A modelling-based economic evaluation of primary-care-based fall-risk screening followed by fall-prevention intervention : a cohort-based Markov model stratified by older age groups

Background fall-risk assessment with fall-prevention intervention referral for at-risk groups to avoid falls could be cost-effective from a care-payer perspective. Aims to model the cost-effectiveness of a fall-risk assessment (QTUG compared to TUG) with referral to one of four fall-prevention interventions (Otago, FaME, Tai Chi, home safety assessment and modification) compared to no care pathway, when the decision to screen is based on older age in a primary care setting for community-dwelling people. Methods a cohort-based, decision analytic Markov model was stratified by five age groupings (65–70, 70–75, 65–89, 70–89 and 75–89) to estimate cost per quality-adjusted life years (QALYs). Costs included fall-risk assessment, fall-prevention intervention and downstream resource use (e.g. inpatient and care home admission). Uncertainty was explored using univariate, bivariate and probabilistic sensitivity analyses. Results screening with QTUG dominates (>QALYs; 85%), relative to those aged 70–74 (~10 < 30%) or 65–69 (<10%). In the older age group, only a 10% referral uptake is required for the QTUG with FaME or Otago modelled care pathways to remain cost-effective. Conclusion the highest probability of cost-effectiveness observed was a care pathway incorporating QTUG with FaME in those aged 75–89. Although the model does not fully represent current NICE Falls guidance, decision makers should still give careful consideration to implementing the aforementioned care pathway due to the modelled high probability of cost-effectiveness

Poisoning by Marsdenia hilariana and Marsdenia megalantha (Apocynaceae) in ruminants

AbstractNeurological signs were observed in cattle consuming the roots of Marsdenia hilariana and sheep consuming leaves of Marsdenia megalantha. Similar nervous signs to those observed in spontaneous poisoning were induced experimentally by the administration of roots of M. hilariana to goats, and by the administration of leaves and roots of M. megalantha to sheep. No lesions were observed at necropsies and on histological examination of the nervous system and other tissues

Granular discharge and clogging for tilted hoppers

We measure the flux of spherical glass beads through a hole as a systematic function of both tilt angle and hole diameter, for two different size beads. The discharge increases with hole diameter in accord with the Beverloo relation for both horizontal and vertical holes, but in the latter case with a larger small-hole cutoff. For large holes the flux decreases linearly in cosine of the tilt angle, vanishing smoothly somewhat below the angle of repose. For small holes it vanishes abruptly at a smaller angle. The conditions for zero flux are discussed in the context of a {\it clogging phase diagram} of flow state vs tilt angle and ratio of hole to grain size

Open-label, cluster randomised controlled trial and economic evaluation of a brief letter from a GP on unscheduled medical contacts associated with the start of the school year: the PLEASANT trial

BACKGROUND: Asthma is seasonal with peaks in exacerbation rates in school-age children associated with the return to school following the summer vacation. A drop in prescription collection in August is associated with an increase in the number of unscheduled contacts after the school return. OBJECTIVE: To assess whether a public health intervention delivered in general practice reduced unscheduled medical contacts in children with asthma. DESIGN: Cluster randomised trial with trial-based economic evaluation. Randomisation was at general practice level, stratified by size of practice. The intervention group received a letter from their general practitioner (GP) in late July outlining the importance of (re)taking asthma medication before the return to school. The control group was usual care. SETTING: General practices in England and Wales. PARTICIPANTS: 12 179 school-age children in 142 general practices (70 randomised to intervention). MAIN OUTCOME: Proportion of children aged 5-16 years who had an unscheduled contact in September. Secondary endpoints included collection of prescriptions in August and medical contacts over 12 months (September-August). Economic endpoints were quality-adjusted life-years gained and health service costs. RESULTS: There was no evidence of effect (OR 1.09; 95% CI 0.96 to 1.25 against treatment) on unscheduled contacts in September. The intervention increased the proportion of children collecting a prescription in August by 4% (OR 1.43; 95% CI 1.24 to 1.64). The intervention also reduced the total number of medical contacts between September-August by 5% (incidence ratio 0.95; 95% CI 0.91 to 0.99).The mean reduction in medical contacts informed the health economics analyses. The intervention was estimated to save £36.07 per patient, with a high probability (96.3%) of being cost-saving. CONCLUSIONS: The intervention succeeded in increasing children collecting prescriptions. It did not reduce unscheduled care in September (the primary outcome), but in the year following the intervention, it reduced the total number of medical contacts. TRIAL REGISTRATION NUMBER: ISRCTN03000938; Results

Estimating cost-effectiveness using alternative preference-based scores and within-trial methods : exploring the dynamics of the Quality-Adjusted Life-Year using the EQ-5D 5-level version and Recovering Quality of Life Utility Index

Objectives This study aimed to explore quality-adjusted life-year (QALY) and subsequent cost-effectiveness estimates based on the more physical health–focused EQ-5D 5-level version (EQ-5D-5L) value set for England or cross-walked EQ-5D 3-level version UK value set scores or more mental health recovery-focused Recovering Quality of Life Utility Index (ReQoL-UI), when using alternative within-trial statistical methods. We describe possible reasons for the different QALY estimates based on the interaction between item scores, health state profiles, preference-based scores, and mathematical and statistical methods chosen. Methods QALYs are calculated over 8 weeks from a case study 2:1 (intervention:control) randomized controlled trial in patients with anxiety or depression. Complete case and with missing cases imputed using multiple-imputation analyses are conducted, using unadjusted and regression baseline-adjusted QALYs. Cost-effectiveness is judged using incremental cost-effectiveness ratios and acceptability curves. We use previously established psychometric results to reflect on estimated QALYs. Results A total of 361 people (241:120) were randomized. EQ-5D-5L crosswalk produced higher incremental QALYs than the value set for England or ReQoL-UI, which produced similar unadjusted QALYs, but contrasting baseline-adjusted QALYs. Probability of cost-effectiveness <£30 000 per QALY ranged from 6% (complete case ReQoL-UI baseline-adjusted QALYs) to 64.3% (multiple-imputation EQ-5D-5L crosswalk unadjusted QALYs). The control arm improved more on average than the intervention arm on the ReQoL-UI, a result not mirrored on the EQ-5D-5L nor condition-specific (Patient-Health Questionnaire-9, depression; Generalized Anxiety Disorder-7, anxiety) measures. Conclusions ReQoL-UI produced contradictory cost-effectiveness results relative to the EQ-5D-5L. The EQ-5D-5L’s better responsiveness and “anxiety/depression” and “usual activities” items drove the incremental QALY results. The ReQoL-UI’s single physical health item and “personal recovery” construct may have influenced its lower 8-week incremental QALY estimates in this patient sample

Can forest management based on natural disturbances maintain ecological resilience?

Given the increasingly global stresses on forests, many ecologists argue that managers must maintain ecological resilience: the capacity of ecosystems to absorb disturbances without undergoing fundamental change. In this review we ask: Can the emerging paradigm of natural-disturbance-based management (NDBM) maintain ecological resilience in managed forests? Applying resilience theory requires careful articulation of the ecosystem state under consideration, the disturbances and stresses that affect the persistence of possible alternative states, and the spatial and temporal scales of management relevance. Implementing NDBM while maintaining resilience means recognizing that (i) biodiversity is important for long-term ecosystem persistence, (ii) natural disturbances play a critical role as a generator of structural and compositional heterogeneity at multiple scales, and (iii) traditional management tends to produce forests more homogeneous than those disturbed naturally and increases the likelihood of unexpected catastrophic change by constraining variation of key environmental processes. NDBM may maintain resilience if silvicultural strategies retain the structures and processes that perpetuate desired states while reducing those that enhance resilience of undesirable states. Such strategies require an understanding of harvesting impacts on slow ecosystem processes, such as seed-bank or nutrient dynamics, which in the long term can lead to ecological surprises by altering the forest's capacity to reorganize after disturbance