Copayments for prescription medicines on a public health insurance scheme in Ireland

Purpose: We assessed the impact of the introduction of a €0.50 prescription copayment, and its increase to €1.50, on adherence to essential and less-essential medicines in a publicly insured population in Ireland. Methods: We used a pre-post longitudinal repeated measures design. We included new users of essential medicines: blood pressure lowering, lipid lowering and oral diabetic agents, thyroid hormone, anti-depressants, and less-essential medicines: non-steroidal anti-inflammatory drugs (NSAIDs), Proton Pump Inhibitors/H2 antagonists (PPIs/H2), and anxiolytics/hypnotics. The outcome was change in adherence, measured using Proportion of Days Covered. We used segmented regression with generalised estimating equations to allow for repeated measurements. Results: Sample sizes ranged from 7145 (thyroid hormone users) to 136111 (NSAID users). The €0.50 copayment was associated with reductions in adherence ranging from -2.1%[95% CI, -2.8 to -1.5] (thyroid hormone) to -8.3%[95% CI, -8.7 to -7.9] (anti-depressants) for essential medicines and reductions in adherence of -2%[95% CI, -2.3 to -1.7] (anxiolytics/hypnotics) to -9.5%[95% CI, -9.8 to -9.1] (PPIs/H2) for less-essential medicines. The €1.50 copayment generally resulted in smaller reductions in adherence to essential medicines. Anti-depressant medications were the exception with a decrease of -10.0% [95% CI, -10.4 to -9.6] after the copayment increase. Larger decreases in adherence were seen for most less-essential medicines; the largest was for PPIs/H2 at -13.5% [95% CI, -13.9 to -13.2] after the €1.50 copayment. Conclusion: Both copayments had a greater impact on adherence to less-essential medicines than essential medicines. The major exception was for anti-depressant medicines. Further research is required to explore heterogeneity across different socio-economic strata and to elicit the impact on clinical outcomes

Comparing two tools for ecosystem service assessments regarding water resources decisions

We present a comparison of two ecohydrologic models commonly used for planning land management to assess the production of hydrologic ecosystem services: the Soil and Water Assessment Tool (SWAT) and the Integrated Valuation of Ecosystem Services and Tradeoffs (InVEST) annual water yield model. We compare these two models at two distinct sites in the US: the Wildcat Creek Watershed in Indiana and the Upper Upatoi Creek Watershed in Georgia. The InVEST and SWAT models provide similar estimates of the spatial distribution of water yield in Wildcat Creek, but very different estimates of the spatial distribution of water yield in Upper Upatoi Creek. The InVEST model may do a poor job estimating the spatial distribution of water yield in the Upper Upatoi Creek Watershed because baseflow provides a significant portion of the site’s total water yield, which means that storage dynamics which are not modeled by InVEST may be important. We also compare the ability of these two models, as well as one newly developed set of ecosystem service indices, to deliver useful guidance for land management decisions focused on providing hydrologic ecosystem services in three particular decision contexts: environmental flow ecosystem services, ecosystem services for potable water supply, and ecosystem services for rainfed irrigation. We present a simple framework for selecting models or indices to evaluate hydrologic ecosystem services as a way to formalize where models deliver useful guidance

Time--delay autosynchronization of the spatio-temporal dynamics in resonant tunneling diodes

The double barrier resonant tunneling diode exhibits complex spatio-temporal patterns including low-dimensional chaos when operated in an active external circuit. We demonstrate how autosynchronization by time--delayed feedback control can be used to select and stabilize specific current density patterns in a noninvasive way. We compare the efficiency of different control schemes involving feedback in either local spatial or global degrees of freedom. The numerically obtained Floquet exponents are explained by analytical results from linear stability analysis.Comment: 10 pages, 16 figure

The Benefits and Harms of Transmitting Into Space

Deliberate and unintentional radio transmissions from Earth propagate into space. These transmissions could be detected by extraterrestrial watchers over interstellar distances. Here, we analyze the harms and benefits of deliberate and unintentional transmissions relevant to Earth and humanity. Comparing the magnitude of deliberate radio broadcasts intended for messaging to extraterrestrial intelligence (METI) with the background radio spectrum of Earth, we find that METI attempts to date have much lower detectability than emissions from current radio communication technologies on Earth. METI broadcasts are usually transient and several orders of magnitude less powerful than other terrestrial sources such as astronomical and military radars, which provide the strongest detectable signals. The benefits of radio communication on Earth likely outweigh the potential harms of detection by extraterrestrial watchers; however, the uncertainty regarding the outcome of contact with extraterrestrial beings creates difficulty in assessing whether or not to engage in long-term and large-scale METI.Comment: Published in Space Polic

Elvis’ Gospel music: Between the secular and the spiritual?

Do fans sanctify their heroes? In the past, I have argued that Elvis fandom is not a neo-religious practice but that attention to a modified version of Durkheim’s theory of religion can, nevertheless, help to explain it as a form of social interaction. I take that argument further here, first by revealing the ethical and analytical advantages of neo-Durkheimian theory, then by pitting this theory against three aspects of Elvis’ sincere engagement with gospel music. Elvis Presley won three Grammy awards for his gospel albums and was the musician who did most to bring the gospel quartet tradition to the mainstream. His eclectic personal ties to spirituality and religion have become a focus of debate within his fan culture. They offer a set of discursive resources through which to explain the emotional impact and social influence of his music. If star musicians are positioned as centres of attention, what happens when they use their privileged position in the spotlight to offer a “spiritual” message

The international generalisability of evidence for health policy: a cross country comparison of medication adherence following policy change

Copayments for prescriptions may increase morbidity and mortality via reductions in adherence to medications. Relevant data can inform policy to minimise such unintended effects. We explored the generalisability of evidence for copayments by comparing two international copayment polices, one in Massachusetts and one in Ireland, to assess whether effects on medication adherence were comparable. We used national prescription data for public health insurance programmes in Ireland and Medicaid data in the U.S. New users of oral anti-hypertensive, anti-hyperlipidaemic and diabetic drugs were included (total n = 14,259 in U.S. and n = 43,843 in Ireland). We examined changes in adherence in intervention and comparator groups in each setting using segmented linear regression with generalised estimating equations. In Massachusetts, a gradual decrease in adherence to anti-hypertensive medications of −1% per month following the policy occurred. In contrast, the response in Ireland was confined to a −2.9% decrease in adherence immediately following the policy, with no further decrease over the 8 month follow-up. Reductions in adherence to oral diabetes drugs were larger in the U.S. group in comparison to the Irish group. No difference in adherence changes between the two settings for anti-hyperlipidaemic drugs occurred. Evidence on cost-sharing for prescription medicines is not ‘one size fits all’. Time since policy implementation and structural differences between health systems may influence the differential impact of copayment policies in international settings

INDELible: A Flexible Simulator of Biological Sequence Evolution

Many methods exist for reconstructing phylogenies from molecular sequence data, but few phylogenies are known and can be used to check their efficacy. Simulation remains the most important approach to testing the accuracy and robustness of phylogenetic inference methods. However, current simulation programs are limited, especially concerning realistic models for simulating insertions and deletions. We implement a portable and flexible application, named INDELible, for generating nucleotide, amino acid and codon sequence data by simulating insertions and deletions (indels) as well as substitutions. Indels are simulated under several models of indel-length distribution. The program implements a rich repertoire of substitution models, including the general unrestricted model and nonstationary nonhomogeneous models of nucleotide substitution, mixture, and partition models that account for heterogeneity among sites, and codon models that allow the nonsynonymous/synonymous substitution rate ratio to vary among sites and branches. With its many unique features, INDELible should be useful for evaluating the performance of many inference methods, including those for multiple sequence alignment, phylogenetic tree inference, and ancestral sequence, or genome reconstruction

Payments for ecosystem services in the tropics: a closer look at effectiveness and equity

We undertake a review of academic literature that examines the effectiveness and equity-related performance of PES initiatives targeting biodiversity conservation in tropical and sub-tropical countries. We investigate the key features of such analyses as regards their analytical and methodological approach and we identify emerging lessons from PES practice, leading to a new suggested research agenda. Our results indicate that analyses of PES effectiveness have to date focused on either ecosystem service provision or habitat proxies, with only half of them making explicit assessment of additionality and most describing that payments have been beneficial for land cover and biodiversity. Studies evaluating the impact of PES on livelihoods suggest more negative outcomes, with an uneven treatment of the procedural and distributive considerations of scheme design and payment distribution, and a large heterogeneity of evaluative frameworks. We propose an agenda for future PES research based on the emerging interest in assessing environmental outcomes more rigorously and documenting social impacts in a more comparative and contextually situated form

Association between adherence to calcium-channel blocker and statin medications and likelihood of cardiovascular events among US managed care enrollees

<p>Abstract</p> <p>Background</p> <p>Prior studies have found that patients taking single-pill amlodipine/atorvastatin (SPAA) have greater likelihood of adherence at 6 months than those taking 2-pill calcium-channel blocker and statin combinations (CCB/statin). This study examines whether this adherence benefit results in fewer cardiovascular (CV) events.</p> <p>Methods</p> <p>A retrospective cohort study was conducted using administrative claims data from the IMS LifeLink: US Health Plan Claims database, identifying adults already taking CCB or statin (but not both) who had an index event of either initiating treatment with SPAA or adding CCB to statin (or vice versa) between April 1, 2004 to August 31, 2005. Inclusion criteria included age 18+ years, continuously enrolled for minimum of 6 months prior and 18 months following treatment initiation, >1 diagnosis of hypertension, and no prescription claims for SPAA or added CCB or statin for 6 months prior. Exclusion criteria included >1 claim with missing or invalid days supplied, age 65+ years and not enrolled in Medicare Advantage, or history of prior CV events, cancer diagnosis, or chronic renal failure. The primary outcome measure was the rate of CV events (myocardial infarction, heart failure, angina, other ischemic heart disease, stroke, peripheral vascular disease, or revascularization procedure) from 6 to 18 months following index date, analyzed at three levels: 1) all adherent vs. non-adherent patients, 2) SPAA vs. dual-pill patients (regardless of adherence level), and 3) adherent SPAA, adherent dual-pill, and non-adherent SPAA patients vs. non-adherent dual-pill patients.</p> <p>Results</p> <p>Of 1,537 SPAA patients, 56.5% were adherent at 6 months, compared with 21.4% of the 17,910 CCB/statin patients (p < 0.001). Logistic regression found SPAA patients more likely to be adherent (OR = 4.7, p < 0.001) than CCB/statin patients. In Cox proportional hazards models, being adherent to either regimen was associated with significantly lower risk of CV event (HR = 0.77, p = 0.003). A similar effect was seen for SPAA vs. CCB/statin patients (HR = 0.68, p = 0.02). In a combined model, the risk of CV events was significantly lower for adherent CCB/statin patients (HR = 0.79, p = 0.01) and adherent SPAA patients (HR = 0.61, p = 0.03) compared to non-adherent CCB/statin patients.</p> <p>Conclusions</p> <p>Patients receiving SPAA rather than a 2-pill CCB/statin regimen are more likely to be adherent. In turn, adherence to CCB and statin medications is associated with lower risk of CV events in primary prevention patients.</p