Does the National Institute for Health and Clinical Excellence take account of factors such as uncertainty and equity as well as incremental cost-effectiveness in commissioning health care services? A binary choice experiment

Background: NICE is an independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in England and Wales. One of NICE’s main roles is to produce national guidance on the use of health technologies within the NHS. Despite the Institute’s recent efforts to clarify the way in which its Appraisal Committees reach their recommendations concerning the use of health technologies, there remains ambiguity about how cost-effectiveness evidence is interpreted alongside other considerations such as the degree of clinical need within the patient population, and the degree of uncertainty surrounding cost-effectiveness estimates. Objective: To explore whether the NICE takes account of factors such as uncertainty and equity as well as incremental cost-effectiveness in commissioning health care services. Methods: A binary choice experiment was undertaken using NICE’s three Appraisal Committees. The experiment included five attributes: (1) Incremental cost-effectiveness (2) Degree of economic uncertainty (3) Age of the target population (4) Baseline health-related quality of life (5) Availability of other therapies A choice questionnaire detailing 18 scenarios was administered to NICE’s Appraisal Committees. For each scenario, respondents were asked to indicate whether they would recommend the intervention under consideration or not. The stated preference data obtained from respondents were analysed using a random effects logit regression model. Results: A response rate of 46% was obtained from the Appraisal Committees. The regression model suggests that increases in cost-effectiveness, economic uncertainty, and the availability of other therapies are associated with statistically significant reductions in the odds of adoption (p<0.05). The transition from a very low to a comparatively high level of health-related quality of life is also associated with a statistically significant reduction in the odds of a positive recommendation. Smaller changes in health-related quality of life, and the age of the target population are not associated with a statistically significant reduction in the odds of a positive recommendation. Analysis of revealed preference data indicates that the model is capable of distinguishing between those technologies which the Appraisal Committees would be highly likely to recommend, and those technologies which appear to be less attractive, although further external validation is warranted. Conclusion: The modelling suggests that cost-effectiveness, uncertainty and certain equity concerns influence the NICE Appraisal Committees’ recommendations on the use of health technologies. The modelling results appear to support Rawlins and Culyer’s notion of a probabilistic cost-effectiveness threshold approach; the "mythical" £30,000 per QALY gained threshold assumed within the literature is not supported by this stated preference modelling analysis

Does the National Institute for Health and Clinical Excellence take account of factors such as uncertainty and equity as well as incremental cost-effectiveness in commissioning health care services? A binary choice experiment

Background NICE is an independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in England and Wales. One of NICE’s main roles is to produce national guidance on the use of health technologies within the NHS. Despite the Institute’s recent efforts to clarify the way in which its Appraisal Committees reach their recommendations concerning the use of health technologies, there remains ambiguity about how cost-effectiveness evidence is interpreted alongside other considerations such as the degree of clinical need within the patient population, and the degree of uncertainty surrounding cost-effectiveness estimates. Objective To explore whether the NICE takes account of factors such as uncertainty and equity as well as incremental cost-effectiveness in commissioning health care services. Methods A binary choice experiment was undertaken using NICE’s three Appraisal Committees. The experiment included five attributes: (1) Incremental cost-effectiveness (2) Degree of economic uncertainty (3) Age of the target population (4) Baseline health-related quality of life (5) Availability of other therapies A choice questionnaire detailing 18 scenarios was administered to NICE’s Appraisal Committees. For each scenario, respondents were asked to indicate whether they would recommend the intervention under consideration or not. The stated preference data obtained from respondents were analysed using a random effects logit regression model. Results A response rate of 46% was obtained from the Appraisal Committees. The regression model suggests that increases in cost-effectiveness, economic uncertainty, and the availability of other therapies are associated with statistically significant reductions in the odds of adoption (puncertainty; equity; cost-effectiveness; public health

Determination of the Kobayashi-Maskawa-Cabibbo matrix element V_{us} under various flavor-symmetry-breaking models in hyperon semileptonic decays

We study the success to describe hyperon semileptonic decays of four models that incorporate second-order SU(3) symmetry breaking corrections. The criteria to assess their success is by determining V_{us} in each of the three relevant hyperon semileptonic decays and comparing the values obtained with one another and also with the one that comes from K_{l3} decays. A strong dependence on the particular symmetry breaking model is observed. Values of V_{us} which do not agree with the one of K_{l3} are generally obtained. However, in the context of chiral perturbation theory, only the model whose corrections are O(m_s) and O(m_s^{3/2}) is successful. Using its predictions for the f_1 form factors one can quote a value of V_{us} from this model, namely, V_{us}=0.2176\pm 0.0026, which is in excellent agreement with the K_{l3} one.Comment: Final versio

‘Ethnic group’, the state and the politics of representation

The assertion, even if only by implication, that ‘ethnic group’ categories represent ‘real’ tangible entities, indeed identities, is commonplace not only in the realms of political and policy discourse but also amongst contemporary social scientists. This paper, following Brubaker (2002), questions this position in a number of key respects: of these three issues will dominate the discussion that follows. First, there is an interrogation of the proposition that those to whom the categories/labels refer constitute sociologically meaningful ‘groups’ as distinct from (mere) human collectivities. Secondly, there is the question of how these categories emerge, i.e. exactly what series of events, negotiations and contestations lie behind their construction and social acceptance. Thirdly, and as a corollary to the latter point, we explore the process of reification that leads to these categories being seen to represent ‘real things in the world’ (ibid.)

A return to strong radio flaring by Circinus X-1 observed with the Karoo Array Telescope test array KAT-7

Circinus X-1 is a bright and highly variable X-ray binary which displays strong and rapid evolution in all wavebands. Radio flaring, associated with the production of a relativistic jet, occurs periodically on a ~17-day timescale. A longer-term envelope modulates the peak radio fluxes in flares, ranging from peaks in excess of a Jansky in the 1970s to an historic low of milliJanskys during the years 1994 to 2007. Here we report first observations of this source with the MeerKAT test array, KAT-7, part of the pathfinder development for the African dish component of the Square Kilometre Array (SKA), demonstrating successful scientific operation for variable and transient sources with the test array. The KAT-7 observations at 1.9 GHz during the period 13 December 2011 to 16 January 2012 reveal in temporal detail the return to the Jansky-level events observed in the 1970s. We compare these data to contemporaneous single-dish measurements at 4.8 and 8.5 GHz with the HartRAO 26-m telescope and X-ray monitoring from MAXI. We discuss whether the overall modulation and recent dramatic brightening is likely to be due to an increase in the power of the jet due to changes in accretion rate or changing Doppler boosting associated with a varying angle to the line of sight.Comment: 7 pages, 5 figures, accepted for publication in MNRAS 14 May 201

Increased plasma viscosity as a reason for inappropriate erythropoietin formation

The aim of this study was to examine whether altered plasma viscosity could contribute to the inappropriately low production rate of erythropoietin (EPO) observed in patients suffering from hypergammaglobulinemias associated with multiple myeloma or Waldenström's disease. We found that the EPO formation in response to anemia in these patients was inversely related to plasma viscosity. A similar inverse relationship between plasma viscosity and EPO production was seen in rats in which EPO formation had been stimulated by exchange transfusion and the plasma viscosity of which was thereby altered by using exchange solutions of different composition to alter plasma viscosity and thus whole blood viscosity independently from hematocrit. Raising the gammaglobulin concentration to approximately 40 mg/ml plasma in the rats almost totally blunted the rise in serum EPO levels despite a fall of the hematocrit to 20%. Determination of renal EPO mRNA levels by RNase protection revealed that the reductions in serum EPO levels at higher plasma viscosities were paralleled by reductions in renal EPO mRNA levels. Taken together, our findings suggest that plasma viscosity may be a significant inhibitory modulator of anemia-induced EPO formation. The increased plasma viscosity in patients with hypergammaglobulinemias may therefore contribute to the inappropriate EPO production, which is a major reason for the anemia developing in these patients

Drivers of intrapopulation variation in resource use in a generalist predator, the macaroni penguin

Intrapopulation variation in resource use occurs in many populations of generalist predators with important community and evolutionary implications. One of the hypothesised mechanisms for such widespread variation is ecological opportunity, i.e. resource availability determined by intrinsic constraints and extrinsic conditions. We combined tracking data and stable isotope analysis to examine how breeding constraints and prey conditions influenced intrapopulation variation in resource use among macaroni penguins Eudyptes chrysolophus. Isotopic variation was also examined as a function of breeding success, individual traits and individual specialisation. Variation in isotope ratios was greatest across multiple tissue types when birds were able to undertake mid-range foraging trips (i.e. during incubation and pre-moult). This variation was highly consistent between years that spanned a 3-fold difference in local krill Euphausia superba density and was also highly consistent at the individual level between 2 years that had similar krill densities. However, by comparing our results with previous work on the same population, it appeared that a decrease in local prey availability can increase intrapopulation variation in resource use during periods with more restricted foraging ranges (i.e. during brood-guard and crèche). This study highlights the importance of considering ecological interactions that operate on multiple spatio-temporal scales when examining the drivers of resource use in populations of generalist predators

Peaks in the Hartle-Hawking Wave Function from Sums over Topologies

Recent developments in ``Einstein Dehn filling'' allow the construction of infinitely many Einstein manifolds that have different topologies but are geometrically close to each other. Using these results, we show that for many spatial topologies, the Hartle-Hawking wave function for a spacetime with a negative cosmological constant develops sharp peaks at certain calculable geometries. The peaks we find are all centered on spatial metrics of constant negative curvature, suggesting a new mechanism for obtaining local homogeneity in quantum cosmology.Comment: 16 pages,LaTeX, no figures; v2: some changes coming from revision of a math reference: wave function peaks sharp but not infinite; v3: added paragraph in intro on interpretation of wave functio

Tackling ageing continence through theory, tools & technology (TACT3)

This is the author's accepted manuscript. The final published article is available from the link below. Copyright @ 2012 Common Ground.After dementia, nothing is more feared by older people than the loss of continence. It is often the reason many people enter care facilities and can contribute to the breakdown of caring relationships. This paper reports on a three-year research project funded by the UK New Dynamics of Aging programme, which has explored three key issues in the predicament of maintaining continence from the “user’s” perspective. Firstly, understanding how continence services operated by the UK National Health Service can be improved to offer cost effective benefits that encourage people to report this sometimes embarrassing condition with confidence. Secondly, working directly with the US Simon Foundation, the project has developed user-requested, assistive devices that target the most embarrassing aspects of the condition, namely issues of personal odor control and urine leakage from continence pads. Lastly, understanding the challenges of managing continence in daily living outside of the home, with particular reference to accessing publicly accessible toilet facilities. The paper will highlight the research that has provided the basis for innovative design solutions.ESRC, EPSRC, BBSRC, MRC, and AHRC