When future change matters: modelling future price and diffusion in health technology assessments of medical devices

Objectives: Whilst health technology assessments (HTAs) that take account of future price change have been examined in the literature, the important issue of price reductions that are generated by the reimbursement decision has been ignored. Our objective is to explore the impact of future price reductions caused by increasing uptake on HTAs and decision making for medical devices. Methods: We demonstrate the use of a two-stage modelling approach to derive estimates of technology price as a consequence of changes in technology uptake over future periods based on existing theory and supported by empirical studies. We explore the impact on cost-effectiveness and expected value of information analysis in an illustrative example based on a technology used in pre-term birth screening that is in development. Results: The application of our approach to the case study technology generates smaller incremental cost-effectiveness ratios (ICERs) compared to the commonly used single cohort approach. The extent of this reduction of the ICER depends on the magnitude of the modelled price reduction, the speed of diffusion and the length of the assumed technology-life horizon. Results of value of information analysis are affected through changes in the expected net benefit calculation, the addition of uncertain parameters and the diffusion-adjusted estimate of the affected patient population. Conclusions: Since modelling future changes in price and uptake has the potential to affect HTA outcomes, modelling techniques that can address such changes should be considered for medical devices that may otherwise be rejected

Results of the Quarterly Tritium Survey of Fourmile Branch and Its Seeplines in the F and H Areas of SRS: May 1995

The Environmental Sciences Section of the Savannah River Technology Center established a quarterly monitoring program of the Fourmile Branch stream and its associated seepline located down gradient from the F- and H-Area Seepage Basins. The primary focus of this program was to survey and track changes in tritium levels; however, specific conductivity, and pH were also surveyed and tracked. The measurement from the eleventh survey (May 1995) exhibited similar tritium levels, conductivity measurements, and pH values to data from previous sampling events. The overall results of the tritium survey and stream monitoring data (Looney et al., 1993) indicate that the tritium plume resulting from the past operation of the seepage basins continues to flush from the Fourmile Branch wetland system

Estimating future health technology diffusion using expert beliefs calibrated to an established diffusion model

Objectives: Estimates of future health technology diffusion, or future uptake over time, are a requirement for different analyses performed within health technology assessments. Methods for obtaining such estimates include constant uptake estimates based on expert opinion or analogous technologies, and extrapolation from initial data points using parametric curves – but remain divorced from established diffusion theory and modelling. We propose an approach to obtaining diffusion estimates using experts’ beliefs calibrated to an established diffusion model to address this methodological gap. Methods: We performed an elicitation of experts’ beliefs on future diffusion of a new preterm birth screening illustrative case study technology. The elicited quantities were chosen such that they could be calibrated to yield the parameters of the Bass model of new product growth, which was chosen based on a review of the diffusion literature. Results: With the elicitation of only three quantities per diffusion curve, our approach enabled us to quantify uncertainty about diffusion of the new technology in different scenarios. Pooled results showed that the attainable number of adoptions was predicted to be relatively low compared with what was thought possible. Further research evidence improved the attainable number of adoptions only slightly but resulted in greater speed of diffusion. Conclusions: The proposed approach of eliciting experts’ beliefs about diffusion and informing the Bass model has the potential to fill the methodological gap evident in value of implementation and research, as well as budget impact and some cost-effectiveness analyses

Direct seeding of chenopod shrubs for saltland and rangeland environments

There are currently two ways of establishing chenopod shrubs: sowing from seed using a niche seeder, or planting nursery-raised seedlings with a tree planter. Planting seedlings is the more reliable method, but is relatively expensive (in excess of $450 per hectare). On the other hand, direct seeding using the specialised “niche seeder” is much less expensive ($100-150 per hectare), but is also less reliable. This project aimed to investigate alternative methods of direct seeding chenopod shrubs for saltland and rangeland areas by developing a greater understanding of their seed biology and agronomic requirements. Our aspiration was that shrubs should be established using more conventional farm machinery. This bulletin reports on a combination of seed biology and agronomic research to develop reliable, low-cost direct seeding options for chenopod shrubs. Experiments into the impact of changing environmental conditions on seeds were studied in the laboratory, and field experiments were conducted to test the applicability of these insights in the field using conventional modified farm seeding machinery. As a result of this work, a successful direct seeding package using farm seeding equipment (modified for wide row spacings and depth control) was developed for Atriplex nummularia (old man saltbush), the most widely planted saltbush species across southern Australia. The nine key elements of the package are: 1. Select suitable paddocks for introduction of new shrubs 2. Prepare a weed-free seedbed using two knockdown herbicide applications (4-6 weeks and 1-2 weeks before seeding) and commence control of rabbits and kangaroos 3. Sow the best seed, by ensuring: a. Large fruits, with a high proportion of viable seeds, have been selected b. Seed is of subspecies nummularia (not subsp. spathulata) c. Fruits have been harvested within the previous six months and stored in a cool, dry environment d. Bracts are retained around the seeds 4. Sow into moisture in late winter - early spring (depending on district) a. If the area to be sown is waterlogged, defer sowing until later in spring b. If insufficient soil moisture, defer sowing until the following year 5. Use a sowing rate of ~10 fruits/m (if germination rate is 15%) to provide at least one plant for every 2 m of row; use higher rates for seed of lower germination 6. Set the seeder up to sow into furrows with trailing press wheels 7. Sow to a depth of 5-10 mm (very critical) 8. Control weeds and pests (insects, mites, kangaroos and rabbits) 9. Defer grazing until seedlings are well established This establishment method has also been shown to work for Rhagodia preissii (mallee saltbush). This project was not able to develop reliable direct seeding packages for other Atriplex species, including A. amnicola and A. undulata. Further work is needed to understand the triggers for their germination, before these species can be direct-seeded with conventional machinery. Direct sowing of M. brevifolia and M. pyramidata appears to be problematic in much of southern Australia, due to their requirement for temperatures >30°C for germination, which do not occur within the normal winter growing season. An exception to this would be areas with more reliable summer rainfall, such as northern New South Wales, where sowing could be deferred until late spring-early summer. An alternative strategy for establishing M. brevifolia, is to encourage natural recruitment of seedlings from seed produced on surrounding bushes (if it is already present in the area), or to transplant a low density of nursery-raised seedlings, which could then act as a seed source for natural recruitment (if it is not already present)

Finitely presented wreath products and double coset decompositions

We characterize which permutational wreath products W^(X)\rtimes G are finitely presented. This occurs if and only if G and W are finitely presented, G acts on X with finitely generated stabilizers, and with finitely many orbits on the cartesian square X^2. On the one hand, this extends a result of G. Baumslag about standard wreath products; on the other hand, this provides nontrivial examples of finitely presented groups. For instance, we obtain two quasi-isometric finitely presented groups, one of which is torsion-free and the other has an infinite torsion subgroup. Motivated by the characterization above, we discuss the following question: which finitely generated groups can have a finitely generated subgroup with finitely many double cosets? The discussion involves properties related to the structure of maximal subgroups, and to the profinite topology.Comment: 21 pages; no figure. To appear in Geom. Dedicat

A multilevel neo-institutional analysis of infection prevention and control in English hospitals: coerced safety culture change?

Despite committed policy, regulative and professional efforts on healthcare safety, little is known about how such macro-interventions permeate organisations and shape culture over time. Informed by neo-institutional theory, we examined how inter-organisational influences shaped safety practices and inter-subjective meanings following efforts for coerced culture change. We traced macro-influences from 2000 to 2015 in infection prevention and control (IPC). Safety perceptions and meanings were inductively analysed from 130 in-depth qualitative interviews with senior- and middle-level managers from 30 English hospitals. A total of 869 institutional interventions were identified; 69% had a regulative component. In this context of forced implementation of safety practices, staff experienced inherent tensions concerning the scope of safety, their ability to be open and prioritisation of external mandates over local need. These tensions stemmed from conflicts among three co-existing institutional logics prevalent in the NHS. In response to requests for change, staff flexibly drew from a repertoire of cognitive, material and symbolic resources within and outside their organisations. They crafted 'strategies of action', guided by a situated assessment of first-hand practice experiences complementing collective evaluations of interventions such as 'pragmatic', 'sensible' and also 'legitimate'. Macro-institutional forces exerted influence either directly on individuals or indirectly by enriching the organisational cultural repertoire

BRST Quantization of String Theory in AdS(3)

We study the BRST quantization of bosonic and NSR strings propagating in AdS(3) x N backgrounds. The no-ghost theorem is proved using the Frenkel-Garland-Zuckerman method. Regular and spectrally-flowed representations of affine SL(2,R) appear on an equal footing. Possible generalizations to related curved backgrounds are discussed.Comment: JHEP style, 23 pages; v2:minor changes and references added; v3: typos corrected, version to appear in JHEP; v4: one reference adde

Stability of circular orbits of spinning particles in Schwarzschild-like space-times

Circular orbits of spinning test particles and their stability in Schwarzschild-like backgrounds are investigated. For these space-times the equations of motion admit solutions representing circular orbits with particles spins being constant and normal to the plane of orbits. For the de Sitter background the orbits are always stable with particle velocity and momentum being co-linear along them. The world-line deviation equations for particles of the same spin-to-mass ratios are solved and the resulting deviation vectors are used to study the stability of orbits. It is shown that the orbits are stable against radial perturbations. The general criterion for stability against normal perturbations is obtained. Explicit calculations are performed in the case of the Schwarzschild space-time leading to the conclusion that the orbits are stable.Comment: eps figures, submitted to General Relativity and Gravitatio

A new approach for the limit to tree height using a liquid nanolayer model

Liquids in contact with solids are submitted to intermolecular forces inferring density gradients at the walls. The van der Waals forces make liquid heterogeneous, the stress tensor is not any more spherical as in homogeneous bulks and it is possible to obtain stable thin liquid films wetting vertical walls up to altitudes that incompressible fluid models are not forecasting. Application to micro tubes of xylem enables to understand why the ascent of sap is possible for very high trees like sequoias or giant eucalyptus.Comment: In the conclusion is a complementary comment to the Continuum Mechanics and Thermodynamics paper. 21 pages, 4 figures. Continuum Mechanics and Thermodynamics 20, 5 (2008) to appea

Pathogenesis of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) represents a spectrum of disease ranging from hepatocellular steatosis through steatohepatitis to fibrosis and irreversible cirrhosis. The prevalence of NAFLD has risen rapidly in parallel with the dramatic rise in obesity and diabetes, and is rapidly becoming the most common cause of liver disease in Western countries. Indeed, NAFLD is now recognized to be the aetiology in many cases previously labelled as cryptogenic cirrhosis