Assessment of the learning curve in health technologies: a systematic review

Objective: We reviewed and appraised the methods by which the issue of the learning curve has been addressed during health technology assessment in the past. Method: We performed a systematic review of papers in clinical databases (BIOSIS, CINAHL, Cochrane Library, EMBASE, HealthSTAR, MEDLINE, Science Citation Index, and Social Science Citation Index) using the search term "learning curve:" Results: The clinical search retrieved 4,571 abstracts for assessment, of which 559 (12%) published articles were eligible for review. Of these, 272 were judged to have formally assessed a learning curve. The procedures assessed were minimal access (51%), other surgical (41%), and diagnostic (8%). The majority of the studies were case series (95%). Some 47% of studies addressed only individual operator performance and 52% addressed institutional performance. The data were collected prospectively in 40%, retrospectively in 26%, and the method was unclear for 31%. The statistical methods used were simple graphs (44%), splitting the data chronologically and performing a t test or chi-squared test (60%), curve fitting (12%), and other model fitting (5%). Conclusions: Learning curves are rarely considered formally in health technology assessment. Where they are, the reporting of the studies and the statistical methods used are weak. As a minimum, reporting of learning should include the number and experience of the operators and a detailed description of data collection. Improved statistical methods would enhance the assessment of health technologies that require learning

Assessing the learning curve effect in health technologies: Lessons from the non-clinical literature

Introduction: Many health technologies exhibit some form of learning effect, and this represents a barrier to rigorous assessment. It has been shown that the statistical methods used are relatively crude. Methods to describe learning curves in fields outside medicine, for example, psychology and engineering, may be better. Methods: To systematically search non–health technology assessment literature (for example, PsycLit and Econlit databases) to identify novel statistical techniques applied to learning curves. Results: The search retrieved 9,431 abstracts for assessment, of which 18 used a statistical technique for analyzing learning effects that had not previously been identified in the clinical literature. The newly identified methods were combined with those previously used in health technology assessment, and categorized into four groups of increasing complexity: a) exploratory data analysis; b) simple data analysis; c) complex data analysis; and d) generic methods. All the complex structured data techniques for analyzing learning effects were identified in the nonclinical literature, and these emphasized the importance of estimating intra- and interindividual learning effects. Conclusion: A good dividend of more sophisticated methods was obtained by searching in nonclinical fields. These methods now require formal testing on health technology data sets

Medical Services Premimum Task Force: Tax Reform Proposals for the Province of British Columbia

In the September 2017 B.C. Budget Update, the government announced that MSP premiums would be eliminated within four years, with advice from a task force of experts on how best to replace the foregone MSP premium revenue. The MSP Task Force was formed in November 2017 and asked to report by March 31, 2018. The Terms of Reference1 for the Task Force required us to apply the principles of fairness, efficiency, business competitiveness, simplicity, revenue stability, and progressivity in determining the best way to replace MSP premium revenues. On February 1, 2018 we provided the Minister with our Interim Report that described our process and what we had heard so far. We conducted a thorough review of the B.C. tax system and met with or received input from 70 individuals and 28 stakeholder groups. The most common theme in the input was that the revenue should be replaced by a combination of an increase to personal income tax and a payroll tax. Other suggestions included taxes on unhealthy activities, corporate tax changes, broadening the Provincial Sales Tax (PST) base, and changing the Home Owner Grant to an income-tested program. Our Interim Report provided the following initial advice to the Minister: }} Eliminate premiums and start collecting the replacement revenues all at once without phase-in; }} Provide reasonable notice to allow employees and employers to prepare for the change; and, }} Use a combination of measures to mitigate the negative impacts of each individual measure. In Budget 2018, delivered on February 20, 2018, the Minister announced that MSP premiums would be eliminated effective January 2020, with foregone revenue offset by the Employer Health Tax, a payroll tax. The budget document also indicated that the Task Force should continue its work and make recommendations to improve the progressivity, fairness, and competitiveness of the tax system. We have built upon some of the ideas we were working on to raise revenue and some observations we made while reviewing the tax system, but our proposals are now generally intended to be revenue-neutral rather than ways to raise revenues

Anisotropy from SKS splitting across the Pacific-North America plate boundary offshore southern California

SKS arrivals from ocean bottom seismometer (OBS) data from an offshore southern California deployment are analysed for shear wave splitting. The project involved 34 OBSs deployed for 12 months in a region extending up to 500 km west of the coastline into the oceanic Pacific plate. The measurement process consisted of removing the effects of anisotropy using a range of values for splitting fast directions and delay times to minimize energy along the transverse seismometer axis. Computed splitting parameters are unexpectedly similar to onland parameters, exhibiting WSW–ENE fast polarization directions and delays between 0.8 and 1.8 s, even for oceanic plate sites. This is the first SKS splitting study to extend across the entire boundary between the North America and Pacific plates, into the oceanic part of the Pacific plate. The splitting results show that the fast direction of anisotropy on the Pacific plate does not align with absolute plate motion (APM), and they extend the trend of anisotropy in southern California an additional 500 km west, well onto the oceanic Pacific plate. We model the finite strain and anisotropy within the asthenosphere associated with density–buoyancy driven mantle flow and the effects of APM. In the absence of plate motion effects, such buoyancy driven mantle flow would be NE-directed beneath the Pacific plate observations. The best-fit patterns of mantle flow are inferred from the tomography-based models that show primary influences from foundering higher-density zones associated with the history of subduction beneath North America. The new offshore SKS measurements, when combined with measurements onshore within the plate boundary zone, indicate that dramatic lateral variations in density-driven upper-mantle flow are required from offshore California into the plate boundary zone in California and western Basin and Range

Retooling National TB Control Programmes (NTPs) with New Diagnostics: The NTP Perspective

Background: A delay is evident between the development of new policies on TB diagnostics and their implementation at country level. The Stop TB Partnership would benefit from information from national TB program (NTP) managers on progress towards implementation of new recommendations as well as the opportunities and challenges encountered in the process. Methods and Findings: To solicit information on the introduction of new TB diagnostics at country level, questionnaires were sent out to NTP managers of high-burden TB countries and a subset of managers was interviewed. The results indicate that about 50 % of high-burden TB countries are using the TB diagnostic tools newly recommended by the World Health Organization (WHO). Most NTP managers reported that new diagnostics would only be implemented when officially endorsed by the WHO. All countries have plans to adopt newly endorsed diagnostics at reference laboratory level, while approaches to optimize smear microscopy at lower levels of the health service are given less attention. NTP managers reported diverse challenges to the implementation of new diagnostics. Conclusions: More information on the obstacles and advantages of introducing new diagnostic tools should be provided to NTP managers to ensure the rational adoption of new diagnostics. A single recommendation covering the introduction of a package of diagnostic tools might be preferable to NTP managers and facilitate implementation in high-burden TB countries

Vitamins and Perinatal Outcomes Among HIV-Negative Women in Tanzania.

Prematurity and low birth weight are associated with high perinatal and infant mortality, especially in developing countries. Maternal micronutrient deficiencies may contribute to these adverse outcomes. In a double-blind trial in Dar es Salaam, Tanzania, we randomly assigned 8468 pregnant women (gestational age of fetus, 12 to 27 weeks) who were negative for human immunodeficiency virus infection to receive daily multivitamins (including multiples of the recommended dietary allowance) or placebo. All the women received prenatal supplemental iron and folic acid. The primary outcomes were low birth weight (<2500 g), prematurity, and fetal death. The incidence of low birth weight was 7.8% among the infants in the multivitamin group and 9.4% among those in the placebo group (relative risk, 0.82; 95% confidence interval [CI], 0.70 to 0.95; P=0.01). The mean difference in birth weight between the groups was modest (67 g, P<0.001). The rates of prematurity were 16.9% in the multivitamin group and 16.7% in the placebo group (relative risk, 1.01; 95% CI, 0.91 to 1.11; P=0.87), and the rates of fetal death were 4.3% and 5.0%, respectively (relative risk, 0.87; 95% CI, 0.72 to 1.05; P=0.15). Supplementation reduced both the risk of a birth size that was small for gestational age (<10th percentile; 10.7% in the multivitamin group vs. 13.6% in the placebo group; relative risk, 0.77; 95% CI, 0.68 to 0.87; P<0.001) and the risk of maternal anemia (hemoglobin level, <11 g per deciliter; relative risk, 0.88; 95% CI, 0.80 to 0.97; P=0.01), although the difference in the mean hemoglobin levels between the groups was small (0.2 g per deciliter, P<0.001). Multivitamin supplementation reduced the incidence of low birth weight and small-for-gestational-age births but had no significant effects on prematurity or fetal death. Multivitamins should be considered for all pregnant women in developing countries. (ClinicalTrials.gov number, NCT00197548 [ClinicalTrials.gov].)

A Catalog of Transient X-ray Sources in M31

From October 1999 to August 2002, 45 transient X-ray sources were detected in M31 by Chandra and XMM-Newton. We have performed spectral analysis of all XMM-Newton and Chandra ACIS detections of these sources, as well as flux measurements of Chandra HRC detections. The result is absorption-corrected X-ray lightcurves for these sources covering this 2.8 year period, along with spectral parameters for several epochs of the outbursts of most of the transient sources. We supply a catalog of the locations, outburst dates, peak observed luminosities, decay time estimates, and spectral properties of the transient sources, and we discuss similarities with Galactic X-ray novae. Duty cycle estimates are possible for 8 of the transients and range from 40% to 2%; upper limits to the duty cycles are estimated for an additional 15 transients and cover a similar range. We find 5 transients which have rapid decay times and may be ultra-compact X-ray binaries. Spectra of three of the transients suggest they may be faint Galactic foreground sources. If even one is a foreground source, this suggests a surface density of faint transient X-ray sources of >~1 deg$^{-2}$.Comment: 63 pages, 22 figures, 3 tables, accepted for publication in Ap

Foraging and habitat specialization by female leopards (Panthera pardus) in the Waterberg Mountains of South Africa

Carnivores that persist outside of protected areas are often deemed to have highly adaptable and generalist foraging strategies. Using data from three GPS-collared female leopards (Panthera pardus) and over an eight-month period, we attempted to establish whether leopards in a mountainous landscape display preferential behaviour (i.e. specialist) or not (i.e. generalist).We investigated whether female leopards used habitats in accordance with availability for both hunting and regular activities, and whether female leopards demonstrated preference for a particular prey species. Finally, we assessed tree caching behaviour and discuss leopard spatial dynamics in the context of superior competitors, such as lions (Panthera leo). Female leopards demonstrated selection for certain prey species. Mixed closed woodland (greatest vegetation density; lowest prey density) and tall open woodland (greatest vegetation biomass; high prey density) were preferred over other habitats. Female leopards on Welgevonden cached significantly larger prey species in trees. Our results suggest that female leopards in this landscape are selecting habitats – enabling the exploitation of certain ecological features – that balance energy expenditure against the likelihood of capturing prey in an attempt to maximize efficiency, whilst reducing inter-specific competition.We suggest that female leopards are limited in their foraging ability as a result of interference competition by superior species like lions, which in turn, affects their choice of prey. These findings highlight the potential importance of numerous ecological, spatio-temporal, and anthropogenic factors that influence leopard behaviour, and therefore have significant implications for leopard persistence and conservation.The Wilson Foundation and the Centre for Wildlife Management. L.H.S. was supported by a NRF grant (No. 74819).http://www.sawma.co.za/am201