US health care spending continues to outpace economic growth, prompting states to implement cost-growth benchmark programs aimed at constraining expenditure growth. However, empirical evidence evaluating their associations with overall spending growth remains limited. To evaluate whether adoption of statewide cost-growth benchmark programs is associated with changes in per capita total medical expenditure (TME) growth. This cohort study used a quasi-experimental, difference-in-differences analysis with 2-way fixed effects to examine data from the Centers for Medicare & Medicaid Services State Health Expenditure Accounts from January 1, 2010, to December 31, 2020. A total of 561 state- and year-level observations across 50 states and Washington, DC, were analyzed. Statistical analysis was performed from January 2025 to April 2026. Adoption of statewide cost-growth benchmark programs in Massachusetts (2013), Maryland (2014), Vermont (2018), Rhode Island (2019), and Delaware (2019); all states paired their benchmark programs with enforcement mechanisms and/or payment reforms except for Delaware, which relied solely on public reporting. The primary outcome was log-transformed per capita TME growth. Secondary outcomes included changes in payer-specific and spending category-specific expenditures. Across all 50 states and Washington, DC, the mean annual per capita TME increased by 3.7% during the study period. Implementation of cost-growth benchmark programs was associated with a 2.0% reduction in TME growth (95% CI, -3.3% to -0.7%; P = .004). Reductions were observed in all treatment states except Delaware. Medicare spending growth decreased across all treatment states (-2.4%; 95% CI, -4.2 to -0.6; P = .009), whereas reductions in commercial spending growth were concentrated in Maryland (-2.2%; 95% CI, -3.6 to -0.8; P = .003) and Rhode Island (-18.3%; 95% CI, -20.3% to -16.2%; P < .001). Spending reductions were primarily driven by decreases in hospital (-5.3%; 95% CI, -7.3% to -3.3%; P < .001) and skilled nursing facility expenditures (-7.7%; 95% CI, -10.5% to -4.9%; P < .001), alongside concomitant spending increases in home health spending (8.9%; 95% CI, 3.2% to 14.8%; P = .002). Findings were robust to multiple sensitivity analyses. This cohort study found that state cost-growth benchmark programs were associated with modest reductions in health care spending growth. These findings suggest that benchmark programs, particularly those paired with enforcement mechanisms or payment reforms, may contribute to slowing expenditure growth and shifting care toward lower-cost settings.
The Annual Price Revision (APR) based on external reference pricing (ERP) is one of the price control measures for the pharmaceutical sector implemented in Portugal. This study evaluates the impact of the APR on branded medicines in the outpatient market in Portugal between 2012 and 2023. A retrospective longitudinal study with time series was conducted using national sell-out data for branded medicines from the outpatient market subject to the APR between 2012 and 2023. Data were retrieved from a panel of over 82% of community pharmacies and extrapolated to the national level. The impact was measured based on two outcomes: the annual and cumulative impacts, both analysed at current and constant prices. Both outcomes estimate the isolated effect of retail price variations resulting from changes in the maximum retail price. Additionally, the impact was assessed considering the inclusion of medicines in Homogeneous Groups (HGs) and according to payer segmentation. The annual impact ranged from a reduction from 128.4 million euros in 2012 to an increase of 2.7 million euros in 2023. Overall, the value of the total cumulative impact of the APR between 2012 and 2023 amounted to 5.3 billion euros. The impact was greater in patent-protected originator medicines, reaching 81.7% in 2023. The public entities captured 56.9% of the total price reductions. This study provides a valuable contribution to the evaluation of price regulation measures based on ERP and can support decision-making by helping to identify and select specific criteria for future price revisions. I; I1; I11; I18; I19.
Genetic variation in the transpiration response to evaporative demand has been mostly studied in controlled environments, individual plants, and small genetic panels. Moving outdoors in field-like situations raises questions about what timeframe to measure transpiration, which metric to represent evaporative demand (vapor pressure deficit, VPD or reference evapotranspiration, ETref), which model to describe transpiration responses (linear slopes or segmented breakpoints), which plant spacing (individual plants, canopies), and which experimental setup for heritable genetic variation. Transpiration responses to evaporative demand were phenotyped in 467 sorghum and pearl millet inbred lines in three contrasting platforms (high-tech, low-tech, and lysimetric systems) outdoors. Across all experiments, ETref consistently explained more variation in transpiration response than VPD. In both species, transpiration responses to increasing ETref were best described by linear relationships. Genotype-specific regression slopes were retained as trait estimates. In pearl millet, transpiration response slopes and transpiration efficiency exhibited significant genetic variation with high heritability (0.61-0.73) across platforms. In sorghum, trait heritability depended on the platform, with higher heritability in the low-tech. Transpiration efficiency was positively associated with transpiration response slopes in both species, while relationships with root traits revealed species-specific patterns of water use and uptake. Overall, ETref was a reliable descriptor of evaporative demand, and linear modelling captured transpiration responses to ETref well outdoors. The low-tech platform enabled reliable phenotyping of transpiration response to ETref of individual plants in large germplasm panels while both the high-tech and lysimeter platforms were reliable to measure transpiration response to ETref in canopies.
This study aims to assess changes in health-related quality of life (HRQoL) and productivity costs following rehabilitation. This prospective cohort study of rheumatic and musculoskeletal diseases (RMDs) and 7 other groups collected HRQoL EuroQol 5-Dimension 5-Level (EQ-5D-5L) data for 12 months and work absence data for 24 months postrehabilitation. Differences from baseline in quality-adjusted life years (QALYs) and productivity costs were estimated using the area-under-the-curve method and human capital approach, respectively. Results were adjusted for age, gender (biologically), and education. We included 3192 patients: mean age 53.1 years, 71% female, 42% had RMDs. HRQoL improved for all participants over 12 months, except for neurological and cancer patients. Differences in QALYs from baseline ranged from -0.014 (neurological diseases) to 0.075 (RMDs). Among 2642 employed participants, productivity costs decreased over 24 months, driven mainly by reduced sick leave (largest in cancer €18,110, smallest in neurological diseases €5747). In contrast, productivity costs for severe obesity increased by €11,614. Mean rehabilitation costs ranged from €3072 to €11,674 for cancer and neurological diseases, respectively, and were €7923 for RMDs. Following rehabilitation, participants improved in HRQoL and reduced productivity costs from baseline, driven mainly by lower sick leave. Randomised controlled trials are needed to confirm the extent to which these improvements are attributable to the rehabilitation.
Despite a critical nationwide need, the Neonatal Nurse Practitioner (NNP) workforce is rapidly declining because of decreased enrollment in NNP programs, compounded by an aging workforce. Neonatal intensive care unit (NICU) nurses are the only professionals eligible to enter NNP education, yet there is limited research on their intentions and barriers to pursuing advanced education. This study aimed to explore NICU nurses' intentions to pursue advanced practice nursing education and identify perceived barriers. This cross-sectional study used random sampling and surveys distributed through NANN and social media to assess NICU nurses' intentions, perceptions of the NNP role, barriers to graduate school, and program preferences. Quantitative data were analyzed with R version 4.4.0, and qualitative responses were categorized thematically. A total of 531 participants completed the survey. Most respondents were younger than 40 years, with a mean of 7.6 years of NICU nursing experience. A majority (77.8%) indicated they intended to return to school. The main obstacles identified included finances, work-life balance, autonomy, responsibility, and interest in other roles. The most common response was a desire for better work-life balance. This study highlights the need for more flexible NNP programs to support nurses returning to school and addressing concerns about work-life balance. With declining NNP graduates, the specialized care in NICUs may be at risk if other specialties fill the gap, potentially affecting outcomes for fragile infants.
The national-level China Healthcare Security Diagnosis-Related Groups (CHS-DRG) reform in China has been underway for 6 years. However, the marginal benefit of controlling medical insurance fund expenditures has been decreasing, mainly due to the emergence of game behaviors among healthcare providers. The study aimed to explore the internal driving factors, effects and their interrelationships of DRG downcoding, upcoding and ambiguous cases to propose the intervention measures based on the hot cheese model. This study was conducted through semi-structured interviews with 22 participants from various positions in hospitals in Shaanxi Province, China. The hot cheese model was introduced for qualitative analysis to systematically analyze the manifestations, subjective and objective driving factors, and internal and external effects of DRG coding abuse. The subjective, objective drivers and effects of DRG coding abuse were revealed, and a hot cheese model was established, consisting of three defensive layers: layers of hospital organization environment, doctor-filled first page of medical records, and medical record/insurance department review. DRG upcoding should be distinguished between subjective and objective driving factors for targeted intervention. The potential effect of DRG downcoding and ambiguous cases should not be underestimated. Future research should focus on intelligent early warning by natural language processing on pre-coding of medical record texts.
This study examined the serial mediating roles of belief in a just world (BJW) and meaning in life in the association between short-form video addiction and psychological resilience among Chinese college students. A total of 4,456 participants (Mage = 20.34, SD = 1.52; 52.1% female) from five universities in Sichuan Province completed measures of short-form video addiction, BJW, meaning in life, and psychological resilience. Serial mediation analysis (PROCESS Model 6; 5,000 bootstrap samples) revealed that short-form video addiction negatively predicted resilience (B = -0.1948, p < 0.001). Three indirect pathways were significant: through BJW alone [Effect = -0.0337, 95% CI (-0.0426, -0.0254)], through meaning in life alone [Effect = -0.0606, 95% CI (-0.0769, -0.0443)], and through BJW sequentially to meaning in life [Effect = -0.0274, 95% CI (-0.0337, -0.0215)]. The total indirect effect accounted for 62.5% of the total effect. Meaning in life was the strongest proximal correlate of resilience (β = 0.5410). These findings are consistent with a cognitive-existential sequential association pattern in which short-form video addiction is associated with weakened worldview beliefs and diminished existential meaning, which in turn are associated with lower resilience. Implications for multi-layered university interventions are discussed.
Rangelands are pivotal for global carbon cycling, climate regulation, and rural livelihoods, yet they are increasingly threatened by overgrazing, land-use conversion, and climate variability. Carbon storage serves as a key ecological indicator, reflecting both ecosystem health and the capacity of rangelands to contribute to climate mitigation. This study assessed carbon storage and its economic value in the Borana rangelands of southern Ethiopia between 2010 and 2024. Four major carbon pools, aboveground biomass, belowground biomass, soil organic carbon, and dead organic matter, were assessed and mapped using the Integrated Valuation of Ecosystem Services and Trade-offs (InVEST) model. Results showed a total-carbon storage decline from 505.18 Mt C in 2010 to 503.93 Mt C in 2024, a net loss of 1.25 Mt C (0.25% of baseline stock). Spatial analysis revealed heterogeneous change patterns: intact bushlands and woodland retained the highest carbon densities, while heavily grazed and cultivated areas experienced substantial depletion. The associated economic valuation showed a Net Present Value loss of US$ 108.16 million over the 14-year period, with per-hectare economic value of carbon loss ranging between US$ 9,174 and 18,952. Although the magnitude of losses is relatively small compared to the total stock, the trend indicates a net release of carbon to the atmosphere, reducing the rangelands' potential to function as a carbon sink. From an ecological and management perspective, these losses serve as an early-warning signal of rangeland degradation. Continued depletion will compromise forage availability, livestock productivity, and ecosystem resilience. Implementing sustainable grazing management and integrating carbon finance and restoration initiatives could enhance local resilience, improve carbon retention, and support pastoral livelihoods, enabling Borana to transition toward a climate-resilient carbon sink, delivering ecological, economic, and social co-benefits while contributing to national and global climate objectives.
Addiction consult services (ACSs) are a growing hospital-based care model that increases quality of care for patients with substance use disorders (SUDs). One implementation barrier has been concern about negative financial impacts for health systems. To examine whether starting an ACS changes hospital length-of-stay and 30-day readmissions for patients with opioid use disorder (OUD) served in a large academic health system. Quasi-experimental difference-in-differences study of opioid-related hospital admissions from January 2018 to December 2024, comparing one hospital that implemented an ACS to three hospitals in the same urban, academic system in Philadelphia, PA without ACSs. Adults (≥ 18 years) with opioid-related hospitalizations. A fully staffed, hospital-based, multidisciplinary ACS launched in July 2023. Primary outcomes were hospital length-of-stay and 30-day readmissions. Secondary outcomes were receipt of any medication for opioid use disorder (MOUD) during hospitalization, discharge on a therapeutic MOUD dose, emergency department visits within 6 months of discharge, and discharges before medically advised. In unadjusted analyses, ACS implementation was associated with a 5 percentage point increase in MOUD receipt (95% CI 0-10) and a 9 percentage point increase in discharge on therapeutic MOUD (95% CI 5-13), without significant changes in length-of-stay or 30-day readmissions. In adjusted analyses, therapeutic MOUD at discharge increased by 8 percentage points (95% CI 4-12), with no significant differences in length-of-stay or 30-day readmission. Results were robust to sensitivity analyses with alternative comparison groups and after accounting for the COVID-19 pandemic. Implementation of an ACS improved evidence-based care for hospitalized patients with OUD without prolonging length-of-stay or increasing readmissions.
Managing marine pollution from expanded polystyrene (EPS) is a critical environmental challenge, yet reliable empirical data on the actual recovery burden are often lacking. This investigation addresses this gap by using primary field data from three comprehensive sampling cycles. Through a combined life cycle assessment and cost analysis, the environmental and economic impacts of remediation versus industrial prevention were compared. The results quantify the cost of inaction, showing that collection from hard-to-reach shores accounts for 99.5% of the total cost and 83% of CO2 emissions, with geographic dispersion and labour intensity as the main limiting factors. In contrast, mechanical processing is technologically mature and has low operating costs. The investigation also redefines sustainability metrics based on the waste's end use, valorizing recycled EPS as a substitute for natural mineral aggregates (sand). This approach turns the disadvantage of low density into an advantage, achieving a greater than 99% reduction in carbon footprint per cubic metre compared to mineral aggregates. The present article clearly highlights that collecting waste before entering the marine environment is essential. At the same time, converting marine EPS into a resource is viable, as the environmental benefits of preserving natural deposits offset the high recovery costs, supporting a practical circular economy strategy.
Why does managerial prioritization of safety more readily correspond to frontline willingness than to frontline action? Drawing on upper echelons theory, the attention-based view, and organizational psychology research on the attitude-behavior gap, this study examines whether managerial safety cognition is associated with frontline safety outcomes through three organizational mechanisms: institutionalization, technological affordance, and team safety climate. Using multi-source, time-lagged data from 183 firms and 667 nested teams in Chinese high-risk industries, this study estimated random-intercept multilevel models and used supervisor-rated behavior for cross-source validation. Managerial safety cognition was positively associated with all three organizational mechanisms. Institutionalization and team safety climate were, in turn, associated with both safety motivation and safety participation. Technological affordance was associated with safety motivation but not safety participation, and formal coefficient comparison tests confirmed that this asymmetry was statistically significant. Performance pressure further bounded behavioral translation in an inverted-U pattern consistent with the job demands-resources model: moderate pressure strengthened, whereas excessive pressure weakened, the behavioral relevance of organizational mechanisms. The findings support an attentional-prioritization account in which top-level safety priorities reach the frontline through differentiated organizational pathways rather than through a single leadership-signal channel. Practically, the findings suggest that digital safety systems should be paired with formal accountability and team-level support if motivational readiness is to translate into proactive safety behavior.
fractional-order modeling provides a powerful framework for representing memory-dependent conduction in excitable biological media. However, existing soliton-based models of myelinated nerve fibers are often theoretical, operator-specific, and insufficiently benchmarked in terms of numerical reproducibility, physiological plausibility, and computational cost. This study aims to compare the Liouville-Caputo, Atangana-Baleanu, and Beta fractional operators for modeling soliton-like action-potential propagation in ephaptically coupled myelinated nerve fibers, with emphasis on waveform stability, energy retention, biological consistency, computational efficiency, and adaptive parameter learning. A comparative computational modeling study was conducted using a coupled fractional nonlinear partial differential equation framework, physiological parameter mapping, numerical sensitivity analysis, and physics-informed neural network-based parameter estimation. A coupled fractional Korteweg-de Vries-type system was solved under identical initial and boundary conditions for the three fractional operators. The time-fractional order α was varied over [0.6, 1.0], while the space-fractional order β was varied over [1.5, 2.0]. Simulations used a uniform spatial grid, fixed time step, localized sech2 initial pulse, and Neumann boundary conditions. The operators were compared using soliton-like velocity, amplitude, pulse width, normalized energy retention, residual error, RMSE, MAE, and CPU runtime. A physics-informed neural network was further used to estimate model parameters while enforcing the fractional PDE residual. The Beta derivative produced the most localized and stable soliton-like pulses, with stronger amplitude preservation, lower energy loss, and shorter runtime than the Liouville-Caputo and Atangana-Baleanu formulations under the tested settings. Increasing ephaptic coupling strength reduced pulse amplitude, whereas increasing α improved propagation velocity and increasing β enhanced waveform localization. Quantitative residual and error analyses confirmed that the Beta-based formulation maintained low numerical error while preserving biologically plausible conduction behavior. The results support the Beta derivative as a biologically plausible and computationally efficient approximation for soliton-like nerve-pulse propagation in coupled myelinated fibers. The Liouville-Caputo and Atangana-Baleanu operators remain valuable for long-memory and fading-memory regimes, respectively. Future work should integrate literature-constrained biological consistency assessment, stochastic ion-channel dynamics, and heterogeneous multidimensional nerve-bundle geometries.
To develop a scale to measure fertility social mentality among women of childbearing age in China and to assess its psychometric properties, including reliability, validity, and measurement invariance. A total of 496, 857, 607, 632 and 362 women of childbearing age were recruited to conduct exploratory factor analysis, reliability and validity testing, and measurement invariance testing, respectively. The Fertility Social Mentality Scale for Women of Childbearing Age comprises 27 items and consists of three factors: fertility social values, fertility social cognition, and fertility social emotions. Confirmatory factor analysis indicated a good fit of the three-factor structural model [χ 2/df = 3.735, CFI = 0.918, TLI = 0.910, SRMR = 0.065, RMSEA = 0.056 (90% CI: 0.053-0.060)]. The average variance extracted (AVE) values were 0.444, 0.466, and 0.509, respectively. Discriminant validity analysis showed that the correlation coefficients among dimensions were all lower than the square roots of the AVE. Criterion analysis revealed that the total score of the scale and its individual dimensions were significantly positively correlated with fertility efficacy and fertility behavior, with correlation coefficients ranging from 0.468 to 0.727 and from 0.403 to 0.551, respectively. The Cronbach's α coefficients for the total scale and the three factors were 0.924, 0.897, 0.871, and 0.892, respectively. The composite reliability (CR) values ranged from 0.765 to 0.809. The test-retest reliability coefficients for the total scale and each dimension were 0.953, 0.949, 0.924, and 0.890, respectively. The developed Fertility Social Mentality Scale for Women of Childbearing Age shows encouraging evidence of structural validity, internal consistency, test-retest reliability, and measurement invariance. The scale may serve as a preliminary instrument for assessing fertility social mentality among women of childbearing age in China.
The electronic Community Health Information System (eCHIS) is a mobile health technology that was scaled nationally to community health workers (CHWs) in Kenya beginning in 2023. Since the rapid scale up, reports on eCHIS uptake show varying adoption rates. The overall purpose of this study was to assess the relationships between implementation process and acceptability of eCHIS by CHWs in Kenya. A cross-sectional study was conducted in 5 counties in Kenya with 310 CHWs (40 community health assistants and 270 community health promoters) selected through convenience stratified sampling. A structured questionnaire, developed by integrating the Technology Acceptance Model questionnaire and the Normalization MeAsure Development (NoMAD) tool, was administered by trained research assistants using Kobo Collect. The data was analyzed using descriptive statistics and structural equation modelling in STATA version 18. Implementation process mechanisms were found to have positive and significant relationships with the acceptability of eCHIS. Specifically, cognitive participation had a significant and positive relationship with perceived usefulness of eCHIS (β = .2783, p < .05). Additionally, coherence (β = .3911, p < .001) and reflexive monitoring (β = .3272, p < .05) had significant and positive relationships with perceived ease of use. The study also revealed inadequate training, financial resources, and technical and management support as the key implementation barriers. Implementation process significantly influences the acceptability of eCHIS. It is therefore important for governments and other implementing partners to strengthen the eCHIS training programs, allocate sufficient financial and technical resources, and provide management support to the CHWs to enhance eCHIS adoption.
With the rise of generative artificial intelligence (GAI) in the field of second (foreign) language writing, GAI-generated feedback has garnered increasing scholarly attention. While previous research has compared the efficacy of GAI and teacher feedback, the academic emotions elicited by GAI during the revision process remain under-explored. To fill this lacuna, this study employed a mixed-methods research design to investigate the emotional experiences and corresponding regulation strategies of L2 students in both teacher and GAI-generated feedback contexts. Eighty-six Chinese master's students participated in the study, with qualitative data gathered from written retrospective reflections, essays with teacher feedback, screenshots documenting the GAI-assisted revision process, and semi-structured interviews. The results revealed that students experienced higher levels of positive emotions in teacher-feedback contexts, whereas GAI-generated feedback was associated with more negative emotions. Furthermore, the findings identified distinct occurrences, types, and developmental trajectories of emotions across the two feedback conditions. This study offers important pedagogical implications, encouraging teachers to adopt hybrid feedback strategies and suggesting ways to help students manage negative emotions by fostering a growth mindset and enhancing feedback literacy.
The importance of conventional plastics is undeniable; however, their non-biodegradability makes them one of the biggest environmental problems. Among the alternatives to mitigate environmental damages, the production of polyhydroxyalkanoates (PHB) provides a biodegradable solution, making them accessible to a wide variety of applications. In general, biopolymers accumulate as energy and carbon storage material in microorganisms such as bacteria and microalgae. In the present study, the impact of different sources like carbon, glucose, nitrogen and sodium was tested on the production of PHB in the cultures of the microalgae Scenedesmus acutus. To evaluate the effect of the variables, a fractional Taguchi experimental design was devised and executed, thus, 16 experimental runs and 3 replicas in each treatment were considered. Results showed calculated concentrations of the biopolymer in a range from 7.5 to 24.7% w/w of dry weight. Additionally, the PHB was identified by spectroscopic and thermogravimetric analysis. Statistical analysis was performed, showing differences in biomass production, PHB concentration in g L- 1 and the percentage of PHB. Likewise, a Pareto diagram was used to consider the biomass production results, with glucose, biomass-glucose, and biomass-sodium as determining factors in the PHB production. The present research provides significant data on critical factors related with PHB production, to the best of our knowledge, thus showing S. acutus may be a promising candidate among PHB producers through a low-cost means.
Infection with human papillomavirus (HPV), the primary cause of cervical cancer, disproportionately affects women in low- and middle-income countries (LMICs). While school-based vaccination of adolescent girls against HPV is highly effective, this strategy systematically excludes out-of-school (OOS) girls. Using the RE-AIM framework, we explored strategies to reach OOS girls with HPV vaccination across six African and Asian LMICs. We conducted semi-structured key informant interviews with 32 vaccination program stakeholders from Cambodia, Cameroon, Kenya, Malawi, Mozambique, and Uganda between May and September 2024. Interviews explored countries' implementation successes, challenges, and strategies to reach OOS girls with HPV vaccination and sustainability considerations. Data were analyzed using a hybrid team-based thematic analysis approach guided by the RE-AIM framework. Community outreach-based strategies, typically integrated into routine immunization outreach, were identified as the most effective approach to reach OOS girls with HPV vaccination. Targeted strategies, such as locating outreach clinics in community venues frequented by OOS girls (e.g., churches, markets) enhanced implementation. Perceived effectiveness of these strategies varied across participants, and formal assessment of effectiveness was constrained by the absence of disaggregated vaccination coverage data by school enrollment status. Some subpopulations of OOS girls (i.e., girls in nomadic or migrant communities, urban OOS girls) were not readily reached through standard outreach approaches, prompting implementation of adapted and tailored strategies for these subpopulations. Costs associated with conducting outreach in harder-to-reach areas were major barriers to reaching OOS girls, presenting challenges to the sustainability and cost-effectiveness of these approaches. Routine community outreach platforms were widely perceived as most effective for reaching OOS girls. Strengthening disaggregated monitoring systems, adapting outreach for harder-to-reach subpopulations of OOS girls, and financing delivery models for tailored outreach strategies will be critical to improving equitable HPV vaccine coverage among OOS girls.
We use rich longitudinal administrative medical records to examine the separate roles of mothers and fathers in children's health care use. We do so distinguishing between different types of care and child sex. Overall, we find limited evidence of an association between parents' education and their children's health care use. Mothers' health care use appears in general more strongly associated than fathers' health care use with that of their children. On the other hand, for some types of care (GP and specialist visits), these associations in health care use are stronger within the same-sex parent-child dyads. These results are not (fully) explained by parental nor children's health needs and health behaviors and are robust to the inclusion of GP fixed effects. These associations remain after controlling for unobserved time-invariant factors suggesting that non-health related family shocks also play a role. Our findings have potentially important policy implications, as patterns of health care seeking are established early in life, which the literature shows have long-lasting effects over people's life course.
Newer cancer treatments, such as small molecule tyrosine kinase inhibitors and monoclonal antibodies that restore anti-tumour immunity, lead to improved survival when delivered as adjuvant or neoadjuvant treatments with surgery or chemoradiotherapy for early and locally advanced non-small cell lung cancer (NSCLC). However, these novel drugs are costly, posing a funding challenge for most health systems. A Markov modelling-based cost-utility analysis was conducted to determine its cost-effectiveness in Sri Lanka from a health system perspective. A decision-analytic model was developed to evaluate the incremental costs and quality-adjusted life-years (QALYs) associated with treating patients diagnosed with stage II-III NSCLC for the following treatments: adjuvant osimertinib following surgery and after curative chemoradiotherapy, adjuvant alectinib after surgery, neoadjuvant nivolumab prior to surgery, adjuvant pembrolizumab and atezolizumab after surgery, perioperative durvalumab and pembrolizumab and consolidation durvalumab after chemoradiotherapy. The study employed 1-month simulation cycles over a lifetime. Sex-specific analyses were conducted and parameter uncertainty was addressed using probabilistic analysis. A willingness-to-pay threshold of US$6700 per QALY was applied. A 5-year budget impact analysis was performed for therapies identified as cost-effective. At the primary threshold, adjuvant osimertinib after surgery and after curative chemoradiotherapy, adjuvant alectinib after surgery and neoadjuvant nivolumab were cost-effective in both males and females. However, conclusions were sensitive to lower opportunity-cost-informed thresholds. At US$3000 per QALY, only osimertinib-based strategies remained robustly cost-effective. Other therapies were not cost-effective at current prices and would require substantial price reductions. The 5-year cumulative budget impact of adopting cost-effective therapies under full implementation was approximately US$11.8 million. Using a common modelling approach and Sri Lanka-specific costing assumptions, we present comparative cost-effectiveness results across multiple novel perioperative, adjuvant and neoadjuvant strategies for stage II-III NSCLC. These findings are intended to support prioritisation of which therapies could be considered first for public funding and to indicate the price reductions required for other agents to represent value for money.
Based on the Global Burden of Diseases (GBD) 2021 data, this study systematically analyzed the trends in the disease burden of diabetic kidney disease (DKD) and predicted its burden over the next decade in 204 countries and regions worldwide from 1990 to 2021. Data on DKD from the GBD study spanning 1990 to 2021 were analyzed for trends using age-standardized rates (ASRs) and average annual percentage change (AAPC). The Joinpoint Regression Model (JRM) was applied to identify turning points, and the Autoregressive Integrated Moving Average (ARIMA) model was used to forecast future trends. Statistical analysis was performed using R software. The age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) of global DKD from 1990 to 2021 showed substantial increases, with cumulative rises of 55.0% (95% CI: 42.3% to 69.8%, P < 0.001) and 57.3% (95% CI: 43.1% to 73.5%, P < 0.001), respectively. The age-standardized prevalence rate (ASPR) declined by 37.5% (95% CI: －45.2% to －28.8%, P < 0.001), while the age-standardized disability-adjusted life years (DALYs) rate rose by 56.2% (95% CI: 42.8% to 71.5%, P < 0.001). Noticeable disparities in disease burden were observed among countries and regions. Greenland experienced the largest increase in ASPR, whereas the United Kingdom had the most substantial decrease. Estonia had the highest rise in ASIR, while Ireland saw the greatest decline. The United States had the most pronounced increase in ASDR, while the Maldives had the largest decrease. East Asia had the highest number of current cases, while South Asia bore the heaviest burden of new cases and DALYs. The increase was more prominent in regions with a low socio-demographic index (SDI). Projections for the next decade (2022-2031) indicate that the global ASPR of DKD will increase by an average of 0.45% per year (95% CI: 0.21% to 0.69%), the ASIR will decrease by an average of 0.23% per year (95% CI: －0.47% to －0.01%), and the age-standardized DALYs rate will increase by an average of 1.12% per year (95% CI: 0.89% to 1.35%). The overall burden of the disease is expected to continue growing. The global burden of DKD is steadily increasing, and it is especially severe in regions with low SDI. It is essential to implement targeted prevention and control measures in high-burden areas to provide a scientific basis for allocating public health resources.