Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England

Background - Priority setting is necessary where competing demands exceed the finite resources available. The aim of the study was to develop and test a prioritization framework based upon programme budgeting and marginal analysis (PBMA) as a tool to assist National Health Service (NHS) commissioners in their management of resources for local NHS dental services. Methods - Twenty-seven stakeholders (5 dentists, 8 commissioners and 14 patients) participated in a case-study based in a former NHS commissioning organization in the north of England. Stakeholders modified local decision-making criteria and applied them to a number of different scenarios. Results - The majority of financial resources for NHS dental services in the commissioning organization studied were allocated to primary care dental practitioners’ contracts in perpetuity, potentially constraining commissioners’ abilities to shift resources. Compiling the programme budget was successful, but organizational flux and difficulties engaging local NHS commissioners significantly impacted upon the marginal analysis phase. Conclusions - NHS dental practitioners’ contracts resemble budget-silos which do not facilitate local resource reallocation. ‘Context-specific’ factors significantly challenged the successful implementation and impact of PBMA. A local PBMA champion embedded within commissioning organizations should be considered. Participants found visual depiction of the cost-value ratio helpful during their initial priority setting deliberations

Injury Alcohol-Attributable Fractions: Methodological Issues and Developments

Background: Alcohol-attributable fractions (AAFs) are routinely used to estimate the burden of injury resulting from alcohol. Recent methodological advances allow AAFs to be estimated using national survey data. However, this requires assuming that the drinking patterns are equivalent to those used by epidemiological studies estimating the relative risk of injury. This study explores the implications of this assumption and presents an improved method of estimating injury AAFs. Methods: Diary survey is used to describe individuals’ drinking occasions and estimate AAFs. Statistical methods and numerical integration are used to combine the evidence on the risk of injury when intoxicated with the diary data. Alternative assumptions are chosen to explore the implications of using national survey data. Results:Overall, an estimated 27% of road traffic accident (RTA) and 23% of non-RTA injuries in Britain are attributable to alcohol. AAF estimates for RTAs range from 54% to 2% and for non-RTAs from 36% to 8% in men aged 16-24 and women aged 55-64 respectively. Two potentially more realistic assumptions relating to the use of national survey data resulted in substantially lower AAF estimates for RTAs. Conclusion: Current methods of estimating injury AAFs using national survey data are flawed for some harms, particularly RTAs, where the data is not consistent with the epidemiological literature. Our findings indicate that the burden of injuries from RTAs in England has been previously overestimated. Further research into the prevalence of risky behaviours when intoxicated is required to refine these methods and produce more robust burden of injury estimates

Improvements in Circumpolar Southern Hemisphere Extratropical Atmospheric Circulation in CMIP6 Compared to CMIP5

One of the major globally relevant systematic biases in previous generations of climate models has been an equatorward bias in the latitude of the Southern Hemisphere (SH) mid‐latitude tropospheric eddy driven westerly jet. The far reaching implications of this for Southern Ocean heat and carbon uptake and Antarctic land and sea ice are key reasons why addressing this bias is a high priority. It is therefore of primary importance to evaluate the representation of the SH westerly jet in the latest generation of global climate and earth‐system models that comprise the Coupled Model Intercomparison Project Phase 6 (CMIP6). In this paper we assess the representation of major indices of SH extratropical atmospheric circulation in CMIP6 by comparison against both observations and the previous generation of CMIP5 models. Indices assessed are the latitude and speed of the westerly jet, variability of the Southern Annular Mode (SAM) and representation of the Amundsen Sea Low (ASL). These are calculated from the historical forcing simulations of both CMIP5 and CMIP6 for time periods matching available observational and reanalysis datasets. From the 39 CMIP6 models available at the time of writing there is an overall reduction in the equatorward bias of the annual mean westerly jet from 1.9° in CMIP5 to 0.4° in CMIP6 and from a seasonal perspective the reduction is clearest in austral spring and summer. This is accompanied by a halving of the bias of SAM decorrelation timescales compared to CMIP5. However, no such overall improvements are evident for the ASL

Summer CO2 evasion from streams and rivers in the Kolyma River basin, north-east Siberia

Inland water systems are generally supersaturated in carbon dioxide (CO2) and are increasingly recognized as playing an important role in the global carbon cycle. The Arctic may be particularly important in this respect, given the abundance of inland waters and carbon contained in Arctic soils; however, a lack of trace gas measurements from small streams in the Arctic currently limits this understanding.We investigated the spatial variability of CO2 evasion during the summer low-flow period from streams and rivers in the northern portion of the Kolyma River basin in north-eastern Siberia. To this end, partial pressure of carbon dioxide (pCO2) and gas exchange velocities (k) were measured at a diverse set of streams and rivers to calculate CO2 evasion fluxes. We combined these CO2 evasion estimates with satellite remote sensing and geographic information system techniques to calculate total areal CO2 emissions. Our results show that small streams are substantial sources of atmospheric CO2 owing to high pCO2 and k, despite being a small portion of total inland water surface area. In contrast, large rivers were generally near equilibrium with atmospheric CO2. Extrapolating our findings across the Panteleikha-Ambolikha sub-watersheds demonstrated that small streams play a major role in CO2 evasion, accounting for 86% of the total summer CO2 emissions from inland waters within these two sub-watersheds. Further expansion of these regional CO2 emission estimates across time and space will be critical to accurately quantify and understand the role of Arctic streams and rivers in the global carbon budget

Changes in European wind energy generation potential within a 1.5°C warmer world

Global climate model simulations from the "Half a degree Additional warming, Prognosis and Projected Impacts" (HAPPI) project were used to assess how wind power generation over Europe would change in a future world where global temperatures reach 1.5°C above pre-industrial levels. Comparing recent historical (2006-2015) and future 1.5°C forcing experiments highlights that the climate models demonstrate a northward shift in the Atlantic jet, leading to a significant (p<0.01) increase in surface winds over the UK and Northern Europe and a significant (p<0.05) reduction over Southern Europe. The northward shift of the jet is in agreement with other studies. We use a wind turbine power model to transform daily near-surface (10 m) wind speeds into daily wind power output, accounting for sub-daily variability, the height of the turbine, and power losses due to transmission and distribution of electricity. To reduce regional model biases we use bias-corrected 10 m wind speeds. We see an increase in power generation potential over much of Europe, with the greatest increase in load factor over the UK of around four percentage points. Increases in variability are seen over much of central and northern Europe with the largest seasonal change in summer. Focusing on the UK, we find that wind energy production during spring and autumn under 1.5°C forcing would become as productive as it is currently during the peak winter season. Similarly, summer winds would increase driving up wind generation to resemble levels currently seen in spring and autumn. We conclude that the potential for wind energy in Northern Europe may be greater than has been previously assumed, with likely increases even in a 1.5°C warmer world. While there is the potential for Southern Europe to see a reduction in their wind resource, these decreases are likely to be negligible

Resource Allocation in a National Dental Service Using Program Budgeting Marginal Analysis

Introduction: In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. Methods: The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. Results: The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. Discussion: The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. Knowledge Transfer Statement: This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems

Resource Allocation in a National Dental Service Using Program Budgeting Marginal Analysis

Introduction: In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. Methods: The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. Results: The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. Discussion: The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. Knowledge Transfer Statement: This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems

Cohesin mutations alter DNA damage repair and chromatin structure and create therapeutic vulnerabilities in MDS/AML

The cohesin complex plays an essential role in chromosome maintenance and transcriptional regulation. Recurrent somatic mutations in the cohesin complex are frequent genetic drivers in cancer including myelodysplatic syndromes (MDS) and acute myeloid leukemia (AML). Here, using genetic dependency screens of STAG2-mutant AML, we identified DNA damage repair and replication as genetic dependencies in cohesin-mutant cells. We demonstrated increased levels of DNA damage and sensitivity of cohesin-mutant cells to PARP inhibition. We developed a mouse model of MDS in which Stag2 mutations arise as clonal secondary lesions in the background of clonal hematopoiesis driven by Tet2 mutations, and demonstrated selective depletion of cohesin-mutant cells with PARP inhibition in vivo. Finally, we demonstrated a shift from STAG2- to STAG1-containing cohesin complexes in cohesin-mutant cells, which is associated with longer DNA loop extrusion, more intermixing of chromatin compartments, and increased interaction with PARP and RPA proteins. Our findings inform the biology and therapeutic opportunities for cohesin-mutant malignancies

SPIDER: Probing the Early Universe with a Suborbital Polarimeter

We evaluate the ability of SPIDER, a balloon-borne polarimeter, to detect a divergence-free polarization pattern ("B-modes") in the Cosmic Microwave Background (CMB). In the inflationary scenario, the amplitude of this signal is proportional to that of the primordial scalar perturbations through the tensor-to-scalar ratio r. We show that the expected level of systematic error in the SPIDER instrument is significantly below the amplitude of an interesting cosmological signal with r=0.03. We present a scanning strategy that enables us to minimize uncertainty in the reconstruction of the Stokes parameters used to characterize the CMB, while accessing a relatively wide range of angular scales. Evaluating the amplitude of the polarized Galactic emission in the SPIDER field, we conclude that the polarized emission from interstellar dust is as bright or brighter than the cosmological signal at all SPIDER frequencies (90 GHz, 150 GHz, and 280 GHz), a situation similar to that found in the "Southern Hole." We show that two ~20-day flights of the SPIDER instrument can constrain the amplitude of the B-mode signal to r<0.03 (99% CL) even when foreground contamination is taken into account. In the absence of foregrounds, the same limit can be reached after one 20-day flight.Comment: 29 pages, 8 figures, 4 tables; v2: matches published version, flight schedule updated, two typos fixed in Table 2, references and minor clarifications added, results unchange