‘Test Driving’ a Financing Instrument for Climate Adaptation: Analyzing Institutional Dilemmas using Simulation Gaming

Urban physical public infrastructure is a frontline defense mechanism to manage and mitigate climate-related impacts. Market instruments are often cited as possible means to spread risk and reduce financial burdens on the public sector. The authors argue that existing research tends to focus on the technical issues of instruments and neglects considering institutional dynamics that may enable or constrain local market-based financing mechanisms. In this article, three core dilemmas (values uncertainty, planning horizon, and indirect benefits) are used to analyze the responses of practitioners to a possible financing instrument. The findings indicate that the practitioner’s responses to tax increment financing were largely shaped by the adaptation dilemmas and not the characteristics of the instrument per se. By mapping the dilemmas onto whether they would recommend it, participants imposed a financial barrier on climate adaptation investments. The authors conclude that a key imperative in the design of policy instruments is to pay attention to the congruency of informal institutions at the ‘street level’ in order to be in-step with the current sociopolitical conditions. The findings also point to four key attributes that a local market-based instrument would need to be aligned and responsive to the Dutch planning and development context

Demographic, clinical and antibody characteristics of patients with digital ulcers in systemic sclerosis: data from the DUO Registry

OBJECTIVES: The Digital Ulcers Outcome (DUO) Registry was designed to describe the clinical and antibody characteristics, disease course and outcomes of patients with digital ulcers associated with systemic sclerosis (SSc). METHODS: The DUO Registry is a European, prospective, multicentre, observational, registry of SSc patients with ongoing digital ulcer disease, irrespective of treatment regimen. Data collected included demographics, SSc duration, SSc subset, internal organ manifestations, autoantibodies, previous and ongoing interventions and complications related to digital ulcers. RESULTS: Up to 19 November 2010 a total of 2439 patients had enrolled into the registry. Most were classified as either limited cutaneous SSc (lcSSc; 52.2%) or diffuse cutaneous SSc (dcSSc; 36.9%). Digital ulcers developed earlier in patients with dcSSc compared with lcSSc. Almost all patients (95.7%) tested positive for antinuclear antibodies, 45.2% for anti-scleroderma-70 and 43.6% for anticentromere antibodies (ACA). The first digital ulcer in the anti-scleroderma-70-positive patient cohort occurred approximately 5 years earlier than the ACA-positive patient group. CONCLUSIONS: This study provides data from a large cohort of SSc patients with a history of digital ulcers. The early occurrence and high frequency of digital ulcer complications are especially seen in patients with dcSSc and/or anti-scleroderma-70 antibodies

Kwaliteitsnormen Nederlandse Vereniging voor Reumatologie

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Determinants of direct costs in Dutch rheumatoid arthritis patients

Objectives: To estimate annual direct costs in four distinct disease duration groups (0 to ⩽2, 2 to ⩽6, 6 to ⩽10, and >10 years) of patients with rheumatoid arthritis (RA), to determine predictors of high costs and to describe characteristics of patients with high and with low costs. Methods: A questionnaire assessing RA related care and resource utilisation rates and costs was completed by 615 RA patients. Predictive variables for incurred costs, as observed during the first year after disease onset, were determined in a subgroup of patients (n = 347). Results: Mean (median) annual direct costs for the four groups with increasing disease duration were respectively: €5235 (2923), €3930 (1968), €4664 (1952), and €8243 (3778), (p < 0.05). During the first 2 years of the disease total direct costs comprised mainly of consultations with heatlhcare workers (28%). After 10 years, devices and adaptations were the main contributors (40%) to total costs. Positive rheumatoid factor results at the time of diagnosis and deterioration of functional disability in the first year of disease were predictors of high costs later on in the course of the disease. Conclusion: Annual direct costs among patients with a disease duration of less than 2 years tend to be lower among patients with a disease duration of between 2 and 10 years than among patients with a disease duration of more than 10 years. In addition, the proportional distribution of different cost categories to total costs increases with with increasing disease duration