PAlliative Care in chronic Kidney diSease: the PACKS study—quality of life, decision making, costs and impact on carers in people managed without dialysis

BACKGROUND: The number of patients with advanced chronic kidney disease opting for conservative management rather than dialysis is unknown but likely to be growing as increasingly frail patients with advanced renal disease present to renal services. Conservative kidney management includes ongoing medical input and support from a multidisciplinary team. There is limited evidence concerning patient and carer experience of this choice. This study will explore quality of life, symptoms, cognition, frailty, performance decision making, costs and impact on carers in people with advanced chronic kidney disease managed without dialysis and is funded by the National Institute of Health Research in the UK.

METHODS: In this prospective, multicentre, longitudinal study, patients will be recruited in the UK, by renal research nurses, once they have made the decision not to embark on dialysis. Carers will be asked to 'opt-in' with consent from patients. The approach includes longitudinal quantitative surveys of quality of life, symptoms, decision making and costs for patients and quality of life and costs for carers, with questionnaires administered quarterly over 12 months. Additionally, the decision making process will be explored via qualitative interviews with renal physicians/clinical nurse specialists.

DISCUSSION: The study is designed to capture patient and carer profiles when conservative kidney management is implemented, and understand trajectories of care-receiving and care-giving with the aim of optimising palliative care for this population. It will explore the interactions that lead to clinical care decisions and the impact of these decisions on informal carers with the intention of improving clinical outcomes for patients and the experiences of care givers.

Overweight and obesity on the island of Ireland: an estimation of costs

Objectives The increasing prevalence of overweight and obesity worldwide continues to compromise population health and creates a wider societal cost in terms of productivity loss and premature mortality. Despite extensive international literature on the cost of overweight and obesity, findings are inconsistent between Europe and the USA, and particularly within Europe. Studies vary on issues of focus, specific costs and methods. This study aims to estimate the healthcare and productivity costs of overweight and obesity for the island of Ireland in 2009, using both top-down and bottom-up approaches.

Methods Costs were estimated across four categories: healthcare utilisation, drug costs, work absenteeism and premature mortality. Healthcare costs were estimated using Population Attributable Fractions (PAFs). PAFs were applied to national cost data for hospital care and drug prescribing. PAFs were also applied to social welfare and national mortality data to estimate productivity costs due to absenteeism and premature mortality.

Results The healthcare costs of overweight and obesity in 2009 were estimated at €437 million for the Republic of Ireland (ROI) and €127.41 million for NI. Productivity loss due to overweight and obesity was up to €865 million for ROI and €362 million for NI. The main drivers of healthcare costs are cardiovascular disease, type II diabetes, colon cancer, stroke and gallbladder disease. In terms of absenteeism, low back pain is the main driver in both jurisdictions, and for productivity loss due to premature mortality the primary driver of cost is coronary heart disease.

Conclusions The costs are substantial, and urgent public health action is required in Ireland to address the problem of increasing prevalence of overweight and obesity, which if left unchecked will lead to unsustainable cost escalation within the health service and unacceptable societal costs.

Interactions of cetaceans with Spanish and Portuguese fisheries in Atlantic waters : costs, benefits and implications for management

With the aim to provide new insights into operational cetacean-fishery interactions in Atlantic waters, this thesis assesses interactions of cetaceans with Spanish and Portuguese fishing vessels operating in Iberian and South West Atlantic waters. Different opportunistic research methodologies were applied, including an interview survey with fishers (mainly skippers) and onboard observations by fisheries observers and skippers, to describe different types of interactions and to identify potential hotspots for cetacean-fishery interactions and the cetacean species most involved, and to quantify the extent and the consequences of these interactions in terms of benefits and costs for cetaceans and fisheries. In addition, the suitability of different mitigation strategies was evaluated and discussed. The results of this work indicate that cetaceans interact frequently with Spanish and Portuguese fishing vessels, sometimes in a beneficial way (e.g. cetaceans indicate fish schools in purse seine fisheries), but mostly with negative consequences (depredation on catch, gear damage and cetacean bycatch). Significant economic loss and high bycatch rates are, however, only reported for certain fisheries and associated with particular cetacean species. In Galician fisheries, substantial economic loss was reported as a result of bottlenose dolphins damaging artisanal coastal gillnets, while high catch loss may arise from common dolphins scattering fish in purse seine fisheries. High cetacean bycatch mortality arises in trawl fisheries, mainly of common dolphin and particularly during trawling in water depths below 350 m, and in coastal set gillnet fisheries (mainly common and bottlenose dolphins). In large-scale bottom-set longline fisheries in South West Atlantic waters, sperm whales may significantly reduce catch rates through depredation on catch. The high diversity of cetacean-fishery interactions observed in the study area indicates that case-specific management strategies are needed to reduce negative impacts on fisheries and cetaceans. Acoustic deterrent devices (pingers) may be used to prevent small cetaceans from approaching and getting entangled in purse seines and set gillnets, although possible problems include cetacean habituation to the pinger sounds, as well as negative side effects on non-target cetaceans (habitat exclusion) and fisheries target species (reduced catch rates). For sardine and horse mackerel, target species of Iberian Atlantic fisheries, no aversive reaction to pinger sounds was detected during tank experiments conducted in the scope of this thesis. Bycatch in trawls may be reduced by the implementation of time/area restrictions of fishing activity. In addition, the avoidance of fishing areas with high cetacean abundance combined with the minimization of fishery-specific sound cues that possibly attract cetaceans, may also help to decrease interactions. In large-scale bottom-set longline fisheries, cetacean depredation on catch may be reduced by covering hooked fish with net sleeves ("umbrellas") provided that catch rates are not negatively affected by this gear modification. Trap fishing, as an alternative fishing method to bottom-set gillnetting and longlining, also has the potential to reduce cetacean bycatch and depredation, given that fish catch rates are similar to the rates obtained by bottom-set gillnets and longlines, whereas cetacean by-catch is unlikely. Economic incentives, such as the eco-certification of dolphin-safe fishing methods, should be promoted in order to create an additional source of income for fishers negatively affected by interactions with cetaceans, which, in turn, may also increase fishers’ willingness to accept and adopt mitigation measures. Although the opportunistic sampling methods applied in this work have certain restrictions concerning their reliability and precision, the results are consistent with previous studies in the same area. Moreover, they allow for the active participation of fishers that can provide important complementary ecological and technical knowledge required for cetacean management and conservation.

The Impacts of Variety on the Costs and Profits of a Hotel Chain’s Properties

In the hotel industry, undistributed operating expenses represent a significant portion of the operating costs for a hotel. Exactly how most of these expenses arise is not well understood. Using data from more than 40 hotels operated by a major chain, the authors examine the links between the variety of a hotel’s products and customers and its undistributed operating expenses and revenues. Their findings show that undistributed operating expenses are related to the extent of the property’s business and product-services mix. The results suggest that although increasing a property's product-service mix results in higher undistributed operating expenses, the incremental costs are compensated for by higher revenues. However, increasing business mix while increasing undistributed operating expenses does not result in higher revenues.

Serving More Segments and Offering More Products: What Are the Costs and Where Are the Profits?

Making more money involves more than targeting new customer segments and offering new services.

Internalising the external costs of light goods vehicle transport in Britain

Report produced as part of the Green Logistics project (EPSRC and Department for Transport funded). To what extent do the taxes paid by the light goods vehicles (LGVs) users in Britain cover their allocated infrastructural, environmental and congestion costs? This report is a continuation of a study on the internalisation of the external costs of heavy goods vehicle activity. Research undertaken jointly by the Transport Studies Group at University of Westminster and Logistics Research Centre at Heriot-Watt University has attempted to answer this question using official government transport statistics and monetary valuations for the external costs.

Internalising the external costs of light and heavy goods vehicle transport in London

Report produced as part of the Green Logistics project (EPSRC and Department for Transport funded). This report provides estimates of the total external costs of LGV and HGV operations in London. In 2006, total LGV and HGV activity imposed external costs of approximately £1.75-£1.8 billion using low, medium and high emission cost values. About 27 per cent of these costs were internalised by duties and taxes paid by LGV operators, compared with 26% in the case of HGVs. If congestion costs are excluded, taxes and duties paid by LGV operators are estimated to be 155% of LGVs' allocated infrastructural and environmental costs, compared with 85% in the case of HGVs. When using the medium emission cost values, LGVs accounted for 56% of these external costs in London and HGVs for 44%.

Logistics management and costs of biomass fuel supply

Discusses part of a project conducted by the authors into the logistics planning and management and costs of supplying biomass fuels to biomass-fired power stations in the UK. Defines biomass fuels and the reasons for the growth in interest in their use for electricity generation. The activities and parties involved in the biomass fuel supply chain are discussed together with the management of the chain in order to achieve smooth and consistent flow of biomass fuel to power stations. Explains the approach used to modelling the delivered costs of biomass fuels for four types of biomass fuel included in the project: forest fuel, short rotation coppice, straw and miscanthus. Comments are given on the environmental impacts of the fuel supply chains. The results indicate that straw supply systems are capable of producing the lowest delivered costs of the four fuels studied. Short rotation coppice and miscanthus, two new energy crops, are likely to have the highest delivered costs at present. This is due to the cost of growing these fuels and the financial incentives required by farmers to persuade them to grow these crops. Logistics costs (i.e. transport, storage and handling) are shown to represent a significant proportion of total delivered cost in biomass supply. Careful supply chain planning and logistics management will be of central importance to the success of the biomass industry.

Internalising the external costs of light and heavy goods vehicles in London

This report provides estimates of the total external costs of LGV and HGV operations in London. In 2006, total LGV and HGV activity imposed external costs of approximately £1.75-£1.8 billion using low, medium and high emission cost values. About 27 per cent of these costs were internalised by duties and taxes paid by LGV operators, compared with 26% in the case of HGVs. If congestion costs are excluded, taxes and duties paid by LGV operators are estimated to be 155% of LGVs' allocated infrastructural and environmental costs, compared with 85% in the case of HGVs. When using the medium emission cost values, LGVs accounted for 56% of these external costs in London and HGVs for 44%.