Impact at Scale: Policy Innovation for Institutional Investment With Social and Environmental Benefit

Explores policy options to maximize impact investing opportunities for institutional investors and accelerate the development of impact investing practices and products. Presents case studies of and insights from investors and service providers

Site response analysis and microzonation of Anchorage, Alaska, USA, using strong-motion data from recent earthquakes

This thesis was previously held under moratorium from 5/11/21 to 5/05/22Anchorage, Alaska, is located in one of the most active tectonic settings in the world. The city and region were significantly impacted by the MW9.2 Great Alaska Earthquake in 1964, and they were recently shaken by a MW7.1 event in 2018. The city was developed in an area underlain by complex soil deposits of varied geological origins and stiffnesses, with the deposits’ thicknesses increasing east to west. Situated at the edge of the North American Plate, with the actively subducting Pacific Plate below, Anchorage is susceptible to both intraslab and interface earthquakes, along with crustal earthquakes. Strong-motion stations were installed across the city in an attempt to capture the variability in site response. Strong-motion recordings from 35 stations over the years of 2004 to 2019 were collected, processed, and prepared for analysis of that variability. The Generalized Inversion Technique (GIT) was used to calculate the Fourier spectral amplification at each strong-motion station and the variability of amplification at 1 Hz and 5 Hz were mapped for Anchorage. The 2018 MW7.1 strong-motion recordings were compared to the lower-magnitude events in the database to evaluate the differences at strong-motion stations related to linear and nonlinear site response. The horizontal to vertical spectral ratio (HVSR) was calculated for each strong-motion station and regional relationships between fpeak and the time-averaged shear wave velocity in the upper 30m (VS30) were developed. A contour map estimating seismic site class across Anchorage was developed using 70 VS30 estimates and measurements at other locations. A methodology is also developed using Fourier spectral amplification and Random Vibration Theory (RVT) to estimate engineering site response spectra at strong-motion stations. An approach to address nonlinear site response is applied to the methodology because the database is predominantly composed of linear site response recordings.Anchorage, Alaska, is located in one of the most active tectonic settings in the world. The city and region were significantly impacted by the MW9.2 Great Alaska Earthquake in 1964, and they were recently shaken by a MW7.1 event in 2018. The city was developed in an area underlain by complex soil deposits of varied geological origins and stiffnesses, with the deposits’ thicknesses increasing east to west. Situated at the edge of the North American Plate, with the actively subducting Pacific Plate below, Anchorage is susceptible to both intraslab and interface earthquakes, along with crustal earthquakes. Strong-motion stations were installed across the city in an attempt to capture the variability in site response. Strong-motion recordings from 35 stations over the years of 2004 to 2019 were collected, processed, and prepared for analysis of that variability. The Generalized Inversion Technique (GIT) was used to calculate the Fourier spectral amplification at each strong-motion station and the variability of amplification at 1 Hz and 5 Hz were mapped for Anchorage. The 2018 MW7.1 strong-motion recordings were compared to the lower-magnitude events in the database to evaluate the differences at strong-motion stations related to linear and nonlinear site response. The horizontal to vertical spectral ratio (HVSR) was calculated for each strong-motion station and regional relationships between fpeak and the time-averaged shear wave velocity in the upper 30m (VS30) were developed. A contour map estimating seismic site class across Anchorage was developed using 70 VS30 estimates and measurements at other locations. A methodology is also developed using Fourier spectral amplification and Random Vibration Theory (RVT) to estimate engineering site response spectra at strong-motion stations. An approach to address nonlinear site response is applied to the methodology because the database is predominantly composed of linear site response recordings

Diabetes Screening Through Community Pharmacies in England: A Cost-Effectiveness Study"

Community pharmacies are commonly used to screen for patients with diabetes. The aim of this paper is to estimate the cost per test and cost per appropriately referred patient from a pharmacy perspective using a one-year decision tree model. One-way sensitivity analysis was performed to estimate the effect of geographical location and patient self-referral rate. Data was used from 164 patients screened and located in an area with average social deprivation and largely white European inhabitants and 172 patients in an area with higher social deprivation (lower than average ability to access society’s resources) and a mixed ethnicity population in England. The diabetes screening consisted of initial risk assessment via questionnaire followed by HbA1c test for those identified as high risk. The cost per person screened was estimated as £28.65. The cost per appropriately referred patient with type 2 diabetes was estimated to range from £7638 to £11,297 in deprived mixed ethnicity and non-deprived areas respectively. This increased to £12,730 and £18,828, respectively, if only 60% of patients referred chose to inform their general practitioner (GP). The cost per test and identification rates through community pharmacies was similar to that reported through medical practices. Locating services in areas of suspected greater diabetes prevalence and increasing the proportion of patients who follow pharmacist advice to attend their medical practice improves cost-effectiveness

An evaluation of a multi-site community pharmacy based chronic obstructive pulmonary disease support service

Background Chronic obstructive pulmonary disease (COPD) is a progressive chronic condition which can be effectively managed by smoking cessation, optimising prescribed therapy and providing treatment to prevent chest infections from causing hospitalisation. The government agenda in the UK is for community pharmacists to become involved in chronic disease management and COPD is one area where they are ideally located to provide a comprehensive service. Objective To evaluate the effect of a community pharmacy based COPD service on patient outcomes. Method Patients in one UK location were recruited over a 3 month period to receive a community pharmacy based COPD support service consisting of signposting to or provision of smoking cessation service, therapy optimisation, and recommendation to obtain a rescue pack containing steroid and antibiotic to prevent hospitalisation as a result of chest infection. Data was collected over a six month period for all recruited patients. Appropriate clinical outcomes, patient reported medication adherence, quality of life and NHS resource utilisation were measured. Key findings 306 patients accessed the service and full data to enable comparison before and after was available for 137. Significant improvements in patient reported adherence, utilisation of rescue packs, quality of life and a reduction in routine GP visits were identified. The intervention cost was estimated to be off-set by reductions in the use of other NHS services (GP and A&E visits and hospital admissions). Conclusion Results suggest that the service improved patient medicine taking behaviours and that it was cost-effective

Community pharmacy type 2 diabetes risk assessment: demographics and risk results

Objectives: To determine the demographics and risk results of patients accessing a community pharmacy diabetes risk assessment service. Method: Participating patients underwent an assessment using a validated questionnaire to determine their 10-year risk of developing type 2 diabetes. Patients were given appropriate lifestyle advice or referred to their general practitioner if necessary. Key findings: In total, 21 302 risk assessments were performed. Nearly one-third (29%) of 3427 risk assessments analysed yielded a result of moderate or high chance of developing the condition. Conclusions: Community pharmacies can identify a significant number of patients at risk of developing type 2 diabetes in the next 10 years. Further follow-up work needs to be done to determine the cost-effectiveness of such a service and the consequences of receiving a risk assessment

Uranium Migration in Crystalline Rocks

The mechanisms controlling the migration of uranium in crystalline rocks such as granites or granodiorites are insufficiently well understood to arrive at a quantitatively defensible safety case for deep disposal of radioactive waste. To help further our knowledge of the relevant processes, a controlled column experiment was undertaken using a disc of metallic (depleted) uranium as a source and granodiorite samples from a former candidate disposal site for spent uranium fuel, Sievi in Finland, as the host medium. The experiment ran for approximately 500 days. This report summarises efforts made to simulate the uranium migration observed during the experiment. The model was developed from blind predictions to an inverse model that attempted to reproduce the measured effluent data. In the absence of independently derived kinetic data for uranium precipitation and dissolution it is difficult to arrive at a truly unique solution. Nevertheless, the exercise has been instructive in highlighting the principal areas of uncertainty and the pit falls that await those seeking to represent far more complex hydrogeochemical systems than that investigated here.JRC.F.7-Energy systems evaluatio

The pharmacy care plan service: Service evaluation and estimate of cost-effectiveness

Background: The UK Community Pharmacy Future group developed the Pharmacy Care Plan (PCP) service with a focus on patient activation, goal setting and therapy management.  Objective: To estimate the effectiveness and cost-effectiveness of the PCP service from a health services perspective.  Methods: Patients over 50 years of age prescribed one or more medicines including at least one for cardiovascular disease or diabetes were eligible. Medication review and person-centred consultation resulted in agreed health goals and actions towards achieving them. Clinical, process and cost-effectiveness data were collected at baseline and 12-months between February 2015 and June 2016. Mean differences are reported for clinical and process measures. Costs (NHS) and quality-adjusted life year scores were estimated and compared for 12 months pre- and post-baseline.  Results: Seven hundred patients attended the initial consultation and 54% had a complete set of data obtained. There was a significant improvement in patient activation score (mean difference 5.39; 95% CI 3.9 – 6.9; p<0.001), systolic (mean difference -2.90 mmHg ; 95% CI -4.7 - -1; p=0.002) and diastolic blood pressure (mean difference -1.81 mmHg; 95% CI -2.8 - -0.8; p<0.001), adherence (mean difference 0.26; 95% CI 0.1 – 0.4; p<0.001) and quality of life (mean difference 0.029; 95% CI 0.015 – 0.044; p<0.001). HDL cholesterol reduced significantly and QRisk2 scores increased significantly over the course of the 12 months. The mean incremental cost associated with the intervention was estimated to be £202.91 (95% CI 58.26 to £346.41) and the incremental QALY gain was 0.024 (95% CI 0.014 to 0.034), giving an incremental cost per QALY of £8,495.  Conclusions: Enrolment in the PCP service was generally associated with an improvement over 12 months in key clinical and process metrics. Results also suggest that the service would be cost-effective to the health system even when using worst case assumptions

Viral Infection: A Potent Barrier to Transplantation Tolerance

Transplantation of allogeneic organs has proven to be an effective therapeutic for a large variety of disease states, but the chronic immunosuppression that is required for organ allograft survival increases the risk for infection and neoplasia and has direct organ toxicity. The establishment of transplantation tolerance, which obviates the need for chronic immunosuppression, is the ultimate goal in the field of transplantation. Many experimental approaches have been developed in animal models that permit long-term allograft survival in the absence of chronic immunosuppression. These approaches function by inducing peripheral or central tolerance to the allograft. Emerging as some of the most promising approaches for the induction of tolerance are protocols based on costimulation blockade. However, as these protocols move into the clinic, there is recognition that little is known as to their safety and efficacy when confronted with environmental perturbants such as virus infection. In animal models, it has been reported that virus infection can prevent the induction of tolerance by costimulation blockade and, in at least one experimental protocol, can lead to significant morbidity and mortality. In this review, we discuss how viruses modulate the induction and maintenance of transplantation tolerance