Improving the efficiency and relevance of health technology assessent: the role of iterative decision analytic modelling

Decision making in health care involves two sets of related decisions: those concerning appropriate service provision on the basis of existing information; and those concerned with whether to fund additional research to reduce the uncertainty relating to the decision. Information acquisition is not costless, and the allocation of funds to the enhancement of the decision makers’ information set, in a budgetconstrained health service, reduces the ‘pot’ of resources available for health service provision. Hence, a framework is necessary to unify these decisions and ensure that HTA is subject to the same evaluation of efficiency as service provision. A framework is presented which addresses these two sets of decisions through the employment of decision analytic models and Bayesian value of information analysis, early and regularly within the health technology assessment process. The model becomes the vehicle of health technology assessment, managing and directing future research effort on an iterative basis over the lifetime of the technology. This ensures consistency in decision making between service provision, research and development priorities and research methods. Fulfilling the aim of the National Health Service HTA programme, that research is “produced in the most economical way” using “cost effective research protocols”. The proposed framework is applied to the decision concerning the appropriate management of female patients with symptoms of urinary tract infection, which was the subject of a recent NHS HTA call for proposals. A probabilistic model is employed to fully characterise and assess the uncertainty surrounding the decision. The expected value of perfect information (EVPI) is then calculated for the full model, for each individual management strategy and for particular model parameters. Research effort can then be focused on those areas where the cost of uncertainty is high and where additional research is potentially cost-effective. The analysis can be used to identify the most appropriate research protocol and to concentrate research upon particular parameters where more precise estimates would be of most value.assessment

Urban life in early Islamic Morocco: new light from the excavations at Walīla (Roman Volubilis)

This article presents a research update from the INSAP-UCL excavations at the UNESCO site of medieval Walīla (Roman Volubilis), Morocco. Though the site is best known as the Roman city of Volubilis, in the Middle Ages, and by then called Walīla, it took on a new importance as a Berber centre, the probable locale of an Umayyad or Abbasid garrison and the capital of Idrīs I, the founder of one of the earliest Islamic states in Morocco. It is the only site in Morocco – and in North Africa more generally – where excavations have uncovered substantial evidence of eighth-century urbanism. As such, Walīla provides an exceptional opportunity to investigate the nature of a Berber town and its transformation into, for a short time, the centre of one of the earliest Islamic states in North Africa. This article presents a summary of our results from the four seasons of fieldwork that have taken place so far, between 2018 and 2022

Moral commitments to community: Mapping social responsibility and its ambiguities among small business owners

This article maps the different moral positions related to social responsibility (SR) as articulated by 25 small business owners and explains how they understand their positions within a range of SR practices. The morality underpinning their social responsibility tended to be embedded in a sense of relationship with and commitment to the well-being of the local geographic community but was threaded with felt ambiguities. Through an ethical analysis, we argue that this moral commitment to community is connected to a relational worldview, distinct from values and assumptions driving the existing economic system, yet they pursue this vision as individual actors rather than working collectively

Political occitanism 1974-2000 : exploring the marginalisation of an ethnoregionalist movement

The thesis investigates the political wing of the Occitan ethnoregionalist movement in the south of France from 1974, a point when it had a comparatively high profile, to 2000, and analyses the reasons for its marginalisation over time. Unlike other ethnoregionalist movements in France, it has been subject to little academic research. A study was made of documentary sources, including the internal bulletins of the political organizations and their published journals, which made possible a micro-level perspective on the movement, and revealed some inaccuracies of interpretation by previous researchers. An overview of the evolution of the political wing is established. An evaluation of the functioning and effectiveness of the organizations, which identifies their internal problems, is followed by an investigation of the external factors which contributed to the marginalisation of the Occitan movement. These include the geographical, historical, demographic and socio-linguistic factors which have differentiated the Occitan movement from other French ethnoregionalist movements, and made mobilization of the target audience difficult. By taking a global view of Occitania, rather than focussing, like previous researchers, on Languedoc, the study highlights the extent to which such factors made the movement's aims for political autonomy for the whole of the territory unrealistic. The relative success of the movement in the mid 1970s resulted from the fact that for a period its aims were congruent with the wave of social movement activity in post-1968 France, but the association was not deep-seated. In the 1980s and 1990s the effects of the decentralization reforms and the growth of the Front National had a negative effect on the movement's mobilizational potential. The issue of leadership, referred to briefly in previous studies, is subjected here to more detailed analysis, and is revealed as a significant factor in the weakness of political Occitanism.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

A Tentative Detection of a Starspot During Consecutive Transits of an Extrasolar Planet from the Ground: No Evidence of a Double Transiting Planet System Around TrES-1

There have been numerous reports of anomalies during transits of the planet TrES-1b. Recently, Rabus and coworkers' analysis of HST observations lead them to claim brightening anomalies during transit might be caused by either a second transiting planet or a cool starspot. Observations of two consecutive transits are presented here from the University of Arizona's 61-inch Kuiper Telescope on May 12 and May 15, 2008 UT. A 5.4 +/- 1.7 mmag (0.54 +/- 0.17%) brightening anomaly was detected during the first half of the transit on May 12 and again in the second half of the transit on May 15th. We conclude that this is a tentative detection of a r greater than or equal to 6 earth radii starspot rotating on the surface of the star. We suggest that all evidence to date suggest TrES-1 has a spotty surface and there is no need to introduce a second transiting planet in this system to explain these anomalies. We are only able to constrain the rotational period of the star to 40.2 +22.9 -14.6 days, due to previous errors in measuring the alignment of the stellar spin axis with the planetary orbital axis. This is consistent with the previously observed P_obs = 33.2 +22.3 -14.3 day period. We note that this technique could be applied to other transiting systems for which starspots exist on the star in the transit path of the planet in order to constrain the rotation rate of the star. (abridged)Comment: 21 pages, 3 tables, 6 figures, Accepted to Ap

Tropical forcing of increased Southern Ocean climate variability revealed by a 140-year subantarctic temperate reconstruction

Occupying 14% of the world’s surface, the Southern Ocean plays a fundamental role in global climate, ocean circulation, carbon cycling and Antarctic ice-sheet stability. Unfortunately, high interannual variability and a dearth of instrumental observations before the 1950s limits our understanding of how marine-atmosphere-ice domains interact on multi-decadal timescales and the impact of anthropogenic forcing. Here we integrate climate-sensitive tree growth with ocean and atmospheric observations on southwest Pacific subantarctic islands that lie at the boundary of polar and subtropical climates (52–54˚S). Our annually-resolved temperature reconstruction captures regional change since the 1870s and demonstrates a significant increase in variability from the mid-twentieth century, a phenomenon predating the observational record. Climate reanalysis and modelling shows a parallel change in tropical Pacific sea surface temperatures that generate an atmospheric Rossby wave train which propagates across a large part of the Southern Hemisphere during the austral spring and summer

Diagnostic value of exome and whole genome sequencing in craniosynostosis

Background Craniosynostosis, the premature fusion of one or more cranial sutures, occurs in ~1 in 2250 births, either in isolation or as part of a syndrome. Mutations in at least 57 genes have been associated with craniosynostosis, but only a minority of these are included in routine laboratory genetic testing. Methods We used exome or whole genome sequencing to seek a genetic cause in a cohort of 40 subjects with craniosynostosis, selected by clinical or molecular geneticists as being high-priority cases, and in whom prior clinically driven genetic testing had been negative. Results We identified likely associated mutations in 15 patients (37.5%), involving 14 different genes. All genes were mutated in single families, except for IL11RA (two families). We classified the other positive diagnoses as follows: commonly mutated craniosynostosis genes with atypical presentation (EFNB1, TWIST1); other core craniosynostosis genes (CDC45, MSX2, ZIC1); genes for which mutations are only rarely associated with craniosynostosis (FBN1, HUWE1, KRAS, STAT3); and known disease genes for which a causal relationship with craniosynostosis is currently unknown (AHDC1, NTRK2). In two further families, likely novel disease genes are currently undergoing functional validation. In 5 of the 15 positive cases, the (previously unanticipated) molecular diagnosis had immediate, actionable consequences for either genetic or medical management (mutations in EFNB1, FBN1, KRAS, NTRK2, STAT3). Conclusions This substantial genetic heterogeneity, and the multiple actionable mutations identified, emphasises the benefits of exome/whole genome sequencing to identify causal mutations in craniosynostosis cases for which routine clinical testing has yielded negative results

The effectiveness of a preferred intensity exercise programme on the mental health outcomes of young people with depression: a sequential mixed methods evaluation

<p>Abstract</p> <p>Background</p> <p>People with mental illness are more likely to suffer physical health problems than comparable populations who do not have mental illness. There is evidence to suggest that exercise, as well has having obvious physical benefits, also has positive effects on mental health. There is a distinct paucity of research testing its effects on young people seeking help for mental health issues. Additionally, it is generally found that compliance with prescribed exercise programmes is low. As such, encouraging young people to exercise at levels recommended by national guidelines may be unrealistic considering their struggle with mental health difficulties. It is proposed that an exercise intervention tailored to young people's preferred intensity may improve mental health outcomes, overall quality of life, and reduce exercise attrition rates.</p> <p>Methods/Design</p> <p>A sequential mixed methods design will be utilised to assess the effectiveness of an individually tailored exercise programme on the mental health outcomes of young people with depression. The mixed methods design incorporates a Randomised Controlled Trial (RCT), focus groups and interviews and an economic evaluation. <it>Participants: </it>158 young people (14-17 years) recruited from primary care and voluntary services randomly allocated to either the intervention group or control group. <it>Intervention group</it>: Participants will undertake a 12 week exercise programme of 12 × 60 minutes of preferred intensity aerobic exercise receiving motivational coaching and support throughout. Participants will also be invited to attend focus groups and 1-1 interviews following completion of the exercise programme to illicit potential barriers facilitators to participation. <it>Control group</it>: Participants will receive treatment as usual. <it>Primary Outcome measure</it>: Depression using the Children's Depression Inventory 2 (CDI-2). <it>Secondary Outcome measures</it>: Quality of Life (EQ-5D), physical fitness (Borg RPE scale, heart rate), incidents of self-harm, treatment received and compliance with treatment, and the cost effectiveness of the intervention. Outcome measures will be taken at baseline, post intervention and 6 month follow up.</p> <p>Discussion</p> <p>The results of this study will inform policy makers of the effectiveness of preferred intensity exercise on the mental health outcomes of young people with depression, the acceptability of such an intervention to this population and its cost effectiveness.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT01474837">NCT01474837</a></p

Cost-Effectiveness of a Telephone-Delivered Intervention for Physical Activity and Diet

Background: Given escalating rates of chronic disease, broad-reach and cost-effective interventions to increase physical activity and improve dietary intake are needed. The cost-effectiveness of a Telephone Counselling intervention to improve physical activity and diet, targeting adults with established chronic diseases in a low socio-economic area of a major Australian city was examined. Methodology/Principal Findings: A cost-effectiveness modelling study using data collected between February 2005 and November 2007 from a cluster-randomised trial that compared Telephone Counselling with a “Usual Care” (brief intervention) alternative. Economic outcomes were assessed using a state-transition Markov model, which predicted the progress of participants through five health states relating to physical activity and dietary improvement, for ten years after recruitment. The costs and health benefits of Telephone Counselling, Usual Care and an existing practice (Real Control) group were compared. Telephone Counselling compared to Usual Care was not cost-effective ($78,489 per quality adjusted life year gained). However, the Usual Care group did not represent existing practice and is not a useful comparator for decision making. Comparing Telephone Counselling outcomes to existing practice (Real Control), the intervention was found to be cost-effective ($29,375 per quality adjusted life year gained). Usual Care (brief intervention) compared to existing practice (Real Control) was also cost-effective ($12,153 per quality adjusted life year gained). Conclusions/Significance: This modelling study shows that a decision to adopt a Telephone Counselling program over existing practice (Real Control) is likely to be cost-effective. Choosing the ‘Usual Care’ brief intervention over existing practice (Real Control) shows a lower cost per quality adjusted life year, but the lack of supporting evidence for efficacy or sustainability is an important consideration for decision makers. The economics of behavioural approaches to improving health must be made explicit if decision makers are to be convinced that allocating resources toward such programs is worthwhile