solid, liquid, and gaseous phases. In this review, the techno-economic and life cycle assessment of these technologies (combustion, gasification, pyrolysis, liquefaction, carbonization, and co-firing) are summarized. Specific indicators (production costs in a techno-economic analysis, functional units and environmental impacts in a life cycle analysis) for different technologies were compared. Finally, gaps in research and future trends in biomass thermochemical conversion were identified. This review could be used to guide future research related to economic and environmental benefits of bioenergy.

Integrated techno-economic and environmental assessments of sixty scenarios for co-firing biomass with coal and natural gas

Displacement of fossil fuel-based power through biomass co-firing could reduce the greenhouse gas (GHG) emissions from fossil fuels. In this study, data-intensive techno-economic models were developed to evaluate different co-firing technologies as well as the configurations of these technologies. The models were developed to study 60 different scenarios involving various biomass feedstocks (wood chips, wheat straw, and forest residues) co-fired either with coal in a 500 MW subcritical pulverized coal (PC) plant or with natural gas in a 500 MW natural gas combined cycle (NGCC) plant to determine their technical potential and costs, as well as to determine environmental benefits. The results obtained reveal that the fully paid-off coal-fired power plant co-fired with forest residues is the most attractive option, having levelized costs of electricity (LCOE) of $53.12–$54.50/MW h and CO2 abatement costs of $27.41–$31.15/tCO2. When whole forest chips are co-fired with coal in a fully paid-off plant, the LCOE and CO2 abatement costs range from $54.68 to $56.41/MW h and $35.60 to $41.78/tCO2, respectively. The LCOE and CO2 abatement costs for straw range from $54.62 to $57.35/MW h and $35.07 to $38.48/tCO2, respectively.

Benefits and resource implications of family meetings for hospitalized palliative care patients: research protocol.

BACKGROUND:
Palliative care focuses on supporting patients diagnosed with advanced, incurable disease; it is 'family centered', with the patient and their family (the unit of care) being core to all its endeavours. However, approximately 30-50% of carers experience psychological distress which is typically under recognised and consequently not addressed. Family meetings (FM) are recommended as a means whereby health professionals, together with family carers and patients discuss psychosocial issues and plan care; however there is minimal empirical research to determine the net effect of these meetings and the resources required to implement them systematically. The aims of this study were to evaluate: (1) if family carers of hospitalised patients with advanced disease (referred to a specialist palliative care in-patient setting or palliative care consultancy service) who receive a FM report significantly lower psychological distress (primary outcome), fewer unmet needs, increased quality of life and feel more prepared for the caregiving role; (2) if patients who receive the FM experience appropriate quality of end-of-life care, as demonstrated by fewer hospital admissions, fewer emergency department presentations, fewer intensive care unit hours, less chemotherapy treatment (in last 30 days of life), and higher likelihood of death in the place of their choice and access to supportive care services; (3) the optimal time point to deliver FM and; (4) to determine the cost-benefit and resource implications of implementing FM meetings into routine practice.
METHODS:
Cluster type trial design with two way randomization for aims 1-3 and health economic modeling and qualitative interviews with health for professionals for aim 4.
DISCUSSION:
The research will determine whether FMs have positive practical and psychological impacts on the family, impacts on health service usage, and financial benefits to the health care sector. This study will also provide clear guidance on appropriate timing in the disease/care trajectory to provide a family meeting.

From brown envelopes to community benefits: the co-option of planning gain agreements under deepening neoliberalism

The provision of physical and social infrastructure in the form of roads, green spaces and community facilities has traditionally been provided for by the state through the general taxation system. However, as the state has been transformed along more neoliberal lines, the private sector is increasingly relied upon to deliver public goods and services. Planning gain agreements have flourished within this context by offering another vehicle through which local facilities are privately funded. Whilst these agreements reflect the broader dynamics of neoliberalism, they are commonly viewed as a tool which can be employed to challenge these very dynamics by empowering local communities to secure more just planning outcomes. This paper counters such claims. Based on evidence gathered from 80 interviews with planners, councillors, developers and community groups in Ireland, the paper demonstrates how planning gain agreements have been strategically redeployed by the holders of political and economic power to serve their own ends. In seeking to understand why and how this has occurred, specific consideration is given to the changing power dynamics between the state and private capital under neoliberalism. The paper highlights how institutional arrangements have enabled developers to infiltrate the political sphere in more subtle and implicit ways than ever before. We conclude by arguing that planning gain must be understood as a mechanism which has been manipulated in ways which essentially work to preserve and enhance, rather than redress, existing power imbalances in the planning system by facilitating large scale transfers of wealth upwards in society.

Sepsis: the LightCycler SeptiFast Test MGRADE®, SepsiTest™ and IRIDICA BAC BSI assay for rapidly identifying bloodstream bacteria and fungi – a systematic review and economic evaluation

Background: Sepsis can lead to multiple organ failure and death. Timely and appropriate treatment can reduce in-hospital mortality and morbidity. Objectives: To determine the clinical effectiveness and cost-effectiveness of three tests [LightCycler SeptiFast Test MGRADE® (Roche Diagnostics, Risch-Rotkreuz, Switzerland); SepsiTest™ (Molzym Molecular Diagnostics, Bremen, Germany); and the IRIDICA BAC BSI assay (Abbott Diagnostics, Lake Forest, IL, USA)] for the rapid identification of bloodstream bacteria and fungi in patients with suspected sepsis compared with standard practice (blood culture with or without matrix-absorbed laser desorption/ionisation time-offlight mass spectrometry). Data sources: Thirteen electronic databases (including MEDLINE, EMBASE and The Cochrane Library) were searched from January 2006 to May 2015 and supplemented by hand-searching relevant articles. Review methods: A systematic review and meta-analysis of effectiveness studies were conducted. A review of published economic analyses was undertaken and a de novo health economic model was constructed. A decision tree was used to estimate the costs and quality-adjusted life-years (QALYs) associated with each test; all other parameters were estimated from published sources. The model was populated with evidence from the systematic review or individual studies, if this was considered more appropriate (base case 1). In a secondary analysis, estimates (based on experience and opinion) from seven clinicians regarding the benefits of earlier test results were sought (base case 2). A NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Scenario analyses were used to assess uncertainty. Results: For the review of diagnostic test accuracy, 62 studies of varying methodological quality were included. A meta-analysis of 54 studies comparing SeptiFast with blood culture found that SeptiFast had an estimated summary specificity of 0.86 [95% credible interval (CrI) 0.84 to 0.89] and sensitivity of 0.65 (95% CrI 0.60 to 0.71). Four studies comparing SepsiTest with blood culture found that SepsiTest had an estimated summary specificity of 0.86 (95% CrI 0.78 to 0.92) and sensitivity of 0.48 (95% CrI 0.21 to 0.74), and four studies comparing IRIDICA with blood culture found that IRIDICA had an estimated summary specificity of 0.84 (95% CrI 0.71 to 0.92) and sensitivity of 0.81 (95% CrI 0.69 to 0.90). Owing to the deficiencies in study quality for all interventions, diagnostic accuracy data should be treated with caution. No randomised clinical trial evidence was identified that indicated that any of the tests significantly improved key patient outcomes, such as mortality or duration in an intensive care unit or hospital. Base case 1 estimated that none of the three tests provided a benefit to patients compared with standard practice and thus all tests were dominated. In contrast, in base case 2 it was estimated that all cost per QALY-gained values were below £20,000; the IRIDICA BAC BSI assay had the highest estimated incremental net benefit, but results from base case 2 should be treated with caution as these are not evidence based. Limitations: Robust data to accurately assess the clinical effectiveness and cost-effectiveness of the interventions are currently unavailable. Conclusions: The clinical effectiveness and cost-effectiveness of the interventions cannot be reliably determined with the current evidence base. Appropriate studies, which allow information from the tests to be implemented in clinical practice, are required.