Product standardisation as a tool to control prescribing costs a case study of alginate liquid preparations

Introduction Product standardisation involves promoting the prescribing of pre-selected products within a particular category across a healthcare region and is designed to improve patient safety by promoting continuity of medicine use across the primary/secondary care interface, in addition to cost containment without compromising clinical care (i.e. maintaining safety and efficacy). Objectives To examine the impact of product standardisation on the prescribing of compound alginate preparations within primary care in Northern Ireland. Methods Data were obtained on alginate prescribing from the Northern Ireland Central Services Agency (Prescription Pricing Branch), covering a period of 43 months. Two standardisation promotion interventions were carried out at months 18 and 33. In addition to conventional statistical analyses, a simple interrupted time series analysis approach, using graphical interpretation, was used to facilitate interpretation of the data. Results There was a significant increase in the prescribed share of the preferred alginate product in each of the four health boards in Northern Ireland and a decrease in the cost per Defined Daily Dose for alginate liquid preparations overall. Compliance with the standardisation policy was, however, incomplete and was influenced to a marked degree by the activities of the pharmaceutical industry. The overall economic impact of the prescribing changes during the study was small (3.1%). Conclusion The findings suggested that product standardisation significantly influenced the prescribing pattern for compound alginate liquid preparations within primary care across Northern Ireland. © 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society.

Low-fat versus low-carbohydrate weight reduction diets:Effects on weight loss, insulin resistance, and cardiovascular risk: a randomized control trial

OBJECTIVE Low-fat hypocaloric diets reduce insulin resistance and prevent type 2 diabetes in those at risk. Low-carbohydrate, high-fat diets are advocated as an alternative, but reciprocal increases in dietary fat may have detrimental effects on insulin resistance and offset the benefits of weight reduction.

RESEARCH DESIGN AND METHODS We investigated a low-fat (20% fat, 60% carbohydrate) versus a low-carbohydrate (60% fat, 20% carbohydrate) weight reduction diet in 24 overweight/obese subjects ([mean ± SD] BMI 33.6 ± 3.7 kg/m2, aged 39 ± 10 years) in an 8-week randomized controlled trial. All food was weighed and distributed, and intake was calculated to produce a 500 kcal/day energy deficit. Insulin action was assessed by the euglycemic clamp and insulin secretion by meal tolerance test. Body composition, adipokine levels, and vascular compliance by pulse-wave analysis were also measured.

RESULTS Significant weight loss occurred in both groups (P < 0.01), with no difference between groups (P = 0.40). Peripheral glucose uptake increased, but there was no difference between groups (P = 0.28), and suppression of endogenous glucose production was also similar between groups. Meal tolerance–related insulin secretion decreased with weight loss with no difference between groups (P = 0.71). The change in overall systemic arterial stiffness was, however, significantly different between diets (P = 0.04); this reflected a significant decrease in augmentation index following the low-fat diet, compared with a nonsignificant increase within the low-carbohydrate group.

CONCLUSIONS This study demonstrates comparable effects on insulin resistance of low-fat and low-carbohydrate diets independent of macronutrient content. The difference in augmentation index may imply a negative effect of low-carbohydrate diets on vascular risk.

The impact of nonadherence to inhaled long-acting β - adrenoceptor agonist/corticosteroid combination therapy on healthcare costs in difficult-to-control asthma

Background: Asthma is a leading, preventable cause of morbidity, mortality and cost. A disproportionate amount of the cost is generated by the 5-10%of patients with difficult-to-control asthma, who are prescribed treatment at step 4/5 of the Global Initiative for Asthma (GINA) guidelines. We have previously demonstrated a high prevalence of nonadherence to inhaled combination therapy (i.e. long-acting ß -adrenoceptor agonist [ß - agonist] and corticosteroid) in this population. The aim of this study was to examine the costs of healthcare utilization in a nonadherent group of patients with difficult-to-control asthma compared with adherent subjects. We also wished to examine potential savings if nonadherence to inhaled combination therapy could be addressed. All costs were measured from the perspective of a publicly funded health service Methods: Adherence was determined through examination of patient prescription refill behaviour and validated with a medical concordance interview. Data on healthcare use were collected from a patient survey and hospital records that included prescribed medicines, hospital admissions, intensive care unit (ICU) admissions and other unscheduled healthcare visits associated with asthma care. Activity was monetized using standard UK references and between-group comparisons based on a series of univariate and multivariate regression analyses. Results: Cost differences were identified for inhaled combination therapy, nebulizer, short acting b2-agonists and hospital costs excluding and including ICU admissions between adherent and nonadherent subjects. Compared with a group who have refractory asthma and who are adherent with medication, additional healthcare costs in nonadherent subjects are offset by the reduction in costs associated with reduced medication utilization. However, if nonadherence can be successfully targeted and hospital admissions avoided in this population, there is a potential $475 ($843-$368) saving per patient, per annum. Conclusion: Nonadherence is an important cause of difficult-to-control asthma. A uniform cost for subjects with difficult-to-control disease can be applied to economic analyses, independent of adherence, as increased healthcare utilization costs are offset by the reduced medication cost due to poor adherence. However, there are substantial potential savings in subjects with difficult-to-control asthma, who are nonadherent to inhaled combination therapy, if cost effective strategies for nonadherence are developed. © 2011 Adis Data Information BV. All rights reserved.

Hidden costs of control: four repetitions and an extension

We report four repetitions of Falk and Kosfeld's (Am. Econ. Rev. 96(5):1611-1630, 2006) low and medium control treatments with 476 subjects. Each repetition employs a sample drawn from a standard subject pool of students and demographics vary across samples. We largely confirm the existence of hidden costs of control but, contrary to the original study, hidden costs of control are usually not substantial enough to significantly undermine the effectiveness of economic incentives. Our subjects were asked, at the end of the experimental session, to complete a questionnaire in which they had to state their work motivation in hypothetical scenarios. Our questionnaires are identical to the ones administered in Falk and Kosfeld's (Am. Econ. Rev. 96(5):1611-1630, 2006) questionnaire study. In contrast to the game play data, our questionnaire data are similar to those of the original questionnaire study. In an attempt to solve this puzzle, we report an extension with 228 subjects where performance-contingent earnings are absent i.e. both principals and agents are paid according to a flat participation fee. We observe that hidden costs significantly outweigh benefits of control under hypothetical incentives.

Psychosocial and academic characteristics of extremely low birth weight (<or =800 g) adolescents who are free of major impairment compared with term-born control subjects

To compare academic and cognitive ability, attention, attitudes, and behavior of extremely low birth weight (ELBW) adolescents who are free of major impairments at 17 years of age with term-born control subjects.

Uncertainty and Sensitivity Analysis in Aircraft Operating Costs in Structural Design Optimization

The paper focuses on the development of an aircraft design optimization methodology that models uncertainty and sensitivity analysis in the tradeoff between manufacturing cost, structural requirements, andaircraft direct operating cost.Specifically,ratherthanonlylooking atmanufacturingcost, direct operatingcost is also consideredintermsof the impact of weight on fuel burn, in addition to the acquisition cost to be borne by the operator. Ultimately, there is a tradeoff between driving design according to minimal weight and driving it according to reduced manufacturing cost. Theanalysis of cost is facilitated withagenetic-causal cost-modeling methodology,andthe structural analysis is driven by numerical expressions of appropriate failure modes that use ESDU International reference data. However, a key contribution of the paper is to investigate the modeling of uncertainty and to perform a sensitivity analysis to investigate the robustness of the optimization methodology. Stochastic distributions are used to characterize manufacturing cost distributions, andMonteCarlo analysis is performed in modeling the impact of uncertainty on the cost modeling. The results are then used in a sensitivity analysis that incorporates the optimization methodology. In addition to investigating manufacturing cost variance, the sensitivity of the optimization to fuel burn cost and structural loading are also investigated. It is found that the consideration of manufacturing cost does make an impact and results in a different optimal design configuration from that delivered by the minimal-weight method. However, it was shown that at lower applied loads there is a threshold fuel burn cost at which the optimization process needs to reduce weight, and this threshold decreases with increasing load. The new optimal solution results in lower direct operating cost with a predicted savings of 640=m2 of fuselage skin over the life, relating to a rough order-of-magnitude direct operating cost savings of $500,000 for the fuselage alone of a small regional jet. Moreover, it was found through the uncertainty analysis that the principle was not sensitive to cost variance, although the margins do change.

The pitfall with PIT tags: Marking freshwater bivalves for translocation induces short-term behavioural costs

Tagging animals is frequently employed in ecological studies to monitor individual behaviour, for example postrelease survival and dispersal of captive-bred animals used in conservation programmes. While the majority of studies focus on the efficacy of tags in facilitating the relocation and identification of individuals, few assess the direct effects of tagging in biasing animal behaviour. We used an experimental approach with a control to differentiate the effects of handling and tagging captive-bred juvenile freshwater pearl mussels, Margaritifera margaritifera, prior to release into the wild. Marking individuals with passive integrated transponder (PIT) tags significantly decreased their burrowing rate and, therefore, increased the time taken to burrow into the substrate. This effect was contributed to, in part, by the detrimental impacts of handling, which also significantly affected activity, burrowing ability and the time taken for each individual to emerge and start probing the substrate. Disturbance during handling and tagging may lead to indirect mortality after release by increasing the risk of predation or dislodgement during flooding, thereby potentially compromising any conservation strategy contingent on population supplementation or reintroduction. This is the first study to demonstrate that handling and PIT tagging has a detrimental impact on invertebrate behaviour. Moreover, our results provide useful information that will inform freshwater bivalve conservation strategies.

Can the protein costs of bacterial resistance be offset by altered feeding behaviour?

1. Mounting an immune response is likely to be costly in terms of energy and nutrients, and so it is predicted that dietary intake should change in response to infection to offset these costs. The present study focuses on the interactions between a specialist grass-feeding caterpillar species, the African armyworm Spodoptera exempta, and an opportunist bacterium, Bacillus subtilis.
2. The main aims of the study were (i) to establish the macronutrient costs to the insect host of surviving a systemic bacterial infection, (ii) to determine the relative importance of dietary protein and carbohydrate to immune system functions, and (iii) to determine whether there is an adaptive change in the host's normal feeding behaviour in response to bacterial challenge, such that the nutritional costs of resisting infection are offset.
3. We show that the survival of bacterially infected larvae increased with increasing dietary protein-to-carbohydrate (P:C) ratio, suggesting a protein cost associated with bacterial resistance. As dietary protein levels increased, there was an increase in antibacterial activity, phenoloxidase (PO) activity and protein levels in the haemolymph, providing a potential source for this protein cost. However, there was also evidence for a physiological trade-off between antibacterial activity and phenoloxidase activity, as larvae whose antibacterial activity levels were elevated in response to immune activation had reduced PO activity.
4. When given a choice between two diets varying in their P:C ratios, larvae injected with a sub-lethal dose of bacteria increased their protein intake relative to control larvae whilst maintaining similar carbohydrate intake levels. These results are consistent with the notion that S. exempta larvae alter their feeding behaviour in response to bacterial infection in a manner that is likely to enhance the levels of protein available for producing the immune system components and other factors required to resist bacterial infections (‘self-medication’).

The costs of bearing arms and armour in the hermit crab Pagurus bernhardus

Hermit crabs use empty gastropod shells as protective armour and enlarged chelipeds as signals and weapons. However, carrying armour and arms may impose energy costs that result in increased lactate and hence potential fatigue and there may be consequent effects on general activity. We investigated whether variation in shell and cheliped size influences lactate levels in hermit crabs. Lactate was positively related to residual cheliped size for both sexes and was higher in males than females; when we controlled for body size, the former had larger chelipeds. Shell weight unexpectedly had no effect on lactate but crabs in small shells had high lactate, possibly because of reduced ability to maintain a respiratory current. The size of natural shells had no effect on activity but the addition of food odour increased locomotion. However, activity was not related to lactate. We conclude that possession of larger chelipeds than expected for body size imposes significant costs and may limit development of sexual dimorphism. (C) 2010 The Association for the Study of Animal Behaviour. Published by Elsevier Ltd. All rights reserved.

Electron-beam treatment of poly(lactic acid) to control degradation profiles

Bioresorbable polymers such as polylactide (PIA) and polylactide-co-glycolide (PLGA) have been used successfully as biomaterials in a wide range of medical applications. However, their slow degradation rates and propensity to lose strength before mass have caused problems. A central challenge for the development of these materials is the assurance of consistent and predictable in vivo degradation. Previous work has illustrated the potential to influence polymer degradation using electron beam (e-beam) radiation. The work addressed in this paper investigates further the utilisation of e-beam radiation in order to achieve a more surface specific effect. Variation of e-beam energy was studied as a means to control the effective penetrative depth in poly-L-lactide (PLEA). PLEA samples were exposed to e-beam radiation at individual energies of 0.5 MeV, 0.75 MeV and 1.5 MeV. The near-surface region of the PLEA samples was shown to be affected by e-beam irradiation with induced changes in molecular weight, morphology, flexural strength and degradation profile. Moreover, the depth to which the physical properties of the polymer were affected is dependent on the beam energy used. Computer modelling of the transmission of each e-beam energy level used corresponded well with these findings. (C) 2010 Elsevier Ltd. All rights reserved.

The Costs of Taking It Slowly Fast and Slow Movement Timing in Older Age

We investigated adult age differences in timing control of fast vs slow repetitive movements using a dual task approach Twenty two young (M = 24 23 yr) and 22 older adults (M = 66 64 yr) performed three cognitive tasks differing in working memory load and response production demands and they tapped series of 550 ms or 2100 ms target Intervals Single task timing was comparable in both groups Dual task timing was characterized by shortening of produced intervals and increases in drift and variability Dual task costs for both cognitive and timing performances were pronounced at slower tapping tempos an effect exacerbated in older adults Our findings implicate attention and working memory processes as critical components of slow movement timing and sources of specific challenges thereof for older adults

Working Memory and Postural Control: Adult Age Differences in Potential for Improvement, Task Priority, and Dual Tasking

We investigate dynamic posture control and working memory (NBack) retest practice in young and older adults, focusing on older adults' potential for improvement in the component tasks but more importantly in dual-task performance. Participants performed the 2 tasks in 11 sessions under single- and dual-task conditions. Posture improvement was observed with retest practice for both groups. Increase in cognitive load after initial practice led to greater dual-task costs in both tasks in older adults and higher costs in memory in young adults. With continued practice, costs were reduced by both groups; however, the 2 groups focused improvement on different tasks: Older adults focused on posture but young adults on cognition. These results emphasize older adults' potential for improvement in dual-task performance and their flexibility to utilize the practice gains in posture to optimize cognitive performance.

Fetch Gating Control through Speculative Instruction Window Weighting

In a dynamic reordering superscalar processor, the front-end fetches instructions and places them in the issue queue. Instructions are then issued by the back-end execution core. Till recently, the front-end was designed to maximize performance without considering energy consumption. The front-end fetches instructions as fast as it can until it is stalled by a filled issue queue or some other blocking structure. This approach wastes energy: (i) speculative execution causes many wrong-path instructions to be fetched and executed, and (ii) back-end execution rate is usually less than its peak rate, but front-end structures are dimensioned to sustained peak performance. Dynamically reducing the front-end instruction rate and the active size of front-end structure (e.g. issue queue) is a required performance-energy trade-off. Techniques proposed in the literature attack only one of these effects.
In previous work, we have proposed Speculative Instruction Window Weighting (SIWW) [21], a fetch gating technique that allows to address both fetch gating and instruction issue queue dynamic sizing. SIWW computes a global weight on the set of inflight instructions. This weight depends on the number and types of inflight instructions (non-branches, high confidence or low confidence branches, ...). The front-end instruction rate can be continuously adapted based on this weight. This paper extends the analysis of SIWW performed in previous work. It shows that SIWW performs better than previously proposed fetch gating techniques and that SIWW allows to dynamically adapt the size of the active instruction queue.