Incentives and disincentives for treating of depression and anxiety in Ontario Family Health Teams: protocol for a grounded theory study.

PubMed

Ashcroft, Rachelle; Menear, Matthew; Silveira, Jose; Dahrouge, Simone; McKenzie, Kwame

2016-11-14

There is strong consensus that prevention and management of common mental disorders (CMDs) should occur in primary care and evidence suggests that treatment of CMDs in these settings can be effective. New interprofessional team-based models of primary care have emerged that are intended to address problems of quality and access to mental health services, yet many people continue to struggle to access care for CMDs in these settings. Insufficient attention directed towards the incentives and disincentives that influence care for CMDs in primary care, and especially in interprofessional team-based settings, may have resulted in missed opportunities to improve care quality and control healthcare costs. Our research is driven by the hypothesis that a stronger understanding of the full range of incentives and disincentives at play and their relationships with performance and other contextual factors will help stakeholders identify the critical levers of change needed to enhance prevention and management of CMDs in interprofessional primary care contexts. Participant recruitment began in May 2016. An explanatory qualitative design, based on a constructivist grounded theory methodology, will be used. Our study will be conducted in the Canadian province of Ontario, a province that features a widely implemented interprofessional team-based model of primary care. Semistructured interviews will be conducted with a diverse range of healthcare professionals and stakeholders that can help us understand how various incentives and disincentives influence the provision of evidence-based collaborative care for CMDs. A final sample size of 100 is anticipated. The protocol was peer reviewed by experts who were nominated by the funding organisation. The model we generate will shed light on the incentives and disincentives that are and should be in place to support high-quality CMD care and help stimulate more targeted, coordinated stakeholder responses to improving primary mental healthcare quality. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Palliative Care Disincentives in CKD: Changing Policy to Improve CKD Care.

PubMed

Tamura, Manjula Kurella; O'Hare, Ann M; Lin, Eugene; Holdsworth, Laura M; Malcolm, Elizabeth; Moss, Alvin H

2018-06-01

The dominant health delivery model for advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States, which focuses on provision of dialysis, is ill-equipped to address many of the needs of seriously ill patients. Although palliative care may address some of these gaps in care, its integration into advanced CKD care has been suboptimal due to several health system barriers. These barriers include uneven access to specialty palliative care services, underdeveloped models of care for seriously ill patients with advanced CKD, and misaligned policy incentives. This article reviews policies that affect the delivery of palliative care for this population, discusses reforms that could address disincentives to palliative care, identifies quality measurement issues for palliative care for individuals with advanced CKD and ESRD, and considers potential pitfalls in the implementation of new models of integrated palliative care. Reforming health care delivery in ways that remove policy disincentives to palliative care for patients with advanced CKD and ESRD will fill a critical gap in care. Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Carrots and sticks: impact of an incentive/disincentive employee flexible credit benefit plan on health status and medical costs.

PubMed

Stein, A D; Karel, T; Zuidema, R

1999-01-01

Employee wellness programs aim to assist in controlling employer costs by improving the health status and fitness of employees, potentially increasing productivity, decreasing absenteeism, and reducing medical claims. Most such programs offer no disincentive for nonparticipation. We evaluated an incentive/disincentive program initiated by a large teaching hospital in western Michigan. The HealthPlus Health Quotient program is an incentive/disincentive approach to health promotion. The employer's contribution to the cafeteria plan benefit package is adjusted based on results of an annual appraisal of serum cholesterol, blood pressure, tobacco use, body fat, physical fitness, motor vehicle safety, nutrition, and alcohol consumption. The adjustment (health quotient [HQ]) can range from -$25 to +$25 per pay period. We examined whether appraised health improved between 1993 and 1996 and whether the HQ predicted medical claims. Mean HQ increased slightly (+$0.47 per pay period in 1993 to +$0.89 per pay period in 1996). Individuals with HQs of less than -$10 per pay period incurred approximately twice the medical claims of the other groups (test for linear trend, p = .003). After adjustment, medical claims of employees in the worst category (HQ < -$10 per pay period) were $1078 (95% confidence interval $429-$1728) greater than those for the neutral (HQ between -$2 and +$2 per pay period) category. A decrease in HQ of at least $6 per pay period from 1993 to 1995 was associated with $956 (95% confidence interval $264-$1647) greater costs in 1996 than was a stable HQ. The HealthPlus Health Quotient program is starting to yield benefits. Most employees are impacted minimally, but savings are accruing to the employer from reductions in medical claims paid and in days lost to illness and disability.

Analysis of tactors for wearable simulator feedback: a tactile vest architecture

NASA Astrophysics Data System (ADS)

Prater, David; Gilbert, Stephen; Winer, Eliot

2013-03-01

Current training simulators for police officers and soldiers lack two critical qualities for establishing a compelling sense of immersion within a virtual environment: a strong disincentive to getting shot, and accurate feedback about the bodily location of a shot. This research addresses these issues with hardware architecture for a Tactical Tactile Training Vest (T3V). In this study, we have evaluated the design space of impact "tactors" and present a T3V prototype that can be viscerally felt. This research focuses on determining the optimal design parameters for creating maximum tactor hitting energy. The energy transferred to the projectile directly relates to the quality of the disincentive. The complete T3V design will include an array of these tactors on front and back of the body to offer accurate spatial feedback. The impact tactor created and tested for this research is an electromagnetic projectile launcher, similar to a solenoid, but lower profile and higher energy. Our best tactor produced projectile energy of approximately 0.08 Joules with an efficiency at just above 0.1%. Users in an informal pilot study described the feeling as "surprising," "irritating," and "startling," suggesting that this level of force is approaching our target level of disincentive.

Innovative Older-Worker Programs.

ERIC Educational Resources Information Center

Jessup, Denise; Greenberg, Barbara

1989-01-01

Describes program innovations to keep older workers employed: retraining, job sharing, flexible working hours, job redesign, and phased retirement. Addresses costs and savings, disincentives for workers and employers, and future trends. (SK)

The use of law to encourage smaller families in Singapore.

PubMed

Smith, T W

1980-01-01

To pursue its goal of rapid economic development, Singapore provides family planning services and has vigorously encouraged its citizens to limit family size. The government has legislated disincentives for families to have more than 2 children. This discussion reviews the history of these legal measures and their usefulness as a tool to promote social change and development. Singapore has used the law as a means to encourage family planning in order to supplement the overall thrust for economic development in the late 1960s. Freed from obligations to the Malaysian Federation and lacking the support of the British military as of 1969, Lee Kuan Yew led his people's economic development along a Western model. Reduction of population growth is an essential component of that model. Lee stressed family planning by providing clinics, by advertising, by promoting housing and lifestyles conducive to nuclear families, and by gradually adopting a set of laws favoring small families. These laws were introduced in different sectors of the economy at different times and were revised as social conditions changed. Typically, they set a minor monetary or priority penalty for parents of 3 or more children. The laws discourage additional births rather than prohibit them, guiding rather than forcing family planning decisions. To what extent the laws were the cause of decreasing family size in Singapore is uncertain, but they contributed to some extent to the country's phenomenal progress in income and lifestyle. The Abortion Act of 1969 legalized abortion on nonmedical grounds with the Singapore Family Planning and Population Board (SFPPB) approval. The Act was amended twice in 1974 to make abortions available "on demand." The charging of progressive delivery (accouchement) fees in government hospitals for mothers with 2 or more children might be considered as the focal point of the total disincentives system. The fees placed financial pressure directly on those who violated the government's stated small family norm. The program, initially instituted in 1969, has proven particularly effective, since 80% of all births in Singapore occur in government hospitals, where the rule may be consistently enforced. In August 1973 women with 2 or more children were made ineligible for maternity benefits, but female government employees could receive paid medical leave if they were sterilized after delivery. In August 1973 income tax relief was limited to the 1st 3 children. Other measures have been in the following areas: child employment; education; sterilization; and housing. The psychological impact of the disincentives may be their greatest effect, but it is difficult to measure. It is also difficult to determine the net effect of the disincentives on individuals. Indications are that the disincentives prohibited parents from attaining their desired family size in a very small number of cases.

Panel discussion on vaccine development to meet U.S. and international needs. Strategies for reducing the disincentives to HIV vaccine development: description of a successful public-private sector international collaboration.

PubMed

Bronnenkant, L

1994-01-01

A representative of Finishing Enterprises, the world's largest manufacturer of intrauterine contraceptive devices (IUDs), discusses how to alter the balance of incentives-disincentives to expedite the development of HIV vaccines for international evaluation. Three main disincentives exist for private manufacturers in the United States to develop a new HIV vaccine to be used in developing countries, outside the profitable North American and western European markets: 1) low profit margin because of limited money, time, and resources. Medium and large-sized corporations are more concerned with a high return on their investment owing to stockholder pressure than with the human benefit of that investment. 2) Lengthy regulatory approval process. The current regulatory process in the US is tedious, time-consuming, and costly. 3) Liability risk. The United States is the most litigious society in the world. Suits filed against US corporations involved in drug manufacture incur legal defence costs, which make an already low profit margin HIV vaccine even lower. Finishing Enterprises' IUD program aimed at providing the safest and most effective IUD at an affordable price in a socially responsible way. The Population Council developed the Copper T and retained the patent rights. They and other international health authorities, such as the World Health Organization, conducted or monitored international clinical trials to determine safety and efficacy. Private foundations and public donor agencies funded these activities. When donor agencies committed to volume purchases for their commodity programs, Finishing Enterprises could commit to volume pricing. Whenever high-margin private sector sales occur, Population Council receives a royalty payment. Thus, the disincentives were overcome: 1) Low profit margin was less an issue for a small, private company created specifically to manufacture IUDs and guaranteed volume orders. 2) Lengthy regulatory approval processes were avoided by various international clinical trials, generating international interest in the product. 3) Liability risk was minimized by the variety of safety tests the product underwent.

Commercialization of opportunities for materials processing in low gravity

NASA Technical Reports Server (NTRS)

Brown, W. S.; Nixon, S. R.

1983-01-01

Business infrastructure required to achieve commercial MPS, incentives and disincentives for MPS, NASA/industry working agreements, small business innovation, NASA/industry agreements, joint venture agreements, and commercial spinoffs are addressed.

ODOT research news : spring 2007.

DOT National Transportation Integrated Search

2007-01-01

The newsletter includes: : 1) FY 2008 Research Projects Prioritized; : 2) What Makes Environmental Streamling Work? : 3) Older Drivers and Driving Cessation; : 4) Incentive/Disincentive Contracting; : 5) When it Rains it Pours; : 6) PSU Transportatio...

Review of road user costs and methods.

DOT National Transportation Integrated Search

2013-07-01

The South Dakota Department of Transportation (SDDOT) uses road user costs (RUC) to calculate incentive or disincentive compensation for contractors, quantify project-specific liquidated damages, select the ideal sequencing of a project, and forecast...

Examination of Veterans Affairs disability compensation as a disincentive for employment in a population-based sample of Veterans under age 65.

PubMed

Tsai, Jack; Rosenheck, Robert A

2013-12-01

Concerns that disability benefits may create disincentives for employment may be especially relevant for young American military veterans, particularly veterans of the recent wars in Iraq and Afghanistan who are facing a current economic recession and turning in large numbers to the Department of Veterans Affairs (VA) for disability compensation. This study describes the rate of employment and VA disability compensation among a nationally representative sample of veterans under the age of 65 and examines the association between levels of VA disability compensation and employment, adjusting for sociodemographics and health status. Data on a total of 4,787 veterans from the 2010 National Survey of Veterans were analyzed using multinomial logistic regressions to compare employed veterans with two groups that were not employed. Two-thirds of veterans under the age of 65 were employed, although only 36 % of veterans with a VA service-connected disability rating of 50 % or higher were employed. Veterans who received no VA disability compensation or who were service-connected 50 % or more were more likely to be unemployed and not looking for employment than veterans who were not service-connected or were service-connected less than 50 %, suggesting high but not all levels of VA disability compensation create disincentives for employment. Results were similar when analyses were limited to veterans who served in Iraq and Afghanistan. Education and vocational rehabilitation interventions, as well as economic work incentives, may be needed to maximize employment among veterans with disabilities.

ENCOURAGING INNOVATION THROUGH UMBRELLA PERMITTING

EPA Science Inventory

The purpose of this project is to assess the behavioral, technical, economic, and environmental effects of removing disincentives to innovation in production and pollution management through more flexible environmental permitting. The study will examine the characteristics of tra...

Rideability issues for asphalt and concrete specification modifications.

DOT National Transportation Integrated Search

2007-12-01

Concerns have been raised regarding the differences between the incentive/disincentive determination procedures as well as pay adjustments for rideability between asphalt and concrete projects. This report will attempt to do the following: : 1. Addre...

Value affect of construction incentive payments on pavement performance.

DOT National Transportation Integrated Search

2009-08-01

The Michigan Department of Transportation (MDOT) has been using monetary incentive payments : for many years to improve contractors conformance with specifications and their overall : workmanship. It was envisioned that incentive/disincentive (I/D...

How motivation influences breastfeeding duration among low-income women.

PubMed

Racine, Elizabeth F; Frick, Kevin D; Strobino, Donna; Carpenter, Laura M; Milligan, Renee; Pugh, Linda C

2009-05-01

In-depth interviews were conducted with 44 low-income breastfeeding women to explore the incentives and disincentives to breastfeeding experienced within 6 months postpartum. Using an individual net benefit maximization (INBM) framework based on economic theory, we assessed women's motivations, incentives, and disincentives for breastfeeding. Based on the framework and their experience breastfeeding, women fell into 3 groups: intrinsically motivated, extrinsically motivated, and successfully experienced with both intrinsic and extrinsic motivation. Successfully experienced women were most likely to breastfeed to 6 months. Intrinsically motivated women valued breastfeeding but often required information and instruction to reach breastfeeding goals. Extrinsically motivated women were least likely to continue breastfeeding even with support and instruction. Providers can screen women to determine their experience and motivation then tailor interventions accordingly. Intrinsically motivated women may need support and instruction, extrinsically motivated women may benefit from motivational interviewing, and successfully experienced women may need only minimal breastfeeding counseling.

Factors influencing nurses' decisions to raise concerns about care quality.

PubMed

Attree, Moira

2007-05-01

To explore factors that influence nurses' decisions to raise concerns about standards of practice. Health care practitioners have a key role in monitoring care quality. Nurses are required by their professional body to raise concerns about standards; however, under-reporting is the norm. Grounded theory was used to collect and analyse data from semi-structured interviews with 142 practising nurses, theoretically sampled from three Acute NHS Trusts in England. Fear of repercussions, retribution, labelling and blame for raising concerns, about which they predicted nothing would be done, were identified as disincentives to raising concerns. Reporting was perceived as a high-risk:low-benefit action. Nurses lacked confidence in reporting systems. Disincentives to reporting need to be addressed if an open culture, which promotes quality, safety and learning, is to be developed. Findings give cause for concern and indicate a need to review organizational and professional guidelines, and organizational reporting systems.

Limiting financial disincentives in live organ donation: a rational solution to the kidney shortage.

PubMed

Gaston, R S; Danovitch, G M; Epstein, R A; Kahn, J P; Matas, A J; Schnitzler, M A

2006-11-01

Availability of kidney transplantation is limited by an inadequate supply of organs, with no apparent remedy on the immediate horizon and increasing reliance on living donors (LDs). While some have advocated financial remuneration to stimulate donation, the National Organ Transplant Act (NOTA) of 1984 expressly forbids the offer of 'valuable consideration.' However, recent developments indicate some fluidity in the definition of valuable consideration while evolving international standards highlight deficiencies (particularly regarding long-term care and follow-up) in the current American system. Recognizing that substantial financial and physical disincentives exist for LDs, we propose a policy change that offers the potential to enhance organ availability as well as address concerns regarding long-term care. Donors assume much greater risk than is widely acknowledged, risk that can be approximated for the purpose of determining appropriate compensation. Our proposal offsets donor risk via a package of specific benefits (life insurance, health insurance and a small amount of cash) to minimize hazard and ensure donor interests are protected after as well as before nephrectomy. It will fund medical follow-up and enable data collection so that long-term risk can be accurately assessed. The proposal should be cost effective with only a small increase in the number of LDs, and the net benefit will become greater if removal of disincentives stimulates even further growth. As importantly, by directly linking compensation to risk, we believe it preserves the essence of kidney donation as a gift, consistent with NOTA and implementable in the United States without altering current legal statutes.

Perspectives of transplant physicians and surgeons on reimbursement, compensation, and incentives for living kidney donors.

PubMed

Tong, Allison; Chapman, Jeremy R; Wong, Germaine; Craig, Jonathan C

2014-10-01

The shortage of donors for organ transplantation has stimulated debate on financial incentives for living kidney donors. This study aims to describe the range of attitudes and opinions of transplant physicians on financial reimbursement, compensation, and incentives in living kidney donation. Qualitative study. 110 transplant nephrologists and surgeons from 12 countries across 43 transplantation units in Europe, Australasia, and North America. Face-to-face semistructured interviews were conducted. Transcripts were thematically analyzed. We identified 7 major themes. Prioritizing the removal of disincentives for living kidney donors was largely deemed acceptable. By contrast, provision of financial incentives raised concerns about undermining benevolence, compromising human dignity and value, and traversing market forces. Some contended that financial incentives potentially were legitimate if regulated, arguing that this would maximize utility in transplantation, but most also acknowledged the difficulty and that operational feasibility of a regulated system of financial incentivization may be limited. Participants were English speaking and from Western high-income countries; therefore, the transferability of our findings may be limited. Transplantation specialists believed that minimizing disincentives would support equity and justice in living kidney donation. Direct financial incentivization for living kidney donors, even in the context of a regulated market, was regarded by most as unjustified because of the potential moral consequences and uncertain feasibility. Removing financial disincentives and safeguarding the intrinsic volunteerism, value, and meaning of donation were viewed to uphold integrity in living kidney donation. Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Advanced quality systems : probabilistic optimization for profit (Prob.O.Prof) software

DOT National Transportation Integrated Search

2009-04-01

Contractors constantly have to make decisions regarding how to maximize profit and minimize risk on paving projects. With more and more States adopting incentive/disincentive pay adjustment provisions for quality, as measured by various acceptance qu...

Inertial and inclinometer based profiler repeatability and accuracy using the IRI model : final report.

DOT National Transportation Integrated Search

2012-12-01

Oregon DOT is transitioning to use the International Roughness Index (IRI) for an incentive\\disincentive program for : pavement smoothness evaluation for newly paved roads. The IRI will typically be determined by contractors using inertial : profiler...

Evaluating the financial cost and impact on long-term pavement performance of expediting Michigan's road construction work.

DOT National Transportation Integrated Search

2014-02-01

The Michigan Department of Transportation (MDOT) has been using monetary incentive payments for many : years to accelerate highway construction work, resulting in reduced delays to the traveling public. It was : envisioned that incentive/disincentive...

Drivers’ attitudes and behaviors toward bicyclists : intermodal interactions and implications for road safety.

DOT National Transportation Integrated Search

2017-06-01

Road safety concerns are a legitimate concern when promoting increased bicycle use. Currently, bicyclist traffic fatalities and injuries present both a public health concern and a disincentive to people taking up or continuing to bicycle for transpor...

45 CFR 152.28 - Preventing insurer dumping.

Code of Federal Regulations, 2010 CFR

2010-10-01

... individuals from remaining enrolled in their current coverage in instances in which such individuals...: (1) Situations where an enrollee or potential enrollee had prior coverage obtained through a group... disenrolling from their coverage, or disincentives for remaining enrolled. (2) Situations where enrollees or...

New Business Models to Accelerate Innovation in Pediatric Oncology Therapeutics: A Review.

PubMed

Das, Sonya; Rousseau, Raphaël; Adamson, Peter C; Lo, Andrew W

2018-06-02

Few patient populations are as helpless and in need of advocacy as children with cancer. Pharmaceutical companies have historically faced significant financial disincentives to pursue pediatric oncology therapeutics, including low incidence, high costs of conducting pediatric trials, and a lack of funding for early-stage research. Review of published studies of pediatric oncology research and the cost of drug development, as well as clinical trials of pediatric oncology therapeutics at ClinicalTrials.gov, identified 77 potential drug development projects to be included in a hypothetical portfolio. The returns of this portfolio were simulated so as to compute the financial returns and risk. Simulated business strategies include combining projects at different clinical phases of development, obtaining partial funding from philanthropic grants, and obtaining government guarantees to reduce risk. The purely private-sector portfolio exhibited expected returns ranging from -24.2% to 10.2%, depending on the model variables assumed. This finding suggests significant financial disincentives for pursuing pediatric oncology therapeutics and implies that financial support from the public and philanthropic sectors is essential. Phase diversification increases the likelihood of a successful drug and yielded expected returns of -5.3% to 50.1%. Standard philanthropic grants had a marginal association with expected returns, and government guarantees had a greater association by reducing downside exposure. An assessment of a proposed venture philanthropy fund demonstrated stronger performance than the purely private-sector-funded portfolio or those with traditional amounts of philanthropic support. A combination of financial and business strategies has the potential to maximize expected return while eliminating some downside risk-in certain cases enabling expected returns as high as 50.1%-that can overcome current financial disincentives and accelerate the development of pediatric oncology therapeutics.

Incentives, population policy, and reproductive rights: ethical issues.

PubMed

Isaacs, S L

1995-01-01

The governments of most Asian countries have used incentives or disincentives as a population policy strategy. In the 1960s the Indian government offered money or gifts to acceptors at mass sterilization campaigns. In the late 1960s through the 1970s Singapore enacted legislation penalizing large families, including delivery fees for the third and subsequent children, denying them government housing and a choice of schools. There were also rewards to small families. During the late 1970s China started its own 1-child policy with the objective of limiting the population to 1.2 billion by the year 2000. Incentives included monthly welfare or nutritional allowances; priorities in housing, education, and medical care; and expanded maternity benefits. Disincentives included fines, deductions from salaries, withdrawal of maternity leave, health coverage, and allowances. There have also been charges of forced sterilization and abortion, which led to the US termination of funding to UNFPA because of its support of China's program. Incentives and disincentives raise the ethical issue of how to balance governmental actions attempting to control population growth against individual reproductive rights. In practice abuse has been rampant, therefore voluntary choice in childbearing should not be infringed upon no matter how strong the government interest is. To this effect some standards are proposed: 1) Governments restricting reproductive choice have the burden of demonstrating that continued population growth threatens the survival of society. 2) The people who are subject to the policy must agree that it is valid. 3) Measures that are less restrictive of voluntary reproductive choice should be tried and proved ineffective before more restrictive measures are employed. 4) The burdens of restrictive measures should be distributed equitably. 5) Penalties that directly punish children for being a high order child should not be used at all.

ASEAN’s Constructive Engagement Policy Toward Myanmar (Burma)

DTIC Science & Technology

2008-06-13

influencing political change in that country. Some have applied disincentives such as sanctions, while others such as the Association of Southeast Asia...ASEAN faces in influencing Myanmar. The study will then use three perspectives to analyze indicators of Myanmar’s progress toward democracy. The...

Incentives and disincentives to participate in prophylactic HIV vaccine research.

PubMed

Jenkins, R A; Temoshok, L R; Virochsiri, K

1995-05-01

An anonymous cross-sectional paper-and-pencil survey was used to assess incentives and disincentives to participate in a Phase I preventive human immunodeficiency virus (HIV) vaccine trial in a potential Thai target population. A total of 255 persons employed in health care service and research settings completed questionnaires after attending informational briefings regarding the proposed vaccine product and the planned trial procedures. Willingness to participate was related to self-perceived benefits from joining a preventive vaccine trial, as well as to concerns about product safety and social discrimination that might result from participation. The distinction between positive results of enzyme-linked immunosorbent assay from vaccine administration and positivity from HIV infection was unclear for many participants. Men were more willing to participate than women, and there was a trend toward greater willingness to participate in those who were less educated. Preparations for preventive vaccine trials may be more successful if they emphasize personal benefits of trial participation, clearly address safety issues, and consider ways to prevent social discrimination against participants.

Effectiveness of a program using a vehicle tracking system, incentives, and disincentives to reduce the speeding behavior of drivers with ADHD.

PubMed

Markham, Paula T; Porter, Bryan E; Ball, J D

2013-04-01

In this article, the authors investigated the effectiveness of a behavior modification program using global positioning system (GPS) vehicle tracking devices with contingency incentives and disincentives to reduce the speeding behavior of drivers with ADHD. Using an AB multiple-baseline design, six participants drove a 5-mile stable driving route weekly while GPS devices recorded speeds. The dependent variable was percentage of feet speeding. Following an initial baseline period, five participants received treatment. One participant remained at baseline. Visual inspection of individual participant graphs, reductions in mean percentages of speeding from baseline to treatment across participants (M = 82%), C-statistic analyses, and visual graphs with applied binomial formula supported a treatment effect. The between-participant analysis using R n Test of Ranks was significant, R n = 6, p < .01, and complemented a clean multiple-baseline result. Results indicated that this treatment program was effective in reducing speeding by drivers with ADHD and warrants replication.

The Economics of Saving Endangered Species: A Teaching Activity.

ERIC Educational Resources Information Center

Schug, Mark C.; Shaw, Jane S.

1997-01-01

Argues that well-intentioned government policies, such as the Endangered Species Act, can actually cause harm to endangered species by creating disincentives to preserving the habitat for endangered species. Maintains that the use of incentives can lead to voluntary species protection. Includes instructions for an in-class teaching activity. (MJP)

Open Access Initiatives in Africa--Structure, Incentives and Disincentives

ERIC Educational Resources Information Center

Nwagwu, Williams E.

2013-01-01

Building open access in Africa is imperative not only for African scholars and researchers doing scientific research but also for the expansion of the global science and technology knowledgebase. This paper examines the structure of homegrown initiatives, and observes very low level of awareness prevailing in the higher educational institutions…

Catholic School Principal Job Satisfaction: Keys to Retention and Recruitment

ERIC Educational Resources Information Center

Fraser, Jennifer; Brock, Barbara L.

2006-01-01

This article presents a study on principal retention in New South Wales, Australia. Factors in job retention included economic security, role enjoyment, and the opportunity to contribute. Disincentives to the principalship included lack of support from the employing authority, inadequate pay, isolation, growing responsibilities, difficult parents,…

75 FR 69486 - Self-Regulatory Organizations; The Depository Trust Company; Notice of Filing and Immediate...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-12

... SECURITIES AND EXCHANGE COMMISSION [Release No. 34-63208A; File No. SR-DTC-2010-13] Self-Regulatory Organizations; The Depository Trust Company; Notice of Filing and Immediate Effectiveness of Proposed Rule Change To Implement a Disincentive Fee Associated With the Deposit Automation Management...

43 CFR 418.37 - Disincentives for lower efficiency.

Code of Federal Regulations, 2013 CFR

2013-10-01

... increasing the severity of drought and yet still allow for variations in efficiency over time due to weather... the percentage of headgate entitlement delivered either through a natural drought or by the District... or equal to the target efficiency. (d) If there is a natural drought and the shortage to the...

43 CFR 418.37 - Disincentives for lower efficiency.

Code of Federal Regulations, 2014 CFR

2014-10-01

... increasing the severity of drought and yet still allow for variations in efficiency over time due to weather... the percentage of headgate entitlement delivered either through a natural drought or by the District... or equal to the target efficiency. (d) If there is a natural drought and the shortage to the...

43 CFR 418.37 - Disincentives for lower efficiency.

Code of Federal Regulations, 2012 CFR

2012-10-01

... increasing the severity of drought and yet still allow for variations in efficiency over time due to weather... the percentage of headgate entitlement delivered either through a natural drought or by the District... or equal to the target efficiency. (d) If there is a natural drought and the shortage to the...

Collegiate Grading Practices and the Gender Pay Gap.

ERIC Educational Resources Information Center

Dowd, Alicia C.

2000-01-01

Presents a theoretical analysis showing that relatively low grading quantitative fields and high grading verbal fields create a disincentive for college women to invest in quantitative study. Extends research by R. Sabot and J. Wakeman-Linn. Models pressures on grading practices using higher education production functions. (Author/SLD)

Disincentives, Identities, and Smoking.

ERIC Educational Resources Information Center

Norman, Nancy M.

When smoking decisions are understood in terms of the beliefs and attitudes which determine them, prevention programs can focus on changing these beliefs and attitudes. A study was conducted to measure students' attitudes and beliefs on the short-term health effects of smoking, on the social consequences of smoking, and on specific identities…

Demotivating and Disincentive Influences in a Health Care Organization.

ERIC Educational Resources Information Center

Jones, Allan P.; Kaye, Deborah F.

Although it has been suggested that organizational reward practices can promote dysfunctional behaviors or restrict employee effort, there is little empirical evidence about their influence on employee attitudes and performance or the degree to which they are affected by supervisor reward/punishment behaviors. To investigate perceived demotivating…

The Government Giveth and the Government Taketh Away: Federal Tax Law and Fund Raising.

ERIC Educational Resources Information Center

Holzman, Donald J.

1982-01-01

Tax laws' incentives and disincentives for charitable giving are outlined. Basics of charitable giving, partial property interests, gifts of future interest in tangible property, undivided interest gifts, ordinary income property, capital gain property, bargain sales, remainder interest gifts, estate tax, and valuation overstatement are discussed…

Employment Patterns Affecting Parents. Staff Brief 86-17.

ERIC Educational Resources Information Center

Sweet, Richard

Prepared in 1986 for the Wisconsin Legislative Council's Special Committee on Employment Disincentives, this staff brief describes employment patterns which affect participation in the work force by persons with children. Part I summarizes the participation of persons with children in the work force, primarily women who are heads of households and…

The Capacity-Building Stewardship Model: Assessment of an agricultural network as a mechanism for improving regional agroecosystem sustainability

USDA-ARS?s Scientific Manuscript database

Working lands have potential to meet agricultural production targets while serving as reservoirs of biological diversity and as sources of ecological services. Yet agricultural policy creates disincentives for this integration of conservation and production goals. While necessary, the development of...

43 CFR 418.37 - Disincentives for lower efficiency.

Code of Federal Regulations, 2010 CFR

2010-10-01

... borrowed will be accounted for in the form of a deficit in Lahontan Reservoir storage. This deficit amount will be added to the actual Lahontan Reservoir storage quantity for the purpose of determining the... and other factors. This approach should allow the District to plan its operation to correct for any...

43 CFR 418.37 - Disincentives for lower efficiency.

Code of Federal Regulations, 2011 CFR

2011-10-01

... borrowed will be accounted for in the form of a deficit in Lahontan Reservoir storage. This deficit amount will be added to the actual Lahontan Reservoir storage quantity for the purpose of determining the... and other factors. This approach should allow the District to plan its operation to correct for any...

Assessment of the Incentives, Disincentives, and Alternatives for Steel Industry CO2 Reduction

DOE Office of Scientific and Technical Information (OSTI.GOV)

Paul T. Leuchte; DR. John Stubbles; Professor Fruehan

This report presents the results of the third element of a trilogy of studies sponsored by the U.S. Department of Energy's Office of Industrial Technologies on the consumption of energy and the emissions of carbon dioxide in the U.S. steel industry

Promoting Population Stabilization: Incentives for Small Families. Worldwatch Paper 54.

ERIC Educational Resources Information Center

Jacobsen, Judith

A wide variety of incentive and disincentive programs are presented in an effort to stabilize the population and prevent bankruptcy of physical, economic, and social resources, particularly in countries like India and China. Following an introduction, the document discusses several programs, including (1) the use of small one-time payments for…

Big Field, Small Potatoes: An Empirical Assessment of EPA's Self-Audit Policy

ERIC Educational Resources Information Center

Pfaff, Alexander; Sanchirico, Chris William

2004-01-01

Environmental self-auditing is said to deserve and require encouragement. Although firms can audit themselves more cheaply and effectively than regulators, they are deterred for fear that information they uncover will be used against them. To reduce this disincentive, the Environmental Protection Agency's (EPA's) Audit Policy lowers punitive fines…

Public Welfare and Work Incentives: Theory and Practice. Studies in Public Welfare. Paper No. 14.

ERIC Educational Resources Information Center

Burke, Vee; Townsend, Alair A.

This chart book summarizes two volumes in the subcommittee's series, "Studies in Public Welfare." Paper No. 4 (Dec. 22, 1972) explored work incentive and disincentive features in existing and proposed public welfare programs (cash welfare, unemployment insurance, social security, veterans' benefits, food stamps, public housing, and medicaid).…

Evaluating effects of travel demand management in a medium-sized urban area : the study of I-40 Greensboro-Winston-Salem corridor

DOT National Transportation Integrated Search

2001-08-01

Travel demand management (TDM) is a set of procedures that have been shown to alleviate unlimited use of automobiles. Demand is managed by limiting highway capacity to meet demand to travel by car and providing incentives or disincentives to increase...

Exploring the Options: Teaching Economic Decision-Making with Poetry

ERIC Educational Resources Information Center

Johnson, Theresa L.

2012-01-01

High-stakes standardized tests in reading and limited instructional time are two powerful disincentives for teaching economics in the elementary classroom. In this article, integrating instruction in poetry and economic decision-making is presented as one way to maximize the use of scarce instructional time. Following a brief introduction to the…

The Labor-Supply Response of Married Women, Husband Present

ERIC Educational Resources Information Center

Cain, Glen G.

1974-01-01

The labor-supply or work-effect response of married women with husband present of families eligible for or receiving subsidies such as negative income tax (Graduated Work Incentive Experiment-New Jersey, Pennsylvania) revealed significant disincentive toward labor-force participation for white wives but not for black and Spanish-speaking wives.…

Incentives and Disincentives in the Work Incentive Program: Final Report.

ERIC Educational Resources Information Center

Hokenson, Earl; And Others

Research identifying the differences, and the relative importance of those differences, between successful and unsuccessful participants in the Work Incentive (WIN) Program is presented in terms of both successful employment at termination from WIN and employment after WIN participation. Over 800 former and current WIN 1 and 2 participants in…

Career Mobility and Departure Intentions among School Principals in the United States: Incentives and Disincentives

ERIC Educational Resources Information Center

Tekleselassie, Abebayehu Aemero; Villarreal, Pedro, III

2011-01-01

Despite concerns about turnover among administrators, conditions that influence career longevity intentions of school principals are less known. To address this gap in the literature, we conducted a three-level Generalized Multilevel Model to estimate variations in school and district characteristics impacting principals' career departure and…

State Aid and Student Performance: A Supply-Demand Analysis

ERIC Educational Resources Information Center

Kinnucan, Henry W.; Zheng, Yuqing; Brehmer, Gerald

2006-01-01

Using a supply-demand framework, a six-equation model is specified to generate hypotheses about the relationship between state aid and student performance. Theory predicts that an increase in state or federal aid provides an incentive to decrease local funding, but that the disincentive associated with increased state aid is moderated when federal…

Meaningful Use of Health Information Technology by Rural Hospitals

ERIC Educational Resources Information Center

McCullough, Jeffrey; Casey, Michelle; Moscovice, Ira; Burlew, Michele

2011-01-01

Purpose: This study examines the current status of meaningful use of health information technology (IT) in Critical Access Hospitals (CAHs), other rural, and urban US hospitals, and it discusses the potential role of Medicare payment incentives and disincentives in encouraging CAHs and other rural hospitals to achieve meaningful use. Methods: Data…

Waste reduction and recycling initiatives in Japanese cities: lessons from Yokohama and Kamakura.

PubMed

Hotta, Yasuhiko; Aoki-Suzuki, Chika

2014-09-01

Waste reduction and recycling at the city level will acquire greater significance in the near future due to rising global volumes of waste. This paper seeks to identify policy-relevant drivers for successful promotion of waste reduction and recycling. Factors influencing the success of waste reduction and recycling campaigns are identified. Two case study cities in Japan which depict the successful use of the 3Rs (reduce, reuse and recycle) at the municipal level are presented. In these cases, the existence of incinerators, which are generally considered as disincentives for recycling, was not functioning as a disincentive but rather as an incentive for waste reduction. Owing to the high cost of incineration facilities, the movement to close incinerators has become a strong incentive for waste reduction and recycling in these two cities. The study suggests that careful consideration is necessary when making decisions concerning high-cost waste treatment facilities with high installation, maintenance and renewal outlays. In addition, intensive source separation and other municipal recycling initiatives have a high potential for producing positive results. © The Author(s) 2014.

Population planning: a well co-ordinated approach required.

PubMed

1984-01-01

This discussion combines information obtained from 5 countries in the Economic and Social Commission for Asia and the Pacific (ESCAP) region on the role of population planning in the context of integrated policies and programs. The countries were asked what specific aspects of the present population policy and program would require concentrated inputs in order to achieve stated goals and targets. In Indonesia 2 program areas are identified for intensification: the organized transmigration scheme which aims at a balanced distribution of population and exploitation of potential resources throughout the country, including islands outside Java and Bali; and the national family planning program as a whole, in order to achieve the target of 60% prevalence rate of contraceptive use among eligible couples in 1990 and a decline of the crude birthrate from 33/1000 to 23/1000 by that date. Both programs are receiving high priority. Nepal policy and programs are aimed at achieving replacement level fertility by 2000. Steps that have been initiated in Bangladesh include intensive motivation activities with strong media inputs, the maintenance of a regular and adequate supply of contraceptives at the doorstep of clients, and strengthening the multisectoral program. The Philippines National Population Program advocates and promotes 4 norms in order to achieve a population growth rate of 2%, a prevalence rate of 54%, and contraceptive effectiveness of 80% by 1987: small family size; birth spacing; delayed marriages; and reduced incidence of teenage pregnancies. The goals envisaged for India are a reduction in the crude birthrate to not more than 21/1000, crude death rate of not more than 9/1000, and an infant mortality rate of less than 60/1000 live births by 2000. Concentrated efforts will be needed in the use of mass media and interpersonal communication strategies with services and supplies being provided as close to the doorstep of the acceptor as possible. In most countries of the region explicit or implicit incentives and/or disincentives are included in the population/family planning program. In the Philippine Population Program, incentives are explicitly given only to volunteer program workers. Disincentives are incorporated in the Internal Revenue Code and the Woman and Child Labor Code. In Indonesia preference is given to incentives rather than to disincentives. The government of Bangladesh is seriously considering the introduction of a package deal of incentives and disincentives in an all out effort to reach desired demographic objectives. In Nepal such a package is already in operation. The more recent innovative measures to encourage the 2-child child family norm in India include: increased compensation money to acceptors of sterilization and IUD and giving lottery tickets to acceptors of sterilization. There is recognition in these countries of the need for an integrated approach to population and development programs.

Self-Injurious Behaviour in Intellectual Disability Syndromes: Evidence for Aberrant Pain Signalling as a Contributing Factor

ERIC Educational Resources Information Center

Peebles, K. A.; Price, T. J.

2012-01-01

Background: In most individuals, injury results in activation of peripheral nociceptors (pain-sensing neurons of the peripheral nervous system) and amplification of central nervous system (CNS) pain pathways that serve as a disincentive to continue harmful behaviour; however, this may not be the case in some developmental disorders that cause…

Solar/hydrogen systems for the 1985-2000 time frame - A review and assessment

NASA Technical Reports Server (NTRS)

Hanson, J. A.; Foster, R. W.; Escher, W. J. D.; Tison, R. R.

1982-01-01

A comprehensive state-of-the-art review of solar/hydrogen technologies has been conducted. From this, solar/hydrogen production systems which could be commercialized by the year 2000 have been characterized technically and economically. Incentives and disincentives for the early commercialization of four solar/hydrogen systems have been explored, conclusions drawn and recommendations made.

Intergovernmental (Dis)incentives, Free-Riding, Teacher Salaries and Teacher Pensions. Upjohn Institute Working Paper No. 15-220

ERIC Educational Resources Information Center

Fitzpatrick, Maria D.

2015-01-01

In this paper, I document evidence that intergovernmental incentives inherent in public sector defined benefit pension systems distort the amount and timing of income for public school teachers. This intergovernmental incentive stems from the fact that, in many states, local school districts are responsible for setting the compensation that…

Incentive and Disincentive to Participation in the Work Incentive Program. Final Report.

ERIC Educational Resources Information Center

Garvin, Charles D., Ed.

Initially this report presents a summary of three Work Incentive Programs (WIN) undertaken by a consortium of schools of social work at the University of Chicago, University of Michigan, and Case Western Reserve University, discussing in detail the design, major findings, and recommendations made. The next two chapters are devoted to discussions…

Financial Disincentives for Welfare Clients to Enter Public Service Employment: The Vermont Experience. Final Report.

ERIC Educational Resources Information Center

Nadworny, M. J.; And Others

From a comparative economic viewpoint, does regular employment secured through temporary subsidized Special Work training afford the publicly supported individual any marginal advantage over his welfare status? A study of 279 Aid to Needy Families with Children (ANFC) recipients was conducted to address this question. The median annual dollar…

Human Capital: The Issues, Enablers and Blocks in Institutional Change.

ERIC Educational Resources Information Center

Hobbs, Daryl

In the last decade, unprecedented rates of job growth and improvements in adult education were accompanied by increased numbers of children living below the poverty line and a decline in real income for most families. There are several possible explanations: (1) a kind of job growth that produces disincentives for a significant number of people to…

When a Dream Becomes a Nightmare: Why Do Indigenous Australian Medical Students Withdraw from Their Courses?

ERIC Educational Resources Information Center

Ellender, Isabel; Drysdale, Marlene; Chesters, Janice; Faulkner, Susan; Kelly, Heather; Turnbull, Leanne

2008-01-01

This paper investigates reasons Indigenous Australian medical students gave for leaving their courses prior to graduation. Indigenous students who had withdrawn or deferred from their medical courses were asked about the barriers and disincentives that had dissuaded them from graduating. Although the response rate to the questionnaire was very…

Talking with Business. The Views of 101 Top Executives of Smaller Businesses on Their Role in Supporting Non-Profit Activities and Partnerships with Schools.

ERIC Educational Resources Information Center

Carroll, Barry J.

A study identified motivations and disincentives for business philanthropy among 101 small and medium-sized corporations operating nationwide, as revealed through interviews conducted with their executives from March through August 1984. Discussions identified several principal incentives to encourage corporate support of community services and…

"Maintenance of Effort": An Evolving Federal-State Policy Approach to Ensuring College Affordability. Policy Matters: A Higher Education Policy Brief

ERIC Educational Resources Information Center

American Association of State Colleges and Universities, 2010

2010-01-01

An analysis of state applications for the American Recovery and Reinvestment Act (ARRA) of 2009 reveals that its maintenance of effort provision appears to have successfully limited the amount of disinvestment in higher education during the current recession. This suggests that federal incentives and disincentives can help assure that states…

Are Teacher Absences Worth Worrying about in the U.S.? NBER Working Paper No. 13648

ERIC Educational Resources Information Center

Clotfelter, Charles T.; Ladd, Helen F.; Vigdor, Jacob L.

2007-01-01

Using detailed data from North Carolina, we examine the frequency, incidence, and consequences of teacher absences in public schools, as well as the impact of an absence disincentive policy. The incidence of teacher absences is regressive: schools in the poorest quartile averaged almost one extra sick day per teacher than schools in the highest…

The Northwest's Phantom Pool: Superintendent Certificate Holders Who Do Not Plan To Apply and Why.

ERIC Educational Resources Information Center

Wolverton, Mimi; Macdonald, R. Timothy

A recent national study suggests that 80 percent of current superintendents are at or near retirement. To compound the problem of a shrinking pool of candidates, highly qualified potential applicants often simply do not want the job. This report focuses on the aspects of the positions that serve as disincentives to seemingly qualified candidates.…

The Place of Assisted Living in Long-Term Care and Related Service Systems

ERIC Educational Resources Information Center

Stone, Robyn I.; Reinhard, Susan C.

2007-01-01

Purpose: The purpose of this article is to describe how assisted living (AL) fits with other long-term-care services. Design and Methods: We analyzed the evolution of AL, including the populations served, the services offered, and federal and state policies that create various incentives or disincentives for using AL to replace other forms of care…

The Impact of Changing Financial Work Incentives on the Earnings of Social Security Disability Insurance (SSDI) Beneficiaries

ERIC Educational Resources Information Center

Weathers, Robert R., II; Hemmeter, Jeffrey

2011-01-01

SSDI beneficiaries lose their entire cash benefit if they perform work that is substantial gainful activity (SGA) after using Social Security work incentive programs. The complete loss of benefits might be a work disincentive for beneficiaries. We report results from a pilot project that replaces the complete loss of benefits with a gradual…

AST/ASTS workshop on increasing organ donation in the United States: creating an "arc of change" from removing disincentives to testing incentives.

PubMed

Salomon, D R; Langnas, A N; Reed, A I; Bloom, R D; Magee, J C; Gaston, R S

2015-05-01

The American Society of Transplantation (AST) and American Society of Transplant Surgeons (ASTS) convened a workshop on June 2-3, 2014, to explore increasing both living and deceased organ donation in the United States. Recent articles in the lay press on illegal organ sales and transplant tourism highlight the impact of the current black market in kidneys that accompanies the growing global organ shortage. We believe it important not to conflate the illegal market for organs, which we reject in the strongest possible terms, with the potential in the United States for concerted action to remove all remaining financial disincentives for donors and critically consider testing the impact and acceptability of incentives to increase organ availability in the United States. However, we do not support any trials of direct payments or valuable considerations to donors or families based on a process of market-assigned values of organs. This White Paper represents a summary by the authors of the deliberations of the Incentives Workshop Group and has been approved by both AST and ASTS Boards. © Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.

The Identification of Financial Disincentives to Educating Children and Youth with Moderate to Severe and Multiple Developmental Disabilities in Their Home Schools. Final Report.

ERIC Educational Resources Information Center

Kane, Douglas N.; And Others

This study examined the flow of all special education funds to Illinois school districts, in order to identify the financial incentives which influence school districts to educate children with disabilities away from their home schools. Background information on inclusive education precedes the study report. The study involved a review of federal…

Relationship of Perceived Barriers to Employment and Return to Work Five Years Later: A Pilot Study among 343 Participants with Spinal Cord Injury

ERIC Educational Resources Information Center

Krause, James S.; Pickelsimer, Elizabeth

2008-01-01

The authors identified perceived barriers to employment in 1998 among 343 unemployed participants with spinal cord injury and correlated these data with employment status 5 years later. Actively looking for work was associated with the greatest likelihood of employment. Health factors, not disincentives or resources, were the primary barriers to…

Disincentive for Overseas Federal Service

DTIC Science & Technology

2007-03-27

the Master of Strategic Studies Degree. The U.S. Army War College is accredited by the Commission on Higher Education of the Middle States...Association of Colleges and Schools, 3624 Market Street, Philadelphia, PA 19104, (215) 662-5606. The Commission on Higher Education is an institutional...accrediting agency recognized by the U.S. Secretary of Education and the Council for Higher Education Accreditation. The views expressed in this

The electronic medical record in dermatology.

PubMed

Grosshandler, Joshua A; Tulbert, Brittain; Kaufmann, Mark D; Bhatia, Ashish; Brodell, Robert T

2010-09-01

Governmental incentives to stimulate the "meaningful use" of electronic medical records and future disincentives for Medicaid and Medicare provide an impetus for dermatologists to consider adding this technology to their clinical practice. Dermatologists should carefully weigh the pros and cons of establishing an electronic medical record system before incorporating this expensive technology. This article reviews available scientific and economic data required for dermatologists to help make an informed choice.

An Examination of the Causes of Grade Inflation in a Teacher Education Program and Implications for Practice

ERIC Educational Resources Information Center

Nikolakakos, Elaine; Reeves, Jennifer L.; Shuch, Sheldon

2012-01-01

Grade inflation is harmful to students as well as faculty. Faculty should not have to fear that honest grading may result in job loss. Students who truly deserve A grades also are negatively impacted when they receive the same grade as students who submit good but not superior work. At the very least, it is a disincentive for students to work to…

Essays on Economic Policy and Foreign Policy,

DTIC Science & Technology

1985-03-01

the puzzle. Reducing taxes on income and on capital gains, and providing increased tax shelters for retirement accounts, were supposed by supply...behavior accordingly. Moreover, the structure of taxes , as well as their rates, still provides a disincentive to save. When interest income that’s...rather than to save and lend. (It’s worth noting that in Japan, interest income on savings deposits is tax exempt.) Inflationary expectations are yet

Hidden concerns of sharing research data by low/middle-income country scientists.

PubMed

Bezuidenhout, Louise; Chakauya, Ereck

2018-01-01

There has considerable interest in bringing low/middle-income countries (LMIC) scientists into discussions on Open Data - both as contributors and users. The establishment of in situ data sharing practices within LMIC research institutions is vital for the development of an Open Data landscape in the Global South. Nonetheless, many LMICs have significant challenges - resource provision, research support and extra-laboratory infrastructures. These low-resourced environments shape data sharing activities, but are rarely examined within Open Data discourse. In particular, little attention is given to how these research environments shape scientists' perceptions of data sharing (dis)incentives. This paper expands on these issues of incentivizing data sharing, using data from a quantitative survey disseminated to life scientists in 13 countries in sub-Saharan Africa. This interrogated not only perceptions of data sharing amongst LMIC scientists, but also how these are connected to the research environments and daily challenges experienced by them. The paper offers a series of analysis around commonly cited (dis)incentives such as data sharing as a means of improving research visibility; sharing and funding; and online connectivity. It identifies key areas that the Open Data community need to consider if true openness in research is to be established in the Global South.

Impacts of a Program to Improve Girls' Enrollment and Persistence in Liberia Elementary Schools: The Challenge of Using Gender Differences in Aggregate Outcome Trends to Identify Program Effects

ERIC Educational Resources Information Center

Bos, Johannes M.; Sherman, Dan; Orgut, Burhan

2014-01-01

Under-enrollment of girls in primary and secondary is a longstanding and well-documented problem in developing countries. Limited parental and communal resources combine with cultural factors to create a disincentive for parents to send their girls to school and to keep them there throughout the school year and for the full primary and secondary…

Do Generous Welfare States Generate Efficiency Gains Which Counterbalance Short Run Losses? Testing Downside Risk Theory with Economic Panel Data for the U.S., Germany and the Netherlands

ERIC Educational Resources Information Center

Headey, Bruce; Muffels, Ruud

2008-01-01

The purpose of the paper is to assess the theory that the downside risk insurance provided by more generous welfare states generates long run efficiency gains, which counterbalance the short run efficiency losses caused by work disincentives in these states (Feldstein 1974, 1976; Sinn 1995, 1996). Testing downside risk theory requires long term…

Economics of an aging population.

PubMed Central

Jackson, P M

1985-01-01

Throughout this century, as in many other countries, the proportion of the British population in the older age groups has increased. The effect this has on the economy is discussed. Topics covered include the determinants of the economic status of old people; the reasons for the choice of retirement ages; the burden of the aged on younger generations; the costs of pension schemes; the disincentive effects of pensions on savings; and poverty in old age. PMID:4009105

Inexpensive health care reform: the mathematics of medicine.

PubMed

Forsyth, Roger A

2010-02-01

There is data to support the hypothesis that US healthcare reform will require systemic changes in their delivery system rather than a segment-by-segment approach to improving individual components such as administrative or pharmaceutical costs or illness-by-illness programs such as comparative effectiveness or disease management. Mathematically, personnel costs provide the largest potential for savings. These costs are reflected in utilization rates. However, when governments or insurers try to control utilization, shortages or dissatisfaction ensue. Therefore, reform should be structured to encourage individually initiated reductions in utilization. This can be facilitated by changing from employer-paid comprehensive group policies of variable coverage to a three-part, standardized, individually purchased, group policy with a targeted deductible and co-pays that provide disincentives to over-utilization and incentives (refunds on unused contributions) to reduce utilization. There will be a public health policy (maternal, infant, and immunizations) that will be very inexpensive and not subject to any disincentives, a catastrophic policy with a deductible and enhanced but diminishing co-pays, and a Health Savings Account that pre-positions funds to cover the deductible and co-pays. These changes will lead to a reduction in administrative costs. The excess capacity created will provide care for the currently uninsured. Savings will be refunded to individuals thereby generating taxes that can pay for needed subsidies. Reform can be inexpensive if it puts the mathematics before the politics.

What happens to the employment of disabled individuals when all financial disincentives to work are abolished?

PubMed

Vall Castelló, Judit

2017-09-01

Policymakers and organizations representing people with disabilities have highlighted the importance of promoting the employment prospects of disabled individuals as a determinant to ensure their broader integration into the society. Policy reforms that attempt to incentivise disabled individuals to work typically involve reduced financial punishments for earning above a predetermined threshold (substantial gainful activity). This paper exploits a Spanish reform that entirely eliminated any disincentives for disabled individuals to work. Partially disabled individuals in Spain are subject to income taxation in all regions except in the province of Bizkaia. Before 2007, partially disabled individuals in Bizkaia were exempt from income taxation if they did not work. In December 2006, a new law was passed in Bizkaia that distinguished between individuals aged 55 or younger, who were no longer tax-exempt, and those who were older than 55 years, who continued to be tax-exempt if they did not work. I exploit this change in the legislation and employ both a difference-in-difference strategy comparing the employment outcomes of disabled young men across provinces and time as well as a triple difference model with disabled men older than 55 years, who are unaffected by the policy. My results show that the reform increased the probability of working by 6.5 percentage points for disabled men aged 55 or younger. Copyright © 2017 John Wiley & Sons, Ltd.

Impact of Rate Design Alternatives on Residential Solar Customer Bills: Increased Fixed Charges, Minimum Bills and Demand-Based Rates

DOE Office of Scientific and Technical Information (OSTI.GOV)

McLaren, Joyce; Davidson, Carolyn; Miller, John

Utilities are proposing changes to residential rate structures to address concerns about lost revenue due to increased adoption of distributed solar generation. An investigation of the impacts of increased fixed charges, minimum bills and residential demand charges on PV and non-PV customer bills suggests that minimum bills more accurately capture utilities' revenue requirement than fixed charges, while not acting as a disincentive to efficiency or negatively impacting low-income customers.

Does integrating AIDS treatment with food assistance affect labor supply? Evidence from Zambia.

PubMed

Tirivayi, Nyasha; Groot, Wim

2018-02-01

In low income settings, food assistance is increasingly becoming part of AIDS treatment and care programs with the aim of improving adherence to AIDS treatment, enhancing household food security and strengthening economic wellbeing. Yet, evidence of its economic impact is sparse. This paper uses primary data to examine the short term impact of a food assistance program on labor supply as measured by the hours worked, labor market participation rates and transitions to employment within HIV/AIDS affected households in Zambia. We find that food assistance is generally a labor supply disincentive to HIV-infected patients receiving treatment as it reduced their hours worked by up to 54%, transitions to employment by up to 70% and also reduced the labor market participation rates of male patients by 72%. Among non-infected adult family members, there were no significant effects on labor market participation. However, propensity score estimates show that food assistance generally increased the intensity of work by males regardless of the length of AIDS treatment, but for females there was a disincentive effect that disappeared when the patient had spent a longer time on AIDS treatment and was therefore healthier and less likely to be cared for. These findings suggest that food assistance can inadvertently reduce the labor supply of HIV-infected individuals, but this is compensated for by the increased labor supply among other family members. Copyright © 2017 Elsevier B.V. All rights reserved.

Generation-specific incentives and disincentives for nurse faculty to remain employed.

PubMed

Tourangeau, Ann E; Wong, Matthew; Saari, Margaret; Patterson, Erin

2015-05-01

The aims of this paper are to: (1) describe work characteristics that nurse faculty report encourage them to remain in or leave their academic positions; and (2) determine if there are generational differences in work characteristics selected. Nurse faculty play key roles in preparing new nurses and graduate nurses. However, educational institutions are challenged to maintain full employment in faculty positions. A cross-sectional, descriptive survey design was employed. Ontario nurse faculty were asked to select, from a list, work characteristics that entice them to remain in or leave their faculty positions. Respondent data (n = 650) were collected using mailed surveys over four months in 2011. While preferred work characteristics differed across generations, the most frequently selected incentives enticing nurse faculty to stay were having: a supportive director/dean, reasonable workloads, supportive colleagues, adequate resources, manageable class sizes and work/life balance. The most frequently selected disincentives included: unmanageable workloads, unsupportive organizations, poor work environments, exposure to bullying, belittling and other types of incivility in the workplace and having an unsupportive director/dean. This research yields new and important knowledge about work characteristics that nurse faculty report shape their decisions to remain in or leave their current employment. Certain work characteristics were rated as important among all generations. Where similarities exist, broad strategies addressing work characteristics may effectively promote nurse faculty retention. However, where generational differences exist, retention-promoting strategies should target generation-specific preferences. © 2014 John Wiley & Sons Ltd.

The influence of motivation in recruitment and retention of rural and remote allied health professionals: a literature review.

PubMed

Campbell, N; McAllister, L; Eley, D

2012-01-01

Recruitment and retention of allied health professionals (AHPs) to remote and rural Australia is challenging and correlates with poorer health status of remote and rural residents. While much has been written about the recruitment and retention problem, this study took a new approach by reviewing the literature describing the motivation of AHPs to work in remote and rural areas and then analyzing the findings from the perspective of motivation theory using Herzberg's extrinsic and intrinsic classification. Intrinsic motivation incentives are known to contribute to job satisfaction and come from within the individual, for example the pleasure derived from autonomy or challenge at work. In contrast, extrinsic motivation incentives are provided by the job and include such factors as salary and professional development provisions. Extrinsic incentives are important because they prevent job dissatisfaction. Job satisfaction has been shown to be linked with increased retention. Thirty-five articles, including 26 from Australia, met the inclusion criteria. The key findings related to motivation from each article are outlined and the results classified into the extrinsic-intrinsic framework. The incentives are then further analyzed as having a positive or a negative influence. In total, 38 different incentives were described a total of 246 times. Of the total, almost half (n=115) comprised extrinsic incentives with a negative influence, with poor access to professional development, professional isolation and insufficient supervision the most frequently reported. Rural lifestyle and diverse caseloads were the most frequently mentioned positive extrinsic incentives, while autonomy and community connectedness were the most cited positive intrinsic incentives. Negative intrinsic incentives were mentioned least frequently (n=18); however, of these, feeling overwhelmed and that your work was not valued by the community were the most commonly reported. The results demonstrate the significant burden of extrinsic incentives with a negative influence that are perceived by AHPs in remote and rural areas. The high turnover rate of AHPs in remote and rural areas is likely to be, in part, due to the job dissatisfaction from these disincentives. More positive intrinsic incentives were reported than negative. This suggests the potential for intrinsic incentives, known to contribute to job satisfaction, to be mediating the extrinsic disincentives. The policy implications of this work include the importance of addressing extrinsic disincentives. Simultaneously, the existing intrinsic incentives need to be nurtured and developed. Organizations that implement strategies to enhance both extrinsic and intrinsic motivation incentives are more likely to successfully address their AHP workforce shortage.

Incentives in financing mental health care in Austria.

PubMed

Zechmeister, Ingrid; Oesterle, August; Denk, Peter; Katschnig, Heinz

2002-09-01

In Austria, financing health care -and even more so mental health care- is characterized by a mix of federal and provincial responsibilities, lack of uniformity in service provision and service providers, and diverse funding arrangements. The division between financing structures for health care and social care makes the situation even more complex. This state of affairs results in various, partly counterproductive and sometimes paradoxical financial incentives and disincentives for the providers, recipients and financiers of mental health services. In several provinces of Austria, recent reform plans in mental health care have focused strongly on establishing community-based and patient-oriented mental health care. One of the main challenges in implementing this new policy is the re-allocation of resources. The authors hypothesize that the existing structure of mental health care financing, with its incentives and disincentives, constitutes an obstacle to patient-oriented community-based mental health care. Analyzing the characteristics of the overall mental health care financing system in one Austrian province, Lower Austria, will provide a better understanding of actor-relationships and inherent incentives and highlight implications for the process of deinstitutionalization. The authors used an analytical framework based on the principal-agent theory, empirical evidence, and information on financial, organizational and legal structures to identify the characteristics of actor-relationships and the position of single actors within the system. The article shows how incentives are linked to existing constellations of actors involved in mental health care financing and identifies significant power relations. As a consequence, incentives and disincentives within the financing system result in hospital- centered and supply-oriented mental health care in Lower Austria. The current system of financing mental health care provides an obstacle to the provision of patient-oriented and community-based mental care. This is due to existing constellations and power relations among the actors where, most importantly, patients are the weakest party in the patient-payer-provider triangle. Balancing power relations will be a significant prerequisite for alternative financing systems. IMPLICATIONS FOR HEALTH POLICIES AND FURTHER RESEARCH: If a community and needs-based mental health care system is to be established in Austria, the financing structures have to be changed accordingly. Applying a principal-agent framework is useful for identifying key aspects in mental health care financing in relation to the provision of services. Further research is needed to help develop alternative financing mechanisms that support community-based and patient-oriented mental health care systems.

INCENTIVES TO IDENTIFY: RACIAL IDENTITY IN THE AGE OF AFFIRMATIVE ACTION

PubMed Central

Antman, Francisca; Duncan, Brian

2016-01-01

We link data on racial self-identification with changes in state-level affirmative action policies to ask whether racial self-identification responds to economic incentives. We find that after a state bans affirmative action, multiracial individuals who face an incentive to identify under affirmative action are about 30 percent less likely to identify with their minority groups. In contrast, multiracial individuals who face a disincentive to identify under affirmative action are roughly 20 percent more likely to identify with their minority groups once affirmative action policies are banned. PMID:27635103

INCENTIVES TO IDENTIFY: RACIAL IDENTITY IN THE AGE OF AFFIRMATIVE ACTION.

PubMed

Antman, Francisca; Duncan, Brian

2015-07-01

We link data on racial self-identification with changes in state-level affirmative action policies to ask whether racial self-identification responds to economic incentives. We find that after a state bans affirmative action, multiracial individuals who face an incentive to identify under affirmative action are about 30 percent less likely to identify with their minority groups. In contrast, multiracial individuals who face a disincentive to identify under affirmative action are roughly 20 percent more likely to identify with their minority groups once affirmative action policies are banned.

Key challenges posed by the Clinton health care reform proposal.

PubMed

Burns, L R; Sechrest, L

1994-08-01

President Clinton's proposal assumes that the bureaucratic, regulatory, informational, and financial demands it places on the health care system may be feasibly met. The authors refute these assumptions and argue that the proposal restricts individual freedom while it requires less individual responsibility. They also challenge the lack of incentives for cost-conscious purchasing of health care and for taking greater responsibility for individual well-being and societal health. The article recommends that behavior that drives up the cost of health care for individuals and society should be strongly discouraged through disincentives.

Differences in wage rates for males and females in the health sector: a consideration of unpaid overtime to decompose the gender wage gap.

PubMed

Vecchio, Nerina; Scuffham, Paul A; Hilton, Michael F; Whiteford, Harvey A

2013-02-25

In Australia a persistent and sizable gender wage gap exists. In recent years this gap has been steadily widening. The negative impact of gender wage differentials is the disincentive to work more hours. This implies a substantial cost on the Australian health sector. This study aimed to identify the magnitude of gender wage differentials within the health sector. The investigation accounts for unpaid overtime. Given the limited availability of information, little empirical evidence exists that accounts for unpaid overtime. Information was collected from a sample of 10,066 Australian full-time employees within the health sector. Initially, ordinary least-squares regression was used to identify the gender wage gap when unpaid overtime was included and then excluded from the model. The sample was also stratified by gender and then by occupation to allow for comparisons. Later the Blinder-Oaxaca decomposition method was employed to identify and quantify the contribution of individual endowments to wage differentials between males and females. The analyses of data revealed a gender wage gap that varied across occupations. The inclusion of unpaid overtime in the analysis led to a slight reduction in the wage differential. The results showed an adjusted wage gap of 16.7%. Unpaid overtime made a significant but small contribution to wage differentials. Being female remained the major contributing factor to the wage gap. Given that wage differentials provide a disincentive to work more hours, serious attempts to deal with the skilled labour shortage in the health sector need to address the gender wage gap.

A decision-aid framework to provide guidance for the enhanced use of best available techniques in industry.

PubMed

Georgopoulou, E; Mirasgedis, S; Sarafidis, Y; Hontou, V; Gakis, N; Lalas, D P; Loukatos, A; Gargoulas, N; Mentzis, A; Economidis, D; Triantafilopoulos, T; Korizi, K; Mavrotas, G

2007-09-01

Best Available Techniques (BATs) contribute significantly to the reduction of industrial environmental burdens with respect to air pollution, wastewater, and solid wastes. In Europe, the application of BATs is prescribed by Directive 96/61/EC, which, however, leaves the selection of specific BATs to plant operators. In making their choices, installations have to consider not only the environmental benefits of BATs, but also all relevant cost components. In assessing the economic attractiveness of potential BATs and their combinations, as well as incentives and disincentives to be instituted, the cost of environmental externalities, usually not reflected in market prices, should be taken into account. In this paper, a decision-aid framework combining an assessment of environmental externalities and the utilization of multicriteria methods and, more specifically, Multiobjective Mathematical Programming, capable of addressing all these issues in a comprehensive and coherent manner, is presented. This is illustrated by its application for the region of Attica in Greece, where over 50% of the industrial basis and Athens, with its 4 million inhabitants, are located. The implementation of the framework and its associated tools to 800 installations led to the identification of the specific BATs, alone or in combination, that provide the most cost-effective reductions of four air pollutants (PM10, SO(2), NO(x), VOC) and CO(2). The results also clearly demonstrate the increased pollution reductions that would result from the adoption of BATs made economically attractive by the inclusion of externalities. Estimates of investments and net present values with and without incentives/disincentives are also provided.

How to influence fertility: the experience so far.

PubMed

Weeks, J R

1990-09-01

Even though fertility in the US is 2, the population grows each year by 2.5 million people due to natural increase and immigration. The US has never had a formal population policy to influence its birth rate. Yet the US government advises other nations, especially developing nations, how they should go about reducing their fertility. Instead the US can learn from population policies of direct disincentives, such as no income tax allowance for 3 children. In Indonesia, the president and Islamic religious leaders strongly support family planning. In Mexico, both the public and private sectors provide family planning services. The US does not have experience in influencing fertility declines, since fertility declined due to economic development over a period of time. Some scholars claim that there are 3 preconditions for a sustained decline in fertility, all of which have significance for setting population policies. The 1st is called rational choice in which conditions are such in a society that women can make their own decision. For example, the existence of legislation that guarantees women the right to act in their own interest, including the right to make their own reproductive decisions. The 2nd involves policies or conditions that motivate individuals and/or couples to limit family size. Incentives and disincentives can provide the needed motivation. For example, the government pays a woman for not having a child for a specific interval. The last precondition includes the necessity of having means available to limit family size. These means include knowledge of contraceptive methods and accessibility to them.

Attitudes to participating in a birth cohort study, views from a multiethnic population: a qualitative study using focus groups.

PubMed

Garg, Neeru; Round, Thomas P; Daker-White, Gavin; Bower, Peter; Griffiths, Chris J

2017-02-01

Recruitment to birth cohort studies is a challenge. Few studies have addressed the attitudes of women about taking part in birth cohort studies particularly those from ethnic minority groups. To seek the views of people from diverse ethnic backgrounds about participation in a proposed birth cohort examining the impact of infections. Eight focus groups of pregnant women and mothers of young children took place in GP surgeries and community centres in an ethnically diverse area of east London. Purposeful sampling and language support ensured representation of people from ethnic minority groups. Audio recordings were taken and transcripts were analysed using the Framework approach. The views of participants about taking part in the proposed birth cohort study, in particular concerning incentives to taking part, disincentives and attitudes to consenting children. There was more convergence of opinion than divergence across groups. Altruism, perceived health gains of participating and financial rewards were motivating factors for most women. Worries about causing harm to their child, inconvenience, time pressure and blood sample taking as well as a perceived lack of health gains were disincentives to most. Mistrust of researchers did not appear to be a significant barrier. The study indicates that ethnicity and other demographic factors influence attitudes to participation. To recruit better, birth cohort studies should incorporate financial and health gains as rewards for participation, promote the altruistic goals of research, give assurances regarding the safety of the participating children and sensitive data, avoid discomfort and maximize convenience. Ethnicity influences attitudes to participation in many ways, and researchers should explore these factors in their target population. © 2016 The Authors. Health Expectations Published by John Wiley & Sons Ltd.

Models of practice organisation using dental therapists: English case studies.

PubMed

Sun, N; Harris, R V

2011-08-12

A new dental remuneration system based on bands of activity has changed the reward system operating in dental practices and influenced practitioner behaviour in relation to the delegation of tasks to English dental therapists (DTs). Since dental practitioners operate as independent contractors they are free to innovate. A variety of models incorporating DTs in general practice teams exist, some of which may overcome the apparent delegation constraints embedded within this system of remuneration. To describe the way different practices are organised to take account of DTs in their teams and identify whether any of these models address delegation disincentives arising from the system of remuneration. A purposive sample of six dental practices was identified, comprising two small, two medium and two large dental practices, including a variety of models of practice organisation. Semi-structured interviews were carried out with principal dentists, associate dentists, DTs, practice managers and dental hygienists (35 participants in total). A thematic analysis was applied to interview transcripts. The six dental practices demonstrated six different models of practice organisation which could be grouped into 'practice payment' and 'dentist payment' models according to whether the salary costs of the DT were met by a central practice fund or from the income of individual dentists in the team. In both of the large practices only some of the dentists in the team referred work to the DT because of reimbursement issues. In two practices the system was perceived to be satisfactory to all parties, one of these being a single-handed practice with two DTs. Although the remuneration system contained some potential disincentives to DT delegation, some practices innovated in their organisations to overcome these issues.

Differences in wage rates for males and females in the health sector: a consideration of unpaid overtime to decompose the gender wage gap

PubMed Central

2013-01-01

Background In Australia a persistent and sizable gender wage gap exists. In recent years this gap has been steadily widening. The negative impact of gender wage differentials is the disincentive to work more hours. This implies a substantial cost on the Australian health sector. This study aimed to identify the magnitude of gender wage differentials within the health sector. The investigation accounts for unpaid overtime. Given the limited availability of information, little empirical evidence exists that accounts for unpaid overtime. Methods Information was collected from a sample of 10,066 Australian full-time employees within the health sector. Initially, ordinary least-squares regression was used to identify the gender wage gap when unpaid overtime was included and then excluded from the model. The sample was also stratified by gender and then by occupation to allow for comparisons. Later the Blinder–Oaxaca decomposition method was employed to identify and quantify the contribution of individual endowments to wage differentials between males and females. Results The analyses of data revealed a gender wage gap that varied across occupations. The inclusion of unpaid overtime in the analysis led to a slight reduction in the wage differential. The results showed an adjusted wage gap of 16.7%. Conclusions Unpaid overtime made a significant but small contribution to wage differentials. Being female remained the major contributing factor to the wage gap. Given that wage differentials provide a disincentive to work more hours, serious attempts to deal with the skilled labour shortage in the health sector need to address the gender wage gap. PMID:23433245

Use of Fees to Discourage Nonmedical Exemptions to School Immunization Laws in US States

PubMed Central

Omer, Saad B.

2016-01-01

Recent outbreaks of vaccine-preventable diseases in the United States have renewed public discourse about state vaccine mandates for children entering schools. With acknowledgment of the challenge of eliminating religious and philosophical exemptions in most states, some have proposed instead to impose additional administrative burdens for parents seeking such exemptions. We review the use of taxes, fines, and fees as financial disincentives in public health. We argue that adding processing fees to a comprehensive set of administrative requirements for obtaining exemptions will avoid the use of taxpayer funding for exemption processing and will help tilt the balance of convenience in favor of vaccination. PMID:26691132

The Scandinavian Fantasy: The Sources of Intergenerational Mobility in Denmark and the US

PubMed Central

Landersø, Rasmus; Heckman, James J.

2017-01-01

This paper examines the sources of differences in social mobility between the U.S. and Denmark. Measured by income mobility, Denmark is a more mobile society, but not when measured by educational mobility. There are pronounced nonlinearities in income and educational mobility in both countries. Greater Danish income mobility is largely a consequence of redistributional tax, transfer, and wage compression policies. While Danish social policies for children produce more favorable cognitive test scores for disadvantaged children, these do not translate into more favorable educational outcomes, partly because of disincentives to acquire education arising from the redistributional policies that increase income mobility. PMID:28649168

Disability Insurance and the Dynamics of the Incentive Insurance Trade-Off.

PubMed

Low, Hamish; Pistaferri, Luigi

2018-10-01

We provide a life-cycle framework for comparing insurance and disincentive effects of disability benefits. The risks that individuals face and the parameters of the Disability Insurance (DI ) program are estimated from consumption, health, disability insurance, and wage data. We characterize the effects of disability insurance and study how policy reforms impact behavior and welfare. DI features high rejection rates of disabled applicants and some acceptance of healthy applicants. Despite worse incentives, welfare increases as programs become less strict or generosity increases. Disability insurance interacts with welfare programs: making unconditional means-tested programs more generous improves disability insurance targeting and increases welfare.

The economy of science.

PubMed

Marks, Andrew R

2004-10-01

We are in the midst of an era of plummeting pay lines at the NIH. History shows that when the federal deficit is high, NIH pay lines tend to fall, and the impact on biomedical research can be disastrous. Equally bad is the disincentive for the future generations of biomedical researchers who observe their mentors struggling to get adequate funding. How many bright young people will be turned away from careers in biomedical research? How much innovative science will be delayed or never initiated, how many new cures never realized? At a time of unprecedented challenges and remarkable technological advances that enable us to address those challenges, lack of funding is a threat to our society.

Motivating participation in open science by examining researcher incentives.

PubMed

Ali-Khan, Sarah E; Harris, Liam W; Gold, E Richard

2017-10-30

Support for open science is growing, but motivating researchers to participate in open science can be challenging. This in-depth qualitative study draws on interviews with researchers and staff at the Montreal Neurological Institute and Hospital during the development of its open science policy. Using thematic content analysis, we explore attitudes toward open science, the motivations and disincentives to participate, the role of patients, and attitudes to the eschewal of intellectual property rights. To be successful, an open science policy must clearly lay out expectations, boundaries and mechanisms by which researchers can engage, and must be shaped to explicitly support their values and those of key partners, including patients, research participants and industry collaborators.

Motivating participation in open science by examining researcher incentives

PubMed Central

Ali-Khan, Sarah E; Harris, Liam W

2017-01-01

Support for open science is growing, but motivating researchers to participate in open science can be challenging. This in-depth qualitative study draws on interviews with researchers and staff at the Montreal Neurological Institute and Hospital during the development of its open science policy. Using thematic content analysis, we explore attitudes toward open science, the motivations and disincentives to participate, the role of patients, and attitudes to the eschewal of intellectual property rights. To be successful, an open science policy must clearly lay out expectations, boundaries and mechanisms by which researchers can engage, and must be shaped to explicitly support their values and those of key partners, including patients, research participants and industry collaborators. PMID:29082866

IPPF re-affirms its policy on sterilization: a free, informed and unpressured choice.

PubMed

1977-01-01

The IPPF has re-affirmed its policy on sterilization that individuals have the right to voluntarily choose a contraceptive method. A sterilization acceptor should understand all the implications and that the procedure should be considered irreversible, although medical techniques should be used to give the greatest chance of reversibility. An individual should know of alternative contraceptive methods and the risks and benefits involved with each. Incentives for family planning programs should ensure that benefits be in addition to the benefits and services which are entitled to everyone; likewise, any disincentives should not conflict with basic human rights. Family planning education should promote informed decisions on contraceptive use including sterilization procedures.

Liability issues in managed care.

PubMed

Ellis, M S

1997-05-01

The explosive growth in Managed Care Organizations as a mechanism for providing health care in the United States has generated an equal explosion in litigation and new legislation related to problems within this delivery system. Abuses have included the "gagging" of physicians from providing full disclosure of medical options for their patients, inappropriate denial of care, denial of specialty referral, false claims data, insurer insolvency, economic credentialling, deselection, financial disincentives to render care, and lack of appeal or grievance mechanisms. These issues and others have resulted in injuries to patients and damage to the patient/physician relationship. This article discusses some of the more dramatic litigated cases and endeavors to alert both physicians and patients to potential legal matters that should be considered before becoming involved within this structure.

Reciprocating living kidney donor generosity: tax credits, health insurance and an outcomes registry

PubMed Central

Joshi, Shivam; Joshi, Sheela; Kupin, Warren

2016-01-01

Kidney transplantation significantly improves patient survival, and is the most cost effective renal replacement option compared with dialysis therapy. Living kidney donors provide a valuable societal gift, but face many formidable disincentive barriers that include not only short- and long-term health risks, but also concerns regarding financial expenditures and health insurance. Other than governmental coverage for their medical evaluation and surgical expenses, donors are often asked to personally bear a significant financial responsibility due to lost work wages and travel expenses. In order to alleviate this economic burden for donors, we advocate for the consideration of tax credits, lifelong health insurance coverage, and an outcomes registry as societal reciprocity to reward their altruistic act of kidney donation. PMID:26798480

Irresponsible and responsible resource management in obstetrics.

PubMed

Arabin, Birgit

2017-08-01

Low budgets constrain and high budgets stimulate choices. In high-income countries, this economic reality may lead to overuse of healthcare services and pose unnecessary risks for mothers and infants. Options for improvement can be created at different levels of healthcare systems. Pregnancy provides an effective opportunity to profile maternal risks and represents a vulnerable but potentially modifiable period from prenatal life to adulthood. In response to system-inherent false incentives, professional responsibility requires obstetricians to strive to improve the future health of families and their offspring despite disincentives for doing so. This chapter addresses professionally responsible resource management in obstetrics and identifies implications for patients, care givers, communities, policy makers, and academic faculties. Copyright © 2017. Published by Elsevier Ltd.

Costs, payments, and incentives in family planning programs: a review for developing countries.

PubMed

Ross, J A; Isaacs, S L

1988-01-01

Anxieties about financing health and family planning programs have grown in recent years, leading to discussions of cost-recovery measures that would raise charges to the consumer. Yet some governments wish to lower cost to encourage contraceptive use, and a few use incentives and disincentives. Data from numerous developing countries are presented on contraceptive cost topics: charges for contraceptive supplies and services, in both public and private sectors, and conversely, payments made to clients and providers to offset costs and to increase contraceptive use. The data show great diversity, and much inconsistency within countries, indicating that the structures of charges, payments, and incentives in many programs could be improved. Ethical considerations are discussed, and guidelines are suggested for developing effective financial policies.

Constraining free riding in public goods games: designated solitary punishers can sustain human cooperation

PubMed Central

O'Gorman, Rick; Henrich, Joseph; Van Vugt, Mark

2008-01-01

Much of human cooperation remains an evolutionary riddle. Unlike other animals, people frequently cooperate with non-relatives in large groups. Evolutionary models of large-scale cooperation require not just incentives for cooperation, but also a credible disincentive for free riding. Various theoretical solutions have been proposed and experimentally explored, including reputation monitoring and diffuse punishment. Here, we empirically examine an alternative theoretical proposal: responsibility for punishment can be borne by one specific individual. This experiment shows that allowing a single individual to punish increases cooperation to the same level as allowing each group member to punish and results in greater group profits. These results suggest a potential key function of leadership in human groups and provides further evidence supporting that humans will readily and knowingly behave altruistically. PMID:18812292

Functional assessment in vocational rehabilitation: a systematic approach to diagnosis and goal setting.

PubMed

Crewe, N M; Athelstan, G T

1981-07-01

The Functional Assessment Inventory (FAI) has been developed for diagnostic use in vocational rehabilitation. This study involved field testing and initial validation of the Inventory as a diagnostic tool. Thirty vocational rehabilitation counselors administered the Inventory to 351 clients. Factor analysis identified 8 scales: Cognitive Function, Motor Function, Personality and Behavior. Vocational Qualifications, Medical Condition, Vision, Hearing, and Economic Disincentives. Content and concurrent validity of the Inventory were assessed by comparing the scores of clients grounded by medical diagnosis and by relating scores to counselors' judgments of severity of disability and employability. Clients with various primary disabilities appeared to differ from one another on the factor scales and on individual items in predictable ways. Total Functional Limitations scores were highly correlated with counselors' ratings of severity of disability and employability.

Rewards.

PubMed

Gunderman, Richard B; Kamer, Aaron P

2011-05-01

For much of the 20th century, psychologists and economists operated on the assumption that work is devoid of intrinsic rewards, and the only way to get people to work harder is through the use of rewards and punishments. This so-called carrot-and-stick model of workplace motivation, when applied to medical practice, emphasizes the use of financial incentives and disincentives to manipulate behavior. More recently, however, it has become apparent that, particularly when applied to certain kinds of work, such approaches can be ineffective or even frankly counterproductive. Instead of focusing on extrinsic rewards such as compensation, organizations and their leaders need to devote more attention to the intrinsic rewards of work itself. This article reviews this new understanding of rewards and traces out its practical implications for radiology today. Copyright © 2011. Published by Elsevier Inc.

The Costs of Decedents in the Medicare Program: Implications for Payments to Medicare+Choice Plans

PubMed Central

Buntin, Melinda Beeuwkes; Garber, Alan M; McClellan, Mark; Newhouse, Joseph P

2004-01-01

Objective To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life—a group that accounts for more than one-quarter of Medicare's annual expenditures. Data Source Medicare administrative claims for 1994 and 1995. Study Design We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. Data Extraction Methods The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. Principal Findings Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. Conclusions More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries. PMID:14965080

Managing Earth's Future: Global Self-Restraint for the Common Good or Domination by Incentive and Power?

NASA Astrophysics Data System (ADS)

Anbar, A. D.; Hartnett, H. E.; Rowan, L. R.; Caldeira, K.

2016-12-01

We are global in our impacts, yet local in our thoughts and feelings. The daunting challenge facing Homo sapiens is learning to cooperate at global scale for the common good. Since the invention of the steam engine, we have been developing ever more efficient ways of generating consumer products. Some of the wealth generated by these more efficient technologies was reinvested into additional capital infrastructure, such as factories and machines. We thus expanded capacity to offer goods and services to insatiable consumers, expanding the ability to extract and transform natural resources into both valuable goods and services and dangerous pollution. Improvements in medical technologies led to quasi-exponential population growth, mirroring and multiplying the quasi-exponential growth in per capita consumption. This quasi-exponential growth is starting to reach boundaries, but these boundaries are not sending signals to the market that would allow a laissez faire approach to work. The central question is: How can we continue improving well-being while diminishing material flows associated with environmental pollution? Globally, if we do not place constraints on ourselves, nature will impose constraints on us. We can impose constraints on ourselves to protect us from what nature would otherwise to do to us. To have a sustainable future, we would need to level off population at the lowest feasible levels. The difference between a future population of 6 billion and 16 billion is a half-child per family less-or-more than the central projection of demographers. Empowering women with education and technology has proven to be a most effective strategy at reducing population growth. To have a sustainable future, we would need strong disincentives on environmental damage, especially from long-lived wastes such as carbon dioxide. It is of course a huge political challenge to get such disincentives in place. If we fail to get these global self-protective guardrails established, planetary management will be largely reactive, driven by competition among those with incentive and power. With better policies in place, we can look forward to a future of continuous innovation and ever-improving well-being, with stable populations and diminishing environmental impact.

Peng Peiyun and Jiang Zhenghua answer questions raised by both Chinese and foreign journalists.

PubMed

1993-04-01

In April 1993, the Minister and Vice Minister of the Chinese State Family Planning (FP) Commission held a news conference for Chinese and foreign journalists on population and FP. The Chinese FP program has lowered the birth rate by .5% in 5 years, thus adverting 15 million births. A 1992 survey of 385,000 people showed that the number of acceptors increased 12.3% during 1988-92, and unplanned births declined by 54.7% in the same period. Early marriage were 48% less frequent; marriage age increased from 21.8 to 22.5 years. The fertility rate has experienced this rapid decline because efforts were strengthened in the past 2 years. Despite achieving below replacement level fertility, efforts will continue to enact the current FP policy. Whereas the sex ratio is higher than international standards (111.3 vs. 106), China has instituted and publicized laws and incentives designed to improve the status of women and enhance the equality of women. The phenomenon of "converse elimination," which occurs with urban intellectuals being confined to one child, whereas rural inhabitants have more children, is a natural result of the condition of rural life which makes more children necessary because of the practical daily problems rural inhabitants face. China's population policy, however, is designed to stress both population control and improvement of the quality of human resources. The current policy was devised as a response to conditions which are unlikely to change before the year 2000. Rural areas require access to education, health care, and culture. The policy includes the use of incentives and disincentives for Fp workers, and this system is subject to abuse. The objective of the incentives and disincentives is encouraged and citizens have recourse in the courts if officials behave irresponsibly. A more favorable environment for FP will be created as China moves toward a socialist market economy. As labor migration from rural to urban areas increases, however, FP management will have to be combined with employment credentials to monitor possible unplanned births.

A model of female labor supply in Italy using cohort data.

PubMed

Colombino, U; De Stavola, B

1985-01-01

This paper develops a behavioral model of Italy's female labor supply using cohort data from 1959 to 1981. Both time-series trends and cross-section patterns by age groups of female participation rates in Italy show rather flat profiles. Using an approximate procedure to obtain an estimate of the relevant wage that is the mean of the wages distribution across the whole female population in a given cohort, results show that the flat time-series profile is presumbly produced by economic incentives effects that counterbalance each other. Interaction terms reveal that cross-section profiles by age group do not reflect steady-state dynamics; aging and the presence of children under 6 are less disincentive to younger cohorts. As is typical of most developed countries, this process implies for Italian female participation the emergence of the bimodal cross-section profile by age groups. In the last 20 years, participation rates for all women decreased slightly during the 1st 10 years and then increased, reaching in 1981 a higher level than in 1961. The dependent variable used in the estimation equation is the ratio between particpant (employed and unemployed) women belonging to a cohort; and the total number of women belonging to a cohort in a given year. Results show that as a cohort increases, the negative effects of age and of children are reduced. The results reveal some main points about rather flat participation rate profiles: 1) a very powerful female wage effect, 2) an equally powerful male wage negative effect, and 3) significant interactions,with a positive sign, between cohort and age and between cohort and children. Moreover, younger cohorts, other things being equal, participate more than older cohorts. This is attributable to the fact that the presence of children under 6 and the aging process are less of a disincentive for them than for older cohorts. Overall, the structure of lifetime participation is changing; younger cohorts participation rates, corresponding to child rearing age groups, are higher than older cohorts', and the decreasing effect of age suggests that a reentering phenomenon (after child rearing ages) could be emerging.

Protecting Contract Workers: Case Study of the US Department of Energy’s Nuclear and Chemical Waste Management

PubMed Central

Gochfeld, Michael; Mohr, Sandra

2007-01-01

Increased reliance on subcontractors in all economic sectors is a serious occupational health and safety challenge. Short-term cost savings are offset by long-term liability. Hiring subcontractors brings specialized knowledge but also young, inexperienced, inadequately trained workers onto industrial and hazardous waste sites, which leads to increased rates of accidents and injuries. Reliable data on subcontractor occupational health and safety programs and performance are sparse. The US Department of Energy has an excellent safety culture on paper, but procurement practices and contract language deliver a mixed message—including some safety disincentives. Its biphasic safety outcome data are consistent with underreporting by some subcontractors and underachievement by others. These observations are relevant to the private and public sectors. Occupational health and safety should be viewed as an asset, not merely a cost. PMID:17666686

Brownfields initiatives offer few incentives for prospective developers, purchasers

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wesolowski, T.; Antol, S.M.

There has been much discussion and analysis in recent years among government agencies and state legislators regarding redevelopment of contaminated industrial sites, or brownfields. The goal of brownfields program is to encourage developers and purchasers to redevelop existing industrial sites, rather than choosing greenfield suburban sites. These programs create initiatives for redevelopment, such as reducing the potential liability of innocent purchasers or developers, streamlining administrative process relating to cleanups, and issuing guidance on cleanup methods and standards. Although such attempts are admirable and important, brownfields initiatives have failed because they address only one component of what is necessary to achievemore » redevelopment. The initiatives attempt to minimize disincentives to brownfields redevelopment; however, what is necessary for progress in this area is to create real economic and other incentives to make such redevelopment more attractive.« less

Cash, rewards, and benefits in organ transplantation: an open letter to Senator Arlen Specter.

PubMed

Danovitch, Gabriel

2009-04-01

To consider proposals to use financial incentives for organ donors that have become a subject of intense controversy in both lay and medical press (in contradistinction to the removal of financial disincentives, which is essentially noncontroversial although typically not practiced). In a concerned response to the shortage of organs the office of Senator Specter of Pennsylvania has been the source of a proposal to amend the 1984 United States National Organ Transplant Act, which has been interpreted to prohibit such incentives. The proposal would permit various forms of financial incentives for donation to no longer be prohibited. The amendment would have unintentional negative consequences that could undermine, rather than strengthen, the national and international organ transplant endeavor. These concerns are considered in my personal correspondence to Senator Specter's office on which the text is based.

Protecting contract workers: case study of the US Department of Energy's nuclear and chemical waste management.

PubMed

Gochfeld, Michael; Mohr, Sandra

2007-09-01

Increased reliance on subcontractors in all economic sectors is a serious occupational health and safety challenge. Short-term cost savings are offset by long-term liability. Hiring subcontractors brings specialized knowledge but also young, inexperienced, inadequately trained workers onto industrial and hazardous waste sites, which leads to increased rates of accidents and injuries. Reliable data on subcontractor occupational health and safety programs and performance are sparse. The US Department of Energy has an excellent safety culture on paper, but procurement practices and contract language deliver a mixed message--including some safety disincentives. Its biphasic safety outcome data are consistent with underreporting by some subcontractors and underachievement by others. These observations are relevant to the private and public sectors. Occupational health and safety should be viewed as an asset, not merely a cost.

Does Increased Spending on Pharmaceutical Marketing Inhibit Pioneering Innovation?

PubMed

Arnold, Denis G; Troyer, Jennifer L

2016-04-01

The pharmaceutical industry has been criticized for developing and aggressively marketing drugs that do not provide significant health benefits relative to existing drugs but retain the benefits of patent protection. Critics argue that drug marketing increases health care expenditures and provides a disincentive for pioneering drug innovation. However, evidence that marketing expenditures have any relationship to new drug approvals has been anecdotal. We hypothesized that, at publicly traded pharmaceutical firms, increased marketing expenditures will result in a reduced volume of pioneering new drugs in comparison to less innovative new drugs. We also hypothesized that additional research and development spending will result in an increased volume of pioneering new drugs in comparison to less innovative drugs. Results confirm our hypotheses. Specific policy recommendations for altering firms' incentives for the development of pioneering drugs are provided. Copyright © 2016 by Duke University Press.

[Incentives and disincentives for research and development of new drugs by the pharmaceutical industry].

PubMed

Curcio, Pasqualina Curcio

2008-10-01

The authors present a model with factors that influence research and development decisions by the pharmaceutical industry: risk of disease transmission and possibility of control; case-fatality and the presence of cure or treatments; income; number of persons who demand the medicine; and opportunity costs for the company. Companies tend to invest in markets with inelastic demand (highly contagious diseases with no possibility of controlling transmission and/or very lethal diseases without treatment) and/or where there is a large population or high per capita income. Companies tend not to invest in markets where marginal costs exceed marginal income, particularly when costs increase permanently as a consequence of rising opportunity costs generated by foregoing profit in other markets. In such cases, policies to subsidize R&D are not effective, and policies must be orientated towards strengthening basic and applied research by public institutions.

Financial considerations in living organ donation.

PubMed

Jacobs, Cheryl; Thomas, Charlie

2003-06-01

The shortage of cadaveric organs and increased success of living donor transplantation support the use of living organ donors. Clinical social workers have the opportunity to explore a variety of donor-specific issues when performing psychosocial evaluations of living donors, including motivation, psychological stability, and personal and family consequences of donation, as well as the direct and indirect financial consequences faced by living donors. Although most donor-related medical costs are covered, other associated expenses are not reimbursable and may put donors at risk for financial hardship. Out-of-pocket expenses also serve as a disincentive to donate for some volunteers. During the evaluation process, healthcare professionals should openly discuss how surgery, recovery, and any potential complications might impact prospective donors' financial situation. Donors can then decide whether they are able to realistically handle the costs of donation. We present the financial dilemmas experienced by many living donors and highlight efforts that have been made to deal with them.

The Complex Relationship Between Diet And Health.

PubMed

Bleich, Sara N; Jones-Smith, Jessica; Wolfson, Julia A; Zhu, Xiaozhou; Story, Mary

2015-11-01

The relationship between food and health is complex. Everyone needs food to live, but too little food, too much food, or the wrong type of food has negative consequences for health. To increase understanding of this relationship, we describe trends and patterns in food-related diseases among both adults and children. Using an ecological framework, we then describe why food intake is complex with a discussion of three broad levels--macro (including policy and social-cultural norms), local community, and individual environments--and their relationship to food consumption. Given the strong relationship between an individual's food choice and his or her surrounding environment, we end with examples of policy responses that aim to help people overcome environmental disincentives toward healthy eating. Finding ways to make eating healthfully easier and affordable for all populations is essential to shifting the average American diet toward one that promotes health. Project HOPE—The People-to-People Health Foundation, Inc.

Barriers to Innovation in Urban Wastewater Utilities: Attitudes of Managers in California.

PubMed

Kiparsky, Michael; Thompson, Barton H; Binz, Christian; Sedlak, David L; Tummers, Lars; Truffer, Bernhard

2016-06-01

In many regions of the world, urban water systems will need to transition into fundamentally different forms to address current stressors and meet impending challenges-faster innovation will need to be part of these transitions. To assess the innovation deficit in urban water organizations and to identify means for supporting innovation, we surveyed wastewater utility managers in California. Our results reveal insights about the attitudes towards innovation among decision makers, and how perceptions at the level of individual managers might create disincentives for experimentation. Although managers reported feeling relatively unhindered organizationally, they also spend less time on innovation than they feel they should. The most frequently reported barriers to innovation included cost and financing; risk and risk aversion; and regulatory compliance. Considering these results in the context of prior research on innovation systems, we conclude that collective action may be required to address underinvestment in innovation.

Impacts of public policies and farmer preferences on agroforestry practices in Kerala, India.

PubMed

Guillerme, S; Kumar, B M; Menon, A; Hinnewinkel, C; Maire, E; Santhoshkumar, A V

2011-08-01

Agroforestry systems are fundamental features of the rural landscape of the Indian state of Kerala. Yet these mixed species systems are increasingly being replaced by monocultures. This paper explores how public policies on land tenure, agriculture, forestry and tree growing on private lands have interacted with farmer preferences in shaping land use dynamics and agroforestry practices. It argues that not only is there no specific policy for agroforestry in Kerala, but also that the existing sectoral policies of land tenure, agriculture, and forestry contributed to promoting plantation crops, even among marginal farmers. Forest policies, which impose restrictions on timber extraction from farmers' fields under the garb of protecting natural forests, have often acted as a disincentive to maintaining tree-based mixed production systems on farmlands. The paper argues that public policies interact with farmers' preferences in determining land use practices.

Debt management and financial planning support for primary care students and residents at Boston University School of Medicine.

PubMed

Terrell, C; Hindle, D

1999-01-01

Boston University Medical Center created the Office of Residency Planning and Practice Management as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative. Since 1995, the office has improved the medical center's ability to promote and support the generalist career decisions of its students and residents by removing indebtedness as a disincentive. After a brief review of the relationship between indebtedness and specialty selection, the authors delineate the nature and volume of debt-management assistance provided by the office to students and residents through individual counseling sessions, workshops, and other means between April 1995 and March 1998. A case study shows the progression of these services throughout residency training. The medical center also coordinates its debt-management assistance with counseling from physician-oriented financial planning groups. In conclusion, the authors discuss several characteristics of a successful debt-management program for residents.

Barriers to Innovation in Urban Wastewater Utilities: Attitudes of Managers in California

NASA Astrophysics Data System (ADS)

Kiparsky, Michael; Thompson, Barton H.; Binz, Christian; Sedlak, David L.; Tummers, Lars; Truffer, Bernhard

2016-06-01

In many regions of the world, urban water systems will need to transition into fundamentally different forms to address current stressors and meet impending challenges—faster innovation will need to be part of these transitions. To assess the innovation deficit in urban water organizations and to identify means for supporting innovation, we surveyed wastewater utility managers in California. Our results reveal insights about the attitudes towards innovation among decision makers, and how perceptions at the level of individual managers might create disincentives for experimentation. Although managers reported feeling relatively unhindered organizationally, they also spend less time on innovation than they feel they should. The most frequently reported barriers to innovation included cost and financing; risk and risk aversion; and regulatory compliance. Considering these results in the context of prior research on innovation systems, we conclude that collective action may be required to address underinvestment in innovation.

Psychological science's contributions to a sustainable environment: extending our reach to a grand challenge of society.

PubMed

Kazdin, Alan E

2009-01-01

Climate change and degradation of the environment are global problems associated with many other challenges (e.g., population increases, reduction of glaciers, and loss of critical habitats). Psychological science can play a critical role in addressing these problems by fostering a sustainable environment. Multiple strategies for fostering a sustainable environment could draw from the diversity of topics and areas of specialization within psychology. Psychological research on fostering environmentally sustainable behaviors is rather well developed, as illustrated by interventions focusing on education of the public, message framing, feedback, decision making, the media, incentives and disincentives, and social marketing. Other sciences and professions as well as religion and ethics are actively involved in fostering a sustainable environment. Psychology ought to be more involved directly, systematically, and visibly to draw on our current knowledge and to have palpable impact. We would serve the world very well and in the process our discipline and profession.

Teaching medical ethics to meet the realities of a changing health care system.

PubMed

Millstone, Michael

2014-06-01

The changing context of medical practice--bureaucratic, political, or economic--demands that doctors have the knowledge and skills to face these new realities. Such changes impose obstacles on doctors delivering ethical care to vulnerable patient populations. Modern medical ethics education requires a focus upon the knowledge and skills necessary to close the gap between the theory and practice of ethical care. Physicians and doctors-in-training must learn to be morally sensitive to ethical dilemmas on the wards, learn how to make professionally grounded decisions with their patients and other medical providers, and develop the leadership, dedication, and courage to fulfill ethical values in the face of disincentives and bureaucratic challenges. A new core focus of medical ethics education must turn to learning how to put ethics into practice by teaching physicians to realistically negotiate the new institutional maze of 21st-century medicine.

Food taxation and pricing strategies to "thin out" the obesity epidemic.

PubMed

Kim, Daniel; Kawachi, Ichiro

2006-05-01

This article highlights characteristics of two related yet distinct economic approaches to addressing the current obesity epidemic in the United States: the general taxation of soft drinks, snack foods, and/or fast foods, and the application of pricing incentives/disincentives on foods sold in schools and worksites. The article specifically focuses on the: (1) rationale for, (2) potential barriers and limitations to, and (3) possible unintended consequences of implementing these policy interventions at the state level. Novel empirical evidence showing strong positive associations between the presence of state-level taxation on soft drinks or snack foods between 1991 and 1998 and relative changes in obesity prevalence over the same time period is further presented. The article concludes by summarizing the similarities and dissimilarities of the two approaches, and by emphasizing some of the gaps and priorities regarding these strategies that should be addressed in future research and policies to best effect obesity prevention.

Accustomed to enduring: experiences of African-American women seeking care for cardiac symptoms.

PubMed

Banks, Angela D; Malone, Ruth E

2005-01-01

Understand the meaning of delayed treatment seeking in African-American women with unstable angina and myocardial infarction. Phenomenologic analysis of in-depth interview data and field notes on 12 African-American women hospitalized with unstable angina or myocardial infarction. Women's interpretation of and response to symptoms were informed by experiences of marginalization and their self-understanding as people who were strong and who had endured life's hardships. When hospitalized, some women experienced trivialization of their complaints by clinicians and a focus on technological procedures over respectfully attending to their concerns, which provided further disincentives to seeking care. Three major themes emerged: misrecognition and discounting of symptoms, enduring, and influence of faith. Experiences of marginalization shape responses to symptoms, care-seeking behavior, and interpretation of subsequent care experiences for African-American women with cardiac disease, who may experience different symptoms as well as interpret them differently than members of other groups.

Promoting energy conservation: An analysis of behavioral research

DOE Office of Scientific and Technical Information (OSTI.GOV)

Katzev, R.D.; Johnson, T.R.

1987-01-01

This book reviews and analyzes the past ten years of research on changing the energy-related behavior of individuals. It reviews the results of about 200 studies and presents them in a form usable by program designers, researchers, and auditors in the field. The book discusses the effectiveness of ways to change people's behavior to save more energy, e.g., to get them to recycle, carpool, or turn down the thermostat. The book analyzes three ways to motivate people to change their behavior: antecedent communications, consequences, and social influences. Antecedent communications are sent to people before they make energy conservation decisions, andmore » include information, prompts, and persuasion. Techniques that change the consequences of acting in a certain way include feedback, incentives, and disincentives. Social influence techniques include group contingencies (rewards predicated on the behavior of a group of people, rather than one individual), demonstrations of ways to conserve energy, and solicitations of individual commitments to conserve. Katzev and Johnson derive lessons from the research on each type of technique.« less

Are patients' decisions to refuse treatment binding on health care professionals?

PubMed

Murphy, Peter

2005-06-01

When patients refuse to receive medical treatment, the consequences of honouring their decisions can be tragic. This is no less true of patients who autonomously decide to refuse treatment. I distinguish three possible implications of these autonomous decisions. According to the Permissibility Claim, such a decision implies that it is permissible for the patient who has made the autonomous decision to forego medical treatment. According to the Anti-Paternalism Claim, it follows that health-care professionals are not morally permitted to treat that patient. According to the Binding Claim it follows that these decisions are binding on health-care professionals. My focus is the last claim. After arguing that it is importantly different from each of the first two claims, I give two arguments to show that it is false. One argument against the Binding Claim draws a comparison with cases in which patients autonomously choose perilous positive treatments. The other argument appeals to considered judgments about cases in which disincentives are used to deter patients from refusing sound treatments.

Why bundled payments could drive innovation: an example from interventional oncology.

PubMed

Steele, Joseph R; Jones, A Kyle; Ninan, Elizabeth P; Clarke, Ryan K; Odisio, Bruno C; Avritscher, Rony; Murthy, Ravi; Mahvash, Armeen

2015-03-01

Some have suggested that the current fee-for-service health care payment system in the United States stifles innovation. However, there are few published examples supporting this concept. We implemented an innovative temporary balloon occlusion technique for yttrium 90 radioembolization of nonresectable liver cancer. Although our balloon occlusion technique was associated with similar patient outcomes, lower cost, and faster procedure times compared with the standard-of-care coil embolization technique, our technique failed to gain widespread acceptance. Financial analysis revealed that because the balloon occlusion technique avoided a procedural step associated with a lucrative Current Procedural Terminology billing code, this new technique resulted in a significant decrease in hospital and physician revenue in the current fee-for-service payment system, even though the new technique would provide a revenue enhancement through cost savings in a bundled payment system. Our analysis illustrates how in a fee-for-service payment system, financial disincentives can stifle innovation and advancement of health care delivery. Copyright © 2015 by American Society of Clinical Oncology.

Opportunities and obstacles to collecting wildlife disease data for public health purposes: Results of a pilot study on Vancouver Island, British Columbia

PubMed Central

Stitt, Tyler; Mountifield, Julie; Stephen, Craig

2007-01-01

Existing sources of wildlife morbidity and mortality data were evaluated and 3 pilot active surveillance projects were undertaken to compare and contrast methods for collecting wildlife disease data on Vancouver Island for public health purposes. Few organizations could collect samples for diagnostic evaluation, fewer still maintained records, and none regularly characterized or reported wildlife disease for public health purposes. Wildlife rehabilitation centers encountered the greatest variety of wildlife from the largest geographic area and frequently received submissions from other organizations. Obstacles to participation included the following: permit restrictions; financial disincentives; staff safety; no mandate to collect relevant data; and lack of contact between wildlife and public health agencies. Despite these obstacles, modest investments in personnel allowed novel pathogens of public health concern to be tracked. Targeted surveillance for known pathogens in specific host species, rather than general surveys for unspecified pathogens, was judged to be a more effective and efficient way to provide useful public health data. PMID:17310627

Psychology's Replication Crisis and the Grant Culture: Righting the Ship.

PubMed

Lilienfeld, Scott O

2017-07-01

The past several years have been a time for soul searching in psychology, as we have gradually come to grips with the reality that some of our cherished findings are less robust than we had assumed. Nevertheless, the replication crisis highlights the operation of psychological science at its best, as it reflects our growing humility. At the same time, institutional variables, especially the growing emphasis on external funding as an expectation or de facto requirement for faculty tenure and promotion, pose largely unappreciated hazards for psychological science, including (a) incentives for engaging in questionable research practices, (b) a single-minded focus on programmatic research, (c) intellectual hyperspecialization, (d) disincentives for conducting direct replications, (e) stifling of creativity and intellectual risk taking, (f) researchers promising more than they can deliver, and (g) diminished time for thinking deeply. Preregistration should assist with (a), but will do little about (b) through (g). Psychology is beginning to right the ship, but it will need to confront the increasingly deleterious impact of the grant culture on scientific inquiry.

Elderly Immigrants' Labor Supply Response to Supplemental Security Income.

PubMed

Kaushal, Neeraj

2010-01-01

This paper examined how the 1996 Personal Responsibility and Work Opportunity Reconciliation Act, which banned Supplemental Security Income to the majority of elderly immigrants, affected their employment, retirement, and family incomes. The policy was found to be associated with a 3.5 percentage point (9.5 percent) increase in the employment and a 3.8 percentage point (7 percent) decrease in the retirement of foreign-born elderly men. Partly as a result of their employment response, SSI ineligibility and the consequent decline in SSI receipt did not have any statistically significant effects on the family incomes of elderly foreign-born men. Noncitizen elderly women, on the other hand, did not experience any increase in employment, and those without family support suffered a 10 to 17 percent decline in income. These findings suggest that access to SSI did not create work disincentives for noncitizen elderly women and that SSI restrictions have imposed financial hardship on those without any family support, many of whom perhaps cannot effectively increase their employment.

Health economics in the United States: cost implications.

PubMed

Whitelaw, G N

1993-01-01

World health care costs are increasing uncontrollably and will continue to grow even if draconian controls are implemented immediately. In the United States, the health care objectives are to control the escalating costs of health care and increase access to quality care. To achieve these goals, new administrative controls will be put in place to respond to the cost pressures. New policies to accommodate these new controls will be made by the state and federal governments and by various private third parties. The policies will contain incentives and disincentives for private and institutional providers and beneficiaries. As a result, providers are responding with various cost-control techniques and payors are attempting to reduce costs. In addition, new decision makers in hospitals, insurance companies, and government will be evaluating new technologies by new standards. In order to gain or maintain significant market penetration for a product, drug and device manufacturers will have to develop a multifaceted strategy to present their products in the most favorable economic light.

Social inequalities in 'sickness': European welfare states and non-employment among the chronically ill.

PubMed

van der Wel, Kjetil A; Dahl, Espen; Thielen, Karsten

2011-12-01

The aim of this paper is to examine educational inequalities in the risk of non-employment among people with illnesses and how they vary between European countries with different welfare state characteristics. In doing so, the paper adds to the growing literature on welfare states and social inequalities in health by studying the often overlooked 'sickness'-dimension of health, namely employment behaviour among people with illnesses. We use European Union Statistics on Income and Living Conditions (EU-SILC) data from 2005 covering 26 European countries linked to country characteristics derived from Eurostat and OECD that include spending on active labour market policies, benefit generosity, income inequality, and employment protection. Using multilevel techniques we find that comprehensive welfare states have lower absolute and relative social inequalities in sickness, as well as more favourable general rates of non-employment. Hence, regarding sickness, welfare resources appear to trump welfare disincentives. Copyright © 2011 Elsevier Ltd. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Crull, A.W.

Natural gas and petroleum issues have caused regional tensions between the producing southwestern states and the rest of the country. High energy prices for intrastate sales have meant that residents of producing states pay more for gas and oil than customers of consuming states. A population shift to the ''Sunbelt'' that includes legal aliens from the north and illegal aliens from Mexico is having social and economic impacts on these states, which are now asking why other states aren't sharing in the environmental costs of developing energy sources. Governor Edwards of Louisiana has led the way in demanding that othermore » states share the burdens of drilling. Legislators are blamed for the financial disincentives that have delayed exploration in the name of environmental protection. The seeming double standard toward East Coast states compared to Gulf States is resented in the Southwest, where state governments and industries are coping and proceeding with energy development. How the proposed Strategic Petroleum Reserve program will be managed and financed is another area of concern. (DCK)« less

Telemedicine: legal and licensure issues

NASA Astrophysics Data System (ADS)

Wood, Michael B.; Whelan, Leo J.

1995-10-01

The National Information Infrastructure program offers a great opportunity for the United States to capitalize on remarkable technological advancements over a broad range of applications benefiting society. One such application, telemedicine, has the potential to offer widespread access to sophisticated medical care, curtailed health care delivery costs, and homogeneous health and health-related educational opportunities. However, there are a variety of barriers to widespread application of telemedicine once the technical infrastructure of the information highway is well established and ubiquitous. These barriers include technical limitations, reimbursement issues, equipment and networking costs, and appropriate scientific studies to document efficacy and cost effectiveness. These issues may prove to be only transient disincentives which can be surmounted. Additional barriers exist, however, that may not be as readily resolved by traditional methods of analysis and more widespread practice applications. These political and regulatory obstacles will require clarification of the issues and solutions based on national consensus. It is the purpose of this discussion to amplify on these particular barriers which include licensure and tort jurisdiction.

The central role of agricultural water-use productivity in sustainable water management (Invited)

NASA Astrophysics Data System (ADS)

Gleick, P. H.

2013-12-01

As global and regional populations continue to rise for the next several decades, the need to grow more food will worsen old -- and produce new -- challenges for water resources. Expansion of irrigated agriculture is slowing due to constraints on land and water, and as a result, some have argued that future new food demands will only be met through improvements in agricultural productivity on existing irrigated and rainfed cropland, reductions in field losses and food waste, and social changes such as dietary preferences. This talk will address the central role that improvements in water-use productivity can play in the food/water/population nexus. In particular, the ability to grow more food with less water will have a great influence on whether future food demands will be met successfully. Such improvements can come about through changes in technology, regulatory systems, economic incentives and disincentives, and education of water users. Example of potential savings from three different strategies to improve agricultural water productivity in California. (From Pacific Institute).

Changing clinicians' behavior: a randomized controlled trial of fees and education.

PubMed

Clarkson, J E; Turner, S; Grimshaw, J M; Ramsay, C R; Johnston, M; Scott, A; Bonetti, D; Tilley, C J; Maclennan, G; Ibbetson, R; Macpherson, L M D; Pitts, N B

2008-07-01

The fissure-sealing of newly erupted molars is an effective caries prevention treatment, but remains underutilized. Two plausible reasons are the financial disincentive produced by the dental remuneration system, and dentists' lack of awareness of evidence-based practice. The primary hypothesis was that implementation strategies based on remuneration or training in evidence-based healthcare would produce a higher proportion of children receiving sealed second permanent molars than standard care. The four study arms were: fee per sealant treatment, education in evidence-based practice, fee plus education, and control. A cost-effectiveness analysis was conducted. Analysis was based on 133 dentists and 2833 children. After adjustment for baseline differences, the primary outcome was 9.8% higher when a fee was offered. The education intervention had no statistically significant effect. 'Fee only' was the most cost-effective intervention. The study contributes to the incentives in health care provision debate, and led to the introduction of a direct fee for this treatment.

Implementation of green infrastructure concept in Citarum Watershed

NASA Astrophysics Data System (ADS)

Maryati, Sri; Humaira, An Nisaa'Siti

2017-03-01

Green infrastructure has several benefits compared to grey infrastructure in term of environmental services and sustainability, such as reducing energy consumption, improving air quality, providing carbon sequestration, and increasing property values. Nevertheless in practice, the implementation of the concept in Indonesia is still limited. Implementation of the certain concept has to be guided in planning document. In this paper, green infrastructure concept in the current spatial plan and other planning documents is assessed. The purpose of this research is to figure out how far the green infrastructure concept is integrated into planning system, based on the analysis of planning documents in Citarum Watershed and expert interviews with local stakeholders. Content analysis method is used to analyze the documents and result of interview. The result shows that green infrastructure concept has not been accommodated in spatial plan or other planning documents widely. There are some challenges in implementing the concept including reward and punishment system (incentive and disincentive), coordination, and lack of human resources.

The children of mama coca: coca, cocaine and the fate of harm reduction in South America.

PubMed

Bastos, Francisco I; Caiaffa, Waleska; Rossi, Diana; Vila, Marcelo; Malta, Monica

2007-03-01

The paper reviews the main findings from substance misuse research carried out over the last two decades in South America looking at the main initiatives aimed at reducing drug related harm and curbing the spread of HIV/AIDS and other sexually transmitted and blood-borne diseases. The current challenges faced by harm reduction in the region are analysed from the perspective of the history of coca and its different uses in South America. Except in Brazil and Argentina, the implementation of initiatives to reduce drug related harm in South America has been very cautious. The paper aims to link the analysis of harms associated with the use of illicit substances, with the often paradoxically harmful effects of supply-side drug policies in the world's largest coca/cocaine producing area. Despite the undeniable success of many initiatives, the broader context of harm maximization through structural violence and entrenched corruption acts as a major disincentive for the comprehensive adoption of sound public health policies.

The barriers to environmental sustainability in post-disaster settings: a case study of transitional shelter implementation in Haiti.

PubMed

Abrahams, Daniel

2014-04-01

Disaster recovery operations that do not account for environmental sustainability (ES) risk exacerbating the impact of the disaster and hindering long-term recovery efforts. Yet aid agencies do not always consider ES. This research is a case study of the recovery that followed the 2010 earthquake in Haiti. Using timber and concrete procurement as proxies for broader post-disaster operations, research examined perceptions of ES as well as attempts at and barriers to incorporating it into programming. Identified barriers can be grouped into two categories: (1) prioritisations and perceptions within the disaster response sector that resulted in limited enthusiasm for incorporating ES into programming, and (2) structural and organisational barriers within the disaster response framework that impeded ES attempts and served as a further disincentive to incorporating ES into programming. As a result of those barriers, incorporation of ES was sporadic and inconsistent and often depended on the capacity and motivation of specific implementers. © 2014 The Author(s). Disasters © Overseas Development Institute, 2014.

Encryption and the loss of patient data.

PubMed

Miller, Amalia R; Tucker, Catherine E

2011-01-01

Fast-paced IT advances have made it increasingly possible and useful for firms to collect data on their customers on an unprecedented scale. One downside of this is that firms can experience negative publicity and financial damage if their data are breached. This is particularly the case in the medical sector, where we find empirical evidence that increased digitization of patient data is associated with more data breaches. The encryption of customer data is often presented as a potential solution, because encryption acts as a disincentive for potential malicious hackers, and can minimize the risk of breached data being put to malicious use. However, encryption both requires careful data management policies to be successful and does not ward off the insider threat. Indeed, we find no empirical evidence of a decrease in publicized instances of data loss associated with the use of encryption. Instead, there are actually increases in the cases of publicized data loss due to internal fraud or loss of computer equipment.

Population and international security

DOE Office of Scientific and Technical Information (OSTI.GOV)

McNamara, R.S.

The former Secretary of Defense examines data on population trends and military spending around the world and concludes that the industrialized world is spending a disproportionate amount of its resources on defense and not enough on intervention to lower the birth rate. Population projections of 11 billion and higher are felt to be untenable. Indications of a declining birth rate in the developing countries, while welcome, are felt to be too slow to achieve an acceptable population level. Government action is called for to bring about a reduction in fertility. Government interventions to encourage smaller families, however, must be accompaniedmore » by the means to do so. Several strategies are outlined that could influence family size by raising standards of health, education, income distribution, and the status of women. Supporting this demand by couples to limit their offspring should be improved family planning, delivery service, a broader choice of contraceptives, and more research on reproductive biology and contraceptive techniques. The government is in a position to encourage socio-economic changes through public information programs and a system of incentives and disincentives designed to achieve the desired goal. (DCK)« less

Policy reform dilemmas in promoting employment of persons with severe mental illness.

PubMed

Noble, J H

1998-06-01

Recent evaluations by the U.S. General Accounting Office and the National Alliance for the Mentally Ill of reemployment efforts of the federal-state vocational rehabilitation program found that services offered by state vocational rehabilitation agencies do not produce long-term earnings for clients with emotional or physical disabilities. This paper examines reasons for these poor outcomes and the implications of recent policy reform recommendations. Congress must decide whether to take action at the federal level to upgrade programs affecting persons with severe mental illnesses or to continue to rely on state decision making. The federal-state program largely wastes an estimated $490 million annually on time-limited services to consumers with mental illnesses. Rechanneled into a variety of innovative and more appropriate integrated services models, the money could buy stable annual vocational rehabilitation funding for 62,000 to 90,000 consumers with severe mental illnesses. Larger macrosystem problems involve the dynamics of the labor market that limit job opportunities and the powerful work disincentives for consumers with severe disabilities now inherent in Social Security Disability Insurance, Supplemental Security Income, Medicare, and Medicaid.

Early intervention services for psychosis and time until application for disability income support: a survival analysis.

PubMed

Krupa, Terry; Oyewumi, Kola; Archie, Suzanne; Lawson, J Stuart; Nandlal, Joan; Conrad, Gretchen

2012-10-01

Ensuring the financial security of individuals recovering from first episode psychosis is imperative, but disability income programs can be powerful disincentives to employment, compromising the social and occupational aspects of recovery. Survival analysis and Cox regression analysis were used to examine the rate at which individuals served by early intervention for psychosis (EIP) services apply for government disability income benefits and factors that predict rate of application. Health records for 558 individuals served by EIP programs were reviewed. Within the first year of receiving services 30% will make application for disability income; 60% will do so by 5 years. Rate of application is predicted by rate of hospital admission, financial status and engagement in productivity roles at the time of entry to EIP service. The findings suggest the need to examine the extent to which the recovery goals of EI services are undermined by early application for government income support. They also suggest the need to develop best practice guidelines related to ensuring the economic security of individuals served.

Basic principles of stability.

PubMed

Egan, William; Schofield, Timothy

2009-11-01

An understanding of the principles of degradation, as well as the statistical tools for measuring product stability, is essential to management of product quality. Key to this is management of vaccine potency. Vaccine shelf life is best managed through determination of a minimum potency release requirement, which helps assure adequate potency throughout expiry. Use of statistical tools such a least squares regression analysis should be employed to model potency decay. The use of such tools provides incentive to properly design vaccine stability studies, while holding stability measurements to specification presents a disincentive for collecting valuable data. The laws of kinetics such as Arrhenius behavior help practitioners design effective accelerated stability programs, which can be utilized to manage stability after a process change. Design of stability studies should be carefully considered, with an eye to minimizing the variability of the stability parameter. In the case of measuring the degradation rate, testing at the beginning and the end of the study improves the precision of this estimate. Additional design considerations such as bracketing and matrixing improve the efficiency of stability evaluation of vaccines.

Human behavioral research in space: quandaries for research subjects and researchers

NASA Technical Reports Server (NTRS)

Shepanek, Marc

2005-01-01

With the advent of long-duration spaceflight on board the International Space Station (ISS) and possible future missions beyond low Earth orbit (LEO) such as Mars, it is critical that those at NASA have a realistic assessment of the challenges that will face individuals on long-duration missions so that they can develop preventive and real-time countermeasures to behavioral health issues. While space travellers are very interested in having countermeasures to the deleterious effects of space missions, they have a powerful disincentive to participate in this research if they feel it could in any way negatively affect their flight status. The behavioral issues of isolation and confinement for extended-duration space missions are reviewed. Areas of basic and clinical behavioral research are listed. And the classical clinical model for research is not considered appropriate for the current configuration of the space program. The use of analogue environments and advanced statistical analysis are suggested as ways to address the limited spaceflight research opportunities. The challenge of research subject or patient confidentiality vs. mission safety and issues of personal flight status are addressed.

Family physicians in Switzerland: transition from residency to family practice.

PubMed

Buddeberg-Fischer, Barbara; Klaghofer, Richard; Stamm, Martina

2011-01-01

The study is concerned with family physicians in the transition phase from residency to practice. Factors relating to the decision to take up a career in family medicine rather than a different medical career are investigated. Further, incentives and disincentives for starting a family practice as well as factors influencing the decision about practice location and practice model are addressed. In a prospective cohort study on physicians' career development, 88 family physicians and 437 physicians aspiring to a different medical career participated in a questionnaire survey on the reasons for their choice of specialty and career, their mentoring support, and their work-life balance aspirations. Quantitative and qualitative data were analyzed using hierarchical logistic regression and content analysis, respectively. Family physician tutors should actively approach trainees in medical school and residency, pointing out the advantages of family medicine in terms of continuity of patient contact and the wide range of illnesses and patients, as well as the prospect of a work-life balance tailored to personal needs. Unlike other countries, Switzerland started its structured residency-training programs only recently.

Debate on vaccines and autoimmunity: Do not attack the author, yet discuss it methodologically.

PubMed

Bragazzi, Nicola Luigi; Watad, Abdulla; Amital, Howard; Shoenfeld, Yehuda

2017-10-09

Since Jenner, vaccines and vaccinations have stirred a hot, highly polarized debate, leading to contrasting positions and feelings, ranging from acritical enthusiasm to blind denial. On the one hand, we find anti-vaccination movements which divulge and disseminate misleading information, myths, prejudices, and even frauds, with the main aim of denying that vaccination practices represent a major public health measure, being effective in controlling infectious diseases and safeguarding the wellbeing of entire communities. Recently, the authors of many vaccine safety investigations are being personally criticized rather than the actual science being methodologically assessed and critiqued. Unfortunately, this could result in making vaccine safety science a "hazardous occupation". Critiques should focus on the science and not on the authors and on the scientists that publish reasonably high-quality science suggesting a problem with a given vaccine. These scientists require adequate professional protection so there are not disincentives to publish and to carry out researches in the field. The issues for vaccine safety are not dissimilar to other areas such as medical errors and drug safety. Copyright © 2017 Elsevier Ltd. All rights reserved.

The prohibition of kidney sales and organ markets should remain.

PubMed

Danovitch, Gabriel M; Delmonico, Francis L

2008-08-01

There is an ongoing vigorous debate regarding the wisdom of the current prohibition of organ sales in the United States. We argue that this prohibition must remain in place. We discuss the current international realities regarding organ vending in order to show that even a so-called 'regulated' market brings with it danger to the welfare of transplant donors, their recipients, and potential recipients of nonrenal organs. We counter the specific arguments made in favor of organ sales while recommending multiple measures that can serve to remove disincentives to noncommercial organ donation. We encourage the investment in innovative healthy transplant practice for the benefit of all. In 'natural experiments' performed in developing countries the outcome for kidney vendors, in terms of both their medical and psychosocial health, has been shown to be poor. A high incidence of serious infections has been reported in recipients of vended organs. Commercialization of living kidney donation does not serve the interests of the donors, endangers the health of recipients, and undermines the healthy development of the international transplant endeavor.

Measuring transplant center performance: The goals are not controversial but the methods and consequences can be.

PubMed

Jay, Colleen; Schold, Jesse D

2017-03-01

Risks of regulatory scrutiny has generated widespread concern about increasingly risk averse transplant center behaviors regarding both donor and candidate acceptance patterns. To address potential unintended consequences threatening access to care, we discuss recent changes in regulatory metrics and potential improvements in quality oversight of transplant centers. Despite many recent changes to one-year patient and graft survival regulatory criteria, the capacity to accurately identify true underperforming centers and avoiding false positive flagging remains an area of great concern. Numerous studies have demonstrated restrictions in transplant volume and access following transplant center flagging. Current regulatory criteria are limited in their capacity to accurately identify poorly performing centers and potentially encourage risk-averse behavior by transplant centers. Efforts to address these concerns should focus on (1) improving risk-adjustment models with better data which captures the acuity of candidate and donor risk, (2) reconsidering primary outcomes measured to assess comprehensive transplant center performance, (3) improving education to address rational or perceived disincentives, and (4) using data more effectively to share best practices.

A moral economy of American medicine in the managed-care era.

PubMed

Sprinkle, R H

2001-06-01

The moral economy of American medicine has been transformed by contentious innovations in organization, administration, regulation, and finance. In many settings old fee-for-service incentives and disincentives have been replaced by those of "managed care", while in other settings they have been diluted or distorted. In the everyday care of patients, old and new may alternate or interact. These innovations may also be having secondary effects on participation in life-sciences research and the development and employment of new technologies, discouraging collective support for preliminary investigation and delaying adoption of improved goods and services until cost-reducing potential has already been realized. This motivational complexity, particularly in its moral dimensions, is hard to address using standard assumptions and methods. I argue for different assumptions, based on the clinical behavior of individual patients rather than the market behavior of aggregated consumers, and I describe a different method, based on an old idea in political economy. I then present a new way to explain the core obligations of clinicians, researchers, and planners and to interpret the policy problems they must now share.

Human behavioral research in space: quandaries for research subjects and researchers.

PubMed

Shepanek, Marc

2005-06-01

With the advent of long-duration spaceflight on board the International Space Station (ISS) and possible future missions beyond low Earth orbit (LEO) such as Mars, it is critical that those at NASA have a realistic assessment of the challenges that will face individuals on long-duration missions so that they can develop preventive and real-time countermeasures to behavioral health issues. While space travellers are very interested in having countermeasures to the deleterious effects of space missions, they have a powerful disincentive to participate in this research if they feel it could in any way negatively affect their flight status. The behavioral issues of isolation and confinement for extended-duration space missions are reviewed. Areas of basic and clinical behavioral research are listed. And the classical clinical model for research is not considered appropriate for the current configuration of the space program. The use of analogue environments and advanced statistical analysis are suggested as ways to address the limited spaceflight research opportunities. The challenge of research subject or patient confidentiality vs. mission safety and issues of personal flight status are addressed.

Blurred edges to population policies.

PubMed

David, H P

1992-05-01

Fertility is now below replacement level in most European countries, especially the industrialized ones. In the last 20 years, several countries have developed or improved pronatalist programs containing incentives that are designed to motivate couples to have a 2nd and especially a 3rd child, to maintain a stable population. The WHO Sexuality and Family Planning Unit called a short consultation on this subject last October. What actually constitutes a pronatalist population program and the connections between public policies and private reproductive behavior were not very clear. Nor is it easy to assess the longer--term demographic effects of pronatalist policies or what influences their effectiveness. The outcome usually reflects the country's history, cultural and religious traditions, changes in lifestyle, and the value given to the family and children. Incentives are defined as monetary or nonmonetary inducements to voluntary reproductive behavior that conforms to specified population policies. They may be small or large, in cash or kind, parity-specific or income-linked, immediate or developed, one-time or incremental, or any combination of these. Disincentives are negative sanctions that are either incurred or thought likely as a result of violating the policy. But both incentives and disincentives are difficult to define. Pronatalist policies designed to encourage early marriage and larger families, thereby raising the future total fertility rate should not be confused with traditional social welfare policies designed simply to ease the burden of childbearing. Some policies have both demographic and social welfare aims. Strong pronatalist policies may be linked with restrictions on contraceptive availability and legal abortion. Moreover, other public policies affecting social security, education, employment, housing, regional planning and the emancipation of women may unintentionally influence demographic behavior. Population policies are the product of politics. Often written in ambiguous language and intended to affect society as a whole, they still depend for their outcome on microlevel changes in a couple's perceptions of the costs and benefits of having children. In theory, they can be carried out in many ways but in practice such policies are severely limited by administrative, political, technological, economic, and ethical constraints. One difficulty is that governments is rarely enunciate precise goals. Their approach may range from noninterference in private reproductive behavior to total coercion using controls ranging from traditional cultural influences to imposition of fertility regulations. In some countries, fertility rates have increased briefly (in terms of period rates) following introduction of pronatalist policies. However, it is not clear how the rates were influenced, particularly in the case of parities 1, 2, and 3. A forthcoming report will describe experiences in Bulgaria, France, Germany, Sweden, and Norway. full text

Identifying Innovative Interventions to Promote Healthy Eating Using Consumption-Oriented Food Supply Chain Analysis.

PubMed

Hawkes, Corinna

2009-07-01

The mapping and analysis of supply chains is a technique increasingly used to address problems in the food system. Yet such supply chain management has not yet been applied as a means of encouraging healthier diets. Moreover, most policies recommended to promote healthy eating focus on the consumer end of the chain. This article proposes a consumption-oriented food supply chain analysis to identify the changes needed in the food supply chain to create a healthier food environment, measured in terms of food availability, prices, and marketing. Along with established forms of supply chain analysis, the method is informed by a historical overview of how food supply chains have changed over time. The method posits that the actors and actions in the chain are affected by organizational, financial, technological, and policy incentives and disincentives, which can in turn be levered for change. It presents a preliminary example of the supply of Coca-Cola beverages into school vending machines and identifies further potential applications. These include fruit and vegetable supply chains, local food chains, supply chains for health-promoting versions of food products, and identifying financial incentives in supply chains for healthier eating.

Breaking up is hard to do: why disinvestment in medical technology is harder than investment.

PubMed

Haas, Marion; Hall, Jane; Viney, Rosalie; Gallego, Gisselle

2012-05-01

Healthcare technology is a two-edged sword - it offers new and better treatment to a wider range of people and, at the same time, is a major driver of increasing costs in health systems. Many countries have developed sophisticated systems of health technology assessment (HTA) to inform decisions about new investments in new healthcare interventions. In this paper, we question whether HTA is also the appropriate framework for guiding or informing disinvestment decisions. In exploring the issues related to disinvestment, we first discuss the various HTA frameworks which have been suggested as a means of encouraging or facilitating disinvestment. We then describe available means of identifying candidates for disinvestment (comparative effectiveness research, clinical practice variations, clinical practice guidelines) and for implementing the disinvestment process (program budgeting and marginal analysis (PBMA) and related techniques). In considering the possible reasons for the lack of progress in active disinvestment, we suggest that HTA is not the right framework as disinvestment involves a different decision making context. The key to disinvestment is not just what to stop doing but how to make it happen - that is, decision makers need to be aware of funding disincentives.

Obesity prevention advocacy in Australia: an analysis of policy impact on autonomy.

PubMed

Haynes, Emily; Hughes, Roger; Reidlinger, Dianne P

2017-06-01

To explore obesity policy options recommended by stakeholders and identify their impact on individual autotomy. Qualitative and quantitative methods were used. A content analysis of submissions to the Australian Government's Inquiry into Obesity was conducted. Each recommendation was categorised by its impact on autonomy, according to existing frameworks. Chi-square test for independence was used to explore the association between autonomy and stakeholder support defined as frequency of recommendation. The extent of support for a policy option was significantly associated with impact on autonomy (p<0.001). Options that reduce autonomy were least frequently recommended in every setting; but more likely in schools (27%) than other settings (<1%). Recommendations to provide incentives (9%) were more common than disincentives (2%) or restrictions (3%), and those that enhance autonomy were most widely recommended (46%). Stakeholders advocated policy options that enhance individual autonomy to a greater extent than those that diminish autonomy. Implications for public health: Targeting obesity policy options that enhance rather than diminish autonomy may be more politically acceptable across most settings, with the exception of schools where more restrictive policy options are appropriate. Re-framing options accordingly may improve leadership by government in obesity policy. © 2017 The Authors.

Mental illness and employment discrimination.

PubMed

Stuart, Heather

2006-09-01

Work is a major determinant of mental health and a socially integrating force. To be excluded from the workforce creates material deprivation, erodes self-confidence, creates a sense of isolation and marginalization and is a key risk factor for mental disability. This review summarizes recent evidence pertaining to employment-related stigma and discrimination experienced by people with mental disabilities. A broad understanding of the stigmatization process is adopted, which includes cognitive, attitudinal, behavioural and structural disadvantages. Stigma is both a proximate and a distal cause of employment inequity for people with a mental disability who experience direct discrimination because of prejudicial attitudes from employers and workmates and indirect discrimination owing to historical patterns of disadvantage, structural disincentives against competitive employment and generalized policy neglect. Against this background, modern mental health rehabilitation models and legislative philosophies, which focus on citizenship rights and full social participation, are to be welcomed. Yet, recent findings demonstrate that the legislation remains vulnerable to the very prejudicial attitudes they are intended to abate. Research conducted during the past year continues to highlight multiple attitudinal and structural barriers that prevent people with mental disabilities from becoming active participants in the competitive labour market.

The science of sustainable supply chains.

PubMed

O'Rourke, Dara

2014-06-06

Recent advances in the science and technology of global supply chain management offer near-real-time demand-response systems for decision-makers across production networks. Technology is helping propel "fast fashion" and "lean manufacturing," so that companies are better able to deliver products consumers want most. Yet companies know much less about the environmental and social impacts of their production networks. The failure to measure and manage these impacts can be explained in part by limitations in the science of sustainability measurement, as well as by weaknesses in systems to translate data into information that can be used by decision-makers inside corporations and government agencies. There also remain continued disincentives for firms to measure and pay the full costs of their supply chain impacts. I discuss the current state of monitoring, measuring, and analyzing information related to supply chain sustainability, as well as progress that has been made in translating this information into systems to advance more sustainable practices by corporations and consumers. Better data, decision-support tools, and incentives will be needed to move from simply managing supply chains for costs, compliance, and risk reduction to predicting and preventing unsustainable practices. Copyright © 2014, American Association for the Advancement of Science.

Recruiting the next generation of nephrologists.

PubMed

Parker, Mark G; Pivert, Kurtis A; Ibrahim, Tod; Molitoris, Bruce A

2013-07-01

The nephrology physician workforce substantially expanded during the past decade, as did the number of fellowship training positions. However, the number of U.S. medical graduates choosing nephrology careers has declined precipitously. Although workforce diversity has improved, the gains are modest. Leadership in kidney disease research and innovation is threatened by significant disincentives to the pursuit of research track careers. Meanwhile, various factors challenge reliable predictions of physician workforce demand: marked growth of the CKD and ESRD populations, shifting health care economics and access, restricted opportunities for international medical graduates, expansion of advanced practitioner utilization, and aging of the contemporary practicing physician cohort. Changing demographics and cultural shifts, including perceptions of work-life balance and quality of life, increasingly influence medical student and resident career choices. Negative student and resident attitudes toward core nephrology educational experiences and perceptions of nephrology careers are disquieting. The American Society of Nephrology has initiated a series of programs aimed at renewing interest among students and residents in nephrology careers and research training and continuing to improve the diversity of the nephrology workforce, both critical to ensuring there will be enough nephrologists to care for a growing kidney disease population. Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Criminal law as a response to medical malpractice: pluses and minuses--comparing Italian and U.S. experiences.

PubMed

Di Landro, Andrea R

2012-06-01

The paper is divided into three parts. The first part sets out the comparative differences between the tort of malpractice in common law and the criminal negligence in civil law: while the common law takes for mens rea only the "gross" negligence, and rarely medical negligence, other law systems instead (and particularly Italian law) criminalize also ordinary negligence, frequently in medical malpractice cases. The second part of the paper addresses the pluses of using criminal law as response to medical malpractice: inadequate medical self-policing and "repeat offenders" problems are analysed, in the perspective of the patient, of the doctor, of the insurance company, and of the community. The third part addresses the minuses of the criminal law as response: medical "shame and blame" mentality, criminal stigma and culture of fear are disincentives to incident reporting and to system analysis (the most important means of prevention); "defensive medicine" and "courts-abiding medicine" are managed not yet in the patient's exclusive interest, but in the egoistic/utilitarian aim to avoid denunciations; finally, the uncertainty of the medicine, the accusatory system and the proof "beyond a reasonable doubt" seem hardly compatible with each other.

Building political will for HIV response: an operational model and strategy options.

PubMed

Brinkerhoff, Derick W

2016-10-01

As global programs for HIV response look to transfer responsibility and financing increasingly to country governments, the political will to take on these responsibilities becomes increasingly prominent. However, defining and assessing political will are problematic; it involves intent and motivation, and thus is inherently difficult to observe. It is intimately connected to capacity and is contextually embedded. This article describes an operational model of political will comprised of seven components that are observable and measurable. Two case studies illustrate the application of the model and shed light on the interconnections among commitment, capacity and context: South Africa and China. Strategy options to build political will for HIV response identify possible actions for both government and civil society. Political will as a concept is most usefully viewed as integrated within larger political and bureaucratic processes, as a product of the complex array of incentives and disincentives that those processes create. However, this conclusion is not a recipe for discouragement or inaction. Agent-based conceptualizations of policy change offer a solid grounding for building political will that supports HIV policy and programs. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Exploring the Teaching Motivations, Satisfaction, and Challenges of Veterinary Preceptors: A Qualitative Study.

PubMed

Hashizume, Cary T; Myhre, Douglas L; Hecker, Kent G; Bailey, Jeremy V; Lockyer, Jocelyn M

2016-01-01

Optimization of clinical veterinary education requires an understanding of what compels veterinary preceptors in their role as clinical educators, what satisfaction they receive from the teaching experience, and what struggles they encounter while supervising students in private practice. We explored veterinary preceptors' teaching motivations, enjoyment, and challenges by undertaking a thematic content analysis of 97 questionnaires and 17 semi-structured telephone interviews. Preceptor motivations included intrinsic factors (obligation to the profession, maintenance of competence, satisfaction) and extrinsic factors (promotion of the veterinary field, recruitment). Veterinarians enjoyed observing the learner (motivation and enthusiasm, skill development) and engaging with the learner (sharing their passion for the profession, developing professional relationships). Challenges for veterinary preceptors included variability in learner interest and engagement, time management, and lack of guidance from the veterinary medicine program. We found dynamic interactions among the teaching motivations, enjoyment, and challenges for preceptors. Our findings suggest that in order to sustain the veterinary preceptor, there is a need to recognize the interplay between the incentives and disincentives for teaching, to foster the motivations and enjoyment for teaching, and to mitigate the challenges of teaching in community private practice.

The rapid reproducers paradox: population control and individual procreative rights.

PubMed

Wissenburg, M

1998-01-01

This article argues that population policies need to be evaluated from macro and micro perspectives and to consider individual rights. Ecological arguments that are stringent conditions of liberal democracy are assessed against a moral standard. The moral standard is applied to a series of reasons for limiting procreative rights in the cause of sustainability. The focus is directly on legally enforced antinatalist measures and not on indirect policies with incentives and disincentives. The explicit assumption is that population policy violates the fairness to individuals for societal gain and that population policies are incompatible with stringent conditions of liberal democracy. The author identifies the individual-societal tradeoff as the "rapid reproducers paradox." The perfect sustainable population level is either not possible or is a repugnant alternative. 12 ecological arguments are presented, and none are found compatible with notions of a liberal democracy. Three alternative antinatalist options are the acceptance of less rigid and still coercive policies, amendments to the conception of liberal democracy, or loss of hope and choice of noncoercive solutions to sustainability, none of which is found viable. If voluntary abstinence and distributive solutions fail, then frugal demand options and technological supply options both will be necessary.

Mental illness among journalists: a systematic review.

PubMed

Aoki, Yuta; Malcolm, Estelle; Yamaguchi, Sosei; Thornicroft, Graham; Henderson, Claire

2013-06-01

Mass media depictions of people with mental illness have a strong influence on public attitudes, to the extent that changes in these depictions can reduce public stigmatization of people with such illness. Journalists' mental health may influence their depiction of those with mental illness, but little is known about this. To investigate mental illness among journalists in five key areas: (1) journalists' mental health status; (2) journalists' personal attitudes towards mental illness; (3) attitudes and support journalists expect or have experienced from colleagues when they have a mental health problem; (4) effect of journalism's professional culture on the course of mental illness; and (5) effect of journalism's professional culture on mass media depictions of people with mental illness. We performed a systematic screening of MEDLINE, PsycINFO, EMBASE, Web of Science and the Cochrane Library regarding the study aims. We identified 19, 12, seven and four studies for aims 1, 2, 3, and 4, respectively. No articles were found for aim 5. The prevalence of post-traumatic stress disorder (PTSD) among journalists is higher than that among the general population. Journalists have positive personal attitudes towards mental illness, but there are perceived workplace disincentives to disclose mental health problems.

Legal themes concerning obesity regulation in the United States: Theory and practice

PubMed Central

Hodge, James G; Garcia, Andrea M; Shah, Supriya

2008-01-01

Despite national health objectives to reduce the incidence of obesity to 15% of the population by 2010, public health data suggest that the incidence of obesity in the United States is actually increasing. The U.S. recognizes that it (like other industrialized countries) faces an epidemic of obesity and related health conditions. How can U.S. jurisdictions (federal, state, and local) and the private sector respond to this epidemic through laws and policies that are directly or indirectly designed to address obesity? This article analyzes the theoretical and practical roles of law as a tool to curb obesity in the U.S. It proffers ten major legal themes to address obesity among the U.S. population, including: (1) use of incentives to encourage healthier behaviors; (2) use of financial disincentives to discourage unhealthy behaviors; (3) requirements to improve food quality, diversity, or availability; (4) compensation for injured persons seeking recourse; (5) restriction of access to unhealthy foods; (6) regulations aimed at influencing consumer choices; (7) control of marketing and advertising; (8) creation of communities that support healthy lifestyles; (9) physical education/fitness requirements; and (10) insurance coverage mandates. PMID:18578873

The Changing Financial Landscape of Renal Transplant Practice: A National Cohort Analysis

PubMed Central

Axelrod, David; Schnitzler, Mark A.; Xiao, Huiling; Naik, Abhijit S.; Segev, Dorry L.; Dharnidharka, Vikas R.; Brennan, Daniel C.; Lentine, Krista L.

2017-01-01

Kidney transplantation has become more resource intensive as recipient complexity has increased and average donor quality has diminished over time. A national retrospective cohort study was performed to assess the impact of kidney donor and recipient characteristics on transplant center cost (exclusive of organ acquisition) and Medicare reimbursement. Data from the national transplant registry, University HealthSystem Consortium hospital costs, and Medicare payments for deceased donor (N=53,862) and living donor (N=36,715) transplants from 2002–2013 were linked and analyzed using multivariate linear regression modeling. Deceased donor kidney transplant costs were correlated with recipient (Expected Post Transplant Survival Score, degree of allosensitization, obesity, cause of renal failure) donor (age, cause of death, donation after cardiac death, terminal creatinine), and transplant (histocompatibility matching) characteristics. Living donor costs rose sharply with higher degrees of allosensitization, and were also associated with obesity, cause of renal failure, recipient work ability, and 0-ABDR mismatching. Analysis of Medicare payments for a subsample of 24,809 transplants demonstrated minimal correlation with patient and donor characteristics. In conclusion, the complexity in the landscape of kidney transplantation increases center costs, posing financial disincentives that may reduce organ utilization and limit access for higher risk populations. PMID:27565133

Impact of risk attitudes and perception on game theoretic driving interactions and safety.

PubMed

Arbis, David; Dixit, Vinayak V; Rashidi, Taha Hossein

2016-09-01

This study employs game theory to investigate behavioural norms of interaction between drivers at a signalised intersection. The choice framework incorporates drivers' risk perception as well as their risk attitudes. A laboratory experiment is conducted to study the impact of risk attitudes and perception in crossing behaviour at a signalised intersection. The laboratory experiment uses methods from experimental economics to induce incentives and study revealed behaviour. Conflicting drivers are considered to have symmetric disincentives for crashing, to represent a no-fault car insurance environment. The study is novel as it uses experimental data collection methods to investigate perceived risk. Further, it directly integrates perceived risk of crashing with other active drivers into the modelling structure. A theoretical model of intersection crossing behaviour is also developed in this paper. This study shows that right-of-way entitlements assigned without authoritative penalties to at-fault drivers may still improve perceptions of safety. Further, risk aversion amongst drivers attributes to manoeuvring strategies at or below Nash mixed strategy equilibrium. These findings offer a theoretical explanation for interactive manoeuvres that lead to crashes, as opposed to purely statistical methods which provide correlation but not necessarily explanation. Copyright © 2016 Elsevier Ltd. All rights reserved.

Allowance trading: Correcting the past and looking to the future

DOE Office of Scientific and Technical Information (OSTI.GOV)

Shah, A.Y.; Canter, L.W.

1995-09-01

Allowance trading is basic to the Title IV acid rain provisions of the 1990 Clean Air Act Amendments (CAAA) in the United States; the provisions seek to achieve a 10-million-ton reduction in annual sulfur dioxide emissions from the electric power utility industry. Allowance trading, a market-based approach, is conceptually similar to the emissions trading policy of the US Environmental Protection Agency (EPA). An allowance is defined as the authorization to emit, during or after a specified calendar year, one ton of sulfur dioxide. This paper provides an overview of the allowance trading program by summarizing some important features, particularly asmore » they are responsive to limitations and concern as related to the precursor emissions trading program in the early to mid-1980s. Such features include a simple definition of baseline emission levels, encouragements for nationwide trading, disincentives for accumulation of excess allowance,s opportunities for leasing other short-term allowance transfer arrangements, enforcement provisions, and benefits of bonus allowances and early emission reductions. Adherence to implementation protocols for the acid rain provisions of Title IV of the CAAA will provide a good opportunity to evaluate this market-based approach for environmental quality management.« less

Identifying Innovative Interventions to Promote Healthy Eating Using Consumption-Oriented Food Supply Chain Analysis

PubMed Central

Hawkes, Corinna

2009-01-01

The mapping and analysis of supply chains is a technique increasingly used to address problems in the food system. Yet such supply chain management has not yet been applied as a means of encouraging healthier diets. Moreover, most policies recommended to promote healthy eating focus on the consumer end of the chain. This article proposes a consumption-oriented food supply chain analysis to identify the changes needed in the food supply chain to create a healthier food environment, measured in terms of food availability, prices, and marketing. Along with established forms of supply chain analysis, the method is informed by a historical overview of how food supply chains have changed over time. The method posits that the actors and actions in the chain are affected by organizational, financial, technological, and policy incentives and disincentives, which can in turn be levered for change. It presents a preliminary example of the supply of Coca-Cola beverages into school vending machines and identifies further potential applications. These include fruit and vegetable supply chains, local food chains, supply chains for health-promoting versions of food products, and identifying financial incentives in supply chains for healthier eating. PMID:23144674

Social Security, retirement incentives, and retirement behavior: an international perspective.

PubMed

Gruber, J; Wise, D

1999-05-01

Escalating rates of early retirement are imposing fiscal pressure on retirement systems around the world. In some developed countries, the labor-force participation rates of men ages 60-64 have fallen by 75 percent over the last three decades. One explanation for this striking decline is social security program provisions which create disincentives to continued labor-force participation by older workers. There are substantial differences among developed nations in the labor-force participation of older workers. While two-thirds of 60-year-old American males are working, only one-quarter of men that age are working in Belgium. Over the entire 55-65 age range, 63 percent of American males are working, compared with only 40 percent of French males and 33 percent of Belgians males. There is strong evidence that the early retirement provisions of social security systems in developed countries determine the modal age of retirement. There is a strong relationship between early retirement ages and labor-force withdrawal rates; for example, in France, 60 percent of those working at the early entitlement age of 60 leave the labor force at that age. The core of this analysis is the construction of "implicit tax/subsidy rates" on additional work at older ages through each nation's social security system. These rates measure the change in a worker's retirement wealth entitlement from delaying retirement for one year, relative to the amount that would have been earned over that year. The U.S. Social Security system has an actuarial adjustment for delayed benefits claiming and other features that avoid financial incentives to leave the labor force at age 62 for a married worker, there is a slight disincentive to work for single workers and high wage earners. However, at ages 65 and older there is a stronger incentive to leave the labor force, with implicit tax rates on work of 19 percent for married workers and 33 percent for single workers. By comparison, other nations do not have actuarially fair adjustments, and as a result impose substantial taxes on additional work at older ages. In several countries, implicit tax rates on work at older ages approach or exceed 100 percent. This is because by delaying retirement, workers forgo benefits which often replace close to their full wage, in addition to having to pay the high payroll taxes required to finance generous social security benefits. There is a striking correlation across nations between high implicit tax rates on additional work and low labor-force participation rates among older workers. This suggests that social security program incentives are an important determinant of retirement. These findings have important policy implications for reforming social security programs in the United States and abroad. Policymakers must consider how program reforms will affect incentives for continued work at older ages.

In California, not-for-profit hospitals spent more operating expenses on charity care than for-profit hospitals spent.

PubMed

Valdovinos, Erica; Le, Sidney; Hsia, Renee Y

2015-08-01

In exchange for sizable tax exemptions, not-for-profit hospitals must engage in activities that meet the Internal Revenue Service's community benefit standard. The provision of charity care-free care to those unable to pay-can help meet that standard. Bad debt, the other form of uncompensated care, cannot be used to meet the standard, although Medicaid shortfalls can. However, the ACA lacks guidelines for providing charity care, and federal law sets no minimum requirements for community benefit activities. Using data from California, we examined whether the levels of charity and uncompensated care provided differed across general acute care hospitals by profit status and other characteristics during 2011-13. The mean proportion of total operating expenses spent on charity care differed significantly between not-for-profit (1.9 percent) and for-profit hospitals (1.4 percent), in contrast to the mean proportion spent on uncompensated care. Both types of spending varied widely across hospitals. Policy makers should consider measures that remove disincentives to meeting the persistent considerable need for charity care-for example, increasing supports to offset rising Medicaid shortfalls resulting from program expansion-and facilitate the tracking of ACA impacts on the distribution of charity care and uncompensated care delivery. Project HOPE—The People-to-People Health Foundation, Inc.

Professional ideologies and the development of syringe exchange: Wales as a case study.

PubMed

Keene, J M; Stimson, G V

1997-12-01

This paper is derived from an evaluative study of HIV prevention programs for drug injectors across Wales. It considers how different professional territories and ideologies, concepts of drug misuse and models of HIV prevention may influence policy development. The research involved monitoring the introduction and development of agency and community based syringe exchange schemes and initiatives taken by community pharmacists. Interviews with staff, managers and administrators, and descriptions of service history, development and delivery inform the discussion. HIV prevention varied in different areas of Wales depending on the particular professional group involved, local ideologies regarding drug use treatment, and the extent to which HIV prevention was seen either as a specialist area of expertise and specific remit of drug workers or a generic health care task. Drug agencies with an abstinence policy rejected syringe exchange; instead, prevention in those areas developed in ad hoc ways as health care workers and pharmacists attempted to develop a community based service. Drug agencies with a pre-existing harm minimisation model easily integrated syringe exchange into their work and played the major part in establishing the service, but there was difficulty in extending it beyond their professional caseloads. As there were disincentives to use treatment agencies, and their catchment areas were limited, these factors influenced effective service provision.

Reconsidering access: park facilities and neighborhood disamenities in New York City.

PubMed

Weiss, Christopher C; Purciel, Marnie; Bader, Michael; Quinn, James W; Lovasi, Gina; Neckerman, Kathryn M; Rundle, Andrew G

2011-04-01

With increasing concern about rising rates of obesity, public health researchers have begun to examine the availability of parks and other spaces for physical activity, particularly in cities, to assess whether access to parks reduces the risk of obesity. Much of the research in this field has shown that proximity to parks may support increased physical activity in urban environments; however, as yet, there has been limited consideration of environmental impediments or disamenities that might influence individuals' perceptions or usage of public recreation opportunities. Prior research suggests that neighborhood disamenities, for instance crime, pedestrian safety, and noxious land uses, might dissuade people from using parks or recreational facilities and vary by neighborhood composition. Motivated by such research, this study estimates the relationship between neighborhood compositional characteristics and measures of park facilities, controlling for variation in neighborhood disamenities, using geographic information systems (GIS) data for New York City parks and employing both kernel density estimation and distance measures. The central finding is that attention to neighborhood disamenities can appreciably alter the relationship between neighborhood composition and spatial access to parks. Policy efforts to enhance the recreational opportunities in urban areas should expand beyond a focus on availability to consider also the hazards and disincentives that may influence park usage.

Marital Status and Return to Work After Living Kidney Donation.

PubMed

Frech, Adrianne; Natale, Ginny; Hayes, Don; Tumin, Dmitry

2018-01-01

Living kidney donation is safe and effective, but patients in need of a transplant continue to outnumber donors. Disincentives to living donation include lost income, risk of job loss, perioperative complications, and unreimbursed medical expenses. This study uses US registry and follow-up data on living kidney donors from 2013 to 2015 to identify social predictors of return to work across gender following living kidney donation. Using logistic regression, we find that predictors of return to work following living kidney donation differ for women and men. Among women, age, education, smoking status, and procedure type are associated with return to work. Among men, education, procedure type, and hospital readmission within 6 weeks postdonation are associated with return to work. Notably, single and divorced men are less likely to return to work compared to married men (odds ratio [OR] for single men 0.51, 95% confidence interval [CI], 0.37-0.69, P < .001; OR for divorced men 0.51, 95% CI, 0.34-0.75, P = .006). Marital status is not associated with return to work for women. Single and divorced men's greater odds of not returning to work are robust to controls for relevant pre- and postdonation characteristics. Single and divorced men's lack of social support may present an obstacle to work resumption following living kidney donation.

What role does performance information play in securing improvement in healthcare? a conceptual framework for levers of change

PubMed Central

Levesque, Jean-Frederic; Sutherland, Kim

2017-01-01

Objective Across healthcare systems, there is consensus on the need for independent and impartial assessment of performance. There is less agreement about how measurement and reporting performance improves healthcare. This paper draws on academic theories to develop a conceptual framework—one that classifies in an integrated manner the ways in which change can be leveraged by healthcare performance information. Methods A synthesis of published frameworks. Results The framework identifies eight levers for change enabled by performance information, spanning internal and external drivers, and emergent and planned processes: (1) cognitive levers provide awareness and understanding; (2) mimetic levers inform about the performance of others to encourage emulation; (3) supportive levers provide facilitation, implementation tools or models of care to actively support change; (4) formative levers develop capabilities and skills through teaching, mentoring and feedback; (5) normative levers set performance against guidelines, standards, certification and accreditation processes; (6) coercive levers use policies, regulations incentives and disincentives to force change; (7) structural levers modify the physical environment or professional cultures and routines; (8) competitive levers attract patients or funders. Conclusion This framework highlights how performance measurement and reporting can contribute to eight different levers for change. It provides guidance into how to align performance measurement and reporting into quality improvement programme. PMID:28851769

Private-sector vaccine purchase costs and insurer payments: a disincentive for using combination vaccines?

PubMed

Clark, Sarah J; Cowan, Anne E; Freed, Gary L

2011-04-01

Combination vaccines have been endorsed as a means to decrease the number of injections needed to complete the childhood immunization schedule, yet anecdotal reports suggest that private providers lose money on combination vaccines. The objective of this study was to determine whether practices purchasing combination vaccines had significantly different vaccine costs and reimbursement compared to practices that were not purchasing combination vaccines. Using cross-sectional purchase and insurer payment data collected from a targeted sample of private practices in five US states, we calculated the average total vaccine cost and reimbursement across the childhood immunization schedule. The average vaccine purchase cost across the childhood schedule was significantly higher for practices using a combined vaccine with diphtheria, tetanus, acellular pertussis vaccine, inactivated polio vaccine, and Hepatitis B vaccine (DTaP-IPV-HepB) than for practices using either separate vaccine products or a combined vaccine with Haemophilus influenzae, type b vaccine and Hepatitis B vaccine (Hib-HepB). The average insurer payment for vaccine administration across the childhood schedule was significantly lower for practices using DTaP-IPV-HepB combination vaccine than for practices using separate vaccine products. This study appears to validate anecdotal reports that vaccine purchase costs and insurer payment for combination vaccines can have a negative financial impact for practices that purchase childhood vaccines.

Views of academic dentists about careers in academic dentistry in the United Kingdom.

PubMed

Goldacre, M; Lee, P; Stear, S; Sidebottom, E; Richards, R

2000-02-12

The aim of this paper is to report the views of academic dentists about careers in academic dentistry assessed by method of a postal questionnaire survey. The subjects of the survey were dentists in academic posts in the United Kingdom. The incentives in pursuing an academic career which respondents rated most highly were the opportunity to teach and the variety of work in an academic career. The greatest disincentives were competing pressures from service work, teaching and research, and the difficulty of getting research grants. Many would like to spend more time on research and less on service work and teaching. The length of time required for training, and the quality of training, was a concern, particularly for junior academics. Most respondents rated the enjoyment of their job highly but scored much lower on satisfaction with the time their job left for domestic and leisure activities. By contrast with academic medicine, in academic dentistry there is typically greater emphasis on teaching and less on research. In conclusion, the balance of activities in academic posts, particularly between service work, teaching and research, needs to be regularly reviewed. The development of a more structured training programme for junior academics, which does not disadvantage academic dentists when compared with their NHS colleagues, may be required.

Significance of the oceanic CO2 sink for national carbon accounts

PubMed Central

McNeil, Ben I

2006-01-01

Background Under the United Nations convention on the law of the sea (1982), each participating country maintains exclusive economic and environmental rights within the oceanic region extending 200 nm from its coastline, known as the Exclusive Economic Zone (EEZ). Although the ocean within each EEZ has a vast capacity to absorb anthropogenic CO2 and therefore potentially be used as a carbon sink, it is not mentioned within the Kyoto Protocol most likely due to inadequate quantitative estimates. Here, I use two methods to estimate the anthropogenic CO2 storage and uptake for a typically large EEZ (Australia). Results Depending on whether the Antarctic territory is included I find that during the 1990s between 30–40% of Australia's fossil-fuel CO2 emissions were absorbed by its own EEZ. Conclusion This example highlights the potential significance of the EEZ carbon sink for national carbon accounts. However, this 'natural anthropogenic CO2 sink' could be used as a disincentive for certain nations to reduce their anthropogenic CO2 emissions, which would ultimately dampen global efforts to reduce atmospheric CO2 concentrations. Since the oceanic anthropogenic CO2 sink has limited ability to be controlled by human activities, current and future international climate change policies should have an explicit 'EEZ' clause excluding its use within national carbon accounts. PMID:16930461

Improving institutional fairness to live kidney donors: donor needs must be addressed by safeguarding donation risks and compensating donation costs.

PubMed

Schulz-Baldes, Annette; Delmonico, Francis L

2007-11-01

The number of kidney transplants from live donors is increasing worldwide, yet donor needs have not been satisfactorily addressed in either developed or developing countries. This paper argues that unmet donor needs are unfair to live kidney donors in two ways. First, when safeguards against the risks of donation are insufficient, live donation can impair the donor's health and thus his or her fair opportunities to access jobs and offices and to function as a free and equal citizen more generally. Secondly, when the financial costs of donation are not fully compensated, operational fairness (associated with the nephrectomy event) is compromised for the donor. The donor assumes the risks of a nontherapeutic intervention--for the good of the recipient and society--and should not have to incur costs for donating. Based on a systematic analysis of unmet donor needs in developed and developing countries, context-relative measures to improve institutional fairness to live kidney donors are delineated in this paper. The identified ways of safeguarding donation risks and compensating donation costs are not merely means to removing disincentives for donation and increasing donation rates. They are essential for preserving institutional fairness in the health care of the live kidney donor.

Worker attitudes towards mental health problems and disclosure.

PubMed

Dewa, C S

2014-10-01

There is a significant proportion of workers with mental disorders who either are struggling at work or who are trying to return to work from a disability leave. Using a population-based survey of working adults in Ontario, Canada, this paper examines the perceptions of workers towards mental disorders in the workplace. Data are from a sample of 2219 working adults identified through random digit dialing who either completed a telephone questionnaire administered by professional interviewers or a web-based survey. A third of workers would not tell their managers if they experienced mental health problems. Rather than a single factor, workers more often identified a combination of factors that would encourage disclosure to their managers. One of the most identified disincentives was the fear of damaging their careers. The most pervasive reasons for concerns about a colleague with a mental health problem included safety and the colleague's reliability. Although critical for workers who experience a mental disorder and who find work challenging, a significant proportion do not seek support. One barrier is fear of negative repercussions. Organizations' policies can create safe environments and the provision of resources and training to managers that enable them to implement them. By making disclosure safe, stigma and the burden of mental disorders in the workplace can be decreased.

'McDonalds and KFC, it's never going to happen': the challenges of working with food outlets to tackle the obesogenic environment.

PubMed

Hanratty, Barbara; Milton, Beth; Ashton, Matthew; Whitehead, Margaret

2012-12-01

Food outlets may make an important contribution to an obesogenic environment. This study investigated barriers and facilitators to public health work with food outlets in disadvantaged areas. In-depth qualitative interviews with 36 directors, managers and public health service delivery staff in a coterminous primary care trust and local authority in northwest England. Data were analysed using the constant comparative method. Three interventions were available to engage with businesses; awards for premises that welcomed breastfeeding mothers or offered healthy menu options and local authority planning powers. Sensitivity to the potential conflict between activities that generate profit and those that promote health, led to compromises, such as awards for cafés that offer only one healthy option on an otherwise unhealthy menu. An absence of existing relationships with businesses and limited time were powerful disincentives to action, leading to greater engagement with public rather than private sector organizations. Hiring staff with commercial experience and incentives for businesses were identified as useful strategies, but seldom used. Encouraging food outlets to contribute to tackling the obesogenic environment is a major challenge for local public health teams that requires supportive national policies. Commitment to engage with the local public health service should be part of any national voluntary agreements with industry.

What types of jobs do people with disabilities want?

PubMed

Ali, Mohammad; Schur, Lisa; Blanck, Peter

2011-06-01

Do non-employed people with disabilities want to work, and if so, what types of jobs do they want? Researchers seeking to explain the low employment rate among people with disabilities have focused primarily on skill gaps, employment disincentives from disability income, accommodation mandates, and (to a lesser extent) employer attitudes and unwelcoming corporate cultures. There has been little attention paid to the attitudes of non-employed people with disabilities. This paper uses the 2006 General Social Survey, a representative national survey of US adults that has disability information and a special supplement on worker preferences, to examine the above question. We find that, relative to their non-disabled counterparts, non-employed people with disabilities are (a) as likely to want a job but less likely to be actively searching, (b) as likely to have prior job experience, and (c) similar in their views of the importance of income, job security, and other valued job characteristics. The results, which vary little by type of impairment, indicate that the low employment rate of people with disabilities is not due to their reluctance to work or different job preferences. Combined with evidence that a large share of new jobs can be performed by people with disabilities, the findings point toward the value of dismantling barriers to employment facing many people with disabilities.

Consumer Acceptance of Population-Level Intervention Strategies for Healthy Food Choices: The Role of Perceived Effectiveness and Perceived Fairness.

PubMed

Bos, Colin; Lans, Ivo Van Der; Van Rijnsoever, Frank; Van Trijp, Hans

2015-09-15

The present study investigates acceptance of intervention strategies for low-calorie snack choices that vary regarding the effect they have on consumers' freedom of choice (providing information, guiding choice through (dis)incentives, and restricting choice). We examine the mediating effects of perceived effectiveness and perceived fairness, and the moderating effects of barriers to choose low-calorie snacks and perceived responsibility for food choice. Data was collected through an online survey, involving three waves that were completed over a seven week timespan. Information was collected on barriers and perceived responsibility, and evaluations of a total of 128 intervention strategies with varying levels of intrusiveness that were further systematically varied in terms of source, location, approach/avoidance, type, and severity. A total of 1173 respondents completed all three waves. We found that the effect of intervention intrusiveness on acceptance was mediated by the perceived personal- and societal effectiveness, and the perceived fairness of interventions. For barriers and perceived responsibility, only main effects on intervention-specific beliefs were found. Government interventions were accepted less than interventions by food manufacturers. In conclusion, the present study shows that acceptance of interventions depends on perceptions of personal- and societal effectiveness and fairness, thereby providing novel starting points for increasing acceptance of both existing and new food choice interventions.

Medicare home health payment reform may jeopardize access for clinically complex and socially vulnerable patients.

PubMed

Rosati, Robert J; Russell, David; Peng, Timothy; Brickner, Carlin; Kurowski, Daniel; Christopher, Mary Ann; Sheehan, Kathleen M

2014-06-01

The Affordable Care Act directed Medicare to update its home health prospective payment system to reflect more recent data on costs and use of services-an exercise known as rebasing. As a result, the Centers for Medicare and Medicaid Services will reduce home health payments 3.5 percent per year in the period 2014-17. To determine the impact that these reductions could have on beneficiaries using home health care, we examined the Medicare reimbursement margins and the use of services in a national sample of 96,621 episodes of care provided by twenty-six not-for-profit home health agencies in 2011. We found that patients with clinically complex conditions and social vulnerability factors, such as living alone, had substantially higher service delivery costs than other home health patients. Thus, the socially vulnerable patients with complex conditions represent less profit-lower-to-negative Medicare margins-for home health agencies. This financial disincentive could reduce such patients' access to care as Medicare payments decline. Policy makers should consider the unique characteristics of these patients and ensure their continued access to Medicare's home health services when planning rebasing and future adjustments to the prospective payment system. Project HOPE—The People-to-People Health Foundation, Inc.

Can biosimilars help achieve the goals of US health care reform?

PubMed

Boccia, Ralph; Jacobs, Ira; Popovian, Robert; de Lima Lopes, Gilberto

2017-01-01

The US Patient Protection and Affordable Care Act (ACA) aims to expand health care coverage, contain costs, and improve health care quality. Accessibility and affordability of innovative biopharmaceuticals are important to the success of the ACA. As it is substantially more difficult to manufacture them compared with small-molecule drugs, many of which have generic alternatives, biologics may increase drug costs. However, biologics offer demonstrated improvements in patient care that can reduce expensive interventions, thus lowering net health care costs. Biosimilars, which are highly similar to their reference biologics, cost less than the originators, potentially increasing access through reduced prescription drug costs while providing equivalent therapeutic results. This review evaluates 1) the progress made toward enacting health care reform since the passage of the ACA and 2) the role of biosimilars, including the potential impact of expanded biosimilar use on access, health care costs, patient management, and outcomes. Barriers to biosimilar adoption in the USA are noted, including low awareness and financial disincentives relating to reimbursement. The evaluated evidence suggests that the ACA has partly achieved some of its aims; however, the opportunity remains to transform health care to fully achieve reform. Although the future is uncertain, increased use of biosimilars in the US health care system could help achieve expanded access, control costs, and improve the quality of care.

Correcting for possible tissue distortion between provocation and assessment in skin testing: the divergent beam UVB photo-test.

PubMed

O'Doherty, Jim; Henricson, Joakim; Falk, Magnus; Anderson, Chris D

2013-11-01

In tissue viability imaging (TiVi), an assessment method for skin erythema, correct orientation of skin position from provocation to assessment optimizes data interpretation. Image processing algorithms could compensate for the effects of skin translation, torsion and rotation realigning assessment images to the position of the skin at provocation. A reference image of a divergent, UVB phototest was acquired, as well as test images at varying levels of translation, rotation and torsion. Using 12 skin markers, an algorithm was applied to restore the distorted test images to the reference image. The algorithm corrected torsion and rotation up to approximately 35 degrees. The radius of the erythemal reaction and average value of the input image closely matched that of the reference image's 'true value'. The image 'de-warping' procedure improves the robustness of the response image evaluation in a clinical research setting and opens the possibility of the correction of possibly flawed images performed away from the laboratory setting by the subject/patient themselves. This opportunity may increase the use of photo-testing and, by extension, other late response skin testing where the necessity of a return assessment visit is a disincentive to performance of the test. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Challenges in using rater judgements in medical education.

PubMed

Albanese, M A

2000-08-01

Changes in the healthcare environment are putting increasing pressure on medical schools to make faculty accountable and to document the quality of the medical education they provide. Faculty's ratings of students' performances and students' ratings of faculty's teaching are important elements in these efforts to document educational quality. This article discusses selected research related to factors affecting raters' judgements, analyses how changes in the health care environment are influencing such judgements, offers some suggestions to moderate some of the effects and links these influences to the system that upholds professional standards. Ratings are known to have a positive bias (generosity error), provide limited discrimination and often fail to document serious deficits. The potential sources of these problems relate to the mechanics of the rating task, the system used to obtain ratings and factors affecting rater judgement. As managed care demands reduce the time faculty have for teaching, as system-wide disincentives to provide negative ratings proliferate and as social engineering challenges, such as the Americans with Disabilities Act, impose differential standards for students, the natural tendency to avoid giving negative ratings becomes even harder to resist. Ultimately, these forces compromise the capability of faculty to uphold the standards of the profession. The author calls for a national effort to stem the erosion of those standards.

Rating educational quality: factors in the erosion of professional standards.

PubMed

Albanese, M

1999-06-01

Changes in the health care environment are putting increasing pressure on medical schools to make faculty accountable and to document the quality of the medical education they provide. Faculty's ratings of students' performances and students' ratings of faculty's teaching are important elements in these efforts to document educational quality. This article discusses selected research related to factors affecting raters' judgments, analyzes how changes in the health care environment are influencing such judgments, and links these influences to the system that upholds professional standards. Ratings are known to have a positive bias (generosity error), provide limited discrimination, and often fail to document serious deficits. The potential sources of these problems relate to the mechanics of the rating task, the system used to obtain ratings, and factors affecting rater judgment. As managed care demands reduce the time faculty have for teaching, as system-wide disincentives to provide negative ratings proliferate, and as social engineering challenges, such as the Americans with Disabilities Act, impose differential standards for students, the natural tendency to avoid giving negative ratings becomes even harder to resist. Ultimately, these forces compromise the capability of faculty to uphold the standards of the profession. The author calls for a national effort to stem the erosion of those standards.

Developing a theory of change for a community-based response to illegal wildlife trade.

PubMed

Biggs, Duan; Cooney, Rosie; Roe, Dilys; Dublin, Holly T; Allan, James R; Challender, Dan W S; Skinner, Diane

2017-02-01

The escalating illegal wildlife trade (IWT) is one of the most high-profile conservation challenges today. The crisis has attracted over US$350 million in donor and government funding in recent years, primarily directed at increased enforcement. There is growing recognition among practitioners and policy makers of the need to engage rural communities that neighbor or live with wildlife as key partners in tackling IWT. However, a framework to guide such community engagement is lacking. We developed a theory of change (ToC) to guide policy makers, donors, and practitioners in partnering with communities to combat IWT. We identified 4 pathways for community-level actions: strengthen disincentives for illegal behavior, increase incentives for wildlife stewardship, decrease costs of living with wildlife, and support livelihoods that are not related to wildlife. To succeed the pathways, all require strengthening of enabling conditions, including capacity building, and of governance. Our ToC serves to guide actions to tackle IWT and to inform the evaluation of policies. Moreover, it can be used to foster dialogue among IWT stakeholders, from local communities to governments and international donors, to develop a more effective, holistic, and sustainable community-based response to the IWT crisis. © 2016 The Authors. Conservation Biology published by Wiley Periodicals, Inc. on behalf of Society for Conservation Biology.

Current Canadian initiatives to reimburse live organ donors for their non-medical expenses.

PubMed

Vlaicu, Sorina; Klarenbach, Scott; Yang, Robert C; Dempster, Todd; Garg, Amit X

2007-01-01

Living organ donors frequently incur non-medical expenses for travel, accommodation, prescription drugs, loss of income, and child care in conjunction with organ donation. Despite international precedent and widespread public support, Canada currently lacks a unified strategy to reimburse donors for these expenses. In 2005, we communicated with 78 individuals within the field of Canadian transplantation to identify which initiatives for reimbursement of living donors existed in each province. Saskatchewan was the only province in which public employees were granted paid leave for organ donation. Six provincial governments partially reimbursed travel and accommodation. At the federal level, other expenses could be partially reimbursed through an income tax credit, while the Employment Insurance program and the Canada Pension Plan provided funding for donors who become unemployed or develop long-term disability as a result of donation. Charities helped a limited number of patients in financial need through grants and no-interest loans, but funding was generally limited by contributions received. While reimbursing living donors for their non-medical expenses is considered just, existing programs only partially reimburse expenses and are not available in all provinces. Developing future reimbursement policies will remove a disincentive faced by some potential donors, and may increase rates of transplantation in Canada.

Equal health, equal work? The role of disability benefits in employment after controlling for health status.

PubMed

Frutos, Eva Maria Lopez; Castello, Judit Vall

2015-04-01

In Spain, an individual can be considered legally disabled in one of the following two ways: by either receiving a disability support benefit and/or holding a certificate of disability. Having at least one of these official sanctions entitles the disabled person to a number of financial and tax advantages. However, only support benefits entail a monthly allowance and, at the same time, the individual is required to undertake a different job to that of his/her previous one. To jointly estimate (after controlling for the health characteristics of the disabling condition and for unobserved factors) the probability of receiving disability benefits and the probability of working, we make use of a newly released database of individuals with a certificate of disability. Additionally, we exploit the rich set of health measures that this database also provides. Our results show that the probability of working is 5% lower (average treatment effect, ATE) for those disabled individuals receiving benefits. However, when we perform the estimation for individuals with differing degrees of disability, the disincentive effects of the benefits are only significant for individuals with the mildest level of disability (33-44%) i.e. those who are on the threshold of being disabled.

New business models for antibiotic innovation.

PubMed

So, Anthony D; Shah, Tejen A

2014-05-01

The increase in antibiotic resistance and the dearth of novel antibiotics have become a growing concern among policy-makers. A combination of financial, scientific, and regulatory challenges poses barriers to antibiotic innovation. However, each of these three challenges provides an opportunity to develop pathways for new business models to bring novel antibiotics to market. Pull-incentives that pay for the outputs of research and development (R&D) and push-incentives that pay for the inputs of R&D can be used to increase innovation for antibiotics. Financial incentives might be structured to promote delinkage of a company's return on investment from revenues of antibiotics. This delinkage strategy might not only increase innovation, but also reinforce rational use of antibiotics. Regulatory approval, however, should not and need not compromise safety and efficacy standards to bring antibiotics with novel mechanisms of action to market. Instead regulatory agencies could encourage development of companion diagnostics, test antibiotic combinations in parallel, and pool and make transparent clinical trial data to lower R&D costs. A tax on non-human use of antibiotics might also create a disincentive for non-therapeutic use of these drugs. Finally, the new business model for antibiotic innovation should apply the 3Rs strategy for encouraging collaborative approaches to R&D in innovating novel antibiotics: sharing resources, risks, and rewards.

Why are potential women being killed?

PubMed

Thomson, A

1993-12-01

The persistence of traditional practices that provide disincentives to having daughters is giving rise to widespread infanticide in India. In a survey conducted in Madras in 1993, over half of the mothers interviewed acknowledged having killed an infant girl. The infanticide rate is believed to be even higher in India's rural areas. Families who can afford ultrasound to determine the fetal sex are reportedly using selective abortion to avert the birth of a daughter. Of 8000 abortions induced in a Bombay clinic, 7999 involved a female fetus. Families cite the financial burden inherent in providing a dowry as the primary reason for female infanticide. Also cited is the need for a son to both provide financial support to parents in old age and to light their funeral pyre. There are reports of mothers who refuse to kill female infants being abandoned or physically battered by their husbands. At present, there are 116 males to every 100 females in India--an imbalance that is likely to increase in the future and make it impossible for many men to form families. Just as television has been implicated in creating a demand for large dowries that would enable husbands' families to purchase Western luxury items, the mass media should use its influence to alter the attitudes that perpetuate the low status of women in India.

Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law.

PubMed

Lavee, J; Ashkenazi, T; Stoler, A; Cohen, J; Beyar, R

2013-03-01

Israel's organ donation rate has always been among the lowest in Western countries. In 2008 two new laws relevant to organ transplantation were introduced. The Brain-Respiratory Death Law defines the precise circumstances and mechanisms to determine brain death. The Organ Transplantation Law bans reimbursing transplant tourism involving organ trade, grants prioritization in organ allocation to candidates who are registered donors and removes disincentives for living donation by providing modest insurance reimbursement and social supportive services. The preliminary impact of the gradual introduction and implementation of these laws has been witnessed in 2011. Compared to previous years, in 2011 there was a significant increase in the number of deceased organ donors directly related to an increase in organ donation rate (from 7.8 to 11.4 donors per million population), in parallel to a significant increase in the number of new registered donors. In addition the number of kidney transplantations from living donors significantly increased in parallel to a significant decrease in the number of kidney transplantations performed abroad (from 155 in 2006 to 35 in 2011). The new laws have significantly increased both deceased and living organ donation while sharply decreasing transplant tourism. © Copyright 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.

Financial incentives to increase Canadian organ donation: quick fix or fallacy?

PubMed

Gill, John S; Klarenbach, Scott; Barnieh, Lianne; Caulfield, Timothy; Knoll, Greg; Levin, Adeera; Cole, Edward H

2014-01-01

Unlike the United States, the potential to increase organ donation in Canada may be sufficient to meet the need for transplantation. However, there has been no national coordinated effort to increase organ donation. Strategies that do not involve payment for organs, such as investment in health care resources to support deceased donor organ donation and introduction of a remuneration framework for the work of deceased organ donation, should be prioritized for implementation. Financial incentives that may be permitted under existing legislation and that pose little risk to existing donation sources should be advanced, including the following: payment of funeral expenses for potential donors who register their decision on organ donation during life (irrespective of the decision to donate or actual organ donation) and removal of disincentives for directed and paired exchange living donation, such as payment of wages, payment for pain and suffering related to the donor surgery, and payment of directed living kidney donors for participation in Canada's paired exchange program. In contrast, it would be premature to contemplate a regulated system of organ sales that would require a paradigm shift in the current approach to organ donation and legislative change to implement. Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

The hidden cost of low prices: limited access to new drugs in India.

PubMed

Berndt, Ernst R; Cockburn, Iain M

2014-09-01

The pricing and accessibility of patent-protected drugs in low- and middle-income countries is a contentious issue in the global context. But questions about price have little meaning if a drug is not available for purchase, and the extent to which patent policy affects when (and if) new drugs become available in these countries has largely been overlooked. We examined data on the sales of 184 drugs approved by the US Food and Drug Administration between 2000 and 2009. We found that 50 percent of those 184 drugs went on sale in India only after lags of more than five years from their first worldwide introduction. More than half of the drugs that became newly available in India during the study period were produced and sold by multiple manufacturers in the country within one year of their introduction. The presence of multiple manufacturers indicates sharp competition and weak patent protection--factors that are disincentives to manufacturers to incur the costs of gaining access to the market. We conclude that modest patent and regulatory reform could bring the faster availability of a wider range of new drugs in India with limited impact on prices--a trade-off that merits greater policy attention. Project HOPE—The People-to-People Health Foundation, Inc.

Integrating Data and Networks: Human Factors

NASA Astrophysics Data System (ADS)

Chen, R. S.

2012-12-01

The development of technical linkages and interoperability between scientific networks is a necessary but not sufficient step towards integrated use and application of networked data and information for scientific and societal benefit. A range of "human factors" must also be addressed to ensure the long-term integration, sustainability, and utility of both the interoperable networks themselves and the scientific data and information to which they provide access. These human factors encompass the behavior of both individual humans and human institutions, and include system governance, a common framework for intellectual property rights and data sharing, consensus on terminology, metadata, and quality control processes, agreement on key system metrics and milestones, the compatibility of "business models" in the short and long term, harmonization of incentives for cooperation, and minimization of disincentives. Experience with several national and international initiatives and research programs such as the International Polar Year, the Group on Earth Observations, the NASA Earth Observing Data and Information System, the U.S. National Spatial Data Infrastructure, the Global Earthquake Model, and the United Nations Spatial Data Infrastructure provide a range of lessons regarding these human factors. Ongoing changes in science, technology, institutions, relationships, and even culture are creating both opportunities and challenges for expanded interoperability of scientific networks and significant improvement in data integration to advance science and the use of scientific data and information to achieve benefits for society as a whole.

How do macro-level contexts and policies affect the employment chances of chronically ill and disabled people? Part II: The impact of active and passive labor market policies.

PubMed

Holland, Paula; Nylén, Lotta; Thielen, Karsten; van der Wel, Kjetil A; Chen, Wen-Hao; Barr, Ben; Burström, Bo; Diderichsen, Finn; Andersen, Per Kragh; Dahl, Espen; Uppal, Sharanjit; Clayton, Stephen; Whitehead, Margaret

2011-01-01

The authors investigate three hypotheses on the influence of labor market deregulation, decommodification, and investment in active labor market policies on the employment of chronically ill and disabled people. The study explores the interaction between employment, chronic illness, and educational level for men and women in Canada, Denmark, Norway, Sweden, and the United Kingdom, countries with advanced social welfare systems and universal health care but with varying types of active and passive labor market policies. People with chronic illness were found to fare better in employment terms in the Nordic countries than in Canada or the United Kingdom. Their employment chances also varied by educational level and country. The employment impact of having both chronic illness and low education was not just additive but synergistic. This amplification was strongest for British men and women, Norwegian men, and Danish women. Hypotheses on the disincentive effects of tighter employment regulation or more generous welfare benefits were not supported. The hypothesis that greater investments in active labor market policies may improve the employment of chronically ill people was partially supported. Attention must be paid to the differential impact of macro-level policies on the labor market participation of chronically ill and disabled people with low education, a group facing multiple barriers to gaining employment.

The Changing Financial Landscape of Renal Transplant Practice: A National Cohort Analysis.

PubMed

Axelrod, D A; Schnitzler, M A; Xiao, H; Naik, A S; Segev, D L; Dharnidharka, V R; Brennan, D C; Lentine, K L

2017-02-01

Kidney transplantation has become more resource intensive as recipient complexity has increased and average donor quality has diminished over time. A national retrospective cohort study was performed to assess the impact of kidney donor and recipient characteristics on transplant center cost (exclusive of organ acquisition) and Medicare reimbursement. Data from the national transplant registry, University HealthSystem Consortium hospital costs, and Medicare payments for deceased donor (N = 53 862) and living donor (N = 36 715) transplants from 2002 to 2013 were linked and analyzed using multivariate linear regression modeling. Deceased donor kidney transplant costs were correlated with recipient (Expected Post Transplant Survival Score, degree of allosensitization, obesity, cause of renal failure), donor (age, cause of death, donation after cardiac death, terminal creatinine), and transplant (histocompatibility matching) characteristics. Living donor costs rose sharply with higher degrees of allosensitization, and were also associated with obesity, cause of renal failure, recipient work status, and 0-ABDR mismatching. Analysis of Medicare payments for a subsample of 24 809 transplants demonstrated minimal correlation with patient and donor characteristics. In conclusion, the complexity in the landscape of kidney transplantation increases center costs, posing financial disincentives that may reduce organ utilization and limit access for higher-risk populations. © Copyright 2016 The American Society of Transplantation and the American Society of Transplant Surgeons.

CNS Anticancer Drug Discovery and Development: 2016 conference insights

PubMed Central

Levin, Victor A; Abrey, Lauren E; Heffron, Timothy P; Tonge, Peter J; Dar, Arvin C; Weiss, William A; Gallo, James M

2017-01-01

CNS Anticancer Drug Discovery and Development, 16-17 November 2016, Scottsdale, AZ, USA The 2016 second CNS Anticancer Drug Discovery and Development Conference addressed diverse viewpoints about why new drug discovery/development focused on CNS cancers has been sorely lacking. Despite more than 70,000 individuals in the USA being diagnosed with a primary brain malignancy and 151,669–286,486 suffering from metastatic CNS cancer, in 1999, temozolomide was the last drug approved by the US FDA as an anticancer agent for high-grade gliomas. Among the topics discussed were economic factors and pharmaceutical risk assessments, regulatory constraints and perceptions and the need for improved imaging surrogates of drug activity. Included were modeling tumor growth and drug effects in a medical environment in which direct tumor sampling for biological effects can be problematic, potential new drugs under investigation and targets for drug discovery and development. The long trajectory and diverse impediments to novel drug discovery, and expectation that more than one drug will be needed to adequately inhibit critical intracellular tumor pathways were viewed as major disincentives for most pharmaceutical/biotechnology companies. While there were a few unanimities, one consensus is the need for continued and focused discussion among academic and industry scientists and clinicians to address tumor targets, new drug chemistry, and more time- and cost-efficient clinical trials based on surrogate end points. PMID:28718326

Honorary authorship epidemic in scholarly publications? How the current use of citation-based evaluative metrics make (pseudo)honorary authors from honest contributors of every multi-author article.

PubMed

Kovacs, Jozsef

2013-08-01

The current use of citation-based metrics to evaluate the research output of individual researchers is highly discriminatory because they are uniformly applied to authors of single-author articles as well as contributors of multi-author papers. In the latter case, these quantitative measures are counted, as if each contributor were the single author of the full article. In this way, each and every contributor is assigned the full impact-factor score and all the citations that the article has received. This has a multiplication effect on each contributor's citation-based evaluative metrics of multi-author articles, because the more contributors an article has, the more undeserved credit is assigned to each of them. In this paper, I argue that this unfair system could be made fairer by requesting the contributors of multi-author articles to describe the nature of their contribution, and to assign a numerical value to their degree of relative contribution. In this way, we could create a contribution-specific index of each contributor for each citation metric. This would be a strong disincentive against honorary authorship and publication cartels, because it would transform the current win-win strategy of accepting honorary authors in the byline into a zero-sum game for each contributor.

Employer-sponsored health insurance coverage limitations: results from the Childhood Cancer Survivor Study.

PubMed

Kirchhoff, Anne C; Kuhlthau, Karen; Pajolek, Hannah; Leisenring, Wendy; Armstrong, Greg T; Robison, Leslie L; Park, Elyse R

2013-02-01

The Affordable Care Act (ACA) will expand health insurance options for cancer survivors in the USA. It is unclear how this legislation will affect their access to employer-sponsored health insurance (ESI). We describe the health insurance experiences for survivors of childhood cancer with and without ESI. We conducted a series of qualitative interviews with 32 adult survivors from the Childhood Cancer Survivor Study to assess their employment-related concerns and decisions regarding health insurance coverage. Interviews were performed from August to December 2009 and were recorded, transcribed, and content analyzed using NVivo 8. Uninsured survivors described ongoing employment limitations, such as being employed at part-time capacity, which affected their access to ESI coverage. These survivors acknowledged they could not afford insurance without employer support. Survivors on ESI had previously been denied health insurance due to their preexisting health conditions until they obtained coverage through an employer. Survivors feared losing their ESI coverage, which created a disincentive to making career transitions. Others reported worries about insurance rescission if their cancer history was discovered. Survivors on ESI reported financial barriers in their ability to pay for health care. Childhood cancer survivors face barriers to obtaining ESI. While ACA provisions may mitigate insurance barriers for cancer survivors, many will still face cost barriers to affording health care without employer support.

Voluntary agreements between government and business - a scoping review of the literature with specific reference to the Public Health Responsibility Deal.

PubMed

Bryden, Anna; Petticrew, Mark; Mays, Nicholas; Eastmure, Elizabeth; Knai, Cecile

2013-05-01

A scoping review was conducted to synthesise the findings of evaluations of voluntary agreements between business and government. It aimed to summarise the types of agreements that exist, how they work in practice, the conditions for their success and how they had been evaluated. Voluntary agreements were included if they involved a transparent signing-up process and where businesses agreed to carry out specific actions or to achieve specific outcomes. Studies of any design published in English were included. 47 studies were identified. Voluntary agreements may help to improve relationships between government and business, and can help both parties agree on target-setting and data-sharing. Governments may also use the experience to help develop subsequent legislation. For voluntary agreements to be successful, targets should be ambitious and clearly defined, with robust independent monitoring. Public knowledge of agreements can help encourage participation and ensure compliance. If properly implemented and monitored, voluntary agreements can be an effective policy approach, though there is little evidence on whether they are more effective than compulsory approaches. Some of the most effective voluntary agreements include substantial disincentives for non-participation and sanctions for non-compliance. Many countries are moving towards these more formal approaches to voluntary agreements. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Consumer Acceptance of Population-Level Intervention Strategies for Healthy Food Choices: The Role of Perceived Effectiveness and Perceived Fairness

PubMed Central

Bos, Colin; Van Der Lans, Ivo; Van Rijnsoever, Frank; Van Trijp, Hans

2015-01-01

The present study investigates acceptance of intervention strategies for low-calorie snack choices that vary regarding the effect they have on consumers’ freedom of choice (providing information, guiding choice through (dis)incentives, and restricting choice). We examine the mediating effects of perceived effectiveness and perceived fairness, and the moderating effects of barriers to choose low-calorie snacks and perceived responsibility for food choice. Data was collected through an online survey, involving three waves that were completed over a seven week timespan. Information was collected on barriers and perceived responsibility, and evaluations of a total of 128 intervention strategies with varying levels of intrusiveness that were further systematically varied in terms of source, location, approach/avoidance, type, and severity. A total of 1173 respondents completed all three waves. We found that the effect of intervention intrusiveness on acceptance was mediated by the perceived personal- and societal effectiveness, and the perceived fairness of interventions. For barriers and perceived responsibility, only main effects on intervention-specific beliefs were found. Government interventions were accepted less than interventions by food manufacturers. In conclusion, the present study shows that acceptance of interventions depends on perceptions of personal- and societal effectiveness and fairness, thereby providing novel starting points for increasing acceptance of both existing and new food choice interventions. PMID:26389949

How are coastal households responding to climate change?

DOE Office of Scientific and Technical Information (OSTI.GOV)

Elrick-Barr, Carmen E.; Smith, Timothy F.; Preston, Benjamin L.

In Australia, shared responsibility is a concept advocated to promote collective climate change adaptation by multiple actors and institutions. However, a shared response is often promoted in the absence of information regarding actions currently taken; in particular, there is limited knowledge regarding action occurring at the household scale. To address this gap, we examine household actions taken to address climate change and associated hazards in two Australian coastal communities. Mixed methods research is conducted to answer three questions: (1) what actions are currently taken (mitigation, actions to lobby for change or adaptation to climate impacts)? (2) why are these actionsmore » taken (e.g. are they consistent with capacity, experience, perceptions of risk); and (3) what are the implications for adaptation? We find that households are predominantly mitigating greenhouse gas emissions and that impact orientated adaptive actions are limited. Coping strategies are considered sufficient to mange climate risks, proving a disincentive for additional adaptive action. Influencing factors differ, but generally, risk perception and climate change belief are associated with action. Furthermore, the likelihood of more action is a function of homeownership and a tendency to plan ahead. Addressing factors that support or constrain household adaptive decision-making and action, from the physical (e.g. homeownership) to the social (e.g. skills in planning and a culture of adapting to change) will be critical in increasing household participation in adaptation.« less

The Ethics of Chronic Dialysis for the Older Patient: Time to Reevaluate the Norms.

PubMed

Thorsteinsdottir, Bjorg; Swetz, Keith M; Albright, Robert C

2015-11-06

Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits. With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis. Nephrologists should ensure that the patient's rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patient's goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases. Copyright © 2015 by the American Society of Nephrology.

Fighting for business: the limits of professional cooperation among American doctors during the First World War.

PubMed

Schafer, James A

2015-04-01

The American medical profession participated extensively in preparedness and mobilization for the First World War, with more than one in five doctors voluntarily enlisting in various branches of the Army and Navy Medical Corps. Medical officers were widely valorized for suspending their civilian careers and for sacrificing their professional income while in service. Because of the meager commissions that medical officers received by comparison with fees many doctors earned in established private medical practices, scores of county medical societies implemented organizational solutions to this business problem, with the hopes of removing a significant disincentive to enlistment. In these "practice protection plans," a civilian doctor promised to take care of the patients of a military doctor, to forward a portion of the fees collected thereby to the family of the military doctor, and to refer these patients to the military doctor upon his return. Despite initial enthusiasm and promotion, these plans ultimately failed to achieve their objectives, leading some medical officers to accuse civilian doctors of being opportunistic, unpatriotic "slackers." This episode reveals the limits of professional cooperation in American medicine at the time and the need to explain organizational failures in the grand narrative of professionalization during the "Golden Age" of American medicine. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Developing competitive and sustainable Polish generic medicines market.

PubMed

Simoens, Steven

2009-10-01

To descriptively analyze the policy environment surrounding the Polish generic medicines retail market. The policy analysis was based on an international literature review. Also, a simulation exercise was carried out to compute potential savings from substituting generic for originator medicines in Poland using IMS Health pharmaceutical intelligence data. Poland has a mature, high-volume, low-value generic medicines market, primarily driven by the establishment of the reference price at the price of the cheapest medicine in combination with pricing regulation and the low level of medicine prices. The practice of discounting in the distribution chain implies that the National Health Fund and patients do not capture the potential savings from a generic medicines market where companies compete on price. This high-volume market has benefited in the past from the limited availability of originator medicines and a short data exclusivity period, even though there are no incentives for physicians to prescribe generic medicines and a financial disincentive for pharmacists to dispense generic medicines. Increased generic substitution would be expected to reduce public expenditure on originator medicines by 21%. To develop a competitive and sustainable market, Poland needs to consider moving away from competition by discount to competition by price. This could be achieved by replacing maximum distribution margins by fixed margins. Also, Poland may wish to raise reference prices as a temporary measure to boost market entry for medicine classes with few generic medicines.

Government regulation to promote healthy food environments--a view from inside state governments.

PubMed

Shill, J; Mavoa, H; Allender, S; Lawrence, M; Sacks, G; Peeters, A; Crammond, B; Swinburn, B

2012-02-01

Food policy interventions are an important component of obesity-prevention strategies and can potentially drive positive changes in obesogenic environments. This study sought to identify regulatory interventions targeting the food environment, and barriers/facilitators to their implementation at the Australian state government level. In-depth interviews were conducted with senior representatives from state/territory governments, statutory authorities and non-government organizations (n =45) to examine participants' (i) suggestions for regulatory interventions for healthier food environments and (ii) support for pre-selected regulatory interventions derived from a literature review. Data were analysed using thematic and constant comparative analyses. Interventions commonly suggested by participants were regulating unhealthy food marketing; limiting the density of fast food outlets; pricing reforms to decrease fruit/vegetable prices and increase unhealthy food prices; and improved food labelling. The most commonly supported pre-selected interventions were related to food marketing and service. Primary production and retail sector interventions were least supported. The dominant themes were the need for whole-of-government and collaborative approaches; the influence of the food industry; conflicting policies/agenda; regulatory challenges; the need for evidence of effectiveness; and economic disincentives. While interventions such as public sector healthy food service policies were supported by participants, marketing restrictions and fiscal interventions face substantial barriers including a push for deregulation and private sector opposition. © 2011 The Authors. obesity reviews © 2011 International Association for the Study of Obesity.

The US pediatric nephrology workforce: a report commissioned by the American Academy of Pediatrics.

PubMed

Primack, William A; Meyers, Kevin E; Kirkwood, Suzanne J; Ruch-Ross, Holly S; Radabaugh, Carrie L; Greenbaum, Larry A

2015-07-01

The US pediatric nephrology workforce is poorly characterized. This report describes clinical and nonclinical activities, motivations and disincentives to a career in pediatric nephrology, future workforce needs, trainee recruitment, and possible explanations for personnel shortages. An e-mail survey was sent in 2013 to all identified US-trained or -practicing pediatric nephrologists. Of 504 respondents, 51% are men, 66% are US graduates, and 73% work in an academic setting. About 20% of trained pediatric nephrologists no longer practice pediatric nephrology. Among the 384 respondents practicing pediatric nephrology full or part-time in the United States, the mean work week was 56.1±14.3 hours, with time divided between patient care (59%), administration (13%), teaching (10%), clinical research (9%), basic research (6%), and other medical activities (3%). Most (>85%) care for dialysis and transplantation patients. The median number of weeks annually on call is 16, and 29% work with one or no partner. One-third of US pediatric nephrologists (n=126) plan to reduce or stop clinical nephrology practice in the next 5 years, and 53% plan to fully or partially retire. Almost half the division chiefs (47%) report inadequate physician staffing. Ongoing efforts to monitor and address pediatric nephrology workforce issues are needed. Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Drawing them in: professional perspectives on the complexities of engaging 'culturally diverse' young people with sexual and reproductive health promotion and care in Sydney, Australia.

PubMed

Botfield, Jessica R; Newman, Christy E; Zwi, Anthony B

2017-04-01

Young people from minority ethnic, migrant and refugee backgrounds are widely recognised as being under-served by mainstream sexual and reproductive healthcare in developed economy nations. This paper documents the views of professionals in Australia on the complexities of, and best practice approaches to, engaging members of this group with sexual and reproductive health promotion and care. Semi-structured interviews were conducted with 23 purposively selected key informants (health service providers, policymakers, academics and community advocates). Interviews were transcribed verbatim and coded in NVivo10 using interpretive thematic analysis. Principles of 'cultural competence' were employed to structure the interpretation of findings. Five key themes reveal pivotal aspects of how professionals work in, and make sense of, this complex field. These may be summarised as: (1) appreciating the complexities of cultural diversity; (2) recognising structural barriers and disincentives to engagement; (3) normalising sexual health; (4) balancing 'youth-friendly' and 'culturally-competent' priorities; and (5) going beyond simple translation. As migration to Australia continues to diversify the population, an integrated, national approach to the design and delivery of sexual and reproductive health promotion and care would be of value, along with training and support for those involved. Implications may have resonance for other countries similarly engaged in facilitating the successful settlement of migrants and refugees.

Toward a Scalable and Sustainable Intervention for Complementary Food Safety.

PubMed

Rahman, Musarrat J; Nizame, Fosiul A; Nuruzzaman, Mohammad; Akand, Farhana; Islam, Mohammad Aminul; Parvez, Sarker Masud; Stewart, Christine P; Unicomb, Leanne; Luby, Stephen P; Winch, Peter J

2016-06-01

Contaminated complementary foods are associated with diarrhea and malnutrition among children aged 6 to 24 months. However, existing complementary food safety intervention models are likely not scalable and sustainable. To understand current behaviors, motivations for these behaviors, and the potential barriers to behavior change and to identify one or two simple actions that can address one or few food contamination pathways and have potential to be sustainably delivered to a larger population. Data were collected from 2 rural sites in Bangladesh through semistructured observations (12), video observations (12), in-depth interviews (18), and focus group discussions (3). Although mothers report preparing dedicated foods for children, observations show that these are not separate from family foods. Children are regularly fed store-bought foods that are perceived to be bad for children. Mothers explained that long storage durations, summer temperatures, flies, animals, uncovered food, and unclean utensils are threats to food safety. Covering foods, storing foods on elevated surfaces, and reheating foods before consumption are methods believed to keep food safe. Locally made cabinet-like hardware is perceived to be acceptable solution to address reported food safety threats. Conventional approaches that include teaching food safety and highlighting benefits such as reduced contamination may be a disincentive for rural mothers who need solutions for their physical environment. We propose extending existing beneficial behaviors by addressing local preferences of taste and convenience. © The Author(s) 2016.

How are coastal households responding to climate change?

DOE PAGES

Elrick-Barr, Carmen E.; Smith, Timothy F.; Preston, Benjamin L.; ...

2016-06-13

In Australia, shared responsibility is a concept advocated to promote collective climate change adaptation by multiple actors and institutions. However, a shared response is often promoted in the absence of information regarding actions currently taken; in particular, there is limited knowledge regarding action occurring at the household scale. To address this gap, we examine household actions taken to address climate change and associated hazards in two Australian coastal communities. Mixed methods research is conducted to answer three questions: (1) what actions are currently taken (mitigation, actions to lobby for change or adaptation to climate impacts)? (2) why are these actionsmore » taken (e.g. are they consistent with capacity, experience, perceptions of risk); and (3) what are the implications for adaptation? We find that households are predominantly mitigating greenhouse gas emissions and that impact orientated adaptive actions are limited. Coping strategies are considered sufficient to mange climate risks, proving a disincentive for additional adaptive action. Influencing factors differ, but generally, risk perception and climate change belief are associated with action. Furthermore, the likelihood of more action is a function of homeownership and a tendency to plan ahead. Addressing factors that support or constrain household adaptive decision-making and action, from the physical (e.g. homeownership) to the social (e.g. skills in planning and a culture of adapting to change) will be critical in increasing household participation in adaptation.« less

Architects' perspectives on construction waste reduction by design

DOE Office of Scientific and Technical Information (OSTI.GOV)

Osmani, M.; Glass, J.; Price, A.D.F.

2008-07-01

The construction, demolition and excavation waste arising in England was estimated at 91 million tonnes in 2003. The current thinking on construction waste minimisation is heavily focussed on several issues relating to physical construction waste and recycling guides. Indeed, much had been published on ways to improve on-site waste management and recycling activities but very few attempts made to address the effect of design practices on waste generation. However, there is a consensus in the literature that the architect has a decisive role to play in helping to reduce waste by focussing on designing out waste. This paper examines previousmore » studies on architects' approach towards construction waste minimisation; and by means of a postal questionnaire, investigates: the origins of waste; waste minimisation design practices in the UK; and responsibilities and barriers within the UK architectural profession. The findings reveal that waste management is not a priority in the design process. Additionally, the architects seemed to take the view that waste is mainly produced during site operations and rarely generated during the design stages; however, about one-third of construction waste could essentially arise from design decisions. Results also indicate that a number of constraints, namely: lack of interest from clients; attitudes towards waste minimisation; and training all act as disincentives to a proactive and sustainable implementation of waste reduction strategies during the design process.« less

Health Insurance and the Labor Supply Decisions of Older Workers: Evidence from a U.S. Department of Veterans Affairs Expansion.

PubMed

Boyle, Melissa A; Lahey, Joanna N

2010-08-01

This paper exploits a major mid-1990s expansion in the U.S. Department of Veterans Affairs health care system to provide evidence on the labor market effects of expanding health insurance availability. Using data from the Current Population Survey, we employ a difference-in-differences strategy to compare the labor market behavior of older veterans and non-veterans before and after the VA health benefits expansion to test the impact of public health insurance on labor supply. We find that older workers are significantly more likely to decrease work both on the extensive and intensive margins after receiving access to non-employer based insurance. Workers with some college education or a college degree are more likely to transition into self-employment, a result consistent with "job-lock" effects. However, less-educated workers are more likely to leave self-employment, a result suggesting that the positive income effect from receiving public insurance dominates the "job-lock" effect for these workers. Some relatively disadvantaged sub-populations may also increase their labor supply after gaining greater access to public insurance, consistent with complementary positive health effects of health care access or decreased work disincentives for these groups. We conclude that this reform has affected employment and retirement decisions, and suggest that future moves toward universal coverage or expansions of Medicare are likely to have significant labor market effects.

Management Options for Reducing the Release of Antibiotics and Antibiotic Resistance Genes to the Environment

PubMed Central

Pruden, Amy; Amézquita, Alejandro; Collignon, Peter; Brandt, Kristian K.; Graham, David W.; Lazorchak, James M.; Suzuki, Satoru; Silley, Peter; Snape, Jason R.; Topp, Edward; Zhang, Tong; Zhu, Yong-Guan

2013-01-01

Background: There is growing concern worldwide about the role of polluted soil and water environments in the development and dissemination of antibiotic resistance. Objective: Our aim in this study was to identify management options for reducing the spread of antibiotics and antibiotic-resistance determinants via environmental pathways, with the ultimate goal of extending the useful life span of antibiotics. We also examined incentives and disincentives for action. Methods: We focused on management options with respect to limiting agricultural sources; treatment of domestic, hospital, and industrial wastewater; and aquaculture. Discussion: We identified several options, such as nutrient management, runoff control, and infrastructure upgrades. Where appropriate, a cross-section of examples from various regions of the world is provided. The importance of monitoring and validating effectiveness of management strategies is also highlighted. Finally, we describe a case study in Sweden that illustrates the critical role of communication to engage stakeholders and promote action. Conclusions: Environmental releases of antibiotics and antibiotic-resistant bacteria can in many cases be reduced at little or no cost. Some management options are synergistic with existing policies and goals. The anticipated benefit is an extended useful life span for current and future antibiotics. Although risk reductions are often difficult to quantify, the severity of accelerating worldwide morbidity and mortality rates associated with antibiotic resistance strongly indicate the need for action. PMID:23735422

Seroepidemiological Study of Interepidemic Rift Valley Fever Virus Infection Among Persons with Intense Ruminant Exposure in Madagascar and Kenya.

PubMed

Gray, Gregory C; Anderson, Benjamin D; LaBeaud, A Desirée; Heraud, Jean-Michel; Fèvre, Eric M; Andriamandimby, Soa Fy; Cook, Elizabeth A J; Dahir, Saidi; de Glanville, William A; Heil, Gary L; Khan, Salah U; Muiruri, Samuel; Olive, Marie-Marie; Thomas, Lian F; Merrill, Hunter R; Merrill, Mary L M; Richt, Juergen A

2015-12-01

In this cross-sectional seroepidemiological study we sought to examine the evidence for circulation of Rift Valley fever virus (RVFV) among herders in Madagascar and Kenya. From July 2010 to June 2012, we enrolled 459 herders and 98 controls (without ruminant exposures) and studied their sera (immunoglobulin G [IgG] and IgM through enzyme-linked immunosorbent assay [ELISA] and plaque reduction neutralization test [PRNT] assays) for evidence of previous RVFV infection. Overall, 59 (12.9%) of 459 herders and 7 (7.1%) of the 98 controls were positive by the IgG ELISA assay. Of the 59 ELISA-positive herders, 23 (38.9%) were confirmed by the PRNT assay (21 from eastern Kenya). Two of the 21 PRNT-positive study subjects also had elevated IgM antibodies against RVFV suggesting recent infection. Multivariate modeling in this study revealed that being seminomadic (odds ratio [OR] = 6.4, 95% confidence interval [CI] = 2.1-15.4) was most strongly associated with antibodies against RVFV. Although we cannot know when these infections occurred, it seems likely that some interepidemic RVFV infections are occurring among herders. As there are disincentives regarding reporting RVFV outbreaks in livestock or wildlife, it may be prudent to conduct periodic, limited, active seroepidemiological surveillance for RVFV infections in herders, especially in eastern Kenya. © The American Society of Tropical Medicine and Hygiene.

Architects' perspectives on construction waste reduction by design.

PubMed

Osmani, M; Glass, J; Price, A D F

2008-01-01

The construction, demolition and excavation waste arising in England was estimated at 91 million tonnes in 2003. The current thinking on construction waste minimisation is heavily focussed on several issues relating to physical construction waste and recycling guides. Indeed, much had been published on ways to improve on-site waste management and recycling activities but very few attempts made to address the effect of design practices on waste generation. However, there is a consensus in the literature that the architect has a decisive role to play in helping to reduce waste by focussing on designing out waste. This paper examines previous studies on architects' approach towards construction waste minimisation; and by means of a postal questionnaire, investigates: the origins of waste; waste minimisation design practices in the UK; and responsibilities and barriers within the UK architectural profession. The findings reveal that waste management is not a priority in the design process. Additionally, the architects seemed to take the view that waste is mainly produced during site operations and rarely generated during the design stages; however, about one-third of construction waste could essentially arise from design decisions. Results also indicate that a number of constraints, namely: lack of interest from clients; attitudes towards waste minimisation; and training all act as disincentives to a proactive and sustainable implementation of waste reduction strategies during the design process.

Employer-Sponsored Health Insurance Coverage Limitations: Results from the Childhood Cancer Survivor Study

PubMed Central

Kirchhoff, Anne C.; Kuhlthau, Karen; Pajolek, Hannah; Leisenring, Wendy; Armstrong, Greg T.; Robison, Leslie L.; Park, Elyse R.

2013-01-01

Purpose The Affordable Care Act (ACA) will expand health insurance options for cancer survivors in the United States. It is unclear how this legislation will affect their access to employer-sponsored health insurance (ESI). We describe the health insurance experiences for survivors of childhood cancer with and without ESI. Methods We conducted a series of qualitative interviews with 32 adult survivors from the Childhood Cancer Survivor Study to assess their employment-related concerns and decisions regarding health insurance coverage. Interviews were performed from August to December 2009 and were recorded, transcribed, and content analyzed using NVivo 8. Results Uninsured survivors described ongoing employment limitations, such as being employed at part-time capacity, which affected their access to ESI coverage. These survivors acknowledged they could not afford insurance without employer support. Survivors on ESI had previously been denied health insurance due to their pre-existing health conditions until they obtained coverage through an employer. Survivors feared losing their ESI coverage, which created a disincentive to making career transitions. Others reported worries about insurance rescission if their cancer history was discovered. Survivors on ESI reported financial barriers in their ability to pay for health care. Conclusions Childhood cancer survivors face barriers to obtaining employer-sponsored health insurance. While Affordable Care Act provisions may mitigate insurance barriers for cancer survivors, many will still face cost barriers to affording health care without employer support. PMID:22717916

Meaningful use of health information technology by rural hospitals.

PubMed

McCullough, Jeffrey; Casey, Michelle; Moscovice, Ira; Burlew, Michele

2011-01-01

This study examines the current status of meaningful use of health information technology (IT) in Critical Access Hospitals (CAHs), other rural, and urban US hospitals, and it discusses the potential role of Medicare payment incentives and disincentives in encouraging CAHs and other rural hospitals to achieve meaningful use. Data from the American Hospital Association (AHA) Annual Survey IT Supplement were analyzed, using t tests and probit regressions to assess whether implementation rates in CAHs and other rural hospitals are significantly different from rates in urban hospitals. Of the many measures we examined, only 4 have been met by a majority of rural hospitals: electronic recording of patient demographics and electronic access to lab reports, radiology reports, and radiology images. Meaningful use is even less prevalent among CAHs. We also find that rural hospitals lag behind urban institutions in nearly every measure of meaningful use. These differences are particularly large and significant for CAHs. The meaningful use incentive system creates many challenges for CAHs. First, investments are evaluated and subsidies determined after adoption. Thus, CAHs must accept financial risk when adopting health IT; this may be particularly important for large expenditures. Second, the subsidies may be low for relatively small expenditures. Third, since the subsidies are based on observable costs, CAHs will receive no support for their intangible costs (eg, workflow disruption). A variety of policies may be used to address these problems of financial risk, uncertain returns in a rural setting, and limited resources. © 2011 National Rural Health Association.

The Cairo conference: feminists vs. the Pope.

PubMed

Grant, L

1994-07-01

The draft Programme of Action to be discussed at the UN International Conference on Population and Development (ICPD) in Cairo is not about population and development, but about women and related agendas, supporting the various family forms (which promote population growth), and incalculable amounts of funding to increase the breadth of goals (e.g., more funding to improve the quality of life in cities). It does little to link those goals with global population growth. The US Department of State supports the militant feminists' agenda, which is for money to be directed to women's advancement activities rather than to direct population programs. Their reasoning is that women will achieve the socially desirable fertility level if they have unimpeded freedom of choice. The Vatican, which opposes birth control and abortion, is chastising the women's groups and the population movement. The US government has shifted its position to accommodate the militant feminists. It is not listening to bioscientists, demographers, and others who might have mellowed the advocacy approach. The draft Programme of Action has no population goals, which are needed to operate a population program. The US government should call for meeting unmet needs for contraception, expansion of family planning facilities and services in developing countries, and reinstatement of goals in the international population dialogue. It should also continue efforts to persuade developing country leaders of the importance of the population issue and of incentives and disincentives. Its first priority should be population, followed by development assistance to maternal and child health services coordinated with family planning services.

Mixing Carrots and Sticks to Conserve Forests in the Brazilian Amazon: A Spatial Probabilistic Modeling Approach

PubMed Central

Börner, Jan; Marinho, Eduardo; Wunder, Sven

2015-01-01

Annual forest loss in the Brazilian Amazon had in 2012 declined to less than 5,000 sqkm, from over 27,000 in 2004. Mounting empirical evidence suggests that changes in Brazilian law enforcement strategy and the related governance system may account for a large share of the overall success in curbing deforestation rates. At the same time, Brazil is experimenting with alternative approaches to compensate farmers for conservation actions through economic incentives, such as payments for environmental services, at various administrative levels. We develop a spatially explicit simulation model for deforestation decisions in response to policy incentives and disincentives. The model builds on elements of optimal enforcement theory and introduces the notion of imperfect payment contract enforcement in the context of avoided deforestation. We implement the simulations using official deforestation statistics and data collected from field-based forest law enforcement operations in the Amazon region. We show that a large-scale integration of payments with the existing regulatory enforcement strategy involves a tradeoff between the cost-effectiveness of forest conservation and landholder incomes. Introducing payments as a complementary policy measure increases policy implementation cost, reduces income losses for those hit hardest by law enforcement, and can provide additional income to some land users. The magnitude of the tradeoff varies in space, depending on deforestation patterns, conservation opportunity and enforcement costs. Enforcement effectiveness becomes a key determinant of efficiency in the overall policy mix. PMID:25650966

Developing Competitive and Sustainable Polish Generic Medicines Market

PubMed Central

Simoens, Steven

2009-01-01

Aim To descriptively analyze the policy environment surrounding the Polish generic medicines retail market. Method The policy analysis was based on an international literature review. Also, a simulation exercise was carried out to compute potential savings from substituting generic for originator medicines in Poland using IMS Health pharmaceutical intelligence data. Results Poland has a mature, high-volume, low-value generic medicines market, primarily driven by the establishment of the reference price at the price of the cheapest medicine in combination with pricing regulation and the low level of medicine prices. The practice of discounting in the distribution chain implies that the National Health Fund and patients do not capture the potential savings from a generic medicines market where companies compete on price. This high-volume market has benefited in the past from the limited availability of originator medicines and a short data exclusivity period, even though there are no incentives for physicians to prescribe generic medicines and a financial disincentive for pharmacists to dispense generic medicines. Increased generic substitution would be expected to reduce public expenditure on originator medicines by 21%. Conclusion To develop a competitive and sustainable market, Poland needs to consider moving away from competition by discount to competition by price. This could be achieved by replacing maximum distribution margins by fixed margins. Also, Poland may wish to raise reference prices as a temporary measure to boost market entry for medicine classes with few generic medicines. PMID:19839067

Economic impact of a primary care career: a harsh reality for medical students and the nation.

PubMed

Palmeri, Martin; Pipas, Catherine; Wadsworth, Eric; Zubkoff, Michael

2010-11-01

The ranks of U.S. medical students choosing careers in primary care (PC) are declining even as the demand for new PC physicians is increasing. Although the decision to choose a career in PC is multifactorial, financial security in the setting of rising medical student debt is often cited as a reason to pursue other medical specialties. The authors sought to quantify the financial factors associated with a career in PC. The authors used economic modeling, which employs a variety of factors, to develop a net income and expense model. They attempted to account for the variability of factors by looking at best, worst, and average expense scenarios. They used published retrospective data from the Bureau of Labor Statistics, the 2007 Physician Compensation Survey, the National Association of Realtors, the College Board, and U.S. News and World Report regarding medical student debt, physician reimbursement, retirement planning, college savings, and cost-of-living expenses to develop their models. PC salaries, in contrast to other subspecialties, result in an initial budgetary deficit and decreased discretionary spending. This gap closes as PC physician income rises in the first few years of practice. Only under scenarios of optimal low cost assumptions or no debt do a PC physician's initial earnings exceed predicted expenses. PC physicians, in the first three to five years following residency, will have expenses that exceed earnings. This reality greatly increases the financial disincentive for pursuing a career in PC compared with other fields of medicine.

Cardiovascular Health Issues in Inner City Populations.

PubMed

Nayyar, Dhruv; Hwang, Stephen W

2015-09-01

Inner city populations in high-income countries carry a disproportionately high burden of cardiovascular disease. Although low individual socioeconomic status has long been associated with higher morbidity and mortality from cardiovascular disease, there is a growing body of evidence that area-level socioeconomic status may also have a major effect on cardiovascular outcomes. A lack of supermarkets, limited green space, and high rates of violent crime in inner city neighbourhoods result in poor dietary intake and low rates of physical activity among residents. The physical and social environments of inner city neighbourhoods may also contribute to high rates of comorbid mental illness in disadvantaged urban populations. Mental illness may lead to the clustering of cardiovascular risk factors through its impact on health behaviours, effects of psychiatric medications, and sequelae of substance abuse. Individuals residing in disadvantaged neighbourhoods experience reduced access to both primary preventive and acute in-hospital cardiovascular care. This may be driven by financial disincentives for caring for patients with low socioeconomic status, as well as system capacity issues in the inner city, and patient-level differences in health-seeking behaviours. Small-scale studies of interventions to improve individual-level health behaviours and access to care in the inner city have demonstrated some success in improving cardiovascular outcomes through the use of mobile clinics, health coaching, and case management approaches. There is a need for further research into community-wide interventions to improve the cardiovascular health of inner city populations. Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Employment barriers for persons with psychiatric disabilities: update of a report for the President's Commission.

PubMed

Cook, Judith A

2006-10-01

A major public policy problem is the extremely low labor force participation of people with severe mental illness coupled with their overrepresentation on the public disability rolls. This situation is especially troubling given the existence of evidence-based practices designed to return them to the labor force. This article reviews research from the fields of disability, economics, health care, and labor studies to describe the nature of barriers to paid work and economic security for people with disabling mental disorders. These barriers include low educational attainment, unfavorable labor market dynamics, low productivity, lack of appropriate vocational and clinical services, labor force discrimination, failure of protective legislation, work disincentives caused by state and federal policies, poverty-level income, linkage of health care access to disability beneficiary status, and ineffective work incentive programs. The article concludes with a discussion of current policy initiatives in health care, mental health, and disability. Recommendations for a comprehensive system of services and supports to address multiple barriers are presented. These include access to affordable health care, including mental health treatment and prescription drug coverage; integrated clinical and vocational services; safe and stable housing that is not threatened by changes in earned income; remedial and postsecondary education and vocational training; benefits counseling and financial literacy education; economic security through asset development; legal aid for dealing with employment discrimination; peer support and self-help to enhance vocational self-image and encourage labor force attachment; and active involvement of U.S. business and employer communities.

Not just maternalism: marriage and fatherhood in American welfare policy.

PubMed

Geva, Dorit

2011-01-01

The United States' 1996 welfare reforms are often interpreted as a historical break in transitioning from supporting motherhood to commodifiying women's labor. However, this cannot account for welfare reform's emphasis upon heterosexual marriage and fatherhood promotion. The paper traces continuities and shifts in over a century of familial regulation through American welfare policy, specifying the place of marriage promotion within welfare policy. Up until 1996, families were key sites of intervention through which the American welfare state was erected, especially through single women as mothers - not wives. However, as of the 1960s, concern with African American men's "failed" familial commitments turned policymakers toward concern over marriage promotion for women and men. While marriage "disincentives" for aid recipients were lifted in the 1960s, the 1996 reforms structured a new form of nuclear family governance actively promoting marriage rooted in, but distinct from, the previous. Given the historical absence of welfare policies available to poor men, Temporary Assistance for Needy Families' (TANF) marriage promotion policies have positioned poor women as nodes connecting the state to poor men, simultaneously structuring poor women as breadwinners, mothers, and wives. Recent welfare reform has also started to target poor men directly, especially in fatherhood and marriage promotion initiatives. The article highlights how, in addition to workfare policies, marriage promotion is a neoliberal policy shifting risk to the shoulders of the poor, aiming to produce "strong families" for the purposes of social security.

Audit of Use and Overuse of Serum Protein Immunofixation Electrophoresis and Serum Free Light Chain Assay in Tertiary Health Care: A Case for Algorithmic Testing to Optimize Laboratory Utilization.

PubMed

Heaton, Christopher; Vyas, Shikhar G; Singh, Gurmukh

2016-04-01

Overuse of laboratory tests is a persistent issue. We examined the use and overuse of serum immunofixation electrophoresis and serum free light chain assays to develop an algorithm for optimizing utilization. A retrospective review of all tests, for investigation of monoclonal gammopathies, for all patients who had any of these tests done from April 24, 2014, through July 25, 2014, was carried out. The test orders were categorized as warranted or not warranted according to criteria presented in the article. A total of 237 patients were tested, and their historical records included 1,503 episodes of testing for one or more of serum protein electrophoresis, serum immunofixation electrophoresis, and serum free light chain assays. Only 46% of the serum immunofixation and 42% serum free light chain assays were warranted. Proper utilization, at our institution alone, would have obviated $64,182.95/year in health care costs, reduced laboratory cost of reagent alone by $26,436.04/year, and put $21,904.92/year of part B reimbursement at risk. Fewer than half of the serum immunofixation and serum free light chain assays added value. The proposed algorithm for testing should improve utilization. Risk to part B billing may be a disincentive to reducing test utilization. © American Society for Clinical Pathology, 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Internal medicine and the journey to medical generalism.

PubMed

Rivo, M L

1993-07-15

The overspecialized U.S. physician workforce and mix of graduating residents undermine strategies to provide quality and affordable health care to all Americans. Several respected advisory bodies have recently proposed fundamental changes in federal policy to better match physician supply and specialty mix with health care needs. They recommend that Congress limit the total number of filled first-year resident positions to 110% of the number of U.S. medical school graduates, a 20% reduction from current levels. They have proposed that positions and funding be allocated to medical schools, teaching hospitals, residency programs, or consortia of such entities to ensure that at least 50% of each graduating residency class enters generalist practice. An all-payer, graduate medical education pool and financing system have been suggested as ways to uncouple the physician workforce from hospital service needs and to eliminate disincentives toward ambulatory and primary care training. Increases in generalist production must be accompanied by decreases in nonprimary care specialty and subspecialty positions. In addition, generalist physicians must be better prepared in managed care competencies. Given today's subspecialist surplus, managed care organizations are considering how to retrain subspecialists as generalists. The Federated Council of Internal Medicine's goal that 50% of its graduates become general internists is an important step because internists compose one sixth of all physicians and one third of all first-year residents. This article identifies the challenges that lay ahead on the road to medical generalism and what it may take to get there.

Residents' Perspectives on Careers in Academic Medicine: Obstacles and Opportunities.

PubMed

Lin, Steven; Nguyen, Cathina; Walters, Emily; Gordon, Paul

2018-03-01

Worsening faculty shortages in medical schools and residency programs are threatening the US medical education infrastructure. Little is known about the factors that influence the decision of family medicine residents to choose or not choose academic careers. Our study objective was to answer the following question among family medicine residents: "What is your greatest concern or fear about pursuing a career in academic family medicine?" Participants were family medicine residents who attended the Faculty for Tomorrow Workshop at the Society of Teachers of Family Medicine Annual Spring Conference in 2016 and 2017. Free responses to the aforementioned prompt were analyzed using a constant comparative method and grounded theory approach. A total of 156 participants registered for the workshops and 95 (61%) answered the free response question. Eight distinct themes emerged from the analysis. The most frequently recurring theme was "lack of readiness or mentorship," which accounted for nearly one-third (31%) of the codes. Other themes included work-life balance and burnout (17%), job availability and logistics (15%), lack of autonomy or flexibility (11%), competing pressures/roles (10%), lower financial rewards (4%), politics and bureaucracy (4%), and research (3%). To our knowledge, this is the first study to identify barriers and disincentives to pursuing a career in academic medicine from the perspective of family medicine residents. There may be at least eight major obstacles, for which we summarize and consider potential interventions. More research is needed to understand why residents choose, or don't choose, academic careers.

Financial costs for teaching in rural and urban Australian general practices: is there a difference?

PubMed

Laurence, Caroline O; Coombs, Maryanne; Bell, Janice; Black, Linda

2014-04-01

To determine if the financial costs of teaching GP registrars differs between rural and urban practices. Cost-benefit analysis of teaching activities in private GP for GP vocational training. Data were obtained from a survey of general practitioners in South Australia and Western Australia. General practitioners and practices teaching in association with the Adelaide to Outback General Practice Training Program or the Western Australian General Practice Training. Net financial effect per week per practice. At all the training levels, rural practices experienced a financial loss for teaching GP registrars, while urban practices made a small financial gain. The differences in net benefit between rural and urban teaching practices was significant at the GPT2/PRRT2 (-$515 per week 95% CI -$1578, -$266) and GPT3/PRRT3 training levels (-$396 per week, 95% CI (-$2568, -$175). The variables contributing greatest to the difference were the higher infrastructure costs for a rural practice and higher income to the practice from the GP registrars in urban practices. There were significant differences in the financial costs and benefits for a teaching rural practice compared with an urban teaching practice. With infrastructure costs which include accommodation, being a key contributor to the difference found, it might be time to review the level of incentives paid to practices in this area. If not addressed, this cost difference might be a disincentive for rural practices to participate in teaching. © 2014 National Rural Health Alliance Inc.

What role does performance information play in securing improvement in healthcare? a conceptual framework for levers of change.

PubMed

Levesque, Jean-Frederic; Sutherland, Kim

2017-08-28

Across healthcare systems, there is consensus on the need for independent and impartial assessment of performance. There is less agreement about how measurement and reporting performance improves healthcare. This paper draws on academic theories to develop a conceptual framework-one that classifies in an integrated manner the ways in which change can be leveraged by healthcare performance information. A synthesis of published frameworks. The framework identifies eight levers for change enabled by performance information, spanning internal and external drivers, and emergent and planned processes: (1) cognitive levers provide awareness and understanding; (2) mimetic levers inform about the performance of others to encourage emulation; (3) supportive levers provide facilitation, implementation tools or models of care to actively support change; (4) formative levers develop capabilities and skills through teaching, mentoring and feedback; (5) normative levers set performance against guidelines, standards, certification and accreditation processes; (6) coercive levers use policies, regulations incentives and disincentives to force change; (7) structural levers modify the physical environment or professional cultures and routines; (8) competitive levers attract patients or funders. This framework highlights how performance measurement and reporting can contribute to eight different levers for change. It provides guidance into how to align performance measurement and reporting into quality improvement programme. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Is globalization good for your health?

PubMed Central

Dollar, D.

2001-01-01

Four points are made about globalization and health. First, economic integration is a powerful force for raising the incomes of poor countries. In the past 20 years several large developing countries have opened up to trade and investment, and they are growing well--faster than the rich countries. Second, there is no tendency for income inequality to increase in countries that open up. The higher growth that accompanies globalization in developing countries generally benefits poor people. Since there is a large literature linking income of the poor to health status, we can be reasonably confident that globalization has indirect positive effects on nutrition, infant mortality and other health issues related to income. Third, economic integration can obviously have adverse health effects as well: the transmission of AIDS through migration and travel is a dramatic recent example. However, both relatively closed and relatively open developing countries have severe AIDS problems. The practical solution lies in health policies, not in policies on economic integration. Likewise, free trade in tobacco will lead to increased smoking unless health-motivated disincentives are put in place. Global integration requires supporting institutions and policies. Fourth, the international architecture can be improved so that it is more beneficial to poor countries. For example, with regard to intellectual property rights, it may be practical for pharmaceutical innovators to choose to have intellectual property rights in either rich country markets or poor country ones, but not both. In this way incentives could be strong for research on diseases in both rich and poor countries. PMID:11584730

The baby killers are still at large.

PubMed

Power, J

1994-08-12

This newspaper editorial reports that the UN Children's Fund's (UNICEF) executive director and recent US Presidential Medal of Freedom recipient believes that 1.5 million infants would survive annually if breast feeding declines worldwide were reversed. UNICEF adopted the International Code of Marketing of Breast Milk Substitutes in the World Health Assembly in 1981. The code restricts direct advertising, inadequate labels, saleswomen dressed as nurses, and promotion of free samples. The Baby Food Action Network is reported to have released a report which states that baby food companies are still donating free supplies of infant formula to hospitals. The UNICEF position is that provision of free supplies is the most important disincentive to breast feeding. 81 governments adopted the guidelines, but 41 countries have hospitals which accept free samples. 28 of these 41 countries adopted the ban. The Nestle Company, which was cited 20 years age for this practice, won the legal battle and today defies the guidelines in 22 countries, including China, Zimbabwe, and Bangladesh. A US company, Mead Johnson, uses advertising on its label that shows Beatrice Potter's Peter Rabbit being bottle fed. The International Code restricts idealization of bottle feeding. Nutrician, a large conglomerate ownership of US and European infant formula companies, brazenly advertises in the Peruvian daily newspapers with photos of baby milk boxes being donated to hospitals. Dr. Derek Jelliffe, an infant nutritionist, is credited with being the first to publicize the dangers of commercialized malnutrition 21 years ago.

Barriers to disclosing and reporting violence among women in Pakistan: findings from a national household survey and focus group discussions.

PubMed

Andersson, Neil; Cockcroft, Anne; Ansari, Umaira; Omer, Khalid; Ansari, Noor M; Khan, Amir; Chaudhry, Ubaid Ullah

2010-11-01

Worldwide, many women who experience domestic violence keep their experience secret. Few report to official bodies. In a national survey of abuse against women in Pakistan, we examined factors related to disclosure: women who had experienced physical violence telling someone about it. In focus groups, we explored why women do not report domestic violence. Nearly one third of the 23,430 women interviewed had experienced physical violence. Only 35% of them had told anyone about it, almost always someone within their own family. Several personal and family factors were associated with disclosure. Having discussed the issue and feeling empowered to discuss violence were consistent associations. Of the 7,895 women who had suffered physical violence, only 14 had reported the matter to the police. Female focus groups said women who report violence risk their reputation and bring dishonor to the family; women fear reporting violence because it may exacerbate the problem and may lead to separation or divorce and loss of their children. Focus groups of men and women were skeptical about community leaders, councilors, and religious leaders supporting reporting of violence. They suggested setting up local groups where abused women could seek help and advice. There are strong disincentives to reporting violence in Pakistan, which are well known to women. Until better systems for reporting and dealing with reported cases are in place, domestic violence will continue to be a hidden scourge here and elsewhere.

Heart failure disease management: implementation and outcomes.

PubMed

Whellan, David J

2005-01-01

Millions of dollars are being spent to identify new therapies to improve mortality and morbidity for the growing epidemic of patients sustaining heart failure. However, in clinical practice, these therapies are currently underused. To bridge the gap between proven therapies and clinical practice, the medical community has turned to disease management. Heart failure disease management interventions vary from vital-sign monitoring to multidisciplinary approaches involving a pharmacist, nutritionist, nurse practitioner, and physician. This review attempts to categorize these inventions based on location. We compared the published results from randomized, controlled trials of the following types of heart failure disease management interventions: inpatient, clinic visits, home visits, and telephone follow up. Although research shows an improvement in the quality of care and a decrease in hospitalizations for patients sustaining heart failure, the economic impact of disease management is still unclear. The current reimbursement structure is a disincentive to providers wanting to offer disease management services to patients sustaining heart failure. Additionally, the cost of providing disease management services such as additional clinical visits, patient education materials, or additional personnel time has not been well documented. Most heart failure disease management studies do confirm the concept that providing increased access to healthcare providers for an at-risk group of patients sustaining heart failure does improve outcomes. However, a large-scale randomized, controlled clinical trial based in the United States is needed to prove that this concept can be implemented beyond a single center and to determine how much it will cost patients, providers, healthcare systems, and payers.

The Promise and the Challenge of Technology-Facilitated Methods for Assessing Behavioral and Cognitive Markers of Risk for Suicide among U.S. Army National Guard Personnel.

PubMed

Baucom, Brian R W; Georgiou, Panayiotis; Bryan, Craig J; Garland, Eric L; Leifker, Feea; May, Alexis; Wong, Alexander; Narayanan, Shrikanth S

2017-03-31

Suicide was the 10th leading cause of death for Americans in 2015 and rates have been steadily climbing over the last 25 years. Rates are particularly high amongst U.S. military personnel. Suicide prevention efforts in the military are significantly hampered by the lack of: (1) assessment tools for measuring baseline risk and (2) methods to detect periods of particularly heightened risk. Two specific barriers to assessing suicide risk in military personnel that call for innovation are: (1) the geographic dispersion of military personnel from healthcare settings, particularly amongst components like the Reserves; and (2) professional and social disincentives to acknowledging psychological distress. The primary aim of this paper is to describe recent technological developments that could contribute to risk assessment tools that are not subject to the limitations mentioned above. More specifically, Behavioral Signal Processing can be used to assess behaviors during interaction and conversation that likely indicate increased risk for suicide, and computer-administered, cognitive performance tasks can be used to assess activation of the suicidal mode. These novel methods can be used remotely and do not require direct disclosure or endorsement of psychological distress, solving two challenges to suicide risk assessment in military and other sensitive settings. We present an introduction to these technologies, describe how they can specifically be applied to assessing behavioral and cognitive risk for suicide, and close with recommendations for future research.

Defining and classifying medical error: lessons for patient safety reporting systems.

PubMed

Tamuz, M; Thomas, E J; Franchois, K E

2004-02-01

It is important for healthcare providers to report safety related events, but little attention has been paid to how the definition and classification of events affects a hospital's ability to learn from its experience. To examine how the definition and classification of safety related events influences key organizational routines for gathering information, allocating incentives, and analyzing event reporting data. In semi-structured interviews, professional staff and administrators in a tertiary care teaching hospital and its pharmacy were asked to describe the existing programs designed to monitor medication safety, including the reporting systems. With a focus primarily on the pharmacy staff, interviews were audio recorded, transcribed, and analyzed using qualitative research methods. Eighty six interviews were conducted, including 36 in the hospital pharmacy. Examples are presented which show that: (1) the definition of an event could lead to under-reporting; (2) the classification of a medication error into alternative categories can influence the perceived incentives and disincentives for incident reporting; (3) event classification can enhance or impede organizational routines for data analysis and learning; and (4) routines that promote organizational learning within the pharmacy can reduce the flow of medication error data to the hospital. These findings from one hospital raise important practical and research questions about how reporting systems are influenced by the definition and classification of safety related events. By understanding more clearly how hospitals define and classify their experience, we may improve our capacity to learn and ultimately improve patient safety.

Advancing HIV research with pregnant women: navigating challenges and opportunities.

PubMed

Krubiner, Carleigh B; Faden, Ruth R; Cadigan, R Jean; Gilbert, Sappho Z; Henry, Leslie M; Little, Margaret O; Mastroianni, Anna C; Namey, Emily E; Sullivan, Kristen A; Lyerly, Anne D

2016-09-24

Concerns about including pregnant women in research have led to a dearth of evidence to guide safe and effective treatment and prevention of HIV in pregnancy. To better understand why these evidence gaps persist and inform guidance for responsible inclusion of pregnant women in the HIV research agenda, we aimed to learn what HIV experts perceive as barriers and constraints to conducting this research. We conducted a series of group and one-on-one consultations with 62 HIV investigators and clinicians to elicit their views and experiences conducting HIV research involving pregnant women. Thematic analysis was used to identify priorities and perceived barriers to HIV research with pregnant women. Experts discussed a breadth of needed research, including safety, efficacy, and appropriate dosing of: newer antiretrovirals for pregnant women, emerging preventive strategies, and treatment for coinfections. Challenges to conducting research on pregnancy and HIV included ethical concerns, such as how to weigh risks and benefits in pregnancy; legal concerns, such as restrictive interpretations of current regulations and liability issues; financial and professional disincentives, including misaligned funder priorities and fear of reputational damage; and analytical and logistical complexities, such as challenges recruiting and retaining pregnant women to sufficiently power analyses. Investigators face numerous challenges to conducting needed HIV research with pregnant women. Advancing such research will require clearer guidance regarding ethical and legal uncertainties; incentives that encourage rather than discourage investigators to undertake such research; and a commitment to earlier development of safety and efficacy data through creative trial designs.

Stuck at the bottom rung: occupational characteristics of workers with disabilities.

PubMed

Kaye, H Stephen

2009-06-01

The proportion of workers reporting disabilities varies tremendously across occupations. Although differences in the occupational distributions may partly explain the large disparities in earnings and job security between workers with and without disabilities, little is known about the reasons that workers with disabilities are underrepresented in certain occupations and overrepresented in others. Using a large, national survey of the US population combined with official data on the skill and experience requirements and occupational risks of 269 occupations, a multilevel regression analysis was performed to identify occupational and individual factors that influence the representation of workers with disabilities across occupations. Models of overall, sensory, mobility, and cognitive disability were constructed for working-age labor force participants, as were models of overall disability for younger, in-between, and older workers. At the occupational level, reported disability is negatively associated with occupational requirements for information and communication skills and with the amount of prior work experience that is required, after controlling for individual factors such as age and educational attainment. Little relationship is found between disability status and a set of occupational risk factors. These findings generally hold true across disability types and age groups. Even after taking into account their lower average educational attainment, workers with disabilities appear to be disproportionately relegated to entry-level occupations that do not emphasize the better-remunerated job skills. Underemployment results in lower wages and less job security and stability. Possible reasons include employer discrimination, low expectations, deficits in relevant skills or experience, and work disincentives.

Laparoscopic robot-assisted pancreas transplantation: first world experience.

PubMed

Boggi, Ugo; Signori, Stefano; Vistoli, Fabio; D'Imporzano, Simone; Amorese, Gabriella; Consani, Giovanni; Guarracino, Fabio; Marchetti, Piero; Focosi, Daniele; Mosca, Franco

2012-01-27

Surgical complications are a major disincentive to pancreas transplantation, despite the undisputed benefits of restored insulin independence. The da Vinci surgical system, a computer-assisted electromechanical device, provides the unique opportunity to test whether laparoscopy can reduce the morbidity of pancreas transplantation. Pancreas transplantation was performed by robot-assisted laparoscopy in three patients. The first patient received a pancreas after kidney transplant, the second a simultaneous pancreas kidney transplantation, and the third a pancreas transplant alone. Operations were carried out through an 11-mm optic port, two 8-mm operative ports, and a 7-cm midline incision. The latter was used to introduce the grafts, enable vascular cross-clamping, and create exocrine drainage into the jejunum. The two solitary pancreas transplants required an operating time of 3 and 5 hr, respectively; the simultaneous pancreas kidney transplantation took 8 hr. Mean warm ischemia time of the pancreas graft was 34 min. All pancreatic transplants functioned immediately, and all recipients became insulin independent. The kidney graft, revascularized after 35 min of warm ischemia, also functioned immediately. No patient had complications during or after surgery. At the longer follow-up of 10, 8, and 6 months, respectively, all recipients are alive with normal graft function. We have shown the feasibility of laparoscopic robot-assisted solitary pancreas and simultaneous pancreas and kidney transplantation. If the safety and feasibility of this procedure can be confirmed by larger series, laparoscopic robot-assisted pancreas transplantation could become a new option for diabetic patients needing beta-cell replacement.

To what extent have relaxed eligibility requirements and increased generosity of disability benefits acted as disincentives for employment? A systematic review of evidence from countries with well-developed welfare systems.

PubMed

Barr, Ben; Clayton, Stephen; Whitehead, Margaret; Thielen, Karsten; Burström, Bo; Nylén, Lotta; Dahl, Espen

2010-12-01

Reductions in the eligibility requirements and generosity of disability benefits have been introduced in several Organisation for Economic Cooperation and Development (OECD) countries in recent years, on the assumption that this will increase work incentives for people with chronic illness and disabilities. This paper systematically reviews the evidence for this assumption in the context of well-developed welfare systems. Systematic review of all empirical studies from five OECD countries from 1970 to December 2009 investigating the effect of changes in eligibility requirements or level of disability benefits on employment of disabled people. Sixteen studies were identified. Only one of five studies found that relaxed eligibility was significantly associated with a decline in employment. The most robust study found no significant effect. On generosity, eight out of 11 studies reported that benefit levels had a significant negative association with employment. The most robust study demonstrated a small but significant negative association. There was no firm evidence that changes in benefit eligibility requirements affected employment. While there was some evidence indicating that benefit level was negatively associated with employment, there was insufficient evidence of a high enough quality to determine the extent of that effect. Policy makers and researchers need to address the lack of a robust empirical basis for assessing the employment impact of these welfare reforms as well as potentially wider poverty impacts.

The influence of state-level policy environments on the activation of the Medicaid SBIRT reimbursement codes.

PubMed

Hinde, Jesse; Bray, Jeremy; Kaiser, David; Mallonee, Erin

2017-02-01

To examine how institutional constraints, comprising federal actions and states' substance abuse policy environments, influence states' decisions to activate Medicaid reimbursement codes for screening and brief intervention for risky substance use in the United States. A discrete-time duration model was used to estimate the effect of institutional constraints on the likelihood of activating the Medicaid reimbursement codes. Primary constraints included federal Screening, Brief Intervention and Referral to Treatment (SBIRT) grant funding, substance abuse priority, economic climate, political climate and interstate diffusion. Study data came from publicly available secondary data sources. Federal SBIRT grant funding did not affect significantly the likelihood of activation (P = 0.628). A $1 increase in per-capita block grant funding was associated with a 10-percentage point reduction in the likelihood of activation (P = 0.003) and a $1 increase in per-capita state substance use disorder expenditures was associated with a 2-percentage point increase in the likelihood of activation (P = 0.004). States with enacted parity laws (P = 0.016) and a Democratic-controlled state government were also more likely to activate the codes. In the United States, the determinants of state activation of Medicaid Screening, Brief Intervention and Referral to Treatment (SBIRT) reimbursement codes are complex, and include more than financial considerations. Federal block grant funding is a strong disincentive to activating the SBIRT reimbursement codes, while more direct federal SBIRT grant funding has no detectable effects. © 2017 Society for the Study of Addiction.

Private practice outcomes: validated outcomes data collection in private practice.

PubMed

Goldstein, Jack

2010-10-01

Improved patient care is related to validated outcome measures requiring the collection of three distinct data types: (1) demographics; (2) patient outcome measures; and (3) physician treatment. Previous impediments to widespread data collection have been: cost, office disruption, personnel requirements, physician motivation, data integration, and security. There are currently few means to collect data to be used for collaborative analysis. We therefore developed an inexpensive, patient-centric mechanism to reduce redundant data entry, limiting cost and personnel requirements. Using an intuitive touch-screen kiosk interface program, all data elements have been captured in a private practice setting since 2000. Developed for small to medium sized offices, this is scalable to larger organizations. Questionnaire navigation is patient driven, with demographics shared with EMR and billing systems. Integration of billing and EMR with outcomes minimizes cost and personnel time. Data are deidentified locally and may be centrally shared. Since data are entered by the patients, minimal personnel costs are incurred. Physician disincentives are minimized with cost reduction, time savings and ease of use. To date, we have collected high level data on most total joint patients, with excellent patient compliance. By addressing impediments to broad application, we may enable widespread local data collection in all practice settings. Data may be shared centrally, allowing comparative effectiveness research to become a reality. Future success will require broad physician participation, uniformity of data collected, and designation of a central site for receipt of data and its collaborative comparative analysis.

The Portuguese generic medicines market: a policy analysis

PubMed Central

Simoens, Steven

2008-01-01

Objectives: This study aims to conduct a descriptive analysis of the policy environment surrounding the generic medicines retail market in Portugal. The policy analysis focuses on supply-side measures (i.e. market access, pricing, reference-pricing and reimbursement of generic medicines) and demand-side measures (i.e. incentives for physicians to prescribe, for pharmacists to dispense and for patients to use generic medicines). Methods: The policy analysis was based on an international literature review. Also, a simulation exercise was carried out to compute potential savings from substituting generic for originator medicines in Portugal using IMS Health data. Results: Portugal has developed a successful generic medicines market by increasing reimbursement of generic medicines (until October 2005), by introducing a reference-pricing system, by encouraging physicians to prescribe by international non-proprietary name (INN), and by allowing generic substitution by pharmacists. However, the development of the generic medicines market has been hindered by the existence of copies, pricing regulation, certain features of the reference-pricing system, weak incentives for physicians to prescribe generic medicines and a financial disincentive for pharmacists to dispense generic medicines. Increased generic substitution would be expected to reduce public expenditure on originator medicines by 45%. Conclusions: The development of the Portuguese generic medicines market has mainly been fuelled by supply-side measures. To support the further expansion of the market, policy makers need to strengthen demand-side measures inciting physicians to prescribe, pharmacists to dispense and patients to use generic medicines. PMID:25152781

The place of assisted living in long-term care and related service systems.

PubMed

Stone, Robyn I; Reinhard, Susan C

2007-01-01

The purpose of this article is to describe how assisted living (AL) fits with other long-term-care services. We analyzed the evolution of AL, including the populations served, the services offered, and federal and state policies that create various incentives or disincentives for using AL to replace other forms of care such as nursing home care or home care. Provider models that have emerged include independent senior housing with services, freestanding AL, nursing home expansion, and continuing care retirement communities. Some integrated health systems have also built AL into their array of services. Federal and state policy rules for financing and programs also shape AL, and states vary in how deliberately they try to create an array of options with specific roles for AL. Among state policies reviewed are reimbursement and rate-setting policies, admission and discharge criteria, and nurse practice policies that permit or prohibit various nursing tasks to be delegated in AL settings. Recent initiatives to increase flexible home care, such as nursing home transition programs, cash and counseling, and money-follows-the-person initiatives may influence the way AL emerges in a particular state. There is no single easy answer about the role of AL. To understand the current role and decide how to shape the future of AL, researchers need information systems that track the transitions individuals make during their long-term-care experiences along with information about the case-mix characteristics and service needs of the clientele.

Fertility targets and policy options in Asia.

PubMed

Bulatao, R A

1984-11-01

The 3rd Asian and Pacific Population Conference in Colombo in 1982 recommended that countries review and modify existing demographic targets and goals for reducing birth and death rates in order to attain low levels as early as possible and to attain replacement level by the year 2000. The demographic goals of selected Asian countries (Bangladesh, Indonesia, Korea, Thailand, India, Pakistan, and the Philippines are assessed and compared to World Bank population projections. It also discusses the underlying rationale for setting fertility targets, and considers what government actions could make them more achievable. 6 stages for controlling population are distinguished: 1) collection and publication of reliable demographic data; 2) enunciation of an official policy to reduce population growth; 3) development of appropriate institutions to integrate demographic projections into economic plans; 4) promotion of family planning; 5) provision of incentives and disincentives, including elimination of all implicit and explicit subsidies for child bearing; and 6) restitution of birth quotas requiring permission for each child born. Principles to maintain and accelerate fertility declines to meet demographic targets include creating appropriate and equitable development policies, increasing the standard of family planning programs, confronting organizational problems, providing easier and more equal access to contraceptive methods, exploring innovative approaches to encourage smaller families and making a firm political commitment to population control. Rapid fertility decline will also require financial commitment. Willingness to spend the necessary amounts, and the capacity to spend them as well, will determine whether the countries of Asia enter the next century in control of their population.

Is globalization good for your health?

PubMed

Dollar, D

2001-01-01

Four points are made about globalization and health. First, economic integration is a powerful force for raising the incomes of poor countries. In the past 20 years several large developing countries have opened up to trade and investment, and they are growing well--faster than the rich countries. Second, there is no tendency for income inequality to increase in countries that open up. The higher growth that accompanies globalization in developing countries generally benefits poor people. Since there is a large literature linking income of the poor to health status, we can be reasonably confident that globalization has indirect positive effects on nutrition, infant mortality and other health issues related to income. Third, economic integration can obviously have adverse health effects as well: the transmission of AIDS through migration and travel is a dramatic recent example. However, both relatively closed and relatively open developing countries have severe AIDS problems. The practical solution lies in health policies, not in policies on economic integration. Likewise, free trade in tobacco will lead to increased smoking unless health-motivated disincentives are put in place. Global integration requires supporting institutions and policies. Fourth, the international architecture can be improved so that it is more beneficial to poor countries. For example, with regard to intellectual property rights, it may be practical for pharmaceutical innovators to choose to have intellectual property rights in either rich country markets or poor country ones, but not both. In this way incentives could be strong for research on diseases in both rich and poor countries.

Mixing carrots and sticks to conserve forests in the Brazilian Amazon: a spatial probabilistic modeling approach.

PubMed

Börner, Jan; Marinho, Eduardo; Wunder, Sven

2015-01-01

Annual forest loss in the Brazilian Amazon had in 2012 declined to less than 5,000 sqkm, from over 27,000 in 2004. Mounting empirical evidence suggests that changes in Brazilian law enforcement strategy and the related governance system may account for a large share of the overall success in curbing deforestation rates. At the same time, Brazil is experimenting with alternative approaches to compensate farmers for conservation actions through economic incentives, such as payments for environmental services, at various administrative levels. We develop a spatially explicit simulation model for deforestation decisions in response to policy incentives and disincentives. The model builds on elements of optimal enforcement theory and introduces the notion of imperfect payment contract enforcement in the context of avoided deforestation. We implement the simulations using official deforestation statistics and data collected from field-based forest law enforcement operations in the Amazon region. We show that a large-scale integration of payments with the existing regulatory enforcement strategy involves a tradeoff between the cost-effectiveness of forest conservation and landholder incomes. Introducing payments as a complementary policy measure increases policy implementation cost, reduces income losses for those hit hardest by law enforcement, and can provide additional income to some land users. The magnitude of the tradeoff varies in space, depending on deforestation patterns, conservation opportunity and enforcement costs. Enforcement effectiveness becomes a key determinant of efficiency in the overall policy mix.

Perspectives of San Juan healthcare practitioners on the detection deficit in oral premalignant and early cancers in Puerto Rico: a qualitative research study

PubMed Central

2011-01-01

Background In Puerto Rico, relative to the United States, a disparity exists in detecting oral precancers and early cancers. To identify factors leading to the deficit in early detection, we obtained the perspectives of San Juan healthcare practitioners whose practice could be involved in the detection of such oral lesions. Methods Key informant (KI) interviews were conducted with ten clinicians practicing in or around San Juan, Puerto Rico. We then triangulated our KI interview findings with other data sources, including recent literature on oral cancer detection from various geographic areas, current curricula at the University of Puerto Rico Schools of Medicine and Dental Medicine, as well as local health insurance regulations. Results Key informant-identified factors that likely contribute to the detection deficit include: many practitioners are deficient in knowledge regarding oral cancer and precancer; oral cancer screening examinations are limited regarding which patients receive them and the elements included. In Puerto Rico, specialists generally perform oral biopsies, and patient referral can be delayed by various factors, including government-subsidized health insurance, often referred to as Reforma. Reforma-based issues include often inadequate clinician knowledge regarding Reforma requirements/provisions, diagnostic delays related to Reforma bureaucracy, and among primary physicians, a perceived financial disincentive in referring Reforma patients. Conclusions Addressing these issues may be useful in reducing the deficit in detecting oral precancers and early oral cancer in Puerto Rico. PMID:21612663

The effect of insurance type on prescription drug use and expenditures among elderly Medicare beneficiaries.

PubMed

Saleh, Shadi S; Weller, Wendy; Hannan, Edward

2007-01-01

The debate over the impact of the new Medicare prescription drug benefit (Part D) has intensified in anticipation of its implementation. This paper contributes additional information related to the effect of different types of prescription drug coverage plans on use and expenditures among elderly Medicare beneficiaries. Cross-sectional design using data from the 2002 Medical Expenditures Panel Survey (MEPS). The two dependent variables were (1) prescription drug use and (2) expenditures. The main independent variable was the type of drug insurance (Medicare FFS only [no Rx insurance], Medicare FFS + Rx insurance and Medicare HMO). Bivariate and multivariate analyses were used to test the effect of insurance type, and beneficiaries' characteristics, on likelihood and level of drug use, as well as expenditures. The findings showed that average total drug expenditures among Medicare FFS enrollees who had Rx insurance (non-HMO) were higher ($182.51) than that of Medicare FFS enrollees with no Rx insurance. In addition, the former group had a higher likelihood (any use) of using prescribed medications. On the other hand, no differences in the likelihood of use were detected between Medicare HMO and Medicare FFS (no Rx insurance) enrollees. However, Medicare HMO enrollees had a higher level of drug use. In conclusion, The differences in drug use and expenditures by insurance type imply that each party (Medicare, Medicare Advantage plans, employers) will have a different set of disincentives for involvement in Medicare Part D.

Health Insurance and the Labor Supply Decisions of Older Workers: Evidence from a U.S. Department of Veterans Affairs Expansion

PubMed Central

Boyle, Melissa A.; Lahey, Joanna N.

2010-01-01

This paper exploits a major mid-1990s expansion in the U.S. Department of Veterans Affairs health care system to provide evidence on the labor market effects of expanding health insurance availability. Using data from the Current Population Survey, we employ a difference-in-differences strategy to compare the labor market behavior of older veterans and non-veterans before and after the VA health benefits expansion to test the impact of public health insurance on labor supply. We find that older workers are significantly more likely to decrease work both on the extensive and intensive margins after receiving access to non-employer based insurance. Workers with some college education or a college degree are more likely to transition into self-employment, a result consistent with “job-lock” effects. However, less-educated workers are more likely to leave self-employment, a result suggesting that the positive income effect from receiving public insurance dominates the “job-lock” effect for these workers. Some relatively disadvantaged sub-populations may also increase their labor supply after gaining greater access to public insurance, consistent with complementary positive health effects of health care access or decreased work disincentives for these groups. We conclude that this reform has affected employment and retirement decisions, and suggest that future moves toward universal coverage or expansions of Medicare are likely to have significant labor market effects. PMID:20694047

Vocational outcome following spinal cord injury.

PubMed

Conroy, L; McKenna, K

1999-09-01

Non-experimental (ex post facto) survey research design involving the use of a fixed alternative format questionnaire. To investigate variables influencing vocational outcome, to identify barriers to gaining and sustaining employment and to identify the effects of variables on the type of work engaged in following spinal cord injury. The two sets of independent variables considered were, individual and injury-related factors (age at onset of injury, time since injury, extent/level of injury, highest educational qualification achieved pre-injury, and pre-injury occupation) and circumstantial factors (means of transport, access difficulties, perceived workplace discrimination, financial disincentives to work and perceived level of skill). The Princess Alexandra Hospital Spinal Injuries Unit, Queensland, Australia. Data on the variables and the vocational outcomes of having ever worked or studied post-injury, current employment status and post-injury occupation were obtained from survey responses. Demographical and medical data were gathered from medical records. Forward stepwise logistic regression revealed that having ever worked or studied post-injury was associated with all individual and injury-related factors except pre-injury occupation, and two circumstantial factors, namely means of transport and access difficulties. Current employment was associated with all circumstantial factors as well as age at injury and pre-injury occupation. Standard multiple regression analyses revealed that post-injury occupation was correlated with all individual and injury-related factors as well as means of transport and perceived workplace discrimination. Tailored rehabilitation programs for individuals with characteristics associated with less successful vocational outcomes may facilitate their employment status after injury.

The Promise and the Challenge of Technology-Facilitated Methods for Assessing Behavioral and Cognitive Markers of Risk for Suicide among U.S. Army National Guard Personnel

PubMed Central

Baucom, Brian R. W.; Georgiou, Panayiotis; Bryan, Craig J.; Garland, Eric L.; Leifker, Feea; May, Alexis; Wong, Alexander; Narayanan, Shrikanth S.

2017-01-01

Suicide was the 10th leading cause of death for Americans in 2015 and rates have been steadily climbing over the last 25 years. Rates are particularly high amongst U.S. military personnel. Suicide prevention efforts in the military are significantly hampered by the lack of: (1) assessment tools for measuring baseline risk and (2) methods to detect periods of particularly heightened risk. Two specific barriers to assessing suicide risk in military personnel that call for innovation are: (1) the geographic dispersion of military personnel from healthcare settings, particularly amongst components like the Reserves; and (2) professional and social disincentives to acknowledging psychological distress. The primary aim of this paper is to describe recent technological developments that could contribute to risk assessment tools that are not subject to the limitations mentioned above. More specifically, Behavioral Signal Processing can be used to assess behaviors during interaction and conversation that likely indicate increased risk for suicide, and computer-administered, cognitive performance tasks can be used to assess activation of the suicidal mode. These novel methods can be used remotely and do not require direct disclosure or endorsement of psychological distress, solving two challenges to suicide risk assessment in military and other sensitive settings. We present an introduction to these technologies, describe how they can specifically be applied to assessing behavioral and cognitive risk for suicide, and close with recommendations for future research. PMID:28362333

What does "success" in public engagement activities mean? A comparison of goals, motivations and embedded assumptions in four polar outreach activities.

NASA Astrophysics Data System (ADS)

Roop, H. A.; Salmon, R. A.

2015-12-01

Using four very different polar outreach case studies, we will discuss scientists' motivations, expectations, and institutional incentives (and dis-incentives) to engage with the public, and argue that improved training, evaluation, and academic value needs to be associated with scientist-led communication efforts - as well as clearer fora for sharing best practice in this field. We will illustrate our argument using examples from an Antarctic festival with public lectures and science cafes, outreach associated with an Antarctic expedition, the global launch of a climate change documentary that had a significant focus on Antarctica, and a series of "Polar Weeks" led by an international community of scientists and educators. While there is an excellent culture of accountability in both formal and informal science communication sectors, the same rigour is not applied to the majority of 'outreach' activities that are initiated by the science research community. Many of these activities are undertaken based on 'what feels right' and opportunism, and are proclaimed to be a success based on little or no formal evaluation. As a result, much of this work goes undocumented, is not evaluated from the perspective of the science community, and is rarely subject to peer-review and its associated benefits, including professional rewards. We therefore recommend new opportunities for publication in this field that would encourage science communication theory and practice to better inform each other, and for scientists to gain professional recognition for their efforts in this arena.

Developing Community-Focused Solutions using a Food-Energy-Water Calculator, with Initial Application to Western Kansas

NASA Astrophysics Data System (ADS)

Hill, M. C.; Pahwa, A.; Rogers, D.; Roundy, J. K.; Barron, R. W.

2017-12-01

Many agricultural areas are facing difficult circumstances. Kansas is one example, with problems that are typical. Past agricultural and hydrologic data document how irrigation in western Kansas has produced a multi-billion-dollar agricultural economy that is now threatened by pumping-induced declines in groundwater levels. Although reduced pumping could mitigate much of the threat and preserve much of Kansas' agricultural economy (albeit at a reduced level) in the long term, a primary disincentive for reducing pumping is the immediate economic impact of diminished irrigation. One alternative to continued unsustainable groundwater use is a water-energy tradeoff program that seeks to reduce pumping from the Ogallala aquifer to sustainable rates while maintaining local income levels. This program would allow development of the region's rich wind and solar energy resources in a way that focuses on local economic benefits, in exchange for water rights concessions from affected stakeholders. In considering this alternative, most citizens are currently unable to address a key question, "What could this mean for me?" Answering this question requires knowledge of agriculture, energy, water, economics, and drought probabilities, knowledge that is available at Kansas universities. This talk presents a joint University of Kansas - Kansas State University effort to address this need through development of the Food-Energy-Water Calculator. This talk will present the idea and discuss how the calculator would work. It is suggested that the framework created provides a powerful way to organize data and analysis results, and thus to seek solutions to difficult problems in many regions of the US and the world.

The ability of land owners and their cooperatives to leverage payments greater than opportunity costs from conservation contracts.

PubMed

Lennox, Gareth D; Armsworth, Paul R

2013-06-01

In negotiations over land-right acquisitions, landowners have an informational advantage over conservation groups because they know more about the opportunity costs of conservation measures on their sites. This advantage creates the possibility that landowners will demand payments greater than the required minimum, where this minimum required payment is known as the landowner’s willingness to accept (WTA). However, in recent studies of conservation costs, researchers have assumed landowners will accept conservation with minimum payments. We investigated the ability of landowners to demand payments above their WTA when a conservation group has identified multiple sites for protection. First, we estimated the maximum payment landowners could potentially demand, which is set when groups of landowners act as a cooperative. Next, through the simulation of conservation auctions, we explored the amount of money above landowners’ WTA (i.e., surplus) that conservation groups could cede to secure conservation agreements, again investigating the influence of landowner cooperatives. The simulations showed the informational advantage landowners held could make conservation investments up to 42% more expensive than suggested by the site WTAs. Moreover, all auctions resulted in landowners obtaining payments greater than their WTA; thus, it may be unrealistic to assume landowners will accept conservation contracts with minimum payments. Of particular significance for species conservation, conservation objectives focused on overall species richness,which therefore recognize site complementarity, create an incentive for land owners to form cooperatives to capture surplus. To the contrary, objectives in which sites are substitutes, such as the maximization of species occurrences, create a disincentive for cooperative formation.

"We weren't the sort that wanted intimacy every night": Birth control and abstinence in England, c.1930-60.

PubMed

Szreter, Simon; Fisher, Kate

2010-06-10

This article presents an exploration of qualitative evidence on the relationship between birth control and abstinence from an oral history project, which interviewed middle and working-class English men and women, who had married between the late 1920s and the early 1950s. Among the working classes the assumption that men were responsible for birth control choices and the disadvantages that contraceptive methods of all types posed, combined with the fear of pregnancy, acted as a disincentive to have sex and resulted in forms of partial abstinence. Among the middle classes, women had much more access to birth control information and as a consequence a greater range of methods was used, including more female methods. However, the reluctance of couples to discuss sexual matters, and some continued preference for male methods meant that while condoms were the most regularly used middle-class male method, both withdrawal and abstinence were also in evidence. Moreover, although partners were more likely to discuss birth control at the start of their marriages, they were less likely to agree that contraception was a male responsibility and there was greater potential for conflict over contraceptive methods, not infrequently resulting in abstinence. The evidence suggests that sexual and contraceptive practices in marriages in England at the end of the secular fertility decline do not present a picture which straightforwardly correlates with the assumptions represented by the popular thesis that this period of increased fertility control was closely associated with the rise of companionate marriage.

Quantitative Financial Analysis of Alternative Energy Efficiency Shareholder Incentive Mechanisms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Cappers, Peter; Goldman, Charles; Chait, Michele

2008-08-03

Rising energy prices and climate change are central issues in the debate about our nation's energy policy. Many are demanding increased energy efficiency as a way to help reduce greenhouse gas emissions and lower the total cost of electricity and energy services for consumers and businesses. Yet, as the National Action Plan on Energy Efficiency (NAPEE) pointed out, many utilities continue to shy away from seriously expanding their energy efficiency program offerings because they claim there is insufficient profit-motivation, or even a financial disincentive, when compared to supply-side investments. With the recent introduction of Duke Energy's Save-a-Watt incentive mechanism andmore » ongoing discussions about decoupling, regulators and policymakers are now faced with an expanded and diverse landscape of financial incentive mechanisms, Determining the 'right' way forward to promote deep and sustainable demand side resource programs is challenging. Due to the renaissance that energy efficiency is currently experiencing, many want to better understand the tradeoffs in stakeholder benefits between these alternative incentive structures before aggressively embarking on a path for which course corrections can be time-consuming and costly. Using a prototypical Southwest utility and a publicly available financial model, we show how various stakeholders (e.g. shareholders, ratepayers, etc.) are affected by these different types of shareholder incentive mechanisms under varying assumptions about program portfolios. This quantitative analysis compares the financial consequences associated with a wide range of alternative incentive structures. The results will help regulators and policymakers better understand the financial implications of DSR program incentive regulation.« less

Financial implications of a model heart failure disease management program for providers, hospital, healthcare systems, and payer perspectives.

PubMed

Whellan, David J; Reed, Shelby D; Liao, Lawrence; Gould, Stuart D; O'connor, Christopher M; Schulman, Kevin A

2007-01-15

Although heart failure disease management (HFDM) programs improve patient outcomes, the implementation of these programs has been limited because of financial barriers. We undertook the present study to understand the economic incentives and disincentives for adoption of disease management strategies from the perspectives of a physician (group), a hospital, an integrated health system, and a third-party payer. Using the combined results of a group of randomized controlled trials and a set of financial assumptions from a single academic medical center, a financial model was developed to compute the expected costs before and after the implementation of a HFDM program by 3 provider types (physicians, hospitals, and health systems), as well as the costs incurred from a payer perspective. The base-case model showed that implementation of HFDM results in a net financial loss to all potential providers of HFDM. Implementation of HFDM as described in our base-case analysis would create a net loss of US dollars 179,549 in the first year for a physician practice, US dollars 464,132 for an integrated health system, and US dollars 652,643 in the first year for a hospital. Third-party payers would be able to save US dollars 713,661 annually for the care of 350 patients with heart failure in a HFDM program. In conclusion, although HFDM programs may provide patients with improved clinical outcomes and decreased hospitalizations that save third-party payers money, limited financial incentives are currently in place for healthcare providers and hospitals to initiate these programs.

A Conceptual Framework for Understanding Unintended Prolonged Opioid Use.

PubMed

Hooten, W Michael; Brummett, Chad M; Sullivan, Mark D; Goesling, Jenna; Tilburt, Jon C; Merlin, Jessica S; St Sauver, Jennifer L; Wasan, Ajay D; Clauw, Daniel J; Warner, David O

2017-12-01

An urgent need exists to better understand the transition from short-term opioid use to unintended prolonged opioid use (UPOU). The purpose of this work is to propose a conceptual framework for understanding UPOU that posits the influence of 3 principal domains that include the characteristics of (1) individual patients, (2) the practice environment, and (3) opioid prescribers. Although no standardized method exists for developing a conceptual framework, the process often involves identifying corroborative evidence, leveraging expert opinion to identify factors for inclusion in the framework, and developing a graphic depiction of the relationships between the various factors and the clinical problem of interest. Key patient characteristics potentially associated with UPOU include (1) medical and mental health conditions; (2) pain etiology; (3) individual affective, behavioral, and neurophysiologic reactions to pain and opioids; and (4) sociodemographic factors. Also, UPOU could be influenced by structural and health care policy factors: (1) the practice environment, including the roles of prescribing clinicians, adoption of relevant practice guidelines, and clinician incentives or disincentives, and (2) the regulatory environment. Finally, characteristics inherent to clinicians that could influence prescribing practices include (1) training in pain management and opioid use; (2) personal attitudes, knowledge, and beliefs regarding the risks and benefits of opioids; and (3) professionalism. As the gatekeeper to opioid access, the behavior of prescribing clinicians directly mediates UPOU, with the 3 domains interacting to determine this behavior. This proposed conceptual framework could guide future research on the topic and allow plausible hypothesis-based interventions to reduce UPOU. Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Navigating financial and supply reliability tradeoffs in regional drought management portfolios

NASA Astrophysics Data System (ADS)

Zeff, Harrison B.; Kasprzyk, Joseph R.; Herman, Jonathan D.; Reed, Patrick M.; Characklis, Gregory W.

2014-06-01

Rising development costs and growing concerns over environmental impacts have led many communities to explore more diversified water management strategies. These "portfolio"-style approaches integrate existing supply infrastructure with other options such as conservation measures or water transfers. Diversified water supply portfolios have been shown to reduce the capacity and costs required to meet demand, while also providing greater adaptability to changing hydrologic conditions. However, this additional flexibility can also cause unexpected reductions in revenue (from conservation) or increased costs (from transfers). The resulting financial instability can act as a substantial disincentive to utilities seeking to implement more innovative water management techniques. This study seeks to design portfolios that employ financial tools (e.g., contingency funds and index insurance) to reduce fluctuations in revenues and costs, allowing these strategies to achieve improved performance without sacrificing financial stability. This analysis is applied to the development of coordinated regional supply portfolios in the "Research Triangle" region of North Carolina, an area comprising four rapidly growing municipalities. The actions of each independent utility become interconnected when shared infrastructure is utilized to enable interutility transfers, requiring the evaluation of regional tradeoffs in up to five performance and financial objectives. Diversified strategies introduce significant tradeoffs between achieving reliability goals and introducing burdensome variability in annual revenues and/or costs. Financial mitigation tools can mitigate the impacts of this variability, allowing for an alternative suite of improved solutions. This analysis provides a general template for utilities seeking to navigate the tradeoffs associated with more flexible, portfolio-style management approaches.

What incentives influence employers to engage in workplace health interventions?

PubMed

Martinsson, Camilla; Lohela-Karlsson, Malin; Kwak, Lydia; Bergström, Gunnar; Hellman, Therese

2016-08-23

To achieve a sustainable working life it is important to know more about what could encourage employers to increase the use of preventive and health promotive interventions. The objective of the study is to explore and describe the employer perspective regarding what incentives influence their use of preventive and health promotive workplace interventions. Semi-structured focus group interviews were carried out with 20 representatives from 19 employers across Sweden. The economic sectors represented were municipalities, government agencies, defence, educational, research, and development institutions, health care, manufacturing, agriculture and commercial services. The interviews were transcribed verbatim and the data were analysed using latent content analysis. Various incentives were identified in the analysis, namely: "law and provisions", "consequences for the workplace", "knowledge of worker health and workplace health interventions", "characteristics of the intervention", "communication and collaboration with the provider". The incentives seemed to influence the decision-making in parallel with each other and were not only related to positive incentives for engaging in workplace health interventions, but also to disincentives. This study suggests that the decision to engage in workplace health interventions was influenced by several incentives. There are those incentives that lead to a desire to engage in a workplace health intervention, others pertain to aspects more related to the intervention use, such as the characteristics of the employer, the provider and the intervention. It is important to take all incentives into consideration when trying to understand the decision-making process for workplace health interventions and to bridge the gap between what is produced through research and what is used in practice.

Investigating motivating factors for sound hospital waste management.

PubMed

Ali, Mustafa; Wang, Wenping; Chaudhry, Nawaz

2016-08-01

Sustainable management of hospital waste requires an active involvement of all key players. This study aims to test the hypothesis that three motivating factors, namely, Reputation, Liability, and Expense, influence hospital waste management. The survey for this study was conducted in two phases, with the pilot study used for exploratory factor analysis and the subsequent main survey used for cross-validation using confirmatory factor analysis. The hypotheses were validated through one-sample t tests. Correlations were established between the three motivating factors and organizational characteristics of hospital type, location, category, and size. The hypotheses were validated, and it was found that the factors of Liability and Expense varied considerably with respect to location and size of a hospital. The factor of Reputation, however, did not exhibit significant variation. In conclusion, concerns about the reputation of a facility and an apprehension of liability act as incentives for sound hospital waste management, whereas concerns about financial costs and perceived overburden on staff act as disincentives. This paper identifies the non economic motivating factors that can be used to encourage behavioral changes regarding waste management at hospitals in resource constrained environments. This study discovered that organizational characteristics such as hospital size and location cause the responses to vary among the subjects. Hence a policy maker must take into account the institutional setting before introducing a change geared towards better waste management outcomes across hospitals. This study covers a topic that has hitherto been neglected in resource constrained countries. Thus it can be used as one of the first steps to highlight and tackle the issue.

Barriers to the provision of smoking cessation assistance: a qualitative study among Romanian family physicians

PubMed Central

Panaitescu, Catalina; Moffat, Mandy A; Williams, Siân; Pinnock, Hilary; Boros, Melinda; Oana, Cristian Sever; Alexiu, Sandra; Tsiligianni, Ioanna

2014-01-01

Background: Smoking cessation is the most effective intervention to prevent and slow down the progression of several respiratory and other diseases and improve patient outcomes. Romania has legislation and a national tobacco control programme in line with the World Health Organization Framework for Tobacco Control. However, few smokers are advised to quit by their family physicians (FPs). Aim: To identify and explore the perceived barriers that prevent Romanian FPs from engaging in smoking cessation with patients. Methods: A qualitative study was undertaken. A total of 41 FPs were recruited purposively from Bucharest and rural areas within 600 km of the city. Ten FPs took part in a focus group and 31 participated in semistructured interviews. Analysis was descriptive, inductive and themed, according to the barriers experienced. Results: Five main barriers were identified: limited perceived role for FPs; lack of time during consultations; past experience and presence of disincentives; patients’ inability to afford medication; and lack of training in smoking cessation skills. Overarching these specific barriers were key themes of a medical and societal hierarchy, which undermined the FP role, stretched resources and constrained care. Conclusions: Many of the barriers described by the Romanian FPs reflected universally recognised challenges to the provision of smoking cessation advice. The context of a relatively hierarchical health-care system and limitations of time and resources exacerbated many of the problems and created new barriers that will need to be addressed if Romania is to achieve the aims of its National Programme Against Tobacco Consumption. PMID:25010432

“We weren’t the sort that wanted intimacy every night”: Birth control and abstinence in England, c.1930–60

PubMed Central

Szreter, Simon; Fisher, Kate

2015-01-01

This article presents an exploration of qualitative evidence on the relationship between birth control and abstinence from an oral history project, which interviewed middle and working-class English men and women, who had married between the late 1920s and the early 1950s. Among the working classes the assumption that men were responsible for birth control choices and the disadvantages that contraceptive methods of all types posed, combined with the fear of pregnancy, acted as a disincentive to have sex and resulted in forms of partial abstinence. Among the middle classes, women had much more access to birth control information and as a consequence a greater range of methods was used, including more female methods. However, the reluctance of couples to discuss sexual matters, and some continued preference for male methods meant that while condoms were the most regularly used middle-class male method, both withdrawal and abstinence were also in evidence. Moreover, although partners were more likely to discuss birth control at the start of their marriages, they were less likely to agree that contraception was a male responsibility and there was greater potential for conflict over contraceptive methods, not infrequently resulting in abstinence. The evidence suggests that sexual and contraceptive practices in marriages in England at the end of the secular fertility decline do not present a picture which straightforwardly correlates with the assumptions represented by the popular thesis that this period of increased fertility control was closely associated with the rise of companionate marriage. PMID:25931803

Promoting flood risk reduction: The role of insurance in Germany and England

NASA Astrophysics Data System (ADS)

Surminski, Swenja; Thieken, Annegret H.

2017-10-01

Improving society's ability to prepare for, respond to and recover from flooding requires integrated, anticipatory flood risk management (FRM). However, most countries still focus their efforts on responding to flooding events if and when they occur rather than addressing their current and future vulnerability to flooding. Flood insurance is one mechanism that could promote a more ex ante approach to risk by supporting risk reduction activities. This paper uses an adapted version of Easton's System Theory to investigate the role of insurance for FRM in Germany and England. We introduce an anticipatory FRM framework, which allows flood insurance to be considered as part of a broader policy field. We analyze if and how flood insurance can catalyze a change toward a more anticipatory approach to FRM. In particular we consider insurance's role in influencing five key components of anticipatory FRM: risk knowledge, prevention through better planning, property-level protection measures, structural protection and preparedness (for response). We find that in both countries FRM is still a reactive, event-driven process, while anticipatory FRM remains underdeveloped. Collaboration between insurers and FRM decision-makers has already been successful, for example in improving risk knowledge and awareness, while in other areas insurance acts as a disincentive for more risk reduction action. In both countries there is evidence that insurance can play a significant role in encouraging anticipatory FRM, but this remains underutilized. Effective collaboration between insurers and government should not be seen as a cost, but as an investment to secure future insurability through flood resilience.

Views and attitudes towards blood donation: a qualitative investigation of Indian non-donors living in England

PubMed Central

Joshi, Dhaara; Meakin, Richard

2017-01-01

Objective To explore the views and attitudes of Indians living in England on blood donation. Background In light of the predicted shortages in blood supply, it is vital to consider ways in which to maximise donation rates. These include addressing the issue of lower donation rates among ethnic minorities, including Indians. However research specifically among minority ethnicities in UK is sparse. Setting General practice in North London. Participants A convenience sample of 12 non-donor Indians living in England. Methods This is a qualitative investigation involving semistructured interviews. Themes derived were analysed using thematic framework analysis. Results Five key themes emerged from the data, and these concerned participants’ perspectives regarding attitudes towards blood, blood donation as a ‘good thing’, donation disincentives, the recipient matters and the donor matters. Conclusion A variety of attitudes were presented, but were generally positive, and blood was conceptualised in a manner previously found to be consistent with donation. However, lack of awareness and accessibility were prominent barriers, indicating the need for improvement in these capacities. In contrast to this, blood was also greatly associated with family and acted as a symbol of kinship: this ‘emotional charge’ often acted to dissuade participants from separating with their blood through donation. Possibly due to this, there was also a strong preference for donated blood to be distributed within the family, as opposed to strangers. This presents a potential barrier to blood donation for some Indians within the current system in which donations are given to unknown recipients. PMID:29061628

Medicare capitation model, functional status, and multiple comorbidities: model accuracy

PubMed Central

Noyes, Katia; Liu, Hangsheng; Temkin-Greener, Helena

2012-01-01

Objective This study examined financial implications of CMS-Hierarchical Condition Categories (HCC) risk-adjustment model on Medicare payments for individuals with comorbid chronic conditions. Study Design The study used 1992-2000 data from the Medicare Current Beneficiary Survey and corresponding Medicare claims. The pairs of comorbidities were formed based on the prior evidence about possible synergy between these conditions and activities of daily living (ADL) deficiencies and included heart disease and cancer, lung disease and cancer, stroke and hypertension, stroke and arthritis, congestive heart failure (CHF) and osteoporosis, diabetes and coronary artery disease, CHF and dementia. Methods For each beneficiary, we calculated the actual Medicare cost ratio as the ratio of the individual’s annualized costs to the mean annual Medicare cost of all people in the study. The actual Medicare cost ratios, by ADLs, were compared to the HCC ratios under the CMS-HCC payment model. Using multivariate regression models, we tested whether having the identified pairs of comorbidities affects the accuracy of CMS-HCC model predictions. Results The CMS-HCC model underpredicted Medicare capitation payments for patients with hypertension, lung disease, congestive heart failure and dementia. The difference between the actual costs and predicted payments was partially explained by beneficiary functional status and less than optimal adjustment for these chronic conditions. Conclusions Information about beneficiary functional status should be incorporated in reimbursement models since underpaying providers for caring for population with multiple comorbidities may provide severe disincentives for managed care plans to enroll such individuals and to appropriately manage their complex and costly conditions. PMID:18837646

Do practitioners and friends support patients with coronary heart disease in lifestyle change? a qualitative study.

PubMed

Cole, Judith A; Smith, Susan M; Hart, Nigel; Cupples, Margaret E

2013-08-28

Healthy lifestyles help to prevent coronary heart disease (CHD) but outcomes from secondary prevention interventions which support lifestyle change have been disappointing. This study is a novel, in-depth exploration of patient factors affecting lifestyle behaviour change within an intervention designed to improve secondary prevention for patients with CHD in primary care using personalised tailored support. We aimed to explore patients' perceptions of factors affecting lifestyle change within a trial of this intervention (the SPHERE Study), using semi-structured, one-to-one interviews, with patients in general practice. Interviews (45) were conducted in purposively selected general practices (15) which had participated in the SPHERE Study. Individuals, with CHD, were selected to include those who succeeded in improving physical activity levels and dietary fibre intake and those who did not. We explored motivations, barriers to lifestyle change and information utilised by patients. Data collection and analysis, using a thematic framework and the constant comparative method, were iterative, continuing until data saturation was achieved. We identified novel barriers to lifestyle change: such disincentives included strong negative influences of social networks, linked to cultural norms which encouraged consumption of 'delicious' but unhealthy food and discouraged engagement in physical activity. Findings illustrated how personalised support within an ongoing trusted patient-professional relationship was valued. Previously known barriers and facilitators relating to support, beliefs and information were confirmed. Intervention development in supporting lifestyle change in secondary prevention needs to more effectively address patients' difficulties in overcoming negative social influences and maintaining interest in living healthily.

Primary vs Conversion Total Hip Arthroplasty: A Cost Analysis

PubMed Central

Chin, Garwin; Wright, David J.; Snir, Nimrod; Schwarzkopf, Ran

2018-01-01

Introduction Increasing hip fracture incidence in the United States is leading to higher occurrences of conversion total hip arthroplasty (THA) for failed surgical treatment of the hip. In spite of studies showing higher complication rates in conversion THA, the Centers for Medicare and Medicaid services currently bundles conversion and primary THA under the same diagnosis-related group. We examined the cost of treatment of conversion THA compared with primary THA. Our hypothesis is that conversion THA will have higher cost and resource use than primary THA. Methods Fifty-one consecutive conversion THA patients (Current Procedure Terminology code 27132) and 105 matched primary THA patients (Current Procedure Terminology code 27130) were included in this study. The natural log-transformed costs for conversion and primary THA were compared using regression analysis. Age, gender, body mass index, American Society of Anesthesiologist, Charlson comorbidity score, and smoker status were controlled in the analysis. Conversion THA subgroups formed based on etiology were compared using analysis of variance analysis. Results Conversion and primary THAs were determined to be significantly different (P < .05) and greater in the following costs: hospital operating direct cost (29.2% greater), hospital operating total cost (28.8% greater), direct hospital cost (24.7% greater), and total hospital cost (26.4% greater). Conclusions Based on greater hospital operating direct cost, hospital operating total cost, direct hospital cost, and total hospital cost, conversion THA has significantly greater cost and resource use than primary THA. In order to prevent disincentives for treating these complex surgical patients, reclassification of conversion THA is needed, as they do not fit together with primary THA. PMID:26387923

Knee-deep and rising: America's recycling crisis.

PubMed

Lodge, G C; Rayport, J F

1991-01-01

Every year, Americans generate 180 million tons of solid waste, 70% of which goes into landfills. Since 1979, the United States has exhausted more than two-thirds of its landfills; another one-fifth will close over the next five years. Solving the problem will require a new understanding between industry and government--an understanding that combines industry competence and government authority. But the two sides are mired in an unfortunate combination of good intentions and failed systems. A classic example that epitomizes the problem is the recycling of plastics. Two stories capture the sense of chaos that pervades the recycling of plastics. The first is a comedy of errors played out in Minneapolis, Minnesota, where the city council passed a measure that would have banned all plastic packaging from the city. In this case, the government acted without the competence of industry. The second story involves McDonald's decision to abandon its polystyrene packaging and switch to plastic-coated paper. In this case, a single business's approach to recycling proved fruitless because of the lack of government authority. According to the authors, five principles provide the underpinnings to a new solid-waste management infrastructure: business and government are partners; the infrastructure is a system and must operate in balance; economics and politics must act as partners; all levels of government have roles to play; and generating less trash and recycling more depends on a workable system. Setting up the system will require an infrastructure that balances supply and demand, an advisory committee to manage the infrastructure, and a management system that uses incentives and disincentives to balance the system.

Public support for policy initiatives regulating high-fat food use in Minnesota: a multicommunity survey.

PubMed

Schmid, T L; Jeffery, R W; Forster, J L; Rooney, B; McBride, C

1989-11-01

Public support of eight policies to regulate the sale and consumption of high-fat food was evaluated in a survey of 438 women and 383 men in seven Minnesota communities. The survey was part of the ongoing activities of the Minnesota Heart Health Program (MHHP). Respondents, when asked to indicate their level of support or opposition to each of eight policies, expressed general support for all but two. Women were consistently more supportive than men. Other sociodemographic characteristics and reported use of food and other substances were generally not predictive of support. Policies that would control conditions of sale or information about the product were the most strongly supported. Taxation as an incentive to food producers to provide alternatives to high-fat food or as a disincentive to consumers to purchase these foods was moderately supported. A proposal to limit sale of high-fat food to children was the most strongly opposed. The majority of respondents indicated that they felt the individual consumer, as opposed to the producer or retailer, is most responsible for problems associated with high-fat food use. The three communities which had received MHHP health promotion activities were significantly more supportive than the comparison communities on two of the eight proposals. There is a moderate level of support in the general public for additional policies to regulate the sale and consumption of high-fat foods. These policy level interventions, similar to policies common in the regulation of alcohol and tobacco use, may be a feasible strategy to help moderate use of potentially health-compromising food products.

Vocational rehabilitation services and employment outcomes for adults with cerebral palsy in the United States.

PubMed

Huang, I-Chun; Holzbauer, Jerome J; Lee, Eun-Jeong; Chronister, Julie; Chan, Fong; O'Neil, John

2013-11-01

The aim of this study was to examine the relationship between vocational rehabilitation services provided and work outcomes among people with cerebral palsy (CP), taking in to account demographic characteristics. From the US Department of Education Rehabilitation Service Administration Case Service Report (RSA-911) database, data from 3162 individuals with CP (1820 males [57.6%] and 1342 females [42.4% age range 16-54 y) whose cases were closed in 2009, were used in this study. A total of 1567 cases (49.6%) were closed with clients being categorized as 'successful employment' and 1595 cases (50.4%) were closed with clients being classified as unemployed. Multivariate logistic regression was used to examine the relationship between services provided and work outcomes with regard to demographic characteristics. Males aged between 26 and 54 years old with higher education attainment were more likely to be employed. Individuals receiving disability benefits were less likely to be employed. After controlling for the effect of demographic and work disincentive variables, five vocational rehabilitation services significantly predicted employment outcomes (p<0.05), including (1) on-the-job training; (2) job placement assistance; (3) on-the-job support; (4) maintenance services; and (5) rehabilitation technology. Medical and health professionals need to be aware of vocational rehabilitation agencies as a resource for providing medical, psychological, educational, and vocational interventions for adults with CP to help them maximize their employability, to address their much needed work adjustment skills, to establish independent living, and to eventually reach their full potential in participation in society. © 2013 Mac Keith Press.

Hip Fractures and the Bundle: A Cost Analysis of Patients Undergoing Hip Arthroplasty for Femoral Neck Fracture vs Degenerative Joint Disease.

PubMed

Grace, Trevor R; Patterson, Joseph T; Tangtiphaiboontana, Jennifer; Krogue, Justin D; Vail, Thomas P; Ward, Derek T

2018-06-01

The purpose of this study is to determine whether episode Target Prices in the Bundled Payment for Care Improvement (BPCI) initiative sufficiently match the complexities and expenses expected for patients undergoing hip arthroplasty for femoral neck fracture (FNF) as compared to hip degenerative joint disease (DJD). Claims data under BPCI Model 2 were collected for patients undergoing hip arthroplasty at a single institution over a 2-year period. Payments from the index hospitalization to 90 days postoperatively were aggregated by Medicare Severity Diagnosis-Related Group (469 or 470), indication (DJD vs FNF), and categorized as index procedure, postacute services, and related hospital readmissions. Actual episode costs and Target Prices were compared in both the FNF and DJD cohorts undergoing hip arthroplasty to gauge the cost discrepancy in each group. A total of 183 patients were analyzed (31 with FNFs, 152 with DJD). In total, the FNF cohort incurred a $415,950 loss under the current episode Target Prices, whereas the DJD cohort incurred a $172,448 gain. Episode Target Prices were significantly higher than actual episode prices for the DJD cohort ($32,573 vs $24,776, P < .001). However, Target Prices were significantly lower than actual episode prices for the FNF cohort ($32,672 vs $49,755, P = .021). Episode Target Prices in the current BPCI model fall dramatically short of the actual expenses incurred by FNF patients undergoing hip arthroplasty. Better risk-adjusting Target Prices for this fragile population should be considered to avoid disincentives and delays in care. Copyright © 2018 Elsevier Inc. All rights reserved.

Hospital cost control in Norway: a decade's experience with prospective payment.

PubMed Central

Crane, T S

1985-01-01

Under Norway's prospective payment system, which was in existence from 1972 to 1980, hospital costs increased 15.8 percent annually, compared with 15.3 percent in the United States. In 1980 the Norwegian national government started paying for all institutional services according to a population-based, morbidity-adjusted formula. Norway's prospective payment system provides important insights into problems of controlling hospital costs despite significant differences, including ownership of medical facilities and payment and spending as a percent of GNP. Yet striking similarities exist. Annual real growth in health expenditures from 1972 to 1980 in Norway was 2.2 percent, compared with 2.4 percent in the United States. In both countries, public demands for cost control were accompanied by demands for more services. And problems of geographic dispersion of new technology and distribution of resources were similar. Norway's experience in the 1970s demonstrates that prospective payment is no panacea. The annual budget process created disincentives to hospitals to control costs. But Norway's changes in 1980 to a population-based methodology suggest a useful approach to achieve a more equitable distribution of resources. This method of payment provides incentives to control variations in both admissions and cost per case. In contrast, the Medicare approach based on Diagnostic Related Groups (DRGs) is limited, and it does not affect variations in admissions and capital costs. Population-based methodologies can be used in adjusting DRG rates to control both problems. In addition, the DRG system only applies to Medicare payments; the Norwegian experience demonstrates that this system may result in significant shifting of costs onto other payors. PMID:3927385

Compliance of medical students with voluntary use of personal data assistants for clerkship assessments.

PubMed

Norman, Geoffrey; Keane, David; Oppenheimer, Lawrence

2008-01-01

For several years, final-year students at McMaster University have been required to complete 10 mini-CEX type assessments per rotation. A similar system was being introduced at Ottawa. To facilitate data capture, we decided to introduce a personal data assistant (PDA)-based system and evaluate its impact. A randomized trial was designed to compare the acceptability of PDA and printed evaluation forms. The trial failed because of clerks' unwillingness to use PDAs. A focus group was held and user surveys were administered, chiefly by e-mail, to explore students' preference for printed forms. Thirty percent of invited clerks (52/176) agreed to use a PDA; 6% (11; 21% of those agreeing) recorded one or more encounters; 2% (4) recorded at least the minimum number of evaluations required by their program. Most survey respondents expressed concerns related primarily to the relative inconvenience of PDAs compared to paper, a judgment reflecting the time required both to install required software and to become familiar with the software and data entry form, and to record information via the form. A minority were also concerned about assessors' willingness or ability to use PDA forms. Before asking students and clinical supervisors to use a PDA-based encounter-evaluation form in clerkship, planners should conduct a careful assessment of the advantages and disadvantages for students of the system they hope to implement. The prima facie greater convenience and efficiency of the PDA may actually be offset by workplace disincentives and inefficiencies in data recording, relative to the incentives and efficiencies associated with a system based on printed (paper) forms.

Why do scientists do outreach, what do we achieve, and how can we better learn from each other, and from research in this field?

NASA Astrophysics Data System (ADS)

Salmon, R. A.; Roop, H. A.

2014-12-01

Using four very different polar outreach case studies, we will discuss scientists' motivations, expectations, and institutional incentives (and dis-incentives) to engage with the public, and argue that improved training, evaluation, and academic value needs to be associated with scientist-led communication efforts - as well as clearer fora for sharing best practice in this field. We will illustrate our argument using examples from an Antarctic festival with public lectures and science cafes, outreach associated with an Antarctic expedition, the global launch of a climate change documentary that had a significant focus on Antarctica, and a series of "Polar Weeks" led by an international community of scientists and educators. While there is an excellent culture of accountability in both formal and informal science communication sectors, the same rigour is not applied to the majority of 'outreach' activities that are initiated by the science research community. Many of these activities are undertaken based on 'what feels right' and opportunism, and are proclaimed to be a success based on little or no formal evaluation. As a result, much of this work goes undocumented, is not evaluated from the perspective of the science community, and is rarely subject to peer-review and its associated benefits, including professional rewards. We therefore conclude with suggestions of new opportunities for publication in this field that would encourage science communication theory and practice to better inform each other, and for scientists to gain professional recognition for their efforts in this arena.

The Effects of Revealed Information on Catastrophe Loss Projection Models' Characterization of Risk: Damage Vulnerability Evidence from Florida.

PubMed

Karl, J Bradley; Medders, Lorilee A; Maroney, Patrick F

2016-06-01

We examine whether the risk characterization estimated by catastrophic loss projection models is sensitive to the revelation of new information regarding risk type. We use commercial loss projection models from two widely employed modeling firms to estimate the expected hurricane losses of Florida Atlantic University's building stock, both including and excluding secondary information regarding hurricane mitigation features that influence damage vulnerability. We then compare the results of the models without and with this revealed information and find that the revelation of additional, secondary information influences modeled losses for the windstorm-exposed university building stock, primarily evidenced by meaningful percent differences in the loss exceedance output indicated after secondary modifiers are incorporated in the analysis. Secondary risk characteristics for the data set studied appear to have substantially greater impact on probable maximum loss estimates than on average annual loss estimates. While it may be intuitively expected for catastrophe models to indicate that secondary risk characteristics hold value for reducing modeled losses, the finding that the primary value of secondary risk characteristics is in reduction of losses in the "tail" (low probability, high severity) events is less intuitive, and therefore especially interesting. Further, we address the benefit-cost tradeoffs that commercial entities must consider when deciding whether to undergo the data collection necessary to include secondary information in modeling. Although we assert the long-term benefit-cost tradeoff is positive for virtually every entity, we acknowledge short-term disincentives to such an effort. © 2015 Society for Risk Analysis.

A Quantitative Assessment of Factors Affecting the Technological Development and Adoption of Companion Diagnostics

PubMed Central

Luo, Dee; Smith, James A.; Meadows, Nick A.; Schuh, A.; Manescu, Katie E.; Bure, Kim; Davies, Benjamin; Horne, Rob; Kope, Mike; DiGiusto, David L.; Brindley, David A.

2016-01-01

Rapid innovation in (epi)genetics and biomarker sciences is driving a new drug development and product development pathway, with the personalized medicine era dominated by biologic therapeutics and companion diagnostics. Companion diagnostics (CDx) are tests and assays that detect biomarkers and specific mutations to elucidate disease pathways, stratify patient populations, and target drug therapies. CDx can substantially influence the development and regulatory approval for certain high-risk biologics. However, despite the increasingly important role of companion diagnostics in the realization of personalized medicine, in the USA, there are only 23 Food and Drug Administration (FDA) approved companion diagnostics on the market for 11 unique indications. Personalized medicines have great potential, yet their use is currently constrained. A major factor for this may lie in the increased complexity of the companion diagnostic and corresponding therapeutic development and adoption pathways. Understanding the market dynamics of companion diagnostic/therapeutic (CDx/Rx) pairs is important to further development and adoption of personalized medicine. Therefore, data collected on a variety of factors may highlight incentives or disincentives driving the development of companion diagnostics. Statistical analysis for 36 hypotheses resulted in two significant relationships and 34 non-significant relationships. The sensitivity of the companion diagnostic was the only factor that significantly correlated with the price of the companion diagnostic. This result indicates that while there is regulatory pressure for the diagnostic and pharmaceutical industry to collaborate and co-develop companion diagnostics for the approval of personalized therapeutics, there seems to be a lack of parallel economic collaboration to incentivize development of companion diagnostics. PMID:26858745

A Quantitative Assessment of Factors Affecting the Technological Development and Adoption of Companion Diagnostics.

PubMed

Luo, Dee; Smith, James A; Meadows, Nick A; Schuh, A; Manescu, Katie E; Bure, Kim; Davies, Benjamin; Horne, Rob; Kope, Mike; DiGiusto, David L; Brindley, David A

2015-01-01

Rapid innovation in (epi)genetics and biomarker sciences is driving a new drug development and product development pathway, with the personalized medicine era dominated by biologic therapeutics and companion diagnostics. Companion diagnostics (CDx) are tests and assays that detect biomarkers and specific mutations to elucidate disease pathways, stratify patient populations, and target drug therapies. CDx can substantially influence the development and regulatory approval for certain high-risk biologics. However, despite the increasingly important role of companion diagnostics in the realization of personalized medicine, in the USA, there are only 23 Food and Drug Administration (FDA) approved companion diagnostics on the market for 11 unique indications. Personalized medicines have great potential, yet their use is currently constrained. A major factor for this may lie in the increased complexity of the companion diagnostic and corresponding therapeutic development and adoption pathways. Understanding the market dynamics of companion diagnostic/therapeutic (CDx/Rx) pairs is important to further development and adoption of personalized medicine. Therefore, data collected on a variety of factors may highlight incentives or disincentives driving the development of companion diagnostics. Statistical analysis for 36 hypotheses resulted in two significant relationships and 34 non-significant relationships. The sensitivity of the companion diagnostic was the only factor that significantly correlated with the price of the companion diagnostic. This result indicates that while there is regulatory pressure for the diagnostic and pharmaceutical industry to collaborate and co-develop companion diagnostics for the approval of personalized therapeutics, there seems to be a lack of parallel economic collaboration to incentivize development of companion diagnostics.

Focus group study of public opinion about paying living kidney donors in Australia.

PubMed

Tong, Allison; Ralph, Angelique F; Chapman, Jeremy R; Wong, Germaine; Gill, John S; Josephson, Michelle A; Craig, Jonathan C

2015-07-07

The unmet demand for kidney transplantation has generated intense controversy about introducing incentives for living kidney donors to increase donation rates. Such debates may affect public perception and acceptance of living kidney donation. This study aims to describe the range and depth of public opinion on financial reimbursement, compensation, and incentives for living kidney donors. Twelve focus groups were conducted with 113 participants recruited from the general public in three Australian states in February 2013. Thematic analysis was used to analyze the transcripts. Five themes were identified: creating ethical impasses (commodification of the body, quandary of kidney valuation, pushing moral boundaries), corrupting motivations (exposing the vulnerable, inevitable abuse, supplanting altruism), determining justifiable risk (compromising kidney quality, undue harm, accepting a confined risk, trusting protective mechanisms, right to autonomy), driving access (urgency of organ shortage, minimizing disadvantage, guaranteeing cost-efficiency, providing impetus, counteracting black markets), and honoring donor deservingness (fairness and reason, reassurance and rewards, merited recompense). Reimbursement and justifiable recompense are considered by the Australian public as a legitimate way of supporting donors and reducing disadvantage. Financial payment beyond reimbursement is regarded as morally reprehensible, with the potential for exploitative commercialism. Some contend that regulated compensation could be a defensible strategy to increased donation rates provided that mechanisms are in place to protect donors. The perceived threat to community values of human dignity, goodwill, and fairness suggests that there could be strong public resistance to any form of financial inducements for living kidney donors. Policy priorities addressing the removal of disincentives may be more acceptable to the public. Copyright © 2015 by the American Society of Nephrology.

Consumer cost sharing and use of biopharmaceuticals for rheumatoid arthritis.

PubMed

Robinson, James C

2013-06-01

To evaluate the effect of consumer cost sharing on use of physician-administered and patient self-administered specialty drugs for rheumatoid arthritis. Multivariate statistical analysis of probability and use of physician-administered specialty drugs, patient self-injected specialty drugs, non-biologic disease-modifying anti-rheumatic drugs, and symptom relief drugs. Analyses were conducted for patients enrolling in preferred provider organization (PPO) plans and health maintenance organization (HMO) plans with different cost-sharing requirements, adjusted for patient demographics, health status, and geographical location. Professional, facility, and pharmaceutical claims for beneficiaries of CalPERS, the public employee insurance purchasing alliance in California, for 2008-2009. Consumer cost-sharing requirements were obtained for each type of drug and service for each type of insurance plan. PPO insurance enrollees face substantially higher cost sharing for physician-administered specialty drugs, compared with HMO enrollees in CalPERS. PPO patients with rheumatoid arthritis are only half as likely as HMO enrollees to choose a physician-administered specialty drug (4.2% vs 9.3%) (P ≤.05), and use 25% less of the drugs if they use any ($10,356 vs $13,678) (P ≤.05). They are 30% more likely to use a self-administered specialty drug than are HMO enrollees (29.3% vs 22.1%) (P ≤.05), and use 35% more of the drugs if any ($16,015 vs $12,378) (P ≤.05). Consumer cost sharing reduces the use of physician-administered specialty drugs for rheumatoid arthritis. The higher use of patient self-administered specialty drugs suggests that the disincentives for use of physician-administered drugs were offset by an increased incentive to use self-administered drugs.

Views and attitudes towards blood donation: a qualitative investigation of Indian non-donors living in England.

PubMed

Joshi, Dhaara; Meakin, Richard

2017-10-22

To explore the views and attitudes of Indians living in England on blood donation. In light of the predicted shortages in blood supply, it is vital to consider ways in which to maximise donation rates. These include addressing the issue of lower donation rates among ethnic minorities, including Indians. However research specifically among minority ethnicities in UK is sparse. General practice in North London. A convenience sample of 12 non-donor Indians living in England. This is a qualitative investigation involving semistructured interviews. Themes derived were analysed using thematic framework analysis. Five key themes emerged from the data, and these concerned participants' perspectives regarding attitudes towards blood, blood donation as a 'good thing', donation disincentives, the recipient matters and the donor matters. A variety of attitudes were presented, but were generally positive, and blood was conceptualised in a manner previously found to be consistent with donation. However, lack of awareness and accessibility were prominent barriers, indicating the need for improvement in these capacities. In contrast to this, blood was also greatly associated with family and acted as a symbol of kinship: this 'emotional charge' often acted to dissuade participants from separating with their blood through donation. Possibly due to this, there was also a strong preference for donated blood to be distributed within the family, as opposed to strangers. This presents a potential barrier to blood donation for some Indians within the current system in which donations are given to unknown recipients. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Balancing the personal, local, institutional, and global: multiple case study and multidimensional scaling analysis of African experiences in addressing complexity and political economy in health research capacity strengthening.

PubMed

Ager, Alastair; Zarowsky, Christina

2015-01-17

Strengthening health research capacity in low- and middle-income countries remains a major policy goal. The Health Research Capacity Strengthening (HRCS) Global Learning (HGL) program of work documented experiences of HRCS across sub-Saharan Africa. We reviewed findings from HGL case studies and reflective papers regarding the dynamics of HRCS. Analysis was structured with respect to common challenges in such work, identified through a multi-dimensional scaling analysis of responses from 37 participants at the concluding symposium of the program of work. Symposium participants identified 10 distinct clusters of challenges: engaging researchers, policymakers, and donors; securing trust and cooperation; finding common interest; securing long-term funding; establishing sustainable models of capacity strengthening; ensuring Southern ownership; accommodating local health system priorities and constraints; addressing disincentives for academic engagement; establishing and retaining research teams; and sustaining mentorship and institutional support. Analysis links these challenges to three key and potentially competing drivers of the political economy of health research: an enduring model of independent researchers and research leaders, the globalization of knowledge and the linked mobility of (elite) individuals, and institutionalization of research within universities and research centres and, increasingly, national research and development agendas. We identify tensions between efforts to embrace the global 'Community of Science' and the promotion and protection of national and institutional agendas in an unequal global health research environment. A nuanced understanding of the dynamics and implications of the uneven global health research landscape is required, along with a willingness to explore pragmatic models that seek to balance these competing drivers.

A Human Alcohol Self-Administration Paradigm to Model Individual Differences in Impaired Control over Alcohol Use

PubMed Central

Leeman, Robert F.; Corbin, William R.; Nogueira, Christine; Krishnan-Sarin, Suchitra; Potenza, Marc N.; O’Malley, Stephanie S.

2014-01-01

We developed an alcohol self-administration paradigm to model individual differences in impaired control. The paradigm includes moderate drinking guidelines meant to model limits on alcohol consumption, which are typically exceeded by people with impaired control. Possible payment reductions provided a disincentive for excessive drinking. Alcohol use above the guideline, despite possible pay reductions, was considered to be indicative of impaired control. Heavy-drinking 21–25 year-olds (N = 39) were randomized to an experimental condition including the elements of the impaired control paradigm or to a free-drinking condition without these elements. Alcohol self-administration was compared between these two conditions to establish the internal validity of the experimental paradigm. In both conditions, participants self-administered beer and non-alcoholic beverages for 3 hours in a bar setting with 1–3 other participants. Experimental condition participants self-administered significantly fewer beers and drank to lower blood-alcohol concentrations (BACs) on average than those in the free-drinking condition. Experimental condition participants were more likely than free-drinking condition participants to intersperse non-alcoholic beverages with beer and to drink at a slower pace. Although experimental condition participants drank more moderately than those in the free-drinking condition overall, their range of drinking was considerable (BAC range = .024–.097) with several participants drinking excessively. A lower initial subjective response to alcohol and earlier age of alcohol use onset were associated with greater alcohol self-administration in the experimental condition. Given the variability in response, the impaired control laboratory paradigm may have utility for preliminary tests of novel interventions in future studies and for identifying individual differences in problem-drinking risk. PMID:23937598

Signed, sealed and delivered: "big tobacco" in Hollywood, 1927-1951.

PubMed

Lum, K L; Polansky, J R; Jackler, R K; Glantz, S A

2008-10-01

Smoking in movies is associated with adolescent and young adult smoking initiation. Public health efforts to eliminate smoking from films accessible to youth have been countered by defenders of the status quo, who associate tobacco imagery in "classic" movies with artistry and nostalgia. The present work explores the mutually beneficial commercial collaborations between the tobacco companies and major motion picture studios from the late 1920s through the 1940s. Cigarette endorsement contracts with Hollywood stars and movie studios were obtained from internal tobacco industry documents at the University of California, San Francisco (UCSF) Legacy Tobacco Documents Library and the Jackler advertising collection at Stanford. Cigarette advertising campaigns that included Hollywood endorsements appeared from 1927 to 1951, with major activity in 1931-2 and 1937-8 for American Tobacco Company's Lucky Strike, and in the late 1940s for Liggett & Myers' Chesterfield. Endorsement contracts and communication between American Tobacco and movie stars and studios explicitly reveal the cross-promotional value of the campaigns. American Tobacco paid movie stars who endorsed Lucky Strike cigarettes US$218,750 in 1937-8 (equivalent to US$3.2 million in 2008) for their testimonials. Hollywood endorsements in cigarette advertising afforded motion picture studios nationwide publicity supported by the tobacco industry's multimillion US dollar advertising budgets. Cross-promotion was the incentive that led to a synergistic relationship between the US tobacco and motion picture industries, whose artefacts, including "classic" films with smoking and glamorous publicity images with cigarettes, continue to perpetuate public tolerance of onscreen smoking. Market-based disincentives within the film industry may be a solution to decouple the historical association between Hollywood films and cigarettes.

Space facilities: Meeting future needs for research, development, and operations

NASA Technical Reports Server (NTRS)

1994-01-01

The National Facilities Study (NFS) represents an interagency effort to develop a comprehensive and integrated long-term plan for world-class aeronautical and space facilities that meet current and projected needs for commercial and government aerospace research and development and space operations. At the request of NASA and the DOD, the National Research Council's Committee on Space Facilities has reviewed the space related findings of the NFS. The inventory of more than 2800 facilities will be an important resource, especially if it continues to be updated and maintained as the NFS report recommends. The data in the inventory provide the basis for a much better understanding of the resources available in the national facilities infrastructure, as well as extensive information on which to base rational decisions about current and future facilities needs. The working groups have used the inventory data and other information to make a set of recommendations that include estimates of cast savings and steps for implementation. While it is natural that the NFS focused on cost reduction and consolidations, such a study is most useful to future planning if it gives equal weight to guiding the direction of future facilities needed to satisfy legitimate national aspirations. Even in the context of cost reduction through facilities closures and consolidations, the study is timid about recognizing and proposing program changes and realignments of roles and missions to capture what could be significant savings and increased effectiveness. The recommendations of the Committee on Space Facilities are driven by the clear need to be more realistic and precise both in recognizing current incentives and disincentives in the aerospace industry and in forecasting future conditions for U.S. space activities.

Banking on Living Kidney Donors-A New Way to Facilitate Donation without Compromising on Ethical Values.

PubMed

Martin, Dominique E; Danovitch, Gabriel M

2017-10-01

Public surveys conducted in many countries report widespread willingness of individuals to donate a kidney while alive to a family member or close friend, yet thousands suffer and many die each year while waiting for a kidney transplant. Advocates of financial incentive programs or "regulated markets" in kidneys present the problem of the kidney shortage as one of insufficient public motivation to donate, arguing that incentives will increase the number of donors. Others believe the solutions lie-at least in part-in facilitating so-called "altruistic donation;" harnessing the willingness of relatives and friends to donate by addressing the many barriers which serve as disincentives to living donation. Strategies designed to minimize financial barriers to donation and the use of paired kidney exchange programs are increasingly enabling donation, and now, an innovative program designed to address what has been termed "chronologically incompatible donation" is being piloted at the University of California, Los Angeles, and elsewhere in the United States. In this program, a person whose kidney is not currently required for transplantation in a specific recipient may instead donate to the paired exchange program; in return, a commitment is made to the specified recipient that priority access for a living-donor transplant in a paired exchange program will be offered when or if the need arises in the future. We address here potential ethical concerns related to this form of organ "banking" from living donors, and argue that it offers significant benefits without undermining the well-established ethical principles and values currently underpinning living donation programs. © The Author 2017. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Awareness and attitude to deceased kidney donation among health-care workers in Sokoto, Nigeria.

PubMed

Agwu, Ngwobia Peter; Awosan, Kehinde Joseph; Ukwuani, Solomon Ifeanyi; Oyibo, Emmanuel Ugbede; Makusidi, Muhammad Aliyu; Ajala, Rotimi Abiodun

2018-01-01

Access to renal replacement therapy by the increasing population of patients with end-stage kidney disease across Sub-Saharan Africa, including Nigeria, has become a major public health challenge. Although deceased kidney donation constitutes a viable source, its uptake by patients is contingent on its acceptance by health-care workers. The aim of this study is to assess the awareness and attitude to deceased kidney donation among health-care workers in Sokoto, Nigeria. A cross-sectional study was conducted among 470 staff of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria (attending a 1-week seminar), selected by universal sampling. Data were collected with a set of pretested, self-administered, and semi-structured questionnaire. The mean age of the respondents was 34.1 ± 7.8 years, and most of them (77.7%) were aged <40 years. Majority of respondents were males (60.6%), married (76.5%), and Moslems (73.5%). While almost all the respondents (98.1%) were aware of deceased kidney donation, only about half (51.9%) were willing to accept deceased kidney donation. Furthermore, 43.4% were willing to give consent to donate deceased relative's kidney, and 26.1% were willing to carry an organ donation card. Predictors of willingness to accept deceased kidney donation were male sex, being a medical doctor or laboratory scientist and being a Moslem (Odds ratio >2, P < 0.05). The major disincentives reported were fear that it may not work (42%) and fear of disease transmission (37.0%). Periodic education of health-care workers on effectiveness and safety of deceased kidney donation is crucial to promoting its acceptance among them.

Economic Evidence and Point-of-Care Testing

PubMed Central

St John, Andrew; Price, Christopher P

2013-01-01

Health economics has been an established feature of the research, policymaking, practice and management in the delivery of healthcare. However its role is increasing as the cost of healthcare begins to drive changes in most healthcare systems. Thus the output from cost effectiveness studies is now being taken into account when making reimbursement decisions, e.g. in Australia and the United Kingdom. Against this background it is also recognised that the health economic tools employed in healthcare, and particularly the output from the use of these tools however, are not always employed in the routine delivery of services. One of the notable consequences of this situation is the poor record of innovation in healthcare with respect to the adoption of new technologies, and the realisation of their benefits. The evidence base for the effectiveness of diagnostic services is well known to be limited, and one consequence of this has been a very limited literature on cost effectiveness. One reason for this situation is undoubtedly the reimbursement strategies employed in laboratory medicine for many years, simplistically based on the complexity of the test procedure, and the delivery as a cost-per-test service. This has proved a disincentive to generate the required evidence, and little effort to generate an integrated investment and disinvestment business case, associated with care pathway changes. Point-of-care testing creates a particularly challenging scenario because, on the one hand, the unit cost-per-test is larger through the loss of the economy of scale offered by automation, whilst it offers the potential of substantial savings through enabling rapid delivery of results, and reduction of facility costs. This is important when many health systems are planning for complete system redesign. We review the literature on economic assessment of point-of-care testing in the context of these developments. PMID:24151342

Medical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection

PubMed Central

Gonzalez, Stevan A.; Fierer, Daniel S.

2017-01-01

Direct-acting antivirals for hepatitis C virus infection may revolutionize treatment among persons with substance use disorders. Despite persons with substance use disorders having the highest hepatitis C virus prevalence and incidence, the vast majority have not engaged into care for the infection. Previously, interferon-based treatments, with substantial side effects and the propensity to exacerbate mental health conditions, were major disincentives to pursuit of care for the infection. Direct-acting antivirals with viral eradication rates of >90%, significantly improved side effect profiles, and shorter treatment duration are dramatic improvements over prior treatment regimens that should promote widespread hepatitis C virus care among persons with substance use disorders. The major unmet need is strategies to promote persons with substance use disorders engagement into care for hepatitis C virus. Although physical integration of treatment for substance use and co-occurring conditions has been widely advocated, it has been difficult to achieve. Telemedicine offers an opportunity for virtual integration of behavioral and medical treatments that could be supplemented by conventional interventions such as hepatitis C virus education, case management, and peer navigation. Furthermore, harm reduction and strategies to reduce viral transmission are important to cease reinfection among persons with substance use disorders. Widespread prescription of therapy for hepatitis C virus infection to substance users will be required to achieve the ultimate goal of global virus elimination. Combinations of medical and behavioral interventions should be used to promote persons with substance use disorders engagement into and adherence with direct-acting antiviral-based treatment approaches. Ultimately, either physical or virtual colocation of hepatitis C virus and substance use treatment has the potential to improve adherence and consequently treatment efficacy. PMID:28701904

The pediatric studies initiative: after 15 years have we reached the limits of the law?

PubMed

Milne, Christopher-Paul; Davis, Jonathan

2014-02-01

Despite considerable disincentives for conducting drug studies in children, 15 years ago the Food and Drug Administration, pediatric health advocates and congressional sponsors created a carrot-and-stick policy approach of voluntary and mandatory programs to encourage the pharmaceutical industry to include children in the drug development process. After several rounds of reauthorization of the laws on a temporary basis, the enabling statutes have been made permanent. The purpose of this analysis is to review the advances that resulted from the law and the areas where further progress is needed. A brief review of the history and results of the pediatric studies initiative was conducted by the authors and a determination made about the accomplishments of the law and remaining challenges. Indicators of the changes that resulted from this pediatric studies initiative are both indirect, such as the increase in the number of indication supplements for new populations, and direct, such as the decrease in the percentage of medicines used off-label in children. Although the pediatric studies initiative has significantly improved therapeutic options for children, concern still exists that drug companies are reluctant to include children in drug development unless continuously incentivized, whether positively or negatively. Two challenges are particularly problematic: neonatal studies and child-friendly formulations. Although the latest round of legislation should provide opportunities to address these problems, significantly more effort will be needed to achieve real culture change. Ultimately, the solution will require full program implementation by the Food and Drug Administration and close collaboration by many key stakeholders to ensure that pediatric studies become a routine part of the drug development process. © 2013 Elsevier HS Journals, Inc. All rights reserved.

Gender, health and population policy.

PubMed

Postel, E

1992-01-01

Indonesia is an international showpiece of successful population control. The number of desired acceptors of family planning is fixed by a coordinating board in cooperation with international advisers including the World Bank. More than 95% of the actual acceptors or users of contraceptives are women rather than couples. Numerical targets are set for districts, subdistricts, villages and hamlets; and local administrators are charged with the execution of the program. Ambitious village or district leaders use a variety of incentives and disincentives to comply with these directives issued by superiors. "2 children is enough" is the slogan on ubiquitous posters in the archipelago. A woman who is pregnant for a 3rd time may face scorn in her village. Although family planning has succeeded in averting births, maternal mortality rates in Indonesia are among the highest in the world. 55% of Indonesian women suffer from anaemia, particularly pregnant or breast feeding women. In principle there is free choice of contraceptives, but effective means such as hormonal implants, IUDs, and sterilization are promoted instead of pills and barrier methods. Thus, a program originally designed to be sensitive to community concerns runs the risk of becoming an oppressive system. Under the rhetoric of human development the quality of family planning services should be improved, the status of women raised by better education and more employment opportunities, no discrimination, and better health services. The aim of United Nations Population Fund (UNFPA) is to extend modern family planning services to 567 million couples, 59% of all married women of reproductive age, by the age 2000. The contraceptive needs of unmarried women have been ignored again, while the plight of unmarried pregnant women has probably increased by increasing violence and wars.

["General Practice is a great job anyway" - a qualitative study with vocational trainees].

PubMed

Steinhäuser, Jost; Paulus, Jan; Roos, Marco; Peters-Klimm, Frank; Ledig, Thomas; Szecsenyi, Joachim; Joos, Stefanie

2011-01-01

Due to the increasing lack of physicians, an ageing and thus multi-morbid society and a misdistribution of physicians in Germany primary care provided by general practitioners is at risk. Therefore, approaches to recruit more physicians for general practice are being sought. The aim of the present study was to explore individual motivations for choosing a career in general practice, vocational trainees' perspectives on the current situation of vocational training and to identify possible approaches to improve the situation with suggestions from vocational trainees in Germany. A qualitative study was conducted by interviewing 13 trainees. The interviews that were based on a predefined interview guideline were recorded and transcribed. The analysis was performed according to Mayring supported by the software Atlas.ti. In general, the reasons given for choosing general practice include the holistic view towards patients, the opportunity to see the direct impact of therapies and self-employment. Furthermore, general practice was perceived as a job with a positive work-life balance. Barriers to vocational training are the lack of structure of individual rotations and the low salaries during the rotation in practice. Furthermore, the basic conditions for working as a self-employed general practitioner in Germany were described as being a disincentive. A general suggestion for improvement was to promote professional recognition of general practice at universities. A qualification of vocational trainers was requested. Specific suggestions were: better payment, better-structured rotations and a specific preparation for the self-employed general practitioner. The results of this study reveal that a single measure is insufficient for recruiting more young doctors for general practice. In fact, a package of measures is necessary to improve aspects of the vocational training but also general conditions for the profession. Copyright © 2010. Published by Elsevier GmbH.

British Asian families and the use of child and adolescent mental health services: a qualitative study of a hard to reach group.

PubMed

Bradby, Hannah; Varyani, Maya; Oglethorpe, Rachel; Raine, Wendy; White, Ishbel; Helen, Minnis

2007-12-01

We explored attitudes to and experiences of Child and Adolescent Mental Health Services (CAMHS) among families of South Asian origin who are underrepresented as service-users in an area of a Scottish city with a high concentration of people of South Asian origin. Six community focus groups were conducted, followed by semi-structured interviews with families who had used CAMHS and with CAMHS professionals involved in those families' cases. Lastly, parents of children who had problems usually referred to CAMHS but who had not used the service were interviewed. Qualitative analysis of transcripts and notes was undertaken using thematic and logical methods. Participants consisted of 35 adults who identified themselves as Asian and had children; 7 parents and/or the young service users him-herself; 7 health care professionals involved in the young person's care plus 5 carers of 6 young people who had not been referred to CAMHS, despite having suitable problems. Focus groups identified the stigma of mental illness and the fear of gossip as strong disincentives to use CAMHS. Families who had been in contact with CAMHS sought to minimise the stigma they suffered by emphasising that mental illness was not madness and could be cured. Families whose children had complex emotional and behavioural problems said that discrimination by health, education and social care professionals exacerbated their child's difficulties. Families of children with severe and enduring mental illness described tolerating culturally inappropriate services. Fear of gossip about children's 'madness' constituted a major barrier to service use for Asian families in this city. Given the widespread nature of the concern over the stigma of children's mental illness, it should be considered in designing culturally competent services for children's mental health.

Cognitive Predictors of Work Among Social Security Disability Insurance Beneficiaries With Psychiatric Disorders Enrolled in IPS Supported Employment.

PubMed

McGurk, Susan R; Drake, Robert E; Xie, Haiyi; Riley, Jarnee; Milfort, Roline; Hale, Thomas W; Frey, William

2018-01-13

Impaired cognitive functioning is a significant predictor of work dysfunction in schizophrenia. Less is known, however about relationships of cognition and work in people with less severe disorders with relatively normal cognitive functioning. This secondary analysis evaluated cognitive predictors of work in Social Security Disability Insurance (SSDI) beneficiaries with a recent work history who were randomized to receive mental health services, supported employment, and freedom from work disincentives over a 2-year study period in the Mental Health Treatment Study. Of the 1045 participants randomized to the treatment package, 945 (90.4%) received a cognitive assessment at study entry. Competitive work activity was evaluated using a computer-assisted timeline follow-back calendar at baseline and quarterly for 24 months. Mood disorders were the most common psychiatric diagnoses (64.9%), followed by schizophrenia or schizoaffective disorder (35.1%). Tobit regression analyses predicting the average number of hours worked per week, controlling for demographic characteristics, diagnosis, and work history indicated that the cognitive composite score (P < .01) and verbal learning subscale scores (P < .001) were associated with fewer hours of weekly work over the study period. Cognitive functioning predicted work over 2 years in SSDI beneficiaries with mood or schizophrenia-spectrum disorders who were receiving supported employment and mental health interventions, despite a relative absence of cognitive impairment in the study participants. The findings suggest cognitive functioning contributes to competitive work outcomes in persons with psychiatric disorders who have relatively unimpaired cognitive abilities, even under optimal conditions of treatment and vocational support. © The Author(s) 2017. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Medical identity theft: prevention and reconciliation initiatives at Massachusetts General Hospital.

PubMed

Judson, Timothy; Haas, Mark; Lagu, Tara

2014-07-01

Medical identity theft refers to the misuse of another individual's identifying medical information to receive medical care. Beyond the financial burden on patients, hospitals, health insurance companies, and government insurance programs, undetected cases pose major patient safety challenges. Inaccuracies in the medical record may persist even after the theft has been identified because of restrictions imposed by patient privacy laws. Massachusetts General Hospital (MGH; Boston) has conducted initiatives to prevent medical identity theft and to better identify and respond to cases when they occur. Since 2007, MGH has used a notification tree to standardize reporting of red flag incidents (warning signs of identity theft, such as suspicious personal identifiers or account activity). A Data Integrity Dashboard allows for tracking and reviewing of all potential incidents of medical identity theft to detect trends and targets for mitigation. An identity-checking policy, VERI-(Verify Everyone's Identity) Safe Patient Care, requires photo identification at every visit and follow-up if it is not provided. Data from MGH suggest that an estimated 120 duplicate medical records are created each month, 25 patient encounters are likely tied to identity theft or fraud each quarter, and 14 patients are treated under the wrong medical record number each year. As of December 2013, 80%-85% of patients were showing photo identification at appointments. Although an organization's policy changes and educational campaigns can improve detection and reconciliation of medical identity theft cases, national policies should be implemented to streamline the process of correcting errors in medical records, reduce the financial disincentive for hospitals to detect and report cases, and create a single point of entry to reduce the burden on individuals and providers to reconcile cases.

A Systematic Review of Financial Incentives for Dietary Behavior Change

PubMed Central

Purnell, Jason Q.; Gernes, Rebecca; Stein, Rick; Sherraden, Margaret S.; Knoblock-Hahn, Amy

2014-01-01

In light of the obesity epidemic, there is growing interest in the use of financial incentives for dietary behavior change. Previous reviews of the literature have focused on randomized, controlled trials and found mixed results. The purpose of this systematic review is to update and expand upon previous reviews by considering a broader range of study designs, including RCTs, quasi-experimental, observational, and simulation studies testing the use of financial incentives to change dietary behavior and to inform both dietetic practice and research. The review was guided by theoretical consideration of the type of incentive used based upon the principles of operant conditioning. There was further examination of whether studies were carried out with an institutional focus and whether incentives took the form of assets or savings. Studies published between 2006 and 2012 were selected for review, and data were extracted regarding study population, intervention design, outcome measures, study duration and follow-up, and key findings. Twelve studies meeting selection criteria were reviewed, with eleven finding a positive association between incentives and dietary behavior change in the short-term. All studies pointed to more specific information on the type, timing, and magnitude of incentives needed to motivate individuals to change behavior, the types of incentives and disincentives most likely to affect the behavior of various socioeconomic groups, and promising approaches for potential policy and practice innovations. Limitations of studies are noted, including the lack of theoretical guidance in the selection of incentive structures and the absence of basic experimental data. Future research should consider these factors even as policymakers and practitioners continue to experiment with this potentially useful approach to addressing obesity. PMID:24836967

Impact of gender and professional education on attitudes towards financial incentives for organ donation: results of a survey among 755 students of medicine and economics in Germany

PubMed Central

2014-01-01

Background There is an ongoing expert debate with regard to financial incentives in order to increase organ supply. However, there is a lacuna of empirical studies on whether citizens would actually support financial incentives for organ donation. Methods Between October 2008 and February 2009 a quantitative survey was conducted among German students of medicine and economics to gain insights into their point of view regarding living and deceased organ donation and different forms of commercialization (n = 755). Results The average (passive) willingness to donate is 63.5% among medical students and 50.0% among students of economics (p = 0.001), while only 24.1% of the respondents were actually holding an organ donor card. 11.3% of students of economics had signed a donor card, however, the number is significantly higher among students of medicine (31.9%, p < 0.001). Women held donor cards significantly more often (28.6%) than men (19.4%, p = 0.004). The majority of students were against direct payments as incentives for deceased and living donations. Nevertheless, 37.5% of the respondents support the idea that the funeral expenses of deceased organ donors should be covered. Women voted significantly less often for the coverage of expenses than men (women 31.6%, men 44.0%, p = 0.003). The number of those in favor of allowing to sell one’s organs for money (living organ donation) was highest among students of economics (p = 0.034). Conclusion Despite a generally positive view on organ donation the respondents refuse to consent to commercialization, but are in favor of removing disincentives or are in favor of indirect models of reward. PMID:24996438

Incentives to yield to Obstetric Referrals in deprived areas of Amansie West district in the Ashanti Region, Ghana.

PubMed

Nuamah, Gladys Buruwaa; Agyei-Baffour, Peter; Akohene, Kofi Mensah; Boateng, Daniel; Dobin, Dominic; Addai-Donkor, Kwasi

2016-07-22

Obstetric referrals, otherwise known as maternal referrals constitute an eminent component of emergency care, and key to ensuring safe delivery and reducing maternal and child mortalities. The efficiency of Obstetric referral systems is however marred by the lack of accessible transportation and socio-economic disparities in access to healthcare. This study evaluated the role of socio-economic factors, perception and transport availability in honouring Obstetric referrals from remote areas to referral centres. This was a cross-sectional study, involving 720 confirmed pregnant women randomly sampled from five (5) sub-districts in the Amansie west district in Ghana, from February to May 2015. Data were collected through structured questionnaire using face-to-face interviewing and analyzed using STATA 11.0 for windows. Logistic regression models were fitted to determine the influence of socio-demographic characteristics and pregnancy history on obstetric referrals. About 21.7 % of the women studied honoured referral by a community health worker to the next level of care. Some of the pregnant women however refused referrals to the next level due to lack of money (58 %) and lack of transport (17 %). A higher household wealth quintile increased the odds of being referred and honouring referral as compared to those in the lowest wealth quintile. Women who perceived their disease conditions as emergencies and severe were also more likely to honour obstetric referrals (OR = 2.3; 95 % CI = 1.3, 3.9). Clients' perceptions about severity of health condition and low income remain barriers to seeking healthcare and disincentives to honour obstetric referrals in a setting with inequitable access to healthcare. Implementing social interventions could improve the situation and help attain maternal health targets in deprived areas.

Modifiable and non-modifiable factors associated with employment outcomes following spinal cord injury: A systematic review

PubMed Central

Trenaman, Logan; Miller, William C; Querée, Matthew; Escorpizo, Reuben

2015-01-01

Context Employment rates in individuals with spinal cord injury (SCI) are approximately 35%, which is considerably lower than that of the general population. In order to improve employment outcomes a clear understanding of what factors influence employment outcomes is needed. Objective To systematically review factors that are consistently and independently associated with employment outcomes in individuals with SCI, and to understand the magnitude of their influence. Methods Through an electronic search of MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, Social Science Abstracts and Social Work databases, we identified studies published between 1952–2014 that investigated factors associated with employment outcomes following SCI. Exclusion criteria included: (1) reviews (2) studies not published in English (3) studies not controlling for potential confounders through a regression analysis, or (4) studies not providing an effect measure in the form of OR, RR, or HR. Data were categorized based on the International Classification of Functioning, Disability and Health framework, with each domain sub-categorized by modifiability. First author, year of publication, sample size, explanatory and outcome variables, and effect measures were extracted. Results Thirty-nine studies met the inclusion criteria. Twenty modifiable and twelve non-modifiable factors have been investigated in the context of employment following SCI. Education, vocational rehabilitation, functional independence, social support, and financial disincentives were modifiable factors that have been consistently and independently associated with employment outcomes. Conclusion A number of key modifiable factors have been identified and can inform interventions aimed at improving employment outcomes for individuals with SCI. Future research should focus on determining which factors have the greatest effect on employment outcomes, in addition to developing and evaluating interventions targeted at these factors. PMID:25989899

Organ trafficking: global solutions for a global problem.

PubMed

Jafar, Tazeen H

2009-12-01

The organ trafficking market is on the rise worldwide. Numerous unfortunate stories of networks of brokers, physicians, and hospitals engaged in illegal trade have been featured in high-profile media. The profitable enterprises facilitating these unregulated services exploit the poor in underresourced countries and offer substandard medical care with unacceptable outcomes to the rich recipients. Despite efforts to boost altruistic organ donation and resolutions to curb transplant tourism, their implementation has been compromised. At the same time, the worldwide escalation in the number of patients with kidney failure coupled with a shortage in the supply of organs continues to fuel this trade. Thus, measures to enhance the donor pool in well-resourced countries to meet their own needs will act as a strong deterrent to the proliferation of transplant tourism in impoverished nations. Regulated schemes that include reimbursement for removing potential disincentives to organ donation and ensure the long-term safety of donors and their families are likely to increase living donations. Such socially responsible programs should be tested in both developed and developing countries for their own populations. It also is vital that developing countries establish a regulated, standardized, and ethical system of organ procurement; create awareness in physicians and the public; upgrade facilities and standardize medical care; and enforce legislation for transplantation. The World Health Organization, National Kidney Foundation, and international transplant and nephrology societies can have an instrumental role in facilitating initiatives in these critical areas. There should be clearly defined codes of conduct for health care facilities and professionals' roles in unregulated paid organ donations and transplants. Ultimately, physicians and transplant surgeons have the responsibility to ensure to the best of their ability that the organs they transplant were obtained upholding the highest standards of ethics.

The impact of interventions to promote healthier ready‐to‐eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review

PubMed Central

Summerbell, C. D.; Moore, H. J.; Routen, A.; Lake, A. A.; Adams, J.; White, M.; Araujo‐Soares, V.; Abraham, C.; Adamson, A. J.; Brown, T. J.

2016-01-01

Summary Introduction Ready‐to‐eat meals sold by food outlets that are accessible to the general public are an important target for public health intervention. We conducted a systematic review to assess the impact of such interventions. Methods Studies of any design and duration that included any consumer‐level or food‐outlet‐level before‐and‐after data were included. Results Thirty studies describing 34 interventions were categorized by type and coded against the Nuffield intervention ladder: restrict choice = trans fat law (n = 1), changing pre‐packed children's meal content (n = 1) and food outlet award schemes (n = 2); guide choice = price increases for unhealthier choices (n = 1), incentive (contingent reward) (n = 1) and price decreases for healthier choices (n = 2); enable choice = signposting (highlighting healthier/unhealthier options) (n = 10) and telemarketing (offering support for the provision of healthier options to businesses via telephone) (n = 2); and provide information = calorie labelling law (n = 12), voluntary nutrient labelling (n = 1) and personalized receipts (n = 1). Most interventions were aimed at adults in US fast food chains and assessed customer‐level outcomes. More ‘intrusive’ interventions that restricted or guided choice generally showed a positive impact on food‐outlet‐level and customer‐level outcomes. However, interventions that simply provided information or enabled choice had a negligible impact. Conclusion Interventions to promote healthier ready‐to‐eat meals sold by food outlets should restrict choice or guide choice through incentives/disincentives. Public health policies and practice that simply involve providing information are unlikely to be effective. PMID:27899007

Space facilities: Meeting future needs for research, development, and operations

NASA Astrophysics Data System (ADS)

The National Facilities Study (NFS) represents an interagency effort to develop a comprehensive and integrated long-term plan for world-class aeronautical and space facilities that meet current and projected needs for commercial and government aerospace research and development and space operations. At the request of NASA and the DOD, the National Research Council's Committee on Space Facilities has reviewed the space related findings of the NFS. The inventory of more than 2800 facilities will be an important resource, especially if it continues to be updated and maintained as the NFS report recommends. The data in the inventory provide the basis for a much better understanding of the resources available in the national facilities infrastructure, as well as extensive information on which to base rational decisions about current and future facilities needs. The working groups have used the inventory data and other information to make a set of recommendations that include estimates of cast savings and steps for implementation. While it is natural that the NFS focused on cost reduction and consolidations, such a study is most useful to future planning if it gives equal weight to guiding the direction of future facilities needed to satisfy legitimate national aspirations. Even in the context of cost reduction through facilities closures and consolidations, the study is timid about recognizing and proposing program changes and realignments of roles and missions to capture what could be significant savings and increased effectiveness. The recommendations of the Committee on Space Facilities are driven by the clear need to be more realistic and precise both in recognizing current incentives and disincentives in the aerospace industry and in forecasting future conditions for U.S. space activities.

Focus Group Study of Public Opinion About Paying Living Kidney Donors in Australia

PubMed Central

Ralph, Angelique F.; Chapman, Jeremy R.; Wong, Germaine; Gill, John S.; Josephson, Michelle A.; Craig, Jonathan C.

2015-01-01

Background and objectives The unmet demand for kidney transplantation has generated intense controversy about introducing incentives for living kidney donors to increase donation rates. Such debates may affect public perception and acceptance of living kidney donation. This study aims to describe the range and depth of public opinion on financial reimbursement, compensation, and incentives for living kidney donors. Design, setting, participants, & measurements Twelve focus groups were conducted with 113 participants recruited from the general public in three Australian states in February 2013. Thematic analysis was used to analyze the transcripts. Results Five themes were identified: creating ethical impasses (commodification of the body, quandary of kidney valuation, pushing moral boundaries), corrupting motivations (exposing the vulnerable, inevitable abuse, supplanting altruism), determining justifiable risk (compromising kidney quality, undue harm, accepting a confined risk, trusting protective mechanisms, right to autonomy), driving access (urgency of organ shortage, minimizing disadvantage, guaranteeing cost-efficiency, providing impetus, counteracting black markets), and honoring donor deservingness (fairness and reason, reassurance and rewards, merited recompense). Reimbursement and justifiable recompense are considered by the Australian public as a legitimate way of supporting donors and reducing disadvantage. Financial payment beyond reimbursement is regarded as morally reprehensible, with the potential for exploitative commercialism. Some contend that regulated compensation could be a defensible strategy to increased donation rates provided that mechanisms are in place to protect donors. Conclusions The perceived threat to community values of human dignity, goodwill, and fairness suggests that there could be strong public resistance to any form of financial inducements for living kidney donors. Policy priorities addressing the removal of disincentives may be more acceptable to the public. PMID:25908793

Well-Child Care Practice Redesign for Low-Income Children: The Perspectives of Health Plans, Medical Groups, and State Agencies

PubMed Central

Coker, Tumaini R.; DuPlessis, Helen M.; Davoudpour, Ramona; Moreno, Candice; Rodriguez, Michael A.; Chung, Paul J.

2015-01-01

Objective The aim of this study was to examine the views of key stakeholders in health care payer organizations on the use of practice redesign strategies to improve the delivery of well-child care (WCC) to low-income children aged 0 to 3 years. Methods We conducted semistructured interviews with 18 key stakeholders (eg, chief medical officers, medical directors) in 11 California health plans and 2 medical group organizations serving low-income children, as well as the 2 state agencies that administer the 2 largest low-income insurance programs for California children. Discussions were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis. Results Participants reported that nonphysicians were underutilized as WCC providers, and group visits and Internet services were likely a more effective way to provide anticipatory guidance and behavioral/developmental services. Participants described barriers to redesign, including the start-up costs required to implement redesign as well as a lack of financial incentives to support innovation in WCC delivery. Participants suggested solutions to these barriers, including using pay-for-performance programs to reward practices that expanded WCC services, and providing practices with start-up grants to implement pilot redesign projects that would eventually become self-sustaining. State-level barriers included poor Medicaid reimbursement rates and disincentives to innovation created by current Healthcare Effectiveness Data and Information Set measures. Conclusions All stakeholders will ultimately be needed to support WCC redesign; however, California payers may need to provide logistic, design, and financial support to practices, whereas state agencies may need to reshape the incentives to reward innovation around child preventive health and developmental services. PMID:22075467

How redesigning AD clinical trials might increase study partners’ willingness to participate

PubMed Central

Karlawish, Jason; Cary, Mark S.; Rubright, Jonathan; TenHave, Tom

2008-01-01

Background: Timely recruiting and retaining participants into Alzheimer disease (AD) clinical trials is a challenge. We used conjoint analysis to identify how alterations in attributes of clinical trial design improve willingness to participate: risk, home visits, car service, or increased chance of receiving intervention. Method: A total of 108 study partners of patients with very mild to severe stage AD rated willingness to allow their relative to participate in eight clinical trials that varied combinations of the four attributes. Results: The highest utility was for home visits (0.89) which essentially compensated for the disutility of high risk (−0.85). The combination of home visits and car service was redundant, with almost no increase in utility over home visits alone. Seventeen percent were willing to participate in a trial with no amenities; the addition of home visits increased predicted willingness to participate to 27%; low risk, home visits, and higher chance of active treatment increased predicted willingness to 60%. The value of reducing the hassles of travel correlated well with measures of AD severity (activities of daily living r = 0.41, p < 0.001; basic activities of daily living r = 0.38, p < 0.001; Neuropsychiatric Inventory severity p = 0.24, p = 0.01; Neuropsychiatric Inventory distress r = 0.23, p < 0.02). No association was found between degree of study partner burden and willingness to tolerate risk of an intervention. Conclusion: Clinical trials that reduce travel inconvenience may offset the disincentive of study features such as the risk of intervention and may also increase willingness to participate. Redesigning trials may also help recruit patients with more severe Alzheimer disease. Shorter recruitment periods and increased retention rates may offset costs of these changes. GLOSSARY AD = Alzheimer disease; BLUP = best linear unbiased prediction; RAQ = Research Attitude Questionnaire. PMID:19047560

How redesigning AD clinical trials might increase study partners' willingness to participate.

PubMed

Karlawish, Jason; Cary, Mark S; Rubright, Jonathan; Tenhave, Tom

2008-12-02

Timely recruiting and retaining participants into Alzheimer disease (AD) clinical trials is a challenge. We used conjoint analysis to identify how alterations in attributes of clinical trial design improve willingness to participate: risk, home visits, car service, or increased chance of receiving intervention. A total of 108 study partners of patients with very mild to severe stage AD rated willingness to allow their relative to participate in eight clinical trials that varied combinations of the four attributes. The highest utility was for home visits (0.89) which essentially compensated for the disutility of high risk (-0.85). The combination of home visits and car service was redundant, with almost no increase in utility over home visits alone. Seventeen percent were willing to participate in a trial with no amenities; the addition of home visits increased predicted willingness to participate to 27%; low risk, home visits, and higher chance of active treatment increased predicted willingness to 60%. The value of reducing the hassles of travel correlated well with measures of AD severity (activities of daily living r = 0.41, p < 0.001; basic activities of daily living r = 0.38, p < 0.001; Neuropsychiatric Inventory severity p = 0.24, p = 0.01; Neuropsychiatric Inventory distress r = 0.23, p < 0.02). No association was found between degree of study partner burden and willingness to tolerate risk of an intervention. Clinical trials that reduce travel inconvenience may offset the disincentive of study features such as the risk of intervention and may also increase willingness to participate. Redesigning trials may also help recruit patients with more severe Alzheimer disease. Shorter recruitment periods and increased retention rates may offset costs of these changes.

Collaborative Audit of Risk Evaluation in Medical Emergency Treatment (CARE-MET I) - an international pilot.

PubMed

Subbe, C P; Gauntlett, W; Kellett, J G

2010-06-01

The absence of an accepted model for risk-adjustment of acute medical admissions leads to suboptimal clinical triage and serves as a disincentive to compare outcomes in different hospitals. The Simple Clinical Score (SCS) is a model based on 16 clinical parameters affecting hospital mortality. We undertook a feasibility pilot in 21 hospitals in Europe and New Zealand each collecting data for 12 or more consecutive medical emergency admissions. Data from 281 patients was analysed. Severity of illness as estimated by SCS was related to risk of admission to the Intensive Care Unit (p<0.001) but not to the Coronary Care Unit. Mortality increased from 0% in the Very Low Risk group to 22% in the Very High Risk Group (p<0.0001). Very low scores were associated with earlier discharge as opposed to very high scores (mean length of stay of 2.4 days vs 5.6 days, p<0.001). There were differences in the pattern of discharges in different hospitals with comparable SCS data. Clinicians reported no significant problems with the collection of data for the score in a number of different health care settings. The SCS appears to be a feasible tool to assist clinical triage of medical emergency admissions. The ability to view the profile of the SCS for different clinical centres opens up the possibility of accurate comparison of outcomes across clinical centres without distortion by different regional standards of health care. This pilot study demonstrates that the adoption of the SCS is practical across an international range of hospitals. Copyright 2010 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Early action to reduce greenhouse gas emissions before the commitment period of the Kyoto protocol: advantages and disadvantages.

PubMed

Michaelowa, A; Rolfe, C

2001-09-01

Current "business as usual" projections suggest greenhouse gas emissions from industrialized nations will grow substantially over the next decade. However, if it comes into force, the Kyoto Protocol will require industrialized nations to reduce emissions to an average of 5% below 1990 levels in the 2008-2012 period. Taking early action to close this gap has a number of advantages. It reduces the risks of passing thresholds that trigger climate change "surprises." Early action also increases future generations' ability to choose greater levels of climate protection, and it leads to faster reductions of other pollutants. From an economic sense, early action is important because it allows shifts to less carbon-intensive technologies during the course of normal capital stock turnover. Moreover, many options for emission reduction have negative costs, and thus are economically worthwhile, because of paybacks in energy costs, healthcare costs, and other benefits. Finally, early emission reductions enhance the probability of successful ratification and lower the risk of noncompliance with the protocol. We discuss policy approaches for the period prior to 2008. Disadvantages of the current proposals for Credit for Early Action are the possibility of adverse selection due to problematic baseline calculation methods as well as the distributionary impacts of allocating a part of the emissions budget already before 2008. One simple policy without drawbacks is the so-called baseline protection, which removes the disincentive to early action due to the expectation that businesses may, in the future, receive emission rights in proportion to past emissions. It is particularly important to adopt policies that shift investment in long-lived capital stock towards less carbon-intensive technologies and to encourage innovation and technology development that will reduce future compliance costs.

Arranging for personal assistance services and assistive technology at work. A report of the rehabilitation research and training center on personal assistance services.

PubMed

Stoddard, Susan; Kraus, Lewis

2006-01-01

For an employee with a disability, reasonable accommodation can make the difference in finding work, maintaining employment, and succeeding on the job. Today, employers and employees alike are more aware that appropriate accommodation, including workplace personal assistance services (PAS) as well as assistive technology, improves an employee's ability to succeed. While assistive technology is in widespread use as an accommodation, workplace personal assistance is less understood. The goal of the study was to learn more about how workplace PAS and AT are arranged for in the workplace, and the issues that arise. Structured phone interviews were conducted with 20 workplace PAS users, 21 employers familiar with workplace PAS, and 19 employment organizations. Interview transcripts are the basis for the qualitative analysis of findings. Requirements for personal assistance accommodations focus on task-related needs. Personal care needs at work are not included in the Americans with Disabilities act but may be needed by the employee. Employers and PAS users have developed many creative ways to address PAS need. Organizations can construct an approach that fits the needs, abilities, and constraints of each organization. The interview respondents have identified a number of practices that are succeeding, including establishment of policies for arranging for PAS; centralization of accommodation budgets to remove work unit disincentives; and providing a shared personal assistant for interpreting or for task-related and personal care tasks. A number of important research questions remain. What is the extent of the need for PAS in the workplace? Will an expanded PAS supply increase the employment opportunities for people with disabilities? Will better models of workplace PAS be adopted by employers?

Modestly increased use of colonoscopy when copayments are waived.

PubMed

Khatami, Shabnam; Xuan, Lei; Roman, Rolando; Zhang, Song; McConnel, Charles; Halm, Ethan A; Gupta, Samir

2012-07-01

Colorectal cancer (CRC) screening with colonoscopy often requires expensive copayments from patients. The 2010 Patient Protection and Affordable Care Act mandated elimination of copayments for CRC screening, including colonoscopy, but little is known about the effects of copayment elimination on use. The University of Texas employee, retiree, and dependent health plan instituted and promoted a waiver of copayments for screening colonoscopies in fiscal year (FY) 2009; we examined the effects of removing cost sharing on colonoscopy use. We conducted a retrospective cohort study of 59,855 beneficiaries of the University of Texas employee, retiree, and dependent health plan, associated with 16 University of Texas health and nonhealth campuses, ages 50-64 years at any point in FYs 2002-2009 (267,191 person-years of follow-up evaluation). The primary outcome was colonoscopy incidence among individuals with no prior colonoscopy. We compared the age- and sex-standardized incidence ratios for colonoscopy in FY 2009 (after the copayment waiver) with the expected incidence for FY 2009, based on secular trends from years before the waiver. The annual incidence of colonoscopy increased to 9.5% after the copayment was waived, compared with an expected incidence of 8.0% (standardized incidence ratio, 1.18; 95% confidence interval, 1.14-1.23; P < .001). After adjusting for age, sex, and beneficiary status, the copayment waiver remained significantly associated with greater use of colonoscopy, with an adjusted hazard ratio of 1.19 (95% confidence interval, 1.12-1.26). Waiving copayments for colonoscopy screening results in a statistically significant, but modest (1.5%), increase in use. Additional strategies beyond removing financial disincentives are needed to increase use of CRC screening. Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.

Workplace-related generational characteristics of nurses: A mixed-method systematic review.

PubMed

Stevanin, Simone; Palese, Alvisa; Bressan, Valentina; Vehviläinen-Julkunen, Katri; Kvist, Tarja

2018-06-01

The aim of this study was to describe and summarize workplace characteristics of three nursing generations: Baby Boomers, Generations X and Y. Generational differences affect occupational well-being, nurses' performance, patient outcomes and safety; therefore, nurse managers, administrators and educators are interested increasingly in making evidence-based decisions about the multigenerational nursing workforce. Mixed-method systematic review. Medline, CINAHL, PsycINFO and Scopus (January 1991-January 2017). (1) The Joanna Briggs Institute's method for conducting mixed-method systematic reviews; (2) the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and (3) the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines. The studies' methodological quality was assessed with the Mixed-Methods Appraisal Tool. Quantitative and mixed-method studies were transformed into qualitative methods using a convergent qualitative synthesis and qualitative findings were combined with a narrative synthesis. Thirty-three studies were included with three main themes and 11 subthemes: (1) Job attitudes (work engagement; turnover intentions, reasons for leaving; reasons, incentives/disincentives to continue nursing); (2) Emotion-related job aspects (stress/resilience; well-being/job satisfaction; affective commitment; unit climate; work ethic) and (3) Practice and leadership-related aspects (autonomy; perceived competence; leadership relationships and perceptions). Baby Boomers reported lower levels of stress and burnout than did Generations X and Y, different work engagement, factors affecting workplace well-being and retention and greater intention to leave compared with Generation Y, which was less resilient, but more cohesive. Although several studies reported methodological limitations and conflicting findings, generational differences in nurses' job attitudes, emotional, practice and leadership factors should be considered to enhance workplace quality. © 2018 John Wiley & Sons Ltd.

Updated Global Burden of Cholera in Endemic Countries

PubMed Central

Ali, Mohammad; Nelson, Allyson R.; Lopez, Anna Lena; Sack, David A.

2015-01-01

Background The global burden of cholera is largely unknown because the majority of cases are not reported. The low reporting can be attributed to limited capacity of epidemiological surveillance and laboratories, as well as social, political, and economic disincentives for reporting. We previously estimated 2.8 million cases and 91,000 deaths annually due to cholera in 51 endemic countries. A major limitation in our previous estimate was that the endemic and non-endemic countries were defined based on the countries’ reported cholera cases. We overcame the limitation with the use of a spatial modelling technique in defining endemic countries, and accordingly updated the estimates of the global burden of cholera. Methods/Principal Findings Countries were classified as cholera endemic, cholera non-endemic, or cholera-free based on whether a spatial regression model predicted an incidence rate over a certain threshold in at least three of five years (2008-2012). The at-risk populations were calculated for each country based on the percent of the country without sustainable access to improved sanitation facilities. Incidence rates from population-based published studies were used to calculate the estimated annual number of cases in endemic countries. The number of annual cholera deaths was calculated using inverse variance-weighted average case-fatality rate (CFRs) from literature-based CFR estimates. We found that approximately 1.3 billion people are at risk for cholera in endemic countries. An estimated 2.86 million cholera cases (uncertainty range: 1.3m-4.0m) occur annually in endemic countries. Among these cases, there are an estimated 95,000 deaths (uncertainty range: 21,000-143,000). Conclusion/Significance The global burden of cholera remains high. Sub-Saharan Africa accounts for the majority of this burden. Our findings can inform programmatic decision-making for cholera control. PMID:26043000

Health System Barriers to Access and Use of Magnesium Sulfate for Women with Severe Pre-Eclampsia and Eclampsia in Pakistan: Evidence for Policy and Practice

PubMed Central

Bigdeli, Maryam; Zafar, Shamsa; Assad, Hafeez; Ghaffar, Adbul

2013-01-01

Severe pre-eclampsia and eclampsia are rare but serious complications of pregnancy that threaten the lives of mothers during childbirth. Evidence supports the use of magnesium sulfate (MgSO4) as the first line treatment option for severe pre-eclampsia and eclampsia. Eclampsia is the third major cause of maternal mortality in Pakistan. As in many other Low- and Middle-Income Countries (LMIC), it is suspected that MgSO4 is critically under-utilized in the country. There is however a lack of information on context-specific health system barriers that prevent optimal use of this life-saving medicine in Pakistan. Combining quantitative and qualitative methods, namely policy document review, key informant interviews, focus group discussions and direct observation at health facility, we explored context-specific health system barriers and enablers that affect access and use of MgSO4 for severe pre-eclampsia and eclampsia in Pakistan. Our study finds that while international recommendations on MgSO4 have been adequately translated in national policies in Pakistan, the gap remains in implementation of national policies into practice. Barriers to access to and effective use of MgSO4 occur at health facility level where the medicine was not available and health staff was reluctant to use it. Low price of the medicine and the small market related to its narrow indications acted as disincentives for effective marketing. Results of our survey were further discussed in a multi-stakeholder round-table meeting and an action plan for increasing access to this life-saving medicine was identified. PMID:23555626

Monte Carlo simulation to analyze the cost-benefit of radioactive seed localization versus wire localization for breast-conserving surgery in fee-for-service health care systems compared with accountable care organizations.

PubMed

Loving, Vilert A; Edwards, David B; Roche, Kevin T; Steele, Joseph R; Sapareto, Stephen A; Byrum, Stephanie C; Schomer, Donald F

2014-06-01

In breast-conserving surgery for nonpalpable breast cancers, surgical reexcision rates are lower with radioactive seed localization (RSL) than wire localization. We evaluated the cost-benefit of switching from wire localization to RSL in two competing payment systems: a fee-for-service (FFS) system and a bundled payment system, which is typical for accountable care organizations. A Monte Carlo simulation was developed to compare the cost-benefit of RSL and wire localization. Equipment utilization, procedural workflows, and regulatory overhead differentiate the cost between RSL and wire localization. To define a distribution of possible cost scenarios, the simulation randomly varied cost drivers within fixed ranges determined by hospital data, published literature, and expert input. Each scenario was replicated 1000 times using the pseudorandom number generator within Microsoft Excel, and results were analyzed for convergence. In a bundled payment system, RSL reduced total health care cost per patient relative to wire localization by an average of $115, translating into increased facility margin. In an FFS system, RSL reduced total health care cost per patient relative to wire localization by an average of $595 but resulted in decreased facility margin because of fewer surgeries. In a bundled payment system, RSL results in a modest reduction of cost per patient over wire localization and slightly increased margin. A fee-for-service system suffers moderate loss of revenue per patient with RSL, largely due to lower reexcision rates. The fee-for-service system creates a significant financial disincentive for providers to use RSL, although it improves clinical outcomes and reduces total health care costs.

Signed, sealed and delivered: “big tobacco” in Hollywood, 1927–1951

PubMed Central

Lum, K L; Polansky, J R; Jackler, R K; Glantz, S A

2008-01-01

Objective: Smoking in movies is associated with adolescent and young adult smoking initiation. Public health efforts to eliminate smoking from films accessible to youth have been countered by defenders of the status quo, who associate tobacco imagery in “classic” movies with artistry and nostalgia. The present work explores the mutually beneficial commercial collaborations between the tobacco companies and major motion picture studios from the late 1920s through the 1940s. Methods: Cigarette endorsement contracts with Hollywood stars and movie studios were obtained from internal tobacco industry documents at the University of California, San Francisco (UCSF) Legacy Tobacco Documents Library and the Jackler advertising collection at Stanford. Results: Cigarette advertising campaigns that included Hollywood endorsements appeared from 1927 to 1951, with major activity in 1931–2 and 1937–8 for American Tobacco Company’s Lucky Strike, and in the late 1940s for Liggett & Myers’ Chesterfield. Endorsement contracts and communication between American Tobacco and movie stars and studios explicitly reveal the cross-promotional value of the campaigns. American Tobacco paid movie stars who endorsed Lucky Strike cigarettes US$218 750 in 1937–8 (equivalent to US$3.2 million in 2008) for their testimonials. Conclusions: Hollywood endorsements in cigarette advertising afforded motion picture studios nationwide publicity supported by the tobacco industry’s multimillion US dollar advertising budgets. Cross-promotion was the incentive that led to a synergistic relationship between the US tobacco and motion picture industries, whose artefacts, including “classic” films with smoking and glamorous publicity images with cigarettes, continue to perpetuate public tolerance of onscreen smoking. Market-based disincentives within the film industry may be a solution to decouple the historical association between Hollywood films and cigarettes. PMID:18818225

Development of Disease-specific, Context-specific Surveillance Models: Avian Influenza (H5N1)-Related Risks and Behaviours in African Countries.

PubMed

Fasina, F O; Njage, P M K; Ali, A M M; Yilma, J M; Bwala, D G; Rivas, A L; Stegeman, A J

2016-02-01

Avian influenza virus (H5N1) is a rapidly disseminating infection that affects poultry and, potentially, humans. Because the avian virus has already adapted to several mammalian species, decreasing the rate of avian-mammalian contacts is critical to diminish the chances of a total adaptation of H5N1 to humans. To prevent the pandemic such adaptation could facilitate, a biology-specific disease surveillance model is needed, which should also consider geographical and socio-cultural factors. Here, we conceptualized a surveillance model meant to capture H5N1-related biological and cultural aspects, which included food processing, trade and cooking-related practices, as well as incentives (or disincentives) for desirable behaviours. This proof of concept was tested with data collected from 378 Egyptian and Nigerian sites (local [backyard] producers/live bird markets/village abattoirs/commercial abattoirs and veterinary agencies). Findings revealed numerous opportunities for pathogens to disseminate, as well as lack of incentives to adopt preventive measures, and factors that promoted epidemic dissemination. Supporting such observations, the estimated risk for H5N1-related human mortality was higher than previously reported. The need for multidimensional disease surveillance models, which may detect risks at higher levels than models that only measure one factor or outcome, was supported. To develop efficient surveillance systems, interactions should be captured, which include but exceed biological factors. This low-cost and easily implementable model, if conducted over time, may identify focal instances where tailored policies may diminish both endemicity and the total adaptation of H5N1 to the human species. © 2015 Blackwell Verlag GmbH.

Modestly Increased Use of Colonoscopy When Copayments Are Waived

PubMed Central

KHATAMI, SHABNAM; XUAN, LEI; ROMAN, ROLANDO; ZHANG, SONG; McCONNEL, CHARLES; HALM, ETHAN A.; GUPTA, SAMIR

2012-01-01

BACKGROUND & AIMS Colorectal cancer (CRC) screening with colonoscopy often requires expensive copayments from patients. The 2010 Patient Protection and Affordable Care Act mandated elimination of copayments for CRC screening, including colonoscopy, but little is known about the effects of copayment elimination on use. The University of Texas employee, retiree, and dependent health plan instituted and promoted a waiver of copayments for screening colonoscopies in fiscal year (FY) 2009; we examined the effects of removing cost sharing on colonoscopy use. METHODS We conducted a retrospective cohort study of 59,855 beneficiaries of the University of Texas employee, retiree, and dependent health plan, associated with 16 University of Texas health and nonhealth campuses, ages 50 – 64 years at any point in FYs 2002–2009 (267,191 person-years of follow-up evaluation). The primary outcome was colonoscopy incidence among individuals with no prior colonoscopy. We compared the age- and sex-standardized incidence ratios for colonoscopy in FY 2009 (after the copayment waiver) with the expected incidence for FY 2009, based on secular trends from years before the waiver. RESULTS The annual incidence of colonoscopy increased to 9.5% after the copayment was waived, compared with an expected incidence of 8.0% (standardized incidence ratio, 1.18; 95% confidence interval, 1.14 –1.23; P < .001). After adjusting for age, sex, and beneficiary status, the copayment waiver remained significantly associated with greater use of colonoscopy, with an adjusted hazard ratio of 1.19 (95% confidence interval, 1.12–1.26). CONCLUSIONS Waiving copayments for colonoscopy screening results in a statistically significant, but modest (1.5%), increase in use. Additional strategies beyond removing financial disincentives are needed to increase use of CRC screening. PMID:22401903

A statewide controlled trial intervention to reduce use of unproven or ineffective breast cancer care.

PubMed

Pezzin, Liliana E; Laud, Purushottam; Neuner, Joan; Yen, Tina W F; Nattinger, Ann B

2016-09-01

Challenged by public opinion, peers and the Congressional Budget Office, medical specialty societies have begun to develop "Top Five" lists of expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The extent to which these lists have influenced the behavior of physicians or patients, however, remains unknown. We partner with a statewide consortium of health systems to examine the effectiveness of two interventions: (i) "basic" public reporting and (ii) an "enhanced" intervention, augmenting public reporting with a smart phone-based application that gives providers just-in-time information, decision-making tools, and personalized patient education materials to support reductions in the use of eight breast cancer interventions targeted by Choosing Wisely® or oncology society guidelines. Our aims are: (1) to examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states; (2) to examine the effectiveness of the enhanced intervention relative to the basic intervention; and (3) to simulate cost savings forthcoming from nationwide implementation of both interventions. The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system for influencing provider behavior that may be easily exportable to other states, and potentially also to large healthcare systems. Findings will be further relevant to the ACO environment, which is expected to provide financial disincentives for ineffective or unproven care. ClinicalTrials.gov number pending. Copyright © 2016 Elsevier Inc. All rights reserved.

A systematic review of financial incentives for dietary behavior change.

PubMed

Purnell, Jason Q; Gernes, Rebecca; Stein, Rick; Sherraden, Margaret S; Knoblock-Hahn, Amy

2014-07-01

In light of the obesity epidemic, there is growing interest in the use of financial incentives for dietary behavior change. Previous reviews of the literature have focused on randomized controlled trials and found mixed results. The purpose of this systematic review is to update and expand on previous reviews by considering a broader range of study designs, including randomized controlled trials, quasi-experimental, observational, and simulation studies testing the use of financial incentives to change dietary behavior and to inform both dietetic practice and research. The review was guided by theoretical consideration of the type of incentive used based on the principles of operant conditioning. There was further examination of whether studies were carried out with an institutional focus. Studies published between 2006 and 2012 were selected for review, and data were extracted regarding study population, intervention design, outcome measures, study duration and follow-up, and key findings. Twelve studies meeting selection criteria were reviewed, with 11 finding a positive association between incentives and dietary behavior change in the short term. All studies pointed to more specific information on the type, timing, and magnitude of incentives needed to motivate individuals to change behavior, the types of incentives and disincentives most likely to affect the behavior of various socioeconomic groups, and promising approaches for potential policy and practice innovations. Limitations of the studies are noted, including the lack of theoretical guidance in the selection of incentive structures and the absence of basic experimental data. Future research should consider these factors, even as policy makers and practitioners continue to experiment with this potentially useful approach to addressing obesity. Copyright © 2014 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.

Impact of gender and professional education on attitudes towards financial incentives for organ donation: results of a survey among 755 students of medicine and economics in Germany.

PubMed

Inthorn, Julia; Wöhlke, Sabine; Schmidt, Fabian; Schicktanz, Silke

2014-07-05

There is an ongoing expert debate with regard to financial incentives in order to increase organ supply. However, there is a lacuna of empirical studies on whether citizens would actually support financial incentives for organ donation. Between October 2008 and February 2009 a quantitative survey was conducted among German students of medicine and economics to gain insights into their point of view regarding living and deceased organ donation and different forms of commercialization (n = 755). The average (passive) willingness to donate is 63.5% among medical students and 50.0% among students of economics (p = 0.001), while only 24.1% of the respondents were actually holding an organ donor card. 11.3% of students of economics had signed a donor card, however, the number is significantly higher among students of medicine (31.9%, p < 0.001). Women held donor cards significantly more often (28.6%) than men (19.4%, p = 0.004). The majority of students were against direct payments as incentives for deceased and living donations. Nevertheless, 37.5% of the respondents support the idea that the funeral expenses of deceased organ donors should be covered. Women voted significantly less often for the coverage of expenses than men (women 31.6%, men 44.0%, p = 0.003). The number of those in favor of allowing to sell one's organs for money (living organ donation) was highest among students of economics (p = 0.034). Despite a generally positive view on organ donation the respondents refuse to consent to commercialization, but are in favor of removing disincentives or are in favor of indirect models of reward.

Children at health risks.

PubMed

Sekar, H R

1992-01-01

In India, 69% of the children of the working class die, most of whom are child laborers. Economic pressure forces parents to make their children work. Employers want child workers because they can manipulate them and pay them low wages, thereby ensuring their viability. The caste system induces social inequality, inheritance invokes cultural inequality, and patriarchal socialization is responsible for gender inequality, all of which perpetuates exploitation of children by employers. In Sivakasi, an estimated 125,000 children make up the child labor force, comprising 30% of the entire labor force. 75% are from the lowest castes. 90% of child workers are girls because they are more obedient and accept even lower wages than boys, and girls need to save for their dowry. Girls often suffer verbal and physical abuse. Like their parents who were also child workers, child workers are illiterate and work long hours. A small rich elite in Sivakasi controls most of the trading and industrial capital, educational institutions, and voluntary organizations. Employers' agents give parents a loan and use their children's labor as security. Each day, they bring child workers to Sivakasi in factory buses from villages to work at least 12 hour days. They work under hazardous conditions, e.g., working with toxic chemicals. Coughing, sore throat, dizziness, methemoglobinemia, and anemia are common effects of ingestion or inhalation of chlorate dust. Inhalation of sulphur dust causes respiratory infections, eye infections, and chronic lung diseases (e.g., asthma). Fires and explosions are common risks for working children. Factory management seldom undertake fire prevention measures. An extensive survey of the problem of child labor is needed in Sivakasi before systematic planning to protect children could be done. Overall development, especially agricultural development, is needed. Parents, employers, enforcement authorities, trade unions, and social groups need to be sensitized to the abomination of child labor. The government should provide monetary incentives to employers that do not use child labor and disincentives to those that do.

Analysis and Comparison of Carbon Capture & Sequestration Policies

NASA Astrophysics Data System (ADS)

Burton, E.; Ezzedine, S. M.; Reed, J.; Beyer, J. H.; Wagoner, J. L.

2010-12-01

Several states and countries have adopted or are in the process of crafting policies to enable geologic carbon sequestration projects. These efforts reflect the recognition that existing statutory and regulatory frameworks leave ambiguities or gaps that elevate project risk for private companies considering carbon sequestration projects, and/or are insufficient to address a government’s mandate to protect the public interest. We have compared the various approaches that United States’ state and federal governments have taken to provide regulatory frameworks to address carbon sequestration. A major purpose of our work is to inform the development of any future legislation in California, should it be deemed necessary to meet the goals of Assembly Bill 1925 (2006) to accelerate the adoption of cost-effective geologic sequestration strategies for the long-term management of industrial carbon dioxide in the state. Our analysis shows a diverse issues are covered by adopted and proposed carbon capture and sequestration (CCS) legislation and that many of the new laws focus on defining regulatory frameworks for underground injection of CO2, ambiguities in property issues, or assigning legal liability. While these approaches may enable the progress of early projects, future legislation requires a longer term and broader view that includes a quantified integration of CCS into a government’s overall climate change mitigation strategy while considering potentially counterproductive impacts on CCS of other climate change mitigation strategies. Furthermore, legislation should be crafted in the context of a vision for CCS as an economically viable and widespread industry. While an important function of new CCS legislation is enabling early projects, it must be kept in mind that applying the same laws or protocols in the future to a widespread CCS industry may result in business disincentives and compromise of the public interest in mitigating GHG emissions. Protection of the public interest requires that monitoring and verification track the long term fate of pipelined CO2 regardless of its end use in order to establish that climate change goals are being met.

Manufacturing work and organizational stresses in export processing zones.

PubMed

Lu, Jinky Leilanie

2009-10-01

In the light of global industrialization, much attention has been focused on occupational factors and their influence on the health and welfare of workers. This was a cross sectional study using stratified sampling technique based on industry sizes. The study sampled 24 industries, 6 were small scale industries and 9 each for medium and large scale industries. From the 24 industries, a total of 500 respondents for the questionnaire was taken. For occupational health and safety standards that industries have to comply with, there was low compliance among small-scale industries relative to the medium and large scale industries. Only one industry had an air cleaning device for cleaning contaminated air prior to emission into the external community. Among the 500 respondents, majority were female (88.8%), single (69.6%) and worked in the production or assembly-line station (87.4%). Sickness absenteeism was relative high among the workers in this study accounting for almost 54% among females and 48% among males. Many of the workers also reported of poor performance at work, boredom, tardiness and absenteeism. For association between work factors and personal factors, the following were found to be statistically significant at p=0.05. Boredom was associated with lack of skills training, lack of promotion, disincentives for sick leaves, poor relationship with boss and poor relationships with employers. On the other hand, poor performance was also associated with lack of skills training, lack of promotions, job insecurity, and poor relationship with employers. From the data generated, important issues that must be dealt with in work organizations include the quality of work life, and health and safety issues. Based on these findings, we can conclude that there are still issues on occupational health and safety (OHS) in the target site of export processing zones in the Philippines. There must be an active campaign for OHS in industries that are produce for the global market such as the target industries in this study.

Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India

PubMed Central

Chakrapani, Venkatesan; Shunmugam, Murali; Dubrow, Robert

2011-01-01

The Indian government provides free antiretroviral treatment (ART) for people living with HIV. To assist in developing policies and programs to advance equity in ART access, we explored barriers to ART access among kothis (men who have sex with men whose gender expression is feminine) and aravanis (transgender women, also known as hijras) living with HIV in Chennai. In the last quarter of 2007, we conducted six focus groups and four key-informant interviews. Data were explored using framework analysis to identify categories and derive themes. We identified barriers to ART access at the family/social-level, healthcare system-level, and individual-level; however we found these barriers to be highly interrelated. The primary individual-level barrier was integrally linked to the family/social and healthcare levels: many kothis and aravanis feared serious adverse consequences if their HIV-positive status were revealed to others. Strong motivations to keep one’s HIV-positive status and same-sex attraction secret were interconnected with sexual prejudice against MSM and transgenders, and HIV stigma prevalent in families, the healthcare system, and the larger society. HIV stigma was present within kothi and aravani communities as well. Consequences of disclosure, including rejection by family, eviction from home, social isolation, loss of subsistence income, and maltreatment (although improving) within the healthcare system, presented powerful disincentives to accessing ART. Given the multi-level barriers to ART access related to stigma and discrimination, interventions to facilitate ART uptake should address multiple constituencies: the general public, healthcare providers, and the kothi and aravani communities. India needs a national policy and action plan to address barriers to ART access at family/social, healthcare system, and individual levels for aravanis, kothis, other subgroups of men who have sex with men and other marginalized groups. PMID:22117127

Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India.

PubMed

Chakrapani, Venkatesan; Newman, Peter A; Shunmugam, Murali; Dubrow, Robert

2011-12-01

The Indian government provides free antiretroviral treatment (ART) for people living with HIV. To assist in developing policies and programs to advance equity in ART access, we explored barriers to ART access among kothis (men who have sex with men [MSM] whose gender expression is feminine) and aravanis (transgender women, also known as hijras) living with HIV in Chennai. In the last quarter of 2007, we conducted six focus groups and four key-informant interviews. Data were explored using framework analysis to identify categories and derive themes. We identified barriers to ART access at the family/social-level, health care system-level, and individual-level; however, we found these barriers to be highly interrelated. The primary individual-level barrier was integrally linked to the family/social and health care levels: many kothis and aravanis feared serious adverse consequences if their HIV-positive status were revealed to others. Strong motivations to keep one's HIV-positive status and same-sex attraction secret were interconnected with sexual prejudice against MSM and transgenders, and HIV stigma prevalent in families, the health care system, and the larger society. HIV stigma was present within kothi and aravani communities as well. Consequences of disclosure, including rejection by family, eviction from home, social isolation, loss of subsistence income, and maltreatment (although improving) within the health care system, presented powerful disincentives to accessing ART. Given the multi-level barriers to ART access related to stigma and discrimination, interventions to facilitate ART uptake should address multiple constituencies: the general public, health care providers, and the kothi and aravani communities. India needs a national policy and action plan to address barriers to ART access at family/social, health care system, and individual levels for aravanis, kothis, other subgroups of MSM and other marginalized groups.

Why is housing tenure associated with a lower risk of admission to a nursing or residential home? Wealth, health and the incentive to keep 'my home'.

PubMed

McCann, Mark; Grundy, Emily; O'Reilly, Dermot

2012-02-01

Previous research has shown that home ownership is associated with a reduced risk of admission to institutional care. The extent to which this reflects associations between wealth and health, between wealth and ability to buy in care or increased motivation to avoid admission related to policies on charging is unclear. Taking account of the value of the home, as well as housing tenure, may provide some clarification as to the relative importance of these factors. To analyse the probability of admission to residential and nursing home care according to housing tenure and house value. Cox regression was used to examine the association between home ownership, house value and risk of care home admissions over 6 years of follow-up among a cohort of 51 619 people aged 65 years or older drawn from the Northern Ireland Longitudinal Study, a representative sample of ≈28% of the population of Northern Ireland. Results 4% of the cohort (2138) was admitted during follow-up. Homeowners were less likely than those who rented to be admitted to care homes (HR 0.77, 95% CI 0.70 to 0.85, after adjusting for age, sex, health, living arrangement and urban/rural differences). There was a strong association between house value/tenure and health with those in the highest valued houses having the lowest odds of less than good health or limiting long-term illness. However, there was no difference in probability of admission according to house value; HRs of 0.78 (95% CI 0.67 to 0.90) and 0.81 (95% CI 0.70 to 0.95), respectively, for the lowest and highest value houses compared with renters. The requirement for people in the UK with capital resources to contribute to their care is a significant disincentive to institutional admission. This may place an additional burden on carers.

The impact of interventions to promote healthier ready-to-eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review.

PubMed

Hillier-Brown, F C; Summerbell, C D; Moore, H J; Routen, A; Lake, A A; Adams, J; White, M; Araujo-Soares, V; Abraham, C; Adamson, A J; Brown, T J

2017-02-01

Ready-to-eat meals sold by food outlets that are accessible to the general public are an important target for public health intervention. We conducted a systematic review to assess the impact of such interventions. Studies of any design and duration that included any consumer-level or food-outlet-level before-and-after data were included. Thirty studies describing 34 interventions were categorized by type and coded against the Nuffield intervention ladder: restrict choice = trans fat law (n = 1), changing pre-packed children's meal content (n = 1) and food outlet award schemes (n = 2); guide choice = price increases for unhealthier choices (n = 1), incentive (contingent reward) (n = 1) and price decreases for healthier choices (n = 2); enable choice = signposting (highlighting healthier/unhealthier options) (n = 10) and telemarketing (offering support for the provision of healthier options to businesses via telephone) (n = 2); and provide information = calorie labelling law (n = 12), voluntary nutrient labelling (n = 1) and personalized receipts (n = 1). Most interventions were aimed at adults in US fast food chains and assessed customer-level outcomes. More 'intrusive' interventions that restricted or guided choice generally showed a positive impact on food-outlet-level and customer-level outcomes. However, interventions that simply provided information or enabled choice had a negligible impact. Interventions to promote healthier ready-to-eat meals sold by food outlets should restrict choice or guide choice through incentives/disincentives. Public health policies and practice that simply involve providing information are unlikely to be effective. © 2016 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.

Pathophysiology, treatment, and animal and cellular models of human ischemic stroke

PubMed Central

2011-01-01

Stroke is the world's second leading cause of mortality, with a high incidence of severe morbidity in surviving victims. There are currently relatively few treatment options available to minimize tissue death following a stroke. As such, there is a pressing need to explore, at a molecular, cellular, tissue, and whole body level, the mechanisms leading to damage and death of CNS tissue following an ischemic brain event. This review explores the etiology and pathogenesis of ischemic stroke, and provides a general model of such. The pathophysiology of cerebral ischemic injury is explained, and experimental animal models of global and focal ischemic stroke, and in vitro cellular stroke models, are described in detail along with experimental strategies to analyze the injuries. In particular, the technical aspects of these stroke models are assessed and critically evaluated, along with detailed descriptions of the current best-practice murine models of ischemic stroke. Finally, we review preclinical studies using different strategies in experimental models, followed by an evaluation of results of recent, and failed attempts of neuroprotection in human clinical trials. We also explore new and emerging approaches for the prevention and treatment of stroke. In this regard, we note that single-target drug therapies for stroke therapy, have thus far universally failed in clinical trials. The need to investigate new targets for stroke treatments, which have pleiotropic therapeutic effects in the brain, is explored as an alternate strategy, and some such possible targets are elaborated. Developing therapeutic treatments for ischemic stroke is an intrinsically difficult endeavour. The heterogeneity of the causes, the anatomical complexity of the brain, and the practicalities of the victim receiving both timely and effective treatment, conspire against developing effective drug therapies. This should in no way be a disincentive to research, but instead, a clarion call to intensify efforts to ameliorate suffering and death from this common health catastrophe. This review aims to summarize both the present experimental and clinical state-of-the art, and to guide future research directions. PMID:21266064

Managed Retreat in New York after Sandy: Incentivizing Participation in High-Cost Areas

NASA Astrophysics Data System (ADS)

McDonnell, S.; Ghorbani, P.; Wolf, C.; Stovall, G.

2017-12-01

Extreme weather events may potentially displace millions of people worldwide by 2100 (Nicholls et al., 2011). In the US, flood-prone areas are still attractive to many residents (Dyckman, St. John, & London, 2014), and the most common policies such as zoning or subsidized flood insurance continue to incentivize more development (Mechler & Bouwer, 2015). An increasingly popular alternative for mitigating flood damage is managed retreat, which consists of buying out properties in hazardous areas and relocating the owners elsewhere. We explore New York State's buyout program—a $680 million program administered under its Community Development Block Grant-Disaster Recovery (CDBG-DR) allocation—in the aftermath of Superstorm Sandy. Buyouts in New York tend to be costlier because of higher housing prices and density (Lincoln Institute, 2016), and potential participants may face challenges finding comparable housing within their communities. Since buyout offers are based on property values, homeowners with lower net property values may have less incentive to participate. We ask what neighborhood, household, and property characteristics affect the likelihood of participating in the buyout program. Specifically, are lower property values a disincentive to participation? We use binomial and multinomial logistic regression analyses to estimate the likelihood of participation for a sample of 2,062 properties invited to the program. Our main predictor compares the net offer amount against the local median housing value, controlling for an array of household and neighborhood characteristics. We find that relative property values are inversely correlated with participation, more visibly pronounced in areas with larger gaps between applicants' property values and local home values. While CDBG-DR is specifically geared towards lower-income families and neighborhoods, our findings imply that its existing structure may hinder engagement of these target groups in high-cost areas. To attract them, we recommend an incentive structure that rewards clustered participation compared to individual properties. We also recommend that additional incentive be provided to help lower-income applicants stay close to their original neighborhoods.

'Maybe it was her fate and maybe she ran out of blood': final caregivers' perspectives on access to care in obstetric emergencies in rural Indonesia.

PubMed

D'Ambruoso, Lucia; Byass, Peter; Qomariyah, Siti Nurul

2010-03-01

Maternal mortality persists in low-income settings despite preventability with skilled birth attendance and emergency obstetric care. Poor access limits the effectiveness of life-saving interventions and is typical of maternal health care in low-income settings. This paper examines access to care in obstetric emergencies from the perspectives of service users, using established and contemporary theoretical frameworks of access and a routine health surveillance method. The implications for health planning are also considered. The final caregivers of 104 women who died during pregnancy or childbirth were interviewed in two rural districts in Indonesia using an adapted verbal autopsy. Qualitative analysis revealed social and economic barriers to access and barriers that arose from the health system itself. Health insurance for the poor was highly problematic. For providers, incomplete reimbursements, and low public pay, acted as disincentives to treat the poor. For users, the schemes were poorly socialized and understood, complicated to use and led to lower quality care. Services, staff, transport, equipment and supplies were also generally unavailable or unaffordable. The multiple barriers to access conferred a cumulative disadvantage that culminated in exclusion. This was reflected in expressions of powerlessness and fatalism regarding the deaths. The analysis suggests that conceiving of access as a structurally determined, complex and dynamic process, and as a reciprocally maintained phenomenon of disadvantaged groups, may provide useful explanatory concepts for health planning. Health planning from this perspective may help to avoid perpetuating exclusion on social and economic grounds, by health systems and services, and help foster a sense of control at the micro-level, among peoples' feelings and behaviours regarding their health. Verbal autopsy surveys provide an opportunity to routinely collect information on the exclusory mechanisms of health systems, important information for equitable health planning.

The role and uptake of private health insurance in different health care systems: are there lessons for developing countries?

PubMed

Odeyemi, Isaac Ao; Nixon, John

2013-01-01

Social and national health insurance schemes are being introduced in many developing countries in moving towards universal health care. However, gaps in coverage are common and can only be met by out-of-pocket payments, general taxation, or private health insurance (PHI). This study provides an overview of PHI in different health care systems and discusses factors that affect its uptake and equity. A representative sample of countries was identified (United States, United Kingdom, The Netherlands, France, Australia, and Latvia) that illustrates the principal forms and roles of PHI. Literature describing each country's health care system was used to summarize how PHI is utilized and the factors that affect its uptake and equity. In the United States, PHI is a primary source of funding in conjunction with tax-based programs to support vulnerable groups; in the UK and Latvia, PHI is used in a supplementary role to universal tax-based systems; in France and Latvia, complementary PHI is utilized to cover gaps in public funding; in The Netherlands, PHI is supplementary to statutory private and social health insurance; in Australia, the government incentivizes the uptake of complementary PHI through tax rebates and penalties. The uptake of PHI is influenced by age, income, education, health care system typology, and the incentives or disincentives applied by governments. The effect on equity can either be positive or negative depending on the type of PHI adopted and its role within the wider health care system. PHI has many manifestations depending on the type of health care system used and its role within that system. This study has illustrated its common applications and the factors that affect its uptake and equity in different health care systems. The results are anticipated to be helpful in informing how developing countries may utilize PHI to meet the aim of achieving universal health care.

Report of the Defense Science Board task force on tritium production technology options. Final technical report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Welch, L.

1999-05-01

The long-standing national security policy of the US to maintain a robust nuclear deterrent continues to be supported by the Congress and the President. The President has stated that ``...the nuclear deterrent posture is one of the most visible and important examples of how US military capabilities can be used effectively to deter aggression and coercion. Nuclear weapons serve as a hedge against an uncertain future, a guarantee of our security commitments to allies, and a disincentive to those who would contemplate developing or otherwise acquiring their own nuclear weapons.`` US nuclear weapons designs require tritium, an isotope of hydrogen,more » which has not been produced in the US since 1988, when the last tritium production facility (the K-Reactor at the Savannah River Site) was shut down. This long period without tritium production in the US has been possible because arms control agreements reached in the early 1990s reduced the size of the US nuclear weapons stockpile and because the Department of Energy (DOE) met stockpile tritium requirements by recycling the tritium removed from dismantled nuclear weapons. However, since tritium decays at a rate of 5.5% each year, a dependable source of tritium is required to continue to sustain the US nuclear weapons stockpile to underwrite national security policy and to support arms control goals. The US does maintain a five-year reserve supply of tritium, but this reserve is to be used only in an emergency. Current guidance states the reserve must be restored to its original level within five years of being used. To sustain the START I level, tritium production needs to begin around 2005 at a production capacity of about 3.0 kg/ year. START II levels could be sustained with production of about 1.5 kg/year beginning around 2011.« less

Trends and Issues in California's Low Carbon Fuel Standard - Learning from Response to Existing Climate Policy

NASA Astrophysics Data System (ADS)

Witcover, J.

2015-12-01

Debate over lower greenhouse gas (GHG) emissions from transportation has included heated discussion about appropriate policies and their cost and feasibility. One prominent policy mechanism, a carbon intensity standard, rates transport fuels based on analysis of lifecycle GHG emissions, and targets lower fuel pool carbon intensity through a market mechanism that uses a system of tradable, bankable credits and deficits. California instituted such a policy -- the Low Carbon Fuel Standard (LCFS) - in 2010, which targets a 10% carbon intensity (CI) reduction by 2020. The program rolled out amid concerns over slow development of new fuels expected to be very low carbon (such as cellulosic) and has faced court challenges that added considerable policy uncertainty. Since the program's start, state transport energy mix has shifted modestly but noticeably. Looking ahead, emerging issues for the program include amendments and re-adoption in response to a court ruling, potential interaction with California's multi-sector cap on carbon emissions (which started covering transport fuels in 2015), and impacts from similar CI standards in other jurisdictions. This study provides an analysis of fuel mix changes since the LCFS was implemented in 2011, and a discussion of emerging issues focusing on policy interaction. Descriptive statistics on alternative fuel use, available fuel pathways, and CI ratings are presented based on data from the California Air Resources Board (which runs the program). They document a shift towards more alternative fuels in a more diverse mix, with lower average CI ratings for most alternative fuel types. Financial incentives for various fuels are compared under the LCFS and the US federal Renewable Fuel Standard; disincentives from conceptually different carbon pricing schemes under the LCFS and the Cap-and-Trade are also outlined. The results provide important information on response to an existing market-based policy mechanism for addressing GHG emissions in transportation, as other jurisdictions weigh similar climate policies and debate mechanisms and costs and California announced an ambitious target of halving petroleum use by 2030.

Transactional sex and the challenges to safer sexual behaviors: a study among male sex workers in Chennai, India.

PubMed

Biello, Katie B; Thomas, Beena E; Johnson, Blake E; Closson, Elizabeth F; Navakodi, Pandiaraja; Dhanalakshmi, A; Menon, Sunil; Mayer, Kenneth H; Safren, Steven A; Mimiaga, Matthew J

2017-02-01

Male sex workers (MSW) are a significant but invisible population in India who are at risk for HIV/sexually transmitted infections (STIs). Few studies from India have documented HIV risk factors and motivations for sex work in this population. Between 2013 and 2014, a community-based convenience sample of 100 MSW in Chennai (south India) completed a baseline risk assessment as part of a behavioral intervention. Participants were ≥18 years, and reported current sex work. We report medians and proportions, and Wilcoxon-Mann-Whitney and chi-square tests are used to examine differences between sex work and sexual behavior measures by income source. Participants were engaged in sex work for 5.0 years (IQR = 2.3-10.0), and earned 3000 (IQR = 2000-8000) Rupees (<50 USD) per month from sex work. Sixty-four percent reported ever testing for HIV and 20.2% for any STI. The most common reasons for starting sex work were money (83.0%) and pleasure (56.0%). Compared to participants with an additional source of income, those whose only source of income was sex work reported more male clients in the past month (10.0 vs. 6.0, p = .017), as well as more condomless anal sex acts with male clients (8.0 vs. 5.0, p = .008). Nearly 70.0% were offered more money not to use a condom during sex with a client, and 74.2% reported accepting more money not to use a condom. Three-quarters reported having experienced difficulty using condoms with clients. MSW in India engage in high levels of sexual risk for HIV/STIs. Money appears to be a driving factor for engaging in sex work and condomless sex with clients. HIV prevention interventions with MSW should focus on facilitating skills that will support their ability to negotiate sexual safety in the context of monetary disincentives.

Stated Preferences of Doctors for Choosing a Job in Rural Areas of Peru: A Discrete Choice Experiment

PubMed Central

Miranda, J. Jaime; Diez-Canseco, Francisco; Lema, Claudia; Lescano, Andrés G.; Lagarde, Mylene; Blaauw, Duane; Huicho, Luis

2012-01-01

Background Doctors’ scarcity in rural areas remains a serious problem in Latin America and Peru. Few studies have explored job preferences of doctors working in underserved areas. We aimed to investigate doctors’ stated preferences for rural jobs. Methods and Findings A labelled discrete choice experiment (DCE) was performed in Ayacucho, an underserved department of Peru. Preferences were assessed for three locations: rural community, Ayacucho city (Ayacucho’s capital) and other provincial capital city. Policy simulations were run to assess the effect of job attributes on uptake of a rural post. Multiple conditional logistic regressions were used to assess the relative importance of job attributes and of individual characteristics. A total of 102 doctors participated. They were five times more likely to choose a job post in Ayacucho city over a rural community (OR 4.97, 95%CI 1.2; 20.54). Salary increases and bonus points for specialization acted as incentives to choose a rural area, while increase in the number of years needed to get a permanent post acted as a disincentive. Being male and working in a hospital reduced considerably chances of choosing a rural job, while not living with a partner increased them. Policy simulations showed that a package of 75% salary increase, getting a permanent contract after two years in rural settings, and getting bonus points for further specialisation increased rural job uptake from 21% to 77%. A package of 50% salary increase plus bonus points for further specialisation would also increase the rural uptake from 21% to 52%. Conclusions Doctors are five times more likely to favour a job in urban areas over rural settings. This strong preference needs to be overcome by future policies aimed at improving the scarcity of rural doctors. Some incentives, alone or combined, seem feasible and sustainable, whilst others may pose a high fiscal burden. PMID:23272065

Unlocking the potential of established products: toward new incentives rewarding innovation in Europe.

PubMed

Nayroles, Gabrielle; Frybourg, Sandrine; Gabriel, Sylvie; Kornfeld, Åsa; Antoñanzas-Villar, Fernando; Espín, Jaime; Jommi, Claudio; Martini, Nello; de Pouvourville, Gérard; Tolley, Keith; Wasem, Jürgen; Toumi, Mondher

2017-01-01

Background : Many established products (EPs - marketed for eight years or more) are widely used off-label despite little evidence on benefit-risk ratio. This exposes patients to risks related to safety and lack of efficacy, and healthcare providers to liability. Introducing new indications for EPs may represent a high societal value; however, manufacturers rarely invest in R&D for EPs. The objective of this research was to describe incentives and disincentives for developing new indications for EPs in Europe and to investigate consequences of current policies. Methods : Targeted literature search and expert panel meetings. Results : Within the current European-level and national-level regulatory framework there are limited incentives for development of new indications with EPs. Extension of indication normally does not allow the price to be increased or maintained, the market protection period to be extended, or exclusion from a reference price system. New indication frequently triggers re-evaluation, resulting in price erosion, regardless of the level of added value with the new indication. In consequence, manufacturers are more prone to undertake R&D efforts at early to mid-stage of product life cycle rather than with EPs, or to invest in new chemical entities, even in therapeutic areas with broad off-label use. This represents a potentially missed opportunity as developing new indications for EPs offers an alternative to off-label use or lengthy and expensive R&D for new therapies, opens new opportunities for potentially cost-effective treatment alternatives, as well as greater equity in patients' access to treatment options. Conclusion : There are potential benefits from the development of new indications for EPs that are currently not being realized due to a lack of regulatory and pricing incentives in Europe. Incentives for orphan or paediatric drugs have proven to be effective in promoting R&D. Similarly, incentives to promote R&D in EPs should be developed, for the benefit of patients and healthcare systems.

Financial disincentives? A three-armed randomised controlled trial of the effect of financial Incentives  in Diabetic Eye Assessment  by Screening (IDEAS) trial.

PubMed

Judah, Gaby; Darzi, Ara; Vlaev, Ivo; Gunn, Laura; King, Derek; King, Dominic; Valabhji, Jonathan; Bicknell, Colin

2018-05-23

Conflicting evidence exists regarding the impact of financial incentives on encouraging attendance at medical screening appointments. The primary aim was to determine whether financial incentives increase attendance at diabetic eye screening in persistent non-attenders. A three-armed randomised controlled trial was conducted in London in 2015. 1051 participants aged over 16 years, who had not attended eye screening appointments for 2 years or more, were randomised (1.4:1:1 randomisation ratio) to receive the usual invitation letter (control), an offer of £10 cash for attending screening (fixed incentive) or a 1 in 100 chance of winning £1000 (lottery incentive) if they attend. The primary outcome was the proportion of invitees attending screening, and a comparative analysis was performed to assess group differences. Pairwise comparisons of attendance rates were performed, using a conservative Bonferroni correction for independent comparisons. 34/435 (7.8%) of control, 17/312 (5.5%) of fixed incentive and 10/304 (3.3%) of lottery incentive groups attended. Participants who received any incentive were significantly less likely to attend their appointment compared with controls (risk ratio (RR)=0.56; 95% CI 0.34 to 0.92). Those in the probabilistic incentive group (RR=0.42; 95% CI 0.18 to 0.98), but not the fixed incentive group (RR=1.66; 95% CI 0.65 to 4.21), were significantly less likely to attend than those in the control group. Financial incentives, particularly lottery-based incentives, attract fewer patients to diabetic eye screening than standard invites in this population. Financial incentives should not be used to promote screening unless tested in context, as they may negatively affect attendance rates. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Water demand management in Malawi: problems and prospects for its promotion

NASA Astrophysics Data System (ADS)

Mulwafu, W.; Chipeta, C.; Chavula, G.; Ferguson, A.; Nkhoma, B. G.; Chilima, G.

This paper discusses the status of water demand management (WDM) in Malawi. Findings from the study indicate that, while WDM is highly advocated in the urban and peri-urban areas, very few aspects of WDM are practiced in the rural areas. The water pricing structure that the supplying institutions established serves as a disincentive for water wastages in the urban areas. Both private firms and individuals use various measures to conserve water as a way of minimizing water consumption. The motives for water conservation range from profit maximization to inadequate financial resources to meet the costs of water respectively. In the rural areas where water is supplied at no cost, the people tend to pay less attention to water conservation. In cases where water providers attempted to institute factors of cost sharing, the rural inhabitants tended to be reluctant to contribute. This is so because people view water as a social good that should be supplied to them free of charge. The paper demonstrates that although some aspects of WDM are being practiced in the country, the existing conditions on the ground militate against its increased expansion as a strategy for promoting an efficient and equitable use of existing water resources. A large section of the population still lack access to potable water and the Malawi government is committed to the provision of basic water services. Yet WDM will become even more critical in future because of the growing competition for water resources, particularly due to the growing population and the increasing economic activities such as farming, industrialization and urbanization. The paper argues that despite the promising benefits that WDM has, its promotion must necessarily be infused with ideas of water supply, considering that the largest population still lacks access to potable water. Coupled with this will be the need for a proper policy framework that promotes public awareness for people to start appreciating the economic value of water especially in the rural areas.

Uranium-Loaded Water Treatment Resins: 'Equivalent Feed' at NRC and Agreement State-Licensed Uranium Recovery Facilities - 12094

DOE Office of Scientific and Technical Information (OSTI.GOV)

Camper, Larry W.; Michalak, Paul; Cohen, Stephen

Community Water Systems (CWSs) are required to remove uranium from drinking water to meet EPA standards. Similarly, mining operations are required to remove uranium from their dewatering discharges to meet permitted surface water discharge limits. Ion exchange (IX) is the primary treatment strategy used by these operations, which loads uranium onto resin beads. Presently, uranium-loaded resin from CWSs and mining operations can be disposed as a waste product or processed by NRC- or Agreement State-licensed uranium recovery facilities if that licensed facility has applied for and received permission to process 'alternate feed'. The disposal of uranium-loaded resin is costly andmore » the cost to amend a uranium recovery license to accept alternate feed can be a strong disincentive to commercial uranium recovery facilities. In response to this issue, the NRC issued a Regulatory Issue Summary (RIS) to clarify the agency's policy that uranium-loaded resin from CWSs and mining operations can be processed by NRC- or Agreement State-licensed uranium recovery facilities without the need for an alternate feed license amendment when these resins are essentially the same, chemically and physically, to resins that licensed uranium recovery facilities currently use (i.e., equivalent feed). NRC staff is clarifying its current alternate feed policy to declare IX resins as equivalent feed. This clarification is necessary to alleviate a regulatory and financial burden on facilities that filter uranium using IX resin, such as CWSs and mine dewatering operations. Disposing of those resins in a licensed facility could be 40 to 50 percent of the total operations and maintenance (O and M) cost for a CWS. Allowing uranium recovery facilities to treat these resins without requiring a license amendment lowers O and M costs and captures a valuable natural resource. (authors)« less

Perinatal regionalization versus hospital competition: the Hartford example.

PubMed

Richardson, D K; Reed, K; Cutler, J C; Boardman, R C; Goodman, K; Moynihan, T; Driscoll, J; Raye, J R

1995-09-01

The increasingly competitive health care environment may undermine effective traditional regional organizations. It is urgent to document the benefits of perinatal regionalization for the emerging health care system. We present a case study that illustrates many of the challenges to and benefits of perinatal regionalization in the 1990s. The controversy in Hartford was sparked by a proposed merger of two major pediatric services into a full-service children's hospital. Community hospitals reacted with plans to upgrade their obstetrics/neonatal facilities toward level II (intermediate) or II+ (intensive) neonatal intensive care units (NICUs). The fear that unrestricted competition would drive up overall health care costs prompted the hospital association and Chamber of Commerce to retain consultants to evaluate the number and location of regional NICU beds. The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges. The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization. Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.

A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients.

PubMed

DeMeester, Rachel H; Lopez, Fanny Y; Moore, Jennifer E; Cook, Scott C; Chin, Marshall H

2016-06-01

Shared decision making (SDM) occurs when patients and clinicians work together to reach care decisions that are both medically sound and responsive to patients' preferences and values. SDM is an important tenet of patient-centered care that can improve patient outcomes. Patients with multiple minority identities, such as sexual orientation and race/ethnicity, are at particular risk for poor SDM. Among these dual-minority patients, added challenges to clear and open communication include cultural barriers, distrust, and a health care provider's lack of awareness of the patient's minority sexual orientation or gender identity. However, organizational factors like a culture of inclusion and private space throughout the visit can improve SDM with lesbian, gay, bisexual, and transgender ("LGBT") racial/ethnic minority patients who have faced stigma and discrimination. Most models of shared decision making focus on the patient-provider interaction, but the health care organization's context is also critical. Context-an organization's structure and operations-can strongly influence the ability and willingness of patients and clinicians to engage in shared decision making. SDM is most likely to be optimal if organizations transform their contexts and patients and providers improve their communication. Thus, we propose a conceptual model that suggests ways in which organizations can shape their contextual structure and operations to support SDM. The model contains six drivers: workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives. These drivers work through four mechanisms to impact care: continuity and coordination, the ease of SDM, knowledge and skills, and attitudes and beliefs. These mechanisms can activate clinicians and patients to engage in high-quality SDM. We provide examples of how specific contextual changes could make SDM more effective for LGBT racial/ethnic minority populations, focusing especially on transformations that would establish a safe environment, build trust, and decrease stigma.

"We're not short of people telling us what the problems are. We're short of people telling us what to do": An appraisal of public policy and mental health

PubMed Central

Petticrew, Mark; Platt, Stephen; McCollam, Allyson; Wilson, Sarah; Thomas, Sian

2008-01-01

Background There is sustained interest in public health circles in assessing the effects of policies on health and health inequalities. We report on the theory, methods and findings of a project which involved an appraisal of current Scottish policy with respect to its potential impacts on mental health and wellbeing. Methods We developed a method of assessing the degree of alignment between Government policies and the 'evidence base', involving: reviewing theoretical frameworks; analysis of policy documents, and nineteen in-depth interviews with policymakers which explored influences on, and barriers to cross-cutting policymaking and the use of research evidence in decisionmaking. Results Most policy documents did not refer to mental health; however most referred indirectly to the determinants of mental health and well-being. Unsurprisingly research evidence was rarely cited; this was more common in health policy documents. The interviews highlighted the barriers to intersectoral policy making, and pointed to the relative value of qualitative and quantitative research, as well as to the imbalance of evidence between "what is known" and "what is to be done". Conclusion Healthy public policy depends on effective intersectoral working between government departments, along with better use of research evidence to identify policy impacts. This study identified barriers to both these. We also demonstrated an approach to rapidly appraising the mental health effects of mainly non-health sector policies, drawing on theoretical understandings of mental health and its determinants, research evidence and policy documents. In the case of the social determinants of health, we conclude that an evidence-based approach to policymaking and to policy appraisal requires drawing strongly upon existing theoretical frameworks, as well as upon research evidence, but that there are significant practical barriers and disincentives. PMID:18793414

Unlocking the potential of established products: toward new incentives rewarding innovation in Europe

PubMed Central

Nayroles, Gabrielle; Frybourg, Sandrine; Gabriel, Sylvie; Kornfeld, Åsa; Antoñanzas-Villar, Fernando; Espín, Jaime; Jommi, Claudio; Martini, Nello; de Pouvourville, Gérard; Tolley, Keith; Wasem, Jürgen; Toumi, Mondher

2017-01-01

ABSTRACT Background: Many established products (EPs – marketed for eight years or more) are widely used off-label despite little evidence on benefit–risk ratio. This exposes patients to risks related to safety and lack of efficacy, and healthcare providers to liability. Introducing new indications for EPs may represent a high societal value; however, manufacturers rarely invest in R&D for EPs. The objective of this research was to describe incentives and disincentives for developing new indications for EPs in Europe and to investigate consequences of current policies. Methods: Targeted literature search and expert panel meetings. Results: Within the current European-level and national-level regulatory framework there are limited incentives for development of new indications with EPs. Extension of indication normally does not allow the price to be increased or maintained, the market protection period to be extended, or exclusion from a reference price system. New indication frequently triggers re-evaluation, resulting in price erosion, regardless of the level of added value with the new indication. In consequence, manufacturers are more prone to undertake R&D efforts at early to mid-stage of product life cycle rather than with EPs, or to invest in new chemical entities, even in therapeutic areas with broad off-label use. This represents a potentially missed opportunity as developing new indications for EPs offers an alternative to off-label use or lengthy and expensive R&D for new therapies, opens new opportunities for potentially cost-effective treatment alternatives, as well as greater equity in patients’ access to treatment options. Conclusion: There are potential benefits from the development of new indications for EPs that are currently not being realized due to a lack of regulatory and pricing incentives in Europe. Incentives for orphan or paediatric drugs have proven to be effective in promoting R&D. Similarly, incentives to promote R&D in EPs should be developed, for the benefit of patients and healthcare systems. PMID:28740616

Carrots and Sticks: A Comprehensive Business Model for the Successful Achievement of Energy Efficiency Resource Standards Environmental Energy Technologies DivisionMarch 2011

DOE Office of Scientific and Technical Information (OSTI.GOV)

Satchwell, Andrew; Cappers, Peter; Goldman, Charles

2011-03-22

Energy efficiency resource standards (EERS) are a prominent strategy to potentially achieve rapid and aggressive energy savings goals in the U.S. As of December 2010, twenty-six U.S. states had some form of an EERS with savings goals applicable to energy efficiency (EE) programs paid for by utility customers. The European Union has initiated a similar type of savings goal, the Energy End-use Efficiency and Energy Services Directive, where it is being implemented in some countries through direct partnership with regulated electric utilities. U.S. utilities face significant financial disincentives under traditional regulation which affects the interest of shareholders and managers inmore » aggressively pursuing cost-effective energy efficiency. Regulators are considering some combination of mandated goals ('sticks') and alternative utility business model components ('carrots' such as performance incentives) to align the utility's business and financial interests with state and federal energy efficiency public policy goals. European countries that have directed their utilities to administer EE programs have generally relied on non-binding mandates and targets; in the U.S., most state regulators have increasingly viewed 'carrots' as a necessary condition for successful achievement of energy efficiency goals and targets. In this paper, we analyze the financial impacts of an EERS on a large electric utility in the State of Arizona using a pro-forma utility financial model, including impacts on utility earnings, customer bills and rates. We demonstrate how a viable business model can be designed to improve the business case while retaining sizable ratepayer benefits. Quantifying these concerns and identifying ways they can be addressed are crucial steps in gaining the support of major stakeholder groups - lessons that can apply to other countries looking to significantly increase savings targets that can be achieved from their own utility-administered EE programs.« less

Indonesian CPO availability analysis to support food and energy security: a system dynamic approach

NASA Astrophysics Data System (ADS)

Rahman, T.; Arkeman, Y.; Setyaningsih, D.; Saparita, R.

2017-05-01

The development of biofuels could be a solution to overcome the energy problem. One of biofuel that has the potential to be developed, namely palm oil biodiesel that is also the raw material for food. As a provider of CPO raw materials, the production of palm biodiesel could trigger competitions, from biofuels demand growth and utilization of agricultural resources. Thus, it needs to be analyzed to determine the adequency of CPO supply to fulfill the need of food and policy recomendation which sets the development of palm oil biodiesel can be synergies with food need especially for the supply of raw material CPO. To obtain the optimal policy in the synergy between the raw material of CPO for food and energy is a need to establish some policy scenarios that allow to be applied and then chosen the best policy alternative of all scenarios. The purpose of this research were to : 1) analysis the availability of CPO to meet the needs of food and energy, 2) provide policy recommendation with regard biodiesel development of food security. The model made used system dynamic method. Several scenarios that used in the model are: 1) existing condition, 2) The scenario increase biodiesel production capacity and increase land productivity, 3) reduction scenario CPO export by 30%, 4) scenario use othe raw material for biodiesel by 20%. The simulation results showed the availability of CPO raw materials would answer all needs of both food and biodiesel when there was an increase in productivity, diversification of raw materials, and also a reduction in palm oil exports. It was needed an integrated policy from upstream to downstream along with the consistency of implementation. Policy suggestions that could be considered were increased productivity through agricultural intensification, enforcement disincentive policies of CPO to exports, and development of non-CPO biodiesel raw materials and development of renewable energy.

Job Preferences of Nurses and Midwives for Taking Up a Rural Job in Peru: A Discrete Choice Experiment

PubMed Central

Huicho, Luis; Miranda, J. Jaime; Diez-Canseco, Francisco; Lema, Claudia; Lescano, Andrés G.; Lagarde, Mylene; Blaauw, Duane

2012-01-01

Background Robust evidence on interventions to improve the shortage of health workers in rural areas is needed. We assessed stated factors that would attract short-term contract nurses and midwives to work in a rural area of Peru. Methods and Findings A discrete choice experiment (DCE) was conducted to evaluate the job preferences of nurses and midwives currently working on a short-term contract in the public sector in Ayacucho, Peru. Job attributes, and their levels, were based on literature review, qualitative interviews and focus groups of local health personnel and policy makers. A labelled design with two choices, rural community or Ayacucho city, was used. Job attributes were tailored to these settings. Multiple conditional logistic regressions were used to assess the determinants of job preferences. Then we used the best-fitting estimated model to predict the impact of potential policy incentives on the probability of choosing a rural job or a job in Ayacucho city. We studied 205 nurses and midwives. The odds of choosing an urban post was 14.74 times than that of choosing a rural one. Salary increase, health center-type of facility and scholarship for specialization were preferred attributes for choosing a rural job. Increased number of years before securing a permanent contract acted as a disincentive for both rural and urban jobs. Policy simulations showed that the most effective attraction package to uptake a rural job included a 75% increase in salary plus scholarship for a specialization, which would increase the proportion of health workers taking a rural job from 36.4% up to 60%. Conclusions Urban jobs were more strongly preferred than rural ones. However, combined financial and non-financial incentives could almost double rural job uptake by nurses and midwifes. These packages may provide meaningful attraction strategies to rural areas and should be considered by policy makers for implementation. PMID:23284636

Fostering Diversity in the Earth and Space Sciences: The Role of AGU

NASA Astrophysics Data System (ADS)

Snow, J. T.; Johnson, R. M.; Hall, F. R.

2002-12-01

In May 2002, AGU's Committee on Education and Human Resources (CEHR) approved a new Diversity Plan, developed in collaboration with the CEHR Subcommittee on Diversity. Efforts to develop a diversity plan for AGU were motivated by the recognition that the present Earth and space science community poorly represents the true diversity of our society. Failure to recruit a diverse scientific workforce in an era of rapidly shifting demographics could have severe impact on the health of our profession. The traditional base of Earth and space scientists in the US (white males) has been shrinking during the past two decades, but women, racial and ethnic minorities, and persons with disabilities are not compensating for this loss. The potential ramifications of this situation - for investigators seeking to fill classes and recruit graduate students, for institutions looking to replace faculty and researchers, and for the larger community seeking continued public support of research funding - could be crippling. AGU's new Diversity Plan proposes a long-term strategy for addressing the lack of diversity in the Earth and space sciences with the ultimate vision of reflecting diversity in all of AGU's activities and programs. Four key goals have been identified: 1) Educate and involve the AGU membership in diversity issues; 2) Enhance and foster the participation of Earth and space scientists, educators and students from underrepresented groups in AGU activities; 3) Increase the visibility of the Earth and space sciences and foster awareness of career opportunities in these fields for underrepresented populations; and 4) Promote changes in the academic culture that both remove barriers and disincentives for increasing diversity in the student and faculty populations and reward member faculty wishing to pursue these goals. A detailed implementation plan that utilizes all of AGU's resources is currently under development in CEHR. Supportive participation by AGU members and coordination between AGU's efforts and those of other scientific society working to improve diversity will be important components in achieving the goals of this plan.

An exploratory qualitative study of Otago adolescents' views of oral health and oral health care.

PubMed

Fitzgerald, Ruth P; Thomson, W Murray; Schafer, Cyril T; Loose, Moragh A T H

2004-09-01

To investigate Otago adolescents' views of oral health and oral health care, in order to increase understanding of the influences on their use or non-use of free care. The study employed a qualitative approach, using focus groups and grounded theory analysis. Participants ranged in age from 13 to 18, and included both genders and a variety of educational attainments, ethnicities and family incomes. Focus groups were conducted in schools, training centres, a place of employment, a CYF (Child, Youth and Family) Home, and a University Hall of Residence. While aware of the normative pressure to attend for free dental care and engage in oral health care, Otago adolescents consider doing so to be "just so gay". They exhibit strongly held preconceptions about the expense of dentistry and the respective competence of dentists and dental therapists. The dental surgery environment was viewed as a major disincentive. Adolescent oral health beliefs centred on two models: the medicalised, pragmatic view of oral health (which valued the function of teeth); and the cosmetic view of oral health (which valued the aesthetics of teeth); or a combination of these two models. In both models, media advertising for oral health care products was a significant source of oral health information. The preferred oral health behaviour associated with the medicalised model was frequent use of chewing gum and rapid toothbrushing, and, for the cosmetic model frequent use of chewing gum and breath fresheners. These findings support the international literature on the use/non-use of dental services even when the financial barriers to seeking such services has been removed. New Zealand dental care has developed without reference to the changing norms of youth culture, and the conventional dental practice setting is not viewed by adolescents as being inviting or appropriate. Increasing the uptake of free oral health care by that group will require some innovative approaches.

Punishments and Prizes for Explaining Global Warming

NASA Astrophysics Data System (ADS)

Somerville, R. C.

2006-12-01

Some few gifted scientists, the late Carl Sagan being an iconic example, are superbly skilled at communicating science clearly and compellingly to non-scientists. Most scientists, however, have serious shortcomings as communicators. The common failings include being verbose, addicted to jargon, caveat- obsessed and focused on details. In addition, it is far easier for a scientist to scoff at the scientific illiteracy of modern society than to work at understanding the viewpoints and concerns of journalists, policymakers and the public. Obstacles await even those scientists with the desire and the talent to communicate science well. Peer pressure and career disincentives can act as powerful deterrents, discouraging especially younger scientists from spending time on non-traditional activities. Scientists often lack mentors and role models to help them develop skills in science communication. Journalists also face real difficulties in getting science stories approved by editors and other gatekeepers. Climate change science brings its own problems in communication. The science itself is unusually wide- ranging and complex. The contentious policies and politics of dealing with global warming are difficult to disentangle from the science. Misinformation and disinformation about climate change are widespread. Intimidation and censorship of scientists by some employers is a serious problem. Polls show that global warming ranks low on the public's list of important issues. Despite all the obstacles, communicating climate change science well is critically important today. It is an art that can be learned and that brings its own rewards and satisfactions. Academic institutions and research funding agencies increasingly value outreach by scientists, and they provide resources to facilitate it. Society needs scientists who can clearly and authoritatively explain the science of global warming and its implications, while remaining objective and policy-neutral. This need will only increase in coming years as climate change makes the transition from a topic of limited public interest to one of great concern to all society.

Carbon dioxide emission and bio-capacity indexing for transportation activities: A methodological development in determining the sustainability of vehicular transportation systems.

PubMed

Labib, S M; Neema, Meher Nigar; Rahaman, Zahidur; Patwary, Shahadath Hossain; Shakil, Shahadat Hossain

2018-06-09

CO 2 emissions from urban traffic are a major concern in an era of increasing ecological disequilibrium. Adding to the problem net CO 2 emissions in urban settings are worsened due to the decline of bio-productive areas in many cities. This decline exacerbates the lack of capacity to sequestrate CO 2 at the micro and meso-scales resulting in increased temperatures and decreased air quality within city boundaries. Various transportation and environmental strategies have been implemented to address traffic related CO 2 emissions, however current literature identifies difficulties in pinpointing these critical areas of maximal net emissions in urban transport networks. This study attempts to close this gap in the literature by creating a new lay-person friendly index that combines CO 2 emissions from vehicles and the bio-capacity of specific traffic zones to identify these areas at the meso-scale within four ranges of values with the lowest index values representing the highest net CO 2 levels. The study used traffic volume, fuel types, and vehicular travel distance to estimate CO 2 emissions at major links in Dhaka, Bangladesh's capital city's transportation network. Additionally, using remote-sensing tools, adjacent bio-productive areas were identified and their bio-capacity for CO 2 sequestration estimated. The bio-productive areas were correlated with each traffic zone under study resulting in an Emission Bio-Capacity index (EBI) value estimate for each traffic node. Among the ten studied nodes in Dhaka City, nine had very low EBI values, correlating to very high CO 2 emissions and low bio-capacity. As a result, the study considered these areas unsustainable as traffic nodes going forward. Key reasons for unsustainability included increasing use of motorized traffic, absence of optimized signal systems, inadequate public transit options, disincentives for fuel free transport (FFT), and a decline in bio-productive areas. Copyright © 2018 Elsevier Ltd. All rights reserved.

Neoliberalism, welfare policy and health: a qualitative meta-synthesis of single parents' experience of the transition from welfare to work.

PubMed

Cook, Kay

2012-09-01

Following the United States' lead, the emergence of neoliberal welfare policy across the western world has resulted in employment programmes for single parents, who are predominantly single mothers. While some governments claim that employment will improve single parents' incomes and well-being, researchers dispute that single parents can unproblematically move into the workforce, with net positive effects. While researchers have quantified the socio-economic effect of these programmes, in particular on participant health, no study has yet synthesized participants' experiences of welfare-to-work. Here, I present a meta-synthesis of eight qualitative health-related studies of single parents' (and exclusively single mothers') welfare-to-work transition. I report that single mothers faced a combination of health and economic issues which made their transition from welfare to work difficult, including degrees of poor physical and mental health. For participants in the United States, these health issues were often compounded by a loss of health benefits on moving into low-wage employment. In countries where a return to employment was required before children reached school age, a lack of affordable and appropriate child care, especially for children with health problems, exacerbated these difficulties. As a result of scarce resources, single mothers in receipt of welfare benefits often relied on food banks or went without food. A return to the workforce did not alleviate this problem as additional child care and reduced government subsidies depleted the funds available for food. I conclude that welfare-to-work policies are underpinned by the neoliberal assumption that the market more efficiently distributes resources than the State. However, for the women in the studies examined here, labour market participation often depleted access to essential resources. Interventions to address the 'problem' of welfare dependency must recognize the complex interplay between work incentives and disincentives and the care-work of single mothers.

Prospective study of determinants and costs of home births in Mumbai slums

PubMed Central

2010-01-01

Background Around 86% of births in Mumbai, India, occur in healthcare institutions, but this aggregate figure hides substantial variation and little is known about urban home births. We aimed to explore factors influencing the choice of home delivery, care practices and costs, and to identify characteristics of women, households and the environment which might increase the likelihood of home birth. Methods As part of the City Initiative for Newborn Health, we used a key informant surveillance system to identify births prospectively in 48 slum communities in six wards of Mumbai, covering a population of 280 000. Births and outcomes were documented prospectively by local women and mothers were interviewed in detail at six weeks after delivery. We examined the prevalence of home births and their associations with potential determinants using regression models. Results We described 1708 (16%) home deliveries among 10 754 births over two years, 2005-2007. The proportion varied from 6% to 24%, depending on area. The most commonly cited reasons for home birth were custom and lack of time to reach a healthcare facility during labour. Seventy percent of home deliveries were assisted by a traditional birth attendant (dai), and 6% by skilled health personnel. The median cost of a home delivery was US$ 21, of institutional delivery in the public sector US$ 32, and in the private sector US$ 118. In an adjusted multivariable regression model, the odds of home delivery increased with illiteracy, parity, socioeconomic poverty, poorer housing, lack of water supply, population transience, and hazardous location. Conclusions We estimate 32 000 annual home births to residents of Mumbai's slums. These are unevenly distributed and cluster with other markers of vulnerability. Since cost does not appear to be a dominant disincentive to institutional delivery, efforts are needed to improve the client experience at public sector institutions. It might also be productive to concentrate on intensive outreach in vulnerable areas by community-based health workers, who could play a greater part in helping women plan their deliveries and making sure that they get help in time. PMID:20670456

Carbohydrates and obesity: from evidence to policy in the UK.

PubMed

Jebb, Susan A

2015-08-01

Carbohydrates provide the major source of energy in the diet and hence the type and amount of carbohydrate consumed is an important consideration for weight control. Recent risk assessments have shown that there is no consistent association between the proportions of energy consumed as carbohydrate and body weight and reinforce the dominance of total energy intake as the primary determinant of body weight. However, they have highlighted evidence that different types of carbohydrate have specific effects on the risk of obesity. Short-term experimental studies suggest that some types of dietary fibre may be linked to increased satiation and cohort studies are supportive of an association between low intakes of fibre-rich, whole-grain foods and weight gain. But these observations are not supported by evidence of effects on body weight in randomised controlled trials, suggesting that high-fibre or whole-grain intake may simply be a marker of a broader dietary pattern. Recent attention has focused on the growing evidence of a positive association between the intake of free sugars and weight gain and particularly the risks linked to consumption of sugar-sweetened beverages (SSB). Given the high population-level intake of free sugars the challenge is to identify actions that will successfully reduce consumption to contribute to reductions in the prevalence of obesity. The present paper considers the range of policy options available, using the Nuffield ladder of intervention to provide a framework for risk management, with a focus on the consumption of SSB. Current policy interventions are largely based around consumer education and encouragement to industry to renovate products to reduce the sugar content of food and drinks and/or reduce portion size, but dietary change has been slow. Further measures, including the use of specific incentives/disincentives may be needed to change consumption patterns, some of which may infringe personal or commercial freedom. For these policies to be implemented will require sustained efforts to create a climate in which such interventions are acceptable or even welcomed by society as an appropriate protection against obesity and other diet-related ill-health.

A New Scaling for Divertor Detachment

NASA Astrophysics Data System (ADS)

Goldston, Robert

2017-10-01

The ITER design and future fusion power plant designs depend on divertor detachment, whether partial, pronounced or complete, both to limit heat flux to plasma-facing components and to limit surface erosion due to sputtering. Generally the parallel heat flux, estimated as proportional to Psep / R or Psep B / R , is used as a proxy for the difficulty of achieving detachment. Here we argue that the impurity cooling required for detachment is strongly dependent on the upstream separatrix density, which is limited by Greenwald scaling. Taking this into account self-consistently, along with the Heuristic Drift (HD) model for the SOL width, and using a Lengyel radiation model that includes non-coronal effects, we find that the relative impurity concentration, cz ≡nz /ne , required for detachment scales dominantly as cz Psep /Bp(nsep /nGW) 2 . The absence of any explicit favorable size scaling is concerning, as Psep must increase by an order of magnitude from present experiments to an economic fusion power system, while increases in the poloidal magnetic field strength are limited by magnet technology and MHD stability. This result should not be surprising, as it follows from the simplest scaling, Psep czne2VSOL , taking into account the Greenwald density limit and the HD SOL volume scaling. Reinke has combined a similar approach with the requirement to maintain H-mode, which sets a lower limit on Psep, and also arrives at an incentive for high field and disincentive for large size. These results should be challenged by comparison with 2D divertor codes and with measurements on existing experiments. In particular measurements are required for extrinsic divertor impurity concentration over a range of power and density conditions far from the regime where detachment can be achieved with deuterium puffing and intrinsic impurities alone. Nonetheless, these results suggest that higher magnetic field, stronger shaping, double-null operation, `advanced' divertor magnetic and baffle configurations, as well as lithium vapor targets merit greater attention. This work supported by the US DOE under contract DE-AC02-09CH11466.

Groundwater Regulation in the Houston-Galveston Region to Control Subsidence - Balancing Total Water Demand, Available Alternative Water Supplies, and Groundwater Withdrawal

NASA Astrophysics Data System (ADS)

Turco, M. J.

2014-12-01

In 1975, as a result of area residents and local governments becoming increasingly alarmed by the continued impact of subsidence on economic growth and quality of life in the region, the Harris-Galveston Coastal Subsidence District was created by the 64th Texas Legislature as an underground water conservation district. The primary mission of what is now the Harris-Galveston Subsidence District, is to provide for the regulation of the withdrawal of groundwater to control subsidence. Subsidence has been a concern in the Houston, TX area throughout most of recent history. Since 1906, over 10 feet of subsidence has occurred, with a broad area of 6 feet of subsidence throughout most of the Houston Area.Over its nearly forty years of existence, the District has developed substantial data sets providing the foundation for its regulatory plan. Annual water-level measurements, a network of deep extensometers, over 80 subsidence GPS monitors, and updated numerical and analytical models have been utilized. Periodically, the District utilizes U.S. Census data to predict the future magnitude and location of population and water demand. In 2013, all of these data sets were combined producing an updated regulatory plan outlining the timelines of conversion to alternative sources of water and defining the maximum percentage groundwater can contribute to a user's total water demand.The management of the groundwater resources within the District has involved significant coordination with regional ground and surface water suppliers; ongoing interaction with other state and local regulatory bodies; analysis of accurate and up to date predictions on water usage; the enforcement of real disincentives to those who rely too heavily on groundwater and a commitment to practicing and promoting water conservation.Water supplies in the region are projected to continue to be stressed in the future due to rapid population increases in the region. Future District efforts will be focused on maintaining the successes of the past while evaluating potential deeper groundwater resources and any potential subsidence resulting from future development.

When the 'soft-path' gets hard: demand management and financial instability for water utilities

NASA Astrophysics Data System (ADS)

Zeff, H. B.; Characklis, G. W.

2014-12-01

In the past, cost benefit analysis (CBA) has been viewed as an effective means of evaluating water utility strategies, particularly those that were dependent on the construction of new supply infrastructure. As water utilities have begun to embrace 'soft-path' approaches as a way to reduce the need for supply-centric development, CBA fails to recognize some important financial incentives affected by reduced water consumption. Demand management, both as a short-term response to drought and in longer-term actions to accommodate demand growth, can introduce revenue risks that adversely affect a utility's ability to repay debt, re-invest in aging infrastructure, or maintain reserve funds for use in a short-term emergency. A utility that does not generate sufficient revenue to support these functions may be subject to credit rating downgrades, which in turn affect the interest rate it pays on its debt. Interest rates are a critical consideration for utility managers in the capital-intensive water sector, where debt payments for infrastructure often account for a large portion of a utility's overall costs. Even a small increase in interest rates can add millions of dollars to the cost of new infrastructure. Recent studies have demonstrated that demand management techniques can lead to significant revenue variability, and credit rating agencies have begun to take notice of drought response plans when evaluating water utility credit ratings, providing utilities with a disincentive to fully embrace soft-path approaches. This analysis examines the impact of demand management schemes on key credit rating metrics for a water utility in Raleigh, North Carolina. The utility's consumer base is currently experiencing rapid population growth, and demand management has the potential to reduce the dependence on costly new supply infrastructure but could lead to financial instability that will significantly increase the costs of financing future projects. This work analyzes how 'soft-path' approaches might be more efficiently integrated with investment in supply-side infrastructure and suggests how financial hedging tools could be used to improve long-term utility planning objectives.

Understanding Critical Socio-political and Hydro-climatic drivers behind Water Management and Increasing Dengue Disease Burden in Arid Regions of Mexico

NASA Astrophysics Data System (ADS)

Akanda, A. S.; Johnson, K.; Frost, M.; Serman, E. A.

2016-12-01

Dengue is a significant public health problem in Mexico, with distribution of dengue throughout the country. Mexico is characterized by a number of attributes likely to contribute to the spread of dengue, including population growth, poor water management, urbanization, significant seasonal migration, and concentrated poverty. Understanding the socio-political and hydro-climatic drivers behind the increasing dengue disease burden in the central arid regions of Mexico is a vital component for modeling the distribution and spread of Aedes aegypti vector borne infections such as Dengue and Zika as more parts of the Americas is affected. Here, we focus on the critical socio-economic and environmental drivers behind water management, urbanization, and population migration in the arid Oaxaca region, situated in the rain shadow of the Sierra Madre Mountains at an altitude of 5000 feet. In contrast to the Pacific Coastal region which hosts climactic conditions conducive to the survival of Aedes aegypti mosquitoes with a moist tropical environment, Oaxaca is arid and exists in a constant state of water insecurity. Within Oaxaca City, water is trucked in and stored in large roof tanks; many of which are failing, allowing for leaks or mosquito infestation. Alternate sources range from existing cisterns, sophisticated collection systems, to open-air rock pits. Few resources exist to improve water security, particularly in poor neighborhoods creating a disincentive to invite surveillance for disease or to move to safer and improved water systems. Meanwhile, the region has experienced significant socio-political and demographic shift including migration, economic reorganization and urbanization over the last decade. The rise in dengue incidence during the dry season suggests human intervention (through migration, water management, sanitation, cultural practices) as a potentially important predictive factor. In this study, we analyze associations of regional hydroclimatic patterns and resulting water scarcity, and urban water sources and management practices with various socio-political and economic factors that influence urbanization, water prices and vendors, to develop a comprehensive understanding of the dominant drivers of dengue burden and the recent upward trends.

Financial sustainability in savings and credit programmes.

PubMed

Havers, M

1996-05-01

This article provides a framework for determining, justifying, and improving financial sustainability of savings and credit programs. Credit programs have income from interest and fees. Income must pay for the cost of funds, loan write-offs, operating costs, and inflation. Reference is made to Otero and Rhyne's four levels of self-sufficiency in credit programs. The Grameen Bank is an example of Level 3 and most credit unions are level 4. Nongovernmental groups in the United Kingdom are level 1 or 2. Experience has shown that removal of subsidies did not affect the quality of services or shift benefits away from the poor. Success in serving poorer people better is attributed 1) to more money being available for lending under tighter management practices, 2) to greater openness to a variety of clients from removal of subsidy restrictions, 3) to a shift to higher interest rates that eliminate richer borrowers, and 4) to a shift to serious collection of loans which is a disincentive to more privileged borrowers. Percentages of loan loss, administration costs, cost of funds, and inflation are useful in measuring the sustainability of credit programs. Interest and fee income must also be measured. Fee repayment rates do not have a common definition of arrears, default, and write-off. A simple measure is the percentage of total costs covered by income. The World Bank recommends the Subsidy Dependence Index. Women tend to be better at repaying loans. Loan size should be related to borrowers' ability to handle the amount of the loan. Low and subsidized interest rates deter depositors and attract richer borrowers. Poorer borrowers are attracted by access to credit and not the cost of credit. Interest rates should be based on market rates. The loan payment should be no longer than necessary. Small groups of borrowers can guarantee each others loans. Group-based loan schemes work best. NGOs must project an image of being serious about loan collections and must take action immediately when a payment is missed. Good repayers should be rewarded with quick repeat loans.

Is Treating Oral and Maxillofacial Trauma Profitable? An Analysis of Hospital and Surgeon Reimbursement at an Academic Medical Center.

PubMed

DeLuke, Dean M; Agarwal, Vickas; Holleman, Trevor; Carrico, Caroline K; Laskin, Daniel M

2017-02-01

During the past 2 decades, there has been a marked decrease in the willingness of community-based oral and maxillofacial surgeons to participate in trauma call. Although many factors can influence the decision not to take trauma call, 1 primary disincentive is the perception that managing facial trauma might be profitable for the hospital, but not profitable for the surgeon. The purpose of this study was to compare the profitability of facial trauma management for the hospital and the surgeon at the Virginia Commonwealth University (VCU) Medical Center (Richmond, VA). In this retrospective cohort study, records were collected for patients who were seen for primary trauma management by the Department of Oral and Maxillofacial Surgery at VCU (VCUOMS) from June 2011 through July 2014. Cost and reimbursement data were analyzed for these patients from the VCU Health System (VCUHS) and the VCUOMS. For the hospital, actual cost data were provided; for the surgeon, cost was calculated based on an average overhead of 50%. For uniformity, patients were excluded if they remained in the hospital for longer than a 23-hour observation period. Patients younger than 18 years also were excluded. In total, 169 patients met the inclusion criteria. There was a statistically relevant difference in the percentage of costs recouped and the actual profit. The average percentage of costs recouped was 230% for the VCUHS versus 47% for the VCUOMS. This amounts to an average profit per case of $3,461 for the hospital versus a loss of $1,162 for the surgeon. The results of this study indicate that in the VCU Medical Center, maxillofacial trauma yields a net profit for the hospital and a net loss for the operating surgeon. Although the results are limited to outpatient management at 1 academic institution, they suggest that hospitals in some settings might be in a position to incentivize surgeons for trauma management. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Legal and Regulatory Barriers to Reverse Innovation.

PubMed

Rowthorn, Virginia; Plum, Alexander J; Zervos, John

Reverse innovation, or the importation of new, affordable, and efficacious models to high-income countries from the developing world, has emerged as a way to improve the health care system in the United States. Reverse innovation has been identified as a key emerging trend in global health systems in part because low-resourced settings are particularly good laboratories for low-cost/high-impact innovations that are developed out of necessity. A difficult question receiving scant attention is that of legal and regulatory barriers. The objective of this paper is to understand and elucidate the legal barriers faced by innovators bringing health interventions to the United States. Semistructured qualitative interviews were conducted with 9 key informants who have directly participated in the introduction of global health care approaches to the United States health system. A purposive sampling scheme was employed to identify participants. Phone interviews were conducted over one week in July 2016 with each participant and lasted an average of 35 minutes each. Purely legal barriers included questions surrounding tort liability, standard of care, and concerns around patient-administered self-care. Regulatory burdens included issues of international medical licensure, reimbursement, and task shifting and scope of work challenges among nonprofessionals (e.g. community health workers). Finally, perceived (i.e. not realized or experienced) legal and regulatory barriers to innovative modalities served as disincentives to bringing products or services developed outside of the United States to the United States market. Conflicting interests within the health care system, safety concerns, and little value placed on low-cost interventions inhibit innovation. Legal and regulatory barriers rank among, and contribute to, an anti-innovation atmosphere in healthcare for domestic and reverse innovators alike. Reverse innovation should be fostered through the thoughtful development of legal and regulatory standards that encourage the introduction and scalable adoption of successful health care innovations developed outside of the US, particularly innovations that support public health goals and do not have the benefit of a large corporate sponsor to facilitate introduction to the market. Copyright © 2016 Icahn School of Medicine at Mount Sinai. Published by Elsevier Inc. All rights reserved.

Transactional sex and the challenges to safer sexual behaviors: a study among male sex workers in Chennai, India

PubMed Central

Biello, Katie B.; Thomas, Beena E.; Johnson, Blake E.; Closson, Elizabeth F.; Navakodi, Pandiaraja; Dhanalakshmi, A.; Menon, Sunil; Mayer, Kenneth H.; Safren, Steven A.; Mimiaga, Matthew J.

2017-01-01

Male sex workers (MSW) are a significant but invisible population in India who are at risk for HIV/STI. Few studies from India have documented HIV risk factors and motivations for sex work in this population. Between 2013 and 2014, a community-based convenience sample of 100 MSW in Chennai (south India) completed a baseline risk assessment as part of a behavioral intervention. Participants were ≥18 years, and reported current sex work. We report medians and proportions, and Wilcoxon-Mann-Whitney and chi-square tests are used to examine differences between sex work and sexual behavior measures by income source. Participants were engaged in sex work for 5.0 years (IQR=2.3-10.0), and earned 3,000 (IQR=2000-8000) Rupees (<50 USD) per month from sex work. Sixty-four percent reported ever testing for HIV and 20.2% for any STI. The most common reasons for starting sex work were money (83.0) and pleasure (56.0%). Participants reported 8.0 (IQR=3.0-15.0) male clients and 7 (IQR=4.0-15.0) condomless anal sex acts with male clients in the past month. Compared to participants with an additional source of income, those whose only source of income was sex work reported more male clients in the past month (10.0 vs. 6.0, p=0.017), as well as more condomless anal sex acts with male clients (8.0 vs. 5.0, p=0.008). Nearly 70.0% were offered more money not to use a condom during sex with a client, and 74.2% reported accepting more money not to use a condom. Three-quarters reported having experienced difficulty using condoms with clients. MSW in India engage in high levels of sexual risk for HIV/STIs. Money appears to be a driving factor for engaging in sex work and condomless sex with clients. HIV prevention interventions with MSW should focus on facilitating skills that will support their ability to negotiate sexual safety in the context of monetary disincentives. PMID:27397549

Australian Secondary Students' Views About Global Warming: Beliefs About Actions, and Willingness to Act

NASA Astrophysics Data System (ADS)

Boyes, Edward; Skamp, Keith; Stanisstreet, Martin

2009-11-01

A 44-item questionnaire was constructed to determine secondary students’ views about how useful various specific actions might be at reducing global warming, their willingness to undertake the various actions, and the extent to which these two might be linked. Responses ( n = 500) were obtained from students in years 7 to 10 in three schools in NSW, Australia. For some pro-environmental actions, the degree to which students professed a willingness to act was greater than might be expected from the extent to which they believed the action to be useful. Such actions are those that involve minimal inconvenience such as switching off un-used electrical appliances, or those that are becoming well embedded in social practice, such as recycling. For other pro-environmental actions, the degree to which students were willing to act seemed less than might be expected, given the extent to which they believed the action to be useful. Actions concerning personal transport, such as buying smaller cars or using public rather than private transport, and obtaining more electricity from nuclear power stations, fell into this category. Here, there are disincentives to acting in a pro-environmental manner relating to personal inconvenience, or concern about nuclear power. The data were also explored to determine the strength of the relationships, for each action, between students’ professed willingness to act and their belief that an action would be effective. This suggested a measure of the potential effectiveness of education about that action. For some actions, this relationship was weak; in such cases, altering belief about the usefulness of the action might not be expected to produce major changes in behaviour. Issues concerning public transport were of this type; clearly, for issues such as these, other approaches and/or inducements may be needed to persuade people to adopt pro-environmental behaviour patterns. For other actions the relationship was stronger, so that in these areas environmental education could well be effective, especially if a large proportion of the population are not already willing to undertake that action.

Impact of the healthcare payment system on patient access to oral anticancer drugs: an illustration from the French and United States contexts.

PubMed

Benjamin, Laure; Buthion, Valérie; Vidal-Trécan, Gwenaëlle; Briot, Pascal

2014-06-20

Oral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients' access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances. French public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far. Funding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients.

Financial incentives for a healthy life style and disease prevention among older people: a systematic literature review.

PubMed

Tambor, Marzena; Pavlova, Milena; Golinowska, Stanisława; Arsenijevic, Jelena; Groot, Wim

2016-09-05

To motivate people to lead a healthier life and to engage in disease prevention, explicit financial incentives, such as monetary rewards for attaining health-related targets (e.g. smoking cessation, weight loss or increased physical activity) or disincentives for reverting to unhealthy habits, are applied. A review focused on financial incentives for health promotion among older people is lacking. Attention to this group is necessary because older people may respond differently to financial incentives, e.g. because of differences in opportunity costs and health perceptions. To outline how explicit financial incentives for healthy lifestyle and disease prevention work among older persons, this study reviews the recent evidence on this topic. We applied the method of systematic literature review and we searched in PUBMED, ECONLIT and COCHRANE LIBRARY for studies focused on explicit financial incentives targeted at older adults to promote health and stimulate primary prevention as well as screening. The publications selected as relevant were analyzed based on directed (relational) content analysis. The results are presented in a narrative manner complemented with an appendix table that describes the study details. We assessed the design of the studies reported in the publications in a qualitative manner. We also checked the quality of our review using the PRISMA 2009 checklist. We identified 15 studies on the role of explicit financial incentives in changing health-related behavior of older people. They include both, quantitative studies on the effectiveness of financial rewards as well as qualitative studies on the acceptability of financial incentives. The quantitative studies are characterized by a great diversity of designs and provide mixed results on the effects of explicit financial incentives. The results of the qualitative studies indicate limited trust of older people in the use of explicit financial incentives for health promotion and prevention. More research is needed on the effects of explicit financial incentives for prevention and promotion among older people before their broader use can be recommended. Overall, the design of the financial incentive system may be a crucial element in their acceptability.

"It's doom alone that counts": can international human rights law be an effective source of rights in correctional conditions litigation?

PubMed

Perlin, Michael L; Dlugacz, Henry A

2009-01-01

Over the past three decades, the U.S. judiciary has grown increasingly less receptive to claims by convicted felons as to the conditions of their confinement while in prison. Although courts have not articulated a return to the "hands off" policy of the 1950s, it is clear that it has become significantly more difficult for prisoners to prevail in constitutional correctional litigation. The passage and aggressive implementation of the Prison Litigation Reform Act has been a powerful disincentive to such litigation in many areas of prisoners' rights law. From the perspective of the prisoner, the legal landscape is more hopeful in matters that relate to mental health care and treatment. Here, in spite of a general trend toward more stringent applications of standards of proof and a reluctance to order sweeping, intrusive remedies, some courts have aggressively protected prisoners' rights to be free from "deliberate indifference" to serious medical needs, and to be free from excessive force on the part of prison officials. A mostly hidden undercurrent in some prisoners' rights litigation has been the effort on the part of some plaintiffs' lawyers to look to international human rights doctrines as a potential source of rights, an effort that has met with some modest success. It receives support by the inclination of other courts to turn to international human rights conventions-even in nations where such conventions have not been ratified-as a kind of "best practice" in the area. The recent publication and subsequent ratification (though not, as of yet, by the United States) of the UN Convention on the Rights of Persons with Disabilities (CRPD) may add new support to those using international human rights documents as a basis for litigating prisoners' rights claims. To the best of our knowledge, there has, as of yet, been no scholarly literature on the question of the implications of the CRPD on the state of prisoners' rights law in a U.S. domestic context. In this article, we raise this question, and offer some tentative conclusions. (c) 2009 John Wiley & Sons, Ltd.

Rewarding the work of individuals: a counterintuitive approach to reducing poverty and strengthening families.

PubMed

Berlin, Gordon L

2007-01-01

Gordon Berlin discusses the nation's long struggle to reduce poverty in families with children, and proposes a counterintuitive solution--rewarding the work of individuals.He notes that policymakers' difficulty in reducing family poverty since 1973 is attributable to two intertwined problems--falling wages among low-skilled workers and the striking increase in children living with a lone parent, usually the mother. As the wages of men with a high school education or less began to decline, their employment rates did likewise. The share of men who could support a family above the poverty line thus began to decline--and with it the willingness of low-income women to marry the fathers of their children. Because the U.S. social welfare system is built around the needs of poor families with children--and largely excludes single adults who are poor (and disproportionately male)--it creates disincentives to work and marry for some families, aggravating these larger trends. Berlin proposes a new policy that would partially overcome the low wages and income of poorly educated males and second earners in two-parent households by using the earned income tax credit (EITC) to supplement the earnings of all low-wage workers aged twenty-one to fifty-four who work full time--regardless of whether they have children or whether they are married. By conditioning the benefit on full-time work and by retaining the existing family-based EITC program while treating EITC payments as individual income rather than as joint income for income tax purposes, the policy would restore equity to the American social compact without distorting incentives to work, marry, and bear children. The largest benefits by far would accrue to two-parent households in which both adults can work full time. Because the policy would carry a large price tag--nearly $30 billion a year when fully implemented--Berlin says that a prudent next step would be to test this strategy rigorously in several states over several years, preferably using a random assignment design.

Policing the drunk driver: measuring law enforcement involvement in reducing alcohol-impaired driving.

PubMed

Dula, Chris S; Dwyer, William O; LeVerne, Gilbert

2007-01-01

With many thousands of deaths still annually attributable to driving under the influence (DUI), it remains imperative that we continually address the problem of producing and sustaining effective countermeasures, and that we subject these efforts to empirical scrutiny. This article presents relevant findings from state-wide datasets. A formula generating a potentially useful metric for assessing aspects of the DUI prosecutorial chain is presented, focusing on the rate of proactive DUI arrests. While in need of cautious interpretation due to issues of inherent inaccuracies in large databases, small numbers of crashes and/or arrests in multiple jurisdictions, and the lack of replication in other states, the analyses show no relationship between the level of DUI arrest activity and DUI-related crashes. This finding brings into question the efficacy of the many millions of dollars devoted each year to targeted DUI enforcement, as it is currently being implemented. Results are discussed in terms of developing adequate disincentives to DUI so as to raise general deterrence via dramatic increases in proactive DUI enforcement and then engaging in pervasive and persistent social marketing of such efforts to maximize the perception that arrest and punishment for DUI is always imminent, that penalties will be swift, certain, and severe. It is echoed that accurate data need to be collected at all levels of the DUI arrest and prosecution process in every jurisdiction within a state, so as to facilitate the empirical assessment of countermeasure efficacy in reducing alcohol-related crashes. Given that this work needs to be replicated, the impact on the traffic safety industry is potentially huge. The present data indicate that law enforcement efforts to further abate DUI-related crashes are apparently ineffective, though likely necessary to maintain reductions achieved in the 80s and early 90s. Thus, to attain additional systematic reductions, a dramatic increase in enforcement will be necessary as will a diversification of abatement efforts, including an increase in aggressive social marketing tactics to positively impact our traffic safety culture by making DUI universally unacceptable (for a discussion of this latter issue and on the use of positive reinforcement to change driver behavior, see Dula & Geller, 2007).

Where are the missing Chinese girls?

PubMed

Keysers, L

1991-01-01

Commentary focuses on the 1990 China Census data on births by sex and the sex ratio differences which suggest that 5% of all infant girls are unaccounted for. A combination of factors may account for this pattern: infanticide, adoption, or hidden births. Parents traditionally prefer sons and the 1 child policy acts as a disincentive to raise a girl child. The May 1990 census results indicate that for every 100 girls 1 year old there were 111.3 boys. This follows the pattern in 1989 of 112.5 boys and in 1987 of 110.5 boys. However in 1964 the sex ratio for newborn infants was 103.8 to 100, and in 1953 104.9 to 100. The figures surged after the institution of the 1 child policy in 1982. The natural sex ratio is 104-106 males for every 100 females. The ratio occurs for 1st born infants in China. The sex ratio is disportionately larger for 2nd or greater births. For 5th born children, the sex ratio is 125 boys to 100 girls. The presumption is that couples will accept a 1st daughter and a 2nd child can be maneuvered either legally or illegally. If a son is born first, most couples usually stop. A recent study by 2 Swedish experts and a Chinese demographer found that up to 50% of the 500,000 girls missing each year are adopted informally. The 2nd explanation offered is that daughters are raised by relatives in order to avoid having to pay fines. Infanticide as an option is considered possible and may account for a large number of killings in spite of the small proportion. Support for the explanation of hidden girls shows that the numbers are sometimes greater for 5 years olds than birth figures 5 years ago. Concern is raised about the use of ultrasound in determining the sex of the fetus. Since 1987, doctors are legally forbidden to inform patients of the sex of the fetus, but it is also recognized that the law is violated.

An Official American Thoracic Society Research Statement: Current Challenges Facing Research and Therapeutic Advances in Airway Remodeling.

PubMed

Prakash, Y S; Halayko, Andrew J; Gosens, Reinoud; Panettieri, Reynold A; Camoretti-Mercado, Blanca; Penn, Raymond B

2017-01-15

Airway remodeling (AR) is a prominent feature of asthma and other obstructive lung diseases that is minimally affected by current treatments. The goals of this Official American Thoracic Society (ATS) Research Statement are to discuss the scientific, technological, economic, and regulatory issues that deter progress of AR research and development of therapeutics targeting AR and to propose approaches and solutions to these specific problems. This Statement is not intended to provide clinical practice recommendations on any disease in which AR is observed and/or plays a role. An international multidisciplinary group from within academia, industry, and the National Institutes of Health, with expertise in multimodal approaches to the study of airway structure and function, pulmonary research and clinical practice in obstructive lung disease, and drug discovery platforms was invited to participate in one internet-based and one face-to-face meeting to address the above-stated goals. Although the majority of the analysis related to AR was in asthma, AR in other diseases was also discussed and considered in the recommendations. A literature search of PubMed was performed to support conclusions. The search was not a systematic review of the evidence. Multiple conceptual, logistical, economic, and regulatory deterrents were identified that limit the performance of AR research and impede accelerated, intensive development of AR-focused therapeutics. Complementary solutions that leverage expertise of academia and industry were proposed to address them. To date, numerous factors related to the intrinsic difficulty in performing AR research, and economic forces that are disincentives for the pursuit of AR treatments, have thwarted the ability to understand AR pathology and mechanisms and to address it clinically. This ATS Research Statement identifies potential solutions for each of these factors and emphasizes the importance of educating the global research community as to the extent of the problem as a critical first step in developing effective strategies for: (1) increasing the extent and impact of AR research and (2) developing, testing, and ultimately improving drugs targeting AR.

Sociodemographic characteristics and waking activities and their role in the timing and duration of sleep.

PubMed

Basner, Mathias; Spaeth, Andrea M; Dinges, David F

2014-12-01

Chronic sleep restriction is prevalent in the U.S. population and associated with increased morbidity and mortality. The primary reasons for reduced sleep are unknown. Using population data on time use, we sought to identify individual characteristics and behaviors associated with short sleep that could be targeted for intervention programs. Analysis of the American Time Use Survey (ATUS). Cross-sectional annual survey conducted by the U.S. Bureau of Labor Statistics. Representative cohort (N = 124,517) of Americans 15 years and older surveyed between 2003 and 2011. None. Telephone survey of activities over 24 hours. Relative to all other waking activities, paid work time was the primary waking activity exchanged for sleep. Time spent traveling, which included commuting to/ from work, and immediate pre- and post-sleep activities (socializing, grooming, watching TV) were also reciprocally related to sleep duration. With every hour that work or educational training started later in the morning, sleep time increased by approximately 20 minutes. Working multiple jobs was associated with the highest odds for sleeping ≤6 hours on weekdays (adjusted OR 1.61, 95% CI 1.44; 1.81). Self-employed respondents were less likely to be short sleepers compared to private sector employees (OR 0.83, 95% CI 0.72; 0.95). Sociodemographic characteristics associated with paid work (age 25-64, male sex, high income, and employment per se) were consistently associated with short sleep. U.S. population time use survey findings suggest that interventions to increase sleep time should concentrate on delaying the morning start time of work and educational activities (or making them more flexible), increasing sleep opportunities, and shortening morning and evening commute times. Reducing the need for multiple jobs may increase sleep time, but economic disincentives from working fewer hours will need to be offset. Raising awareness of the importance of sufficient sleep for health and safety may be necessary to positively influence discretionary behaviors that reduce sleep time, including television viewing and morning grooming. © 2014 Associated Professional Sleep Societies, LLC.

Impact of Large Scale Energy Efficiency Programs On Consumer Tariffs and Utility Finances in India

DOE Office of Scientific and Technical Information (OSTI.GOV)

Abhyankar, Nikit; Phadke, Amol

2011-01-20

Large-scale EE programs would modestly increase tariffs but reduce consumers' electricity bills significantly. However, the primary benefit of EE programs is a significant reduction in power shortages, which might make these programs politically acceptable even if tariffs increase. To increase political support, utilities could pursue programs that would result in minimal tariff increases. This can be achieved in four ways: (a) focus only on low-cost programs (such as replacing electric water heaters with gas water heaters); (b) sell power conserved through the EE program to the market at a price higher than the cost of peak power purchase; (c) focusmore » on programs where a partial utility subsidy of incremental capital cost might work and (d) increase the number of participant consumers by offering a basket of EE programs to fit all consumer subcategories and tariff tiers. Large scale EE programs can result in consistently negative cash flows and significantly erode the utility's overall profitability. In case the utility is facing shortages, the cash flow is very sensitive to the marginal tariff of the unmet demand. This will have an important bearing on the choice of EE programs in Indian states where low-paying rural and agricultural consumers form the majority of the unmet demand. These findings clearly call for a flexible, sustainable solution to the cash-flow management issue. One option is to include a mechanism like FAC in the utility incentive mechanism. Another sustainable solution might be to have the net program cost and revenue loss built into utility's revenue requirement and thus into consumer tariffs up front. However, the latter approach requires institutionalization of EE as a resource. The utility incentive mechanisms would be able to address the utility disincentive of forgone long-run return but have a minor impact on consumer benefits. Fundamentally, providing incentives for EE programs to make them comparable to supply-side investments is a way of moving the electricity sector toward a model focused on providing energy services rather than providing electricity.« less

"Managed competition" for Ireland? The single versus multiple payer debate.

PubMed

Mikkers, Misja; Ryan, Padhraig

2014-09-26

A persistent feature of international health policy debate is whether a single-payer or multiple-payer system can offer superior performance. In Ireland, a major reform proposal is the introduction of 'managed competition' based on the recent reforms in the Netherlands, which would replace many functions of Ireland's public payer with a system of competing health insurers from 2016. This article debates whether Ireland meets the preconditions for effective managed competition, and whether the government should implement the reform according to its stated timeline. We support our arguments by discussing the functioning of the Dutch and Irish systems. Although Ireland currently lacks key preconditions for effective implementation, the Dutch experience demonstrates that some of these can be implemented over time, such as a more rigorous risk equalization system. A fundamental problem may be Ireland's sparse hospital distribution. This may increase the market power of hospitals and weaken insurers' ability to exclude inefficient or poor quality hospitals from contracts, leading to unwarranted spending growth. To mitigate this, the government proposes to introduce a system of price caps for hospital services.The Dutch system of competition is still in transition and it is premature to judge its success. The new system may have catalyzed increased transparency regarding clinical performance, but outcome measurement remains crude. A multi-payer environment creates some disincentives for quality improvement, one of which is free-riding by insurers on their rivals' quality investments. If a Dutch insurer invests in improving hospital quality, hospitals will probably offer equivalent quality to consumers enrolled with other insurance companies. This enhances equity, but may weaken incentives for improvement. Consequently the Irish government, rather than insurers, may need to assume responsibility for investing in clinical quality. Plans are in place to assure consumers of free choice of insurer, but a key concern is a potential shortfall of institutional capacity to regulate managed competition. Managed competition requires a long transition period and the requisite preconditions are not yet in place. The Irish government should refrain from introducing managed competition until sufficient preconditions are in place to allow effective performance.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 9: conceptualising disinvestment in the local healthcare setting.

PubMed

Harris, Claire; Green, Sally; Ramsey, Wayne; Allen, Kelly; King, Richard

2017-09-08

This is the ninth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The disinvestment literature has broadened considerably over the past decade; however there is a significant gap regarding systematic, integrated, organisation-wide approaches. This debate paper presents a discussion of the conceptual aspects of disinvestment from the local perspective. Four themes are discussed: Terminology and concepts, Motivation and purpose, Relationships with other healthcare improvement paradigms, and Challenges to disinvestment. There are multiple definitions for disinvestment, multiple concepts underpin the definitions and multiple alternative terms convey these concepts; some definitions overlap and some are mutually exclusive; and there are systematic discrepancies in use between the research and practice settings. Many authors suggest that the term 'disinvestment' should be avoided due to perceived negative connotations and propose that the concept be considered alongside investment in the context of all resource allocation decisions and approached from the perspective of optimising health care. This may provide motivation for change, reduce disincentives and avoid some of the ethical dilemmas inherent in other disinvestment approaches. The impetus and rationale for disinvestment activities are likely to affect all aspects of the process from identification and prioritisation through to implementation and evaluation but have not been widely discussed. A need for mechanisms, frameworks, methods and tools for disinvestment is reported. However there are several health improvement paradigms with mature frameworks and validated methods and tools that are widely-used and well-accepted in local health services that already undertake disinvestment-type activities and could be expanded and built upon. The nature of disinvestment brings some particular challenges for policy-makers, managers, health professionals and researchers. There is little evidence of successful implementation of 'disinvestment' projects in the local setting, however initiatives to remove or replace technologies and practices have been successfully achieved through evidence-based practice, quality and safety activities, and health service improvement programs. These findings suggest that the construct of 'disinvestment' may be problematic at the local level. A new definition and two potential approaches to disinvestment are proposed to stimulate further research and discussion.

Fertility trends in Singapore.

PubMed

Singh, K; Viegas, O; Ratnam, S S

1988-10-01

In 1966, the Singapore National Family Planning and Population Program established the goal of reaching replacement fertility by 1990 and zero population growth by the year 2030. To achieve this goal, the government relied on a series of incentives and disincentives to discourage births above the 3rd birth order, including tax relief for the 1st 3 children only, paid medical leave for women undergoing sterilization after the 3rd or subsequent birth, monetary stipends in some cases where the mother is sterilized after the 1st or 2nd birth, and increasing accouchement charges for increasing birth orders. Also important to demographic planning were liberalization of Singapore's abortion legislation and more aggressive promotion of contraception. As a result of these efforts, Singapore's crude birth rate has declined from 29.5/1000 population in 1965 to 16.6/1000 in 1985. Also observed have been dramatic declines in infant mortality in this same period, from 26.2/1000 live births to 9.3/1000, and in maternal mortality, from 52/100,000 live births to 10/100,000. In 1985, 42% of total births were to women in the 25-29-year age group. The numbers of 4th and later births fell by 90% between 1966 and 1985. The total fertility rate has declined from 4.6/woman in 1965 to 3.1 in 1970 to 1.6 in 1986. Below replacement level fertility was achieved in 1975, in part because of government policy but also as a result of cultural and socioeconomic factors such as increasing female labor force participation rates, a break-up of the extended family system, a rise in the age at 1st marriage, and rises in educational attainment. The drop in fertility was contributed mainly by the higher socioeconomic class, more affluent, and educated Singaporeans. Thus, in 1981, the government introduced certain pronatalist policies and incentives to encourage better educated women to produce more children, e.g., tax relief and the elimination of monetary incentives to sterilization acceptors above a median income level.

Control of fertility in the People's Republic of China.

PubMed

Blayo, Y

1993-06-01

The nature of the changing family planning and population control policies in China and their impact on fertility are discussed. The basic trust of policy was to destroy traditional structures and replace them with social institutions and a new administrative systems. During the 1950s, the Marriage Law was implemented and communes, brigades, and teams in rural areas and work units and district and residents' committees effectively administered the means of population control. The means were political involving mass campaigns and permanent mobilization and administrative involving registration of households. This system was shocked by the Great Leap Forward in 1958 and the after effects and the Cultural Revolution in 1966. State machinery was restored and in place for the third campaign of birth quotas and standards of procreation. Quotas were determined by year and by province, then by municipalities and districts. Meetings were held and women selected to bear children. The legal minimum marriage for males to marry was 20 years and 18 years for females; however, it was strongly urged that females not marry until 23 years in rural areas and 25 years in urban areas males; 25 or 28 years). Rural areas stipulated a birth interval of 3 years and urban areas required 4-5 years. The limit on births was 2 in urban areas. In rural areas it was 3 until 1977 when the number was reduced to 2. Unplanned pregnancies should be terminated. By 1975-76, the program was universally applied, but fertility decline still did not meet the goals of the Four Modernizations for 1978. The single-child campaign was then established in 1979. Incentives and bonuses were offered to those bearing only 1 child and disincentives and penalties were applied to those who had additional children. The Modernization campaign returned productivity to the family unit and children became more valuable; communes were abolished and administrative means of control were limited. A floating population with mobility was able to escape the control of family planning workers. The Marriage Act of 1981 reduced the marriage age to 20 years for females and 22 years for males; the result was increased fertility. The new mobilization of 1983 attempted to restrict births to 1 more vigorously; abortions became compulsory and sterilizations were introduced. Coercion was deemed necessary. The campaign was relaxed in 1984, but by then the floating population had increased.

Epidemiology of low back pain.

PubMed

Skovron, M L

1992-10-01

At present, although there have been many epidemiological studies of risk factors for low back pain, there are few risk factors established in prospective studies; and our understanding of them remains relatively crude. Individuals in jobs requiring manual materials handling, particularly repeated heavy lifting and lifting while twisting, are at increased risk of back pain leading to work absence. In addition, exposure to whole-body vibration and job requirements for static postures are associated with back pain. Individual trunk strength has not been consistently demonstrated as associated with back pain; although there is some suggestion that when work requirements for heavy lifting exceed individual capacities, back pain is more likely to occur. The pattern of peak age at onset in the 20's is consistent with back pain development early in working life. Among other individual characteristics, only cigarette smoking has consistently been associated with back pain; and the biological mechanism for this finding is not understood. Evidence with respect to spinal flexibility, aerobic capacity, educational attainment and other variables is suggestive but not consistent. There is some evidence that the individual's relation to work, expressed as job satisfaction or supervisor rating, is also related to work absence due to back pain. While it is possible to describe, however crudely, the characteristics placing people at risk for back pain leading to work absence and/or medical attention, the problem of predicting chronicity and thus identifying patients for more intensive clinical intervention remains unresolved. At this time, only age of the patient and certain clinical features of the back pain such as the presence of sciatic symptoms, duration of the current episode, and history of prior episodes are consistently demonstrated predictors. In chronic patients, there is suggestive evidence that spinal flexibility, trunk strength, and certain psychological characteristics such as coping skills, fear and avoidance of pain or movement, job satisfaction, attribution of fault and hysterical or hypochondriacal features are associated with treatment failure. In addition, there is suggestive evidence that the availability of alternative work placement may allow for earlier return to work than otherwise. While the availability of disability compensation in excess of usual wages may serve as a disincentive to return to work. The latter-cited remain to be verified, while findings in chronic patients remain to be tested in acute. Further, the role of physical demands of work in duration of back pain episodes has not been well studied.

Can Economic Analysis Contribute to Disease Elimination and Eradication? A Systematic Review.

PubMed

Sicuri, Elisa; Evans, David B; Tediosi, Fabrizio

2015-01-01

Infectious diseases elimination and eradication have become important areas of focus for global health and countries. Due to the substantial up-front investments required to eliminate and eradicate, and the overall shortage of resources for health, economic analysis can inform decision making on whether elimination/eradication makes economic sense and on the costs and benefits of alternative strategies. In order to draw lessons for current and future initiatives, we review the economic literature that has addressed questions related to the elimination and eradication of infectious diseases focusing on: why, how and for whom? A systematic review was performed by searching economic literature (cost-benefit, cost-effectiveness and economic impact analyses) on elimination/eradication of infectious diseases published from 1980 to 2013 from three large bibliographic databases: one general (SCOPUS), one bio-medical (MEDLINE/PUBMED) and one economic (IDEAS/REPEC). A total of 690 non-duplicate papers were identified from which only 43 met the inclusion criteria. In addition, only one paper focusing on equity issues, the "for whom?" question, was found. The literature relating to "why?" is the largest, much of it focusing on how much it would cost. A more limited literature estimates the benefits in terms of impact on economic growth with mixed results. The question of how to eradicate or eliminate was informed by an economic literature highlighting that there will be opportunities for individuals and countries to free-ride and that forms of incentives and/or disincentives will be needed. This requires government involvement at country level and global coordination. While there is little doubt that eliminating infectious diseases will eventually improve equity, it will only happen if active steps to promote equity are followed on the path to elimination and eradication. The largest part of the literature has focused on costs and economic benefits of elimination/eradication. To a lesser extent, challenges associated with achieving elimination/eradication and ensuring equity have also been explored. Although elimination and eradication are, for some diseases, good investments compared with control, countries' incentives to eliminate do not always align with the global good and the most efficient elimination strategies may not prioritize the poorest populations. For any infectious disease, policy-makers will need to consider realigning contrasting incentives between the individual countries and the global community and to assure that the process towards elimination/eradication considers equity.

The global pediatric antiretroviral market: analyses of product availability and utilization reveal challenges for development of pediatric formulations and HIV/AIDS treatment in children.

PubMed

Waning, Brenda; Diedrichsen, Ellen; Jambert, Elodie; Bärnighausen, Till; Li, Yun; Pouw, Mieke; Moon, Suerie

2010-10-17

Important advances in the development and production of quality-certified pediatric antiretroviral (ARV) formulations have recently been made despite significant market disincentives for manufacturers. This progress resulted from lobbying and innovative interventions from HIV/AIDS activists, civil society organizations, and international organizations. Research on uptake and dispersion of these improved products across countries and international organizations has not been conducted but is needed to inform next steps towards improving child health. We used information from the World Health Organization Prequalification Programme and the United States Food and Drug Administration to describe trends in quality-certification of pediatric formulations and used 7,989 donor-funded, pediatric ARV purchase transactions from 2002-2009 to measure uptake and dispersion of new pediatric ARV formulations across countries and programs. Prices for new pediatric ARV formulations were compared to alternative dosage forms. Fewer ARV options exist for HIV/AIDS treatment in children than adults. Before 2005, most pediatric ARVs were produced by innovator companies in single-component solid and liquid forms. Five 2-in1 and four 3-in-1 generic pediatric fixed-dose combinations (FDCs) in solid and dispersible forms have been quality-certified since 2005. Most (67%) of these were produced by one quality-certified manufacturer. Uptake of new pediatric FDCs outside of UNITAID is low. UNITAID accounted for 97-100% of 2008-2009 market volume. In total, 33 and 34 countries reported solid or dispersible FDC purchases in 2008 and 2009, respectively, but most purchases were made through UNITAID. Only three Global Fund country recipients reported purchase of these FDCs in 2008. Prices for pediatric FDCs were considerably lower than liquids but typically higher than half of an adult FDC. Pediatric ARV markets are more fragile than adult markets. Ensuring a long-term supply of quality, well-adapted ARVs for children requires ongoing monitoring and improved understanding of global pediatric markets, including country-based research to explain and address low uptake of new, improved formulations. Continued innovation in pediatric ARV development may be threatened by outdated procurement practices failing to connect clinicians making prescribing decisions, supply chain staff dealing with logistics, donors, international organizations, and pharmaceutical manufacturers. Perceptions of global demand must be better informed by accurate estimates of actual country-level demand.

Biochemical Disincentives to Fertilizing Cellulosic Ethanol Crops

NASA Astrophysics Data System (ADS)

Gallagher, M. E.; Hockaday, W. C.; Snapp, S.; McSwiney, C.; Baldock, J.

2010-12-01

Corn grain biofuel crops produce the highest yields when the cropping ecosystem is not nitrogen (N)-limited, achieved by application of fertilizer. There are environmental consequences for excessive fertilizer application to crops, including greenhouse gas emissions, hypoxic “dead zones,” and health problems from N runoff into groundwater. The increase in corn acreage in response to demand for alternative fuels (i.e. ethanol) could exacerbate these problems, and divert food supplies to fuel production. A potential substitute for grain ethanol that could reduce some of these impacts is cellulosic ethanol. Cellulosic ethanol feedstocks include grasses (switchgrass), hardwoods, and crop residues (e.g. corn stover, wheat straw). It has been assumed that these feedstocks will require similar N fertilization rates to grain biofuel crops to maximize yields, but carbohydrate yield versus N application has not previously been monitored. We report the biochemical stocks (carbohydrate, protein, and lignin in Mg ha-1) of a corn ecosystem grown under varying N levels. We measured biochemical yield in Mg ha-1 within the grain, leaf and stem, and reproductive parts of corn plants grown at seven N fertilization rates (0-202 kg N ha-1), to evaluate the quantity and quality of these feedstocks across a N fertilization gradient. The N fertilization rate study was performed at the Kellogg Biological Station-Long Term Ecological Research Site (KBS-LTER) in Michigan. Biochemical stocks were measured using 13C nuclear magnetic resonance spectroscopy (NMR), combined with a molecular mixing model (Baldock et al. 2004). Carbohydrate and lignin are the main biochemicals of interest in ethanol production since carbohydrate is the ethanol feedstock, and lignin hinders the carbohydrate to ethanol conversion process. We show that corn residue carbohydrate yields respond only weakly to N fertilization compared to grain. Grain carbohydrate yields plateau in response to fertilization at moderate levels (67 kg N ha-1). Increasing fertilizer application beyond the point of diminishing returns for grain (67 kg N ha-1) to double the regionally-recommended amount (202 kg N ha-1) resulted in only marginal increases (25%) in crop residue carbohydrate yield, while increasing lignin yields 41%. In the case of at least this ecosystem, high fertilization rates did not result in large carbohydrate yield increases in the crop residue, and instead produced a lower quality feedstock for cellulosic ethanol production.

Reasons for accepting or declining Down syndrome screening in Dutch prospective mothers within the context of national policy and healthcare system characteristics: a qualitative study.

PubMed

Crombag, Neeltje M T H; Boeije, Hennie; Iedema-Kuiper, Rita; Schielen, Peter C J I; Visser, Gerard H A; Bensing, Jozien M

2016-05-26

Uptake rates for Down syndrome screening in the Netherlands are low compared to other European countries. To investigate the low uptake, we explored women's reasons for participation and possible influences of national healthcare system characteristics. Dutch prenatal care is characterised by an approach aimed at a low degree of medicalisation, with pregnant women initially considered to be at low risk. Prenatal screening for Down syndrome is offered to all women, with a 'right not to know' for women who do not want to be informed on this screening. At the time this study was performed, the test was not reimbursed for women aged 35 and younger. We conducted a qualitative study to explore reasons for participation and possible influences of healthcare system characteristics. Data were collected via ten semi-structured focus groups with women declining or accepting the offer of Down syndrome screening (n = 46). All focus groups were audio- and videotaped, transcribed verbatim, coded and content analysed. Women declining Down syndrome screening did not consider Down syndrome a condition severe enough to justify termination of pregnancy. Young women declining felt supported in their decision by perceived confirmation of their obstetric caregiver and reassured by system characteristics (costs and age restriction). Women accepting Down syndrome screening mainly wanted to be reassured or be prepared to care for a child with Down syndrome. By weighing up the pros and cons of testing, obstetric caregivers supported young women who accepted in the decision-making process. This was helpful, although some felt the need to defend their decision to accept the test offer due to their young age. For some young women accepting testing, costs were considered a disincentive to participate. Presentation of prenatal screening affects how the offer is attended to, perceived and utilised. By offering screening with age restriction and additional costs, declining is considered the preferred choice, which might account for low Dutch uptake rates. Autonomous and informed decision-making in Down syndrome screening should be based on the personal interest in knowing the individual risk of having a child with Down syndrome and system characteristics should not influence participation.

Impact of the healthcare payment system on patient access to oral anticancer drugs: an illustration from the French and United States contexts

PubMed Central

2014-01-01

Background Oral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients’ access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances. Discussion French public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far. Summary Funding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients. PMID:24950778

Marshak Lectureship Talk: Women in Physics in the Baltic States Region: Problems and Solutions

NASA Astrophysics Data System (ADS)

Satkovskiene, Dalia

2008-03-01

In this contribution the gender equality problem in physics will be discussed on the basis of the results obtained implementing the project ``Baltic States Network: Women in Sciences and High Technology'' (BASNET) initiated by Lithuanian women physicists and financed by European Commission. The main goal of BASNET project was creation of the regional Strategy how to deal with women in sciences problem in the Baltic States. It has some stages and the contribution follows them. The first one was in depth sociological study aiming to find out disincentives and barriers women scientists face in their career and work at science and higher education institutions. Analysis of results revealed wide range of problems concerned with science organization, management and financing common for both counterparts. However it also proved the existence of women discrimination in sciences. As main factors influencing women under-representation in Physics was found: the stereotypes existing in the society where physics is assigned to the masculine area of activity; failings of the science management system, where highest positions are distributed not using the institutionalized objective criteria but by voting, where the correctness of majority solutions is anticipated implicitly. In physics where male scientists are the majority (they also usually compose executive boards, committees etc.) results of such a procedures often are unfavorable for women. The same reasons also influence women ``visibility'' in physicist's community and as the consequence possibility to receive needed recourses for their research as well as appropriate presentation of results obtained. The study revealed also the conservatism of scientific community- reluctance to face existing in the scientific society problems and to start solving them. On the basis of the results obtained as well practice of other countries the common strategy of solving women in physics (sciences) in the Baltic States region was formulated. As changing the stereotypes is long lasting process it was decided firstly to concentrate strategy implementation plans on changes in science management policy tackling the problem from the top and allowing receive the most quick results. For this we created the regional Baltic States Network among the corresponding international women working groups, professional organizations (Scientific societies) and corresponding departments of the governmental institutions. BASNET also became a full member of European Platform of Women Scientists (EPWS)-prestige women organization signally influencing the European Community science policy.

Sociodemographic Characteristics and Waking Activities and their Role in the Timing and Duration of Sleep

PubMed Central

Basner, Mathias; Spaeth, Andrea M.; Dinges, David F.

2014-01-01

Study Objectives: Chronic sleep restriction is prevalent in the U.S. population and associated with increased morbidity and mortality. The primary reasons for reduced sleep are unknown. Using population data on time use, we sought to identify individual characteristics and behaviors associated with short sleep that could be targeted for intervention programs. Design: Analysis of the American Time Use Survey (ATUS). Setting: Cross-sectional annual survey conducted by the U.S. Bureau of Labor Statistics. Participants: Representative cohort (N = 124,517) of Americans 15 years and older surveyed between 2003 and 2011. Interventions: None. Measurements and Results: Telephone survey of activities over 24 hours. Relative to all other waking activities, paid work time was the primary waking activity exchanged for sleep. Time spent traveling, which included commuting to/from work, and immediate pre- and post-sleep activities (socializing, grooming, watching TV) were also reciprocally related to sleep duration. With every hour that work or educational training started later in the morning, sleep time increased by approximately 20 minutes. Working multiple jobs was associated with the highest odds for sleeping ≤ 6 hours on weekdays (adjusted OR 1.61, 95% CI 1.44; 1.81). Self-employed respondents were less likely to be short sleepers compared to private sector employees (OR 0.83, 95% CI 0.72; 0.95). Sociodemographic characteristics associated with paid work (age 25-64, male sex, high income, and employment per se) were consistently associated with short sleep. Conclusions: U.S. population time use survey findings suggest that interventions to increase sleep time should concentrate on delaying the morning start time of work and educational activities (or making them more flexible), increasing sleep opportunities, and shortening morning and evening commute times. Reducing the need for multiple jobs may increase sleep time, but economic disincentives from working fewer hours will need to be offset. Raising awareness of the importance of sufficient sleep for health and safety may be necessary to positively influence discretionary behaviors that reduce sleep time, including television viewing and morning grooming. Citation: Basner M, Spaeth AM, Dinges DF. Sociodemographic characteristics and waking activities and their role in the timing and duration of sleep. SLEEP 2014;37(12):1889-1906. PMID:25325472

The global pediatric antiretroviral market: analyses of product availability and utilization reveal challenges for development of pediatric formulations and HIV/AIDS treatment in children

PubMed Central

2010-01-01

Background Important advances in the development and production of quality-certified pediatric antiretroviral (ARV) formulations have recently been made despite significant market disincentives for manufacturers. This progress resulted from lobbying and innovative interventions from HIV/AIDS activists, civil society organizations, and international organizations. Research on uptake and dispersion of these improved products across countries and international organizations has not been conducted but is needed to inform next steps towards improving child health. Methods We used information from the World Health Organization Prequalification Programme and the United States Food and Drug Administration to describe trends in quality-certification of pediatric formulations and used 7,989 donor-funded, pediatric ARV purchase transactions from 2002-2009 to measure uptake and dispersion of new pediatric ARV formulations across countries and programs. Prices for new pediatric ARV formulations were compared to alternative dosage forms. Results Fewer ARV options exist for HIV/AIDS treatment in children than adults. Before 2005, most pediatric ARVs were produced by innovator companies in single-component solid and liquid forms. Five 2-in1 and four 3-in-1 generic pediatric fixed-dose combinations (FDCs) in solid and dispersible forms have been quality-certified since 2005. Most (67%) of these were produced by one quality-certified manufacturer. Uptake of new pediatric FDCs outside of UNITAID is low. UNITAID accounted for 97-100% of 2008-2009 market volume. In total, 33 and 34 countries reported solid or dispersible FDC purchases in 2008 and 2009, respectively, but most purchases were made through UNITAID. Only three Global Fund country recipients reported purchase of these FDCs in 2008. Prices for pediatric FDCs were considerably lower than liquids but typically higher than half of an adult FDC. Conclusion Pediatric ARV markets are more fragile than adult markets. Ensuring a long-term supply of quality, well-adapted ARVs for children requires ongoing monitoring and improved understanding of global pediatric markets, including country-based research to explain and address low uptake of new, improved formulations. Continued innovation in pediatric ARV development may be threatened by outdated procurement practices failing to connect clinicians making prescribing decisions, supply chain staff dealing with logistics, donors, international organizations, and pharmaceutical manufacturers. Perceptions of global demand must be better informed by accurate estimates of actual country-level demand. PMID:20950492

Learning to write in the sand. Educating girls in India.

PubMed

Datta, B

1993-01-01

In India, the conclusion from experience of the URMUL Rural Health Research and Development Trust is that literacy involves attitude change. In remote and rural areas in Rajasthan parents see no need for literacy when .01% of women in 24 villages cannot read and write. The female literacy rate in Bikaner District is 17.57%; the annual population growth rate is 4.2%. Rajasthan had the lowest literacy rate in India in 1991 (20.84% vs. 39.52% for all India). There are many examples of traditional customs that place women in inferior positions: the wearing of the ghunghat (a thin veil) when men are around; confinement to the house even in illness; the belief that a girl is another's wealth, so why bother investing in her? The definition of a good wife is one who is willing to walk 10 km to fetch water. The desert habitat forces a demanding existence which does not leave much room for education. In degraded habitats, women's work is increased, and their girl helpers are also encumbered. In the government school at Mithariya, only 15 girls out of 125 students attend school. The URMUL program in a nonformal school has better girl enrollment (14 out of 25 children), but when the weather is good, the girls are working on the farms. In the village of 4BGM, a trust school is run by the Shiksha-Karmi Program of the state government; funding has come from the Swedish Development Authority. Teachers are recruited from the local population because of the remoteness of the area. Female teachers with 5-8 years of formal schooling are difficult to find and are instrumental in securing girl students, when parents refuse to send their daughters unless there is a female teacher. The importance of having female teachers was recognized in 1991 by the Ramamurti Committee of Education, which recommended at least 50% of teachers at all educational levels, be women. In 4BGM village, Sharada Devi was the only female teacher available, because husbands would not allow their wives to teach. An incentive to promote the value of literacy skills is to emphasize that daughters will be able to write home after marriage. Child marriage is still widely practiced, and is a great disincentive to girl's schooling and impairs health. The trust also runs nonformal adult literacy programs.

A methodology for optimal MSW management, with an application in the waste transportation of Attica Region, Greece.

PubMed

Economopoulou, M A; Economopoulou, A A; Economopoulos, A P

2013-11-01

The paper describes a software system capable of formulating alternative optimal Municipal Solid Wastes (MSWs) management plans, each of which meets a set of constraints that may reflect selected objections and/or wishes of local communities. The objective function to be minimized in each plan is the sum of the annualized capital investment and annual operating cost of all transportation, treatment and final disposal operations involved, taking into consideration the possible income from the sale of products and any other financial incentives or disincentives that may exist. For each plan formulated, the system generates several reports that define the plan, analyze its cost elements and yield an indicative profile of selected types of installations, as well as data files that facilitate the geographic representation of the optimal solution in maps through the use of GIS. A number of these reports compare the technical and economic data from all scenarios considered at the study area, municipality and installation level constituting in effect sensitivity analysis. The generation of alternative plans offers local authorities the opportunity of choice and the results of the sensitivity analysis allow them to choose wisely and with consensus. The paper presents also an application of this software system in the capital Region of Attica in Greece, for the purpose of developing an optimal waste transportation system in line with its approved waste management plan. The formulated plan was able to: (a) serve 113 Municipalities and Communities that generate nearly 2 milliont/y of comingled MSW with distinctly different waste collection patterns, (b) take into consideration several existing waste transfer stations (WTS) and optimize their use within the overall plan, (c) select the most appropriate sites among the potentially suitable (new and in use) ones, (d) generate the optimal profile of each WTS proposed, and (e) perform sensitivity analysis so as to define the impact of selected sets of constraints (limitations in the availability of sites and in the capacity of their installations) on the design and cost of the ensuing optimal waste transfer system. The results show that optimal planning offers significant economic savings to municipalities, while reducing at the same time the present levels of traffic, fuel consumptions and air emissions in the congested Athens basin. Copyright © 2013 Elsevier Ltd. All rights reserved.

[Catheter ablation of atrial fibrillation: Health Technology Assessment Report from the Italian Association of Arrhythmology and Cardiac Pacing (AIAC)].

PubMed

Themistoclakis, Sakis; Tritto, Massimo; Bertaglia, Emanuele; Berto, Patrizia; Bongiorni, Maria Grazia; Catanzariti, Domenico; De Fabrizio, Giuseppe; De Ponti, Roberto; Grimaldi, Massimo; Pandozi, Claudio; Tondo, Claudio; Gulizia, Michele

2011-11-01

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and significantly impact patients' quality of life, morbidity and mortality. The number of affected patients is expected to increase as well as the costs associated with AF management, mainly driven by hospitalizations. Over the last decade, catheter ablation techniques targeting pulmonary vein isolation have demonstrated to be effective in treating AF and preventing AF recurrence. This Health Technology Assessment report of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) aims to define the current role of catheter ablation of AF in terms of effectiveness, efficiency and appropriateness. On the basis of an extensive review of the available literature, this report provides (i) an overview of the epidemiology, clinical impact and socio-economic burden of AF; (ii) an evaluation of therapeutic options other than catheter ablation of AF; and (iii) a detailed presentation of clinical outcomes and cost-benefit ratio associated with catheter ablation. The costs of catheter ablation of AF in Italy were obtained using a bottom-up analysis of a resource utilization survey of 52 hospitals that were considered a representative sample, including 4 Centers that contributed with additional unit cost information in a separate questionnaire. An analysis of budget impact was also performed to evaluate the impact of ablation on the management costs of AF. Results of this analysis show that (1) catheter ablation is effective, safe and superior to antiarrhythmic drug therapy in maintaining sinus rhythm; (2) the cost of an ablation procedure in Italy typically ranges from €8868 to €9455, though current reimbursement remains insufficient, covering only about 60% of the costs; (3) the costs of follow-up are modest (about 8% of total costs); (4) assuming an adjustment of reimbursement to the real cost of an ablation procedure and a 5-10% increase in the annual rate of ablation procedures, after approximately 5-6 years this would result in significant incremental savings for the Italian Healthcare System. In conclusion, catheter ablation of AF is a cost-effective procedure that is inadequately reimbursed in Italy. Insufficient reimbursement may serve as disincentive to perform AF ablation, thereby limiting patient access to this treatment. Considering the healthcare system perspective, higher initial costs for ablation procedures in the short term may be offset by cost savings mainly associated with decreased hospitalizations over time.

Analysis of the ‘reformpool’-activity in Austria: is the challenge met?

PubMed Central

Czypionka, Thomas; Röhrling, Gerald

2009-01-01

Aim The purpose of our study is to analyse the activities initiated by the foundation of the reformpools on the regional level. We wanted to see not only what projects have emerged from these funds, but also how the incentives of this special way of funding influence the activity and what overall impact can be expected on health services delivery in the future. Context In Austria, all expenses in the outpatient sector are borne by the statutory health insurance. But in the inpatient sector, SHI just co-finances about 45% of all costs incurred by patients, with the rest contributed by the federal, regional and municipal level. This, however, leads to a number of problems in today's epidemiological situation with patients in need of many different interventions in the course of their chronic disease. Originally with the aim of finding solutions to these interface problems between inpatient and outpatient care, the healthcare reform 2005 instated the instrument of the reformpool. The reformpool unites funds from social health insurance and regions to finance projects that develop new ways of health services delivery across the sectors. In the course of recent reforms, it became explicitly possible to sponsor projects of integrated care, which had de facto already been the case before. Theory The reform pool has various disincentives or wrong incentives compared to e.g. the German ‘Anschubfinanzierung’ for IC-contracts, which was probably a role-model for the Austrian reformpool, because of the underlying differences in the healthcare system and the distinct differences in the regulation. For example, the ‘Anschubfinanzierung’ in Germany withdraws money from the available funds for contract physicians to finance IC-projects, whereas in Austria, their fees are fixed. So in Austria, there is no incentive to retrieve money by participating in such projects. For the stakeholders supplying the pool, mainly the sickness funds and the regions, many projects inflict additional costs on the one or on the other in the future. So as both parties have to agree on projects, there is a strong basic disincentive to grant funds in the present. If a project is in both their interest because it is reducing costs, the care providers might not be interested to participate, as this would diminish their revenues in the future. What is more, the federal control over the (region-based) funds and projects is poor, which might lead to duplication of efforts and missing scale-efficiency in some regions. Methods and data For our analysis, we conducted a survey with a standardised questionnaire sent to the management of the regional health funds, which are responsible for the reformpool funds. The questionnaire was checked by experts of the federal association of social security institutions. We also conducted an on-site visit of the reformpool-manager, a programme which can be used to evaluate the reformpool-projects. In addition, we used all available evaluation reports of projects to assess the situation of evaluation of the projects. Furthermore, we used financial data from the regional health funds, the federal association of social security institutions, from the ministry of health and the regional health funds to assess the usage of the reformpool. (Preliminary) Results The qualitative results are mixed. Some projects are promising with regard to improvements of the current situation and are well evaluated. Many projects neglect the requirement of the reformpool to be such as to yield a monetary benefit for the system but only focus on improving service delivery. Some evaluations are not well operationalised and thus, arguments why these projects should be transformed to ordinarily financed services will be lacking. The reformpool activity set on very slowly, with only one project already started in 2005, the first possible year. In 2007 we see the highest number (23) of new projects granted and the highest monetary volume, €11 Mio total for 21 of them 1, with activity subsiding in 2008 (6 projects with a volume of € 2.5 Mio total for 5 of them 1) and most certainly in 2009 (with diminishing tax revenues and health insurance contributions) with only one project granted in the first quarter of the year. Of all funds (theoretically) available, only about 16% have been put to use in a reformpool project per year, with high variation (e.g. in the region of Styria over 30%, in Tyrol only 1.5%). (Preliminary) Conclusions From our study we can tell that the instrument of reformpool was not devised well concerning its incentive structure, and the interest to conduct such projects is diminishing. Stricter control of the requirements by the federal level, more pronounced requirements, a dedication of the funds to projects instead of a virtual budget and more cooperation between regions could improve the effectiveness of the instrument. Conflicts of interest: The project was funded by the federal association of social security institutions. All authors are researchers at the IHS and hold no commercial interests in the subject. Additional information: Founded by the economist Oskar Morgenstern and the sociologist Paul Lazarsfeld, the IHS (Institute for Advanced Studies) is a non-profit post-graduate teaching and research facility in the fields of economics, sociology and politology, and one of the two Austrian institutes preparing the official economic forecast for Austria. For more than a decade, it has been one of the major research facilities in the fields of health economics and health policy in Austria.

Tensions between materials and environmental quality.

PubMed

Carpenter, R A

1976-02-20

The tensions between availability of materials and quality of the environment will increase with economic growth and the appreciation of environmental values. These tensions can be relieved to an extent by internalizing the costs of environmental protection so that they are reflected in the price of materials. Economic incentives and disincentives, such as effluent fees, are receiving renewed attention (5, pp. 49-51). In addition, government regulation to protect the environment will, perhaps arbitrarily, affect the availability and use of materials. The report, Man, Materials, and Environment (5, p. 25), concluded that: A national materials policy should be based upon the principle that calculations of benefits and costs associated with the extraction, transport, processing, use, and disposal of materials should take full account of the value of common property resources and of any change in the value of common properties resulting from the impact of materials on the environment; and should support the principle that those responsible for impairment of the environment should bear the costs of damage or repair. These principles should become a commonplace element of property rights, legislation, and administrative practice at all levels of government. The difficulty of measuring benefits and costs should not delay adoption of these principles but suggests the need for continuous observation and experimentation. Environmental protection regulations will result in: (i) increased costs for many materials; (ii) disruptive changes in use of materials, due to environmental characteristics and revised cost effectiveness calculations; (iii) restrictions on the siting of processing and manufacturing installations; (iv) preemption of access and surface rights to some mineral bearing lands, particularly those that are federally controlled; (v) diversion of capital from new production facilities; and (vi) frustrating delays in decisions, such as those affecting leasing and plant siting. In return for these generally undesirable disruptions in the continued development and supply of materials, society will obtain: (i) improved quality of air and water; (ii) long-term protection of the natural ecosystems of which man is a part; (iii) more efficient allocation of natural resources on the basis of more accurate and complete accounting of costs; (iv) improved human health through decreased contamination of the environment with toxic substances; and (v) conservation of materials through a closing of the production, use, and disposal cycle. Ingenuity and a more complete understanding of the parts and interactions of the energy, materials, and environment system can do much to reduce the tensions in these conflicts and bring about equitable trade-offs among societal goals.

Modifier 22 for acetabular fractures in morbidly obese patients: does it affect reimbursement?

PubMed

Bergin, Patrick F; Kneip, Christopher; Pierce, Christine; Hendrix, Stephen T; Porter, Scott E; Graves, Matthew L; Russell, George V

2014-11-01

Modifier 22 in the American Medical Association's Current Procedural Terminology (CPT®) book is a billing code for professional fees used to reflect an increased amount of skill, time, and work required to complete a procedure. There is little disagreement that using this code in the setting of surgery for acetabulum fractures in the obese patient is appropriate; however, to our knowledge, the degree to which payers value this additional level of complexity has not been determined. We asked whether (1) the use of Modifier 22 increased reimbursements in morbidly obese patients and (2) there was any difference between private insurance and governmental payer sources in treatment of Modifier 22. Over a 4-year period, we requested immediate adjudication with payers when using Modifier 22 for morbidly obese patients with acetabular fractures. We provided payers with evidence of the increased time and effort required in treating this population. Reimbursements were calculated for morbidly obese and nonmorbidly obese patients. Of the 346 patients we reviewed, 57 had additional CPT® codes or modifiers appended to their charges and were excluded, leaving 289 patients. Thirty (10%) were morbidly obese and were billed with Modifier 22. Fifty-three (18%) were insured by our largest private insurer and 69 (24%) by governmental programs (Medicare/Medicaid). Eight privately insured patients (15%) and seven governmentally insured patients (10%) were morbidly obese and were billed with Modifier 22. For our primary question, we compared reimbursement rates between patients with and without Modifier 22 for obesity within the 289 patients. We then performed the same comparison for the 53 privately insured patients and the 69 governmentally insured patients. Overall, there was no change in mean reimbursement when using Modifier 22 in morbidly obese patients, compared to nonmorbidly obese patients (USD 2126 versus USD 2149, p < 0.94). There was also no difference in mean reimbursements with Modifier 22 in either the privately insured patients (USD 3445 versus USD 2929, p = 0.16) or the governmentally insured patients (USD 1367 versus USD 1224, p=0.83). Despite educating payers on the increased complexity and time needed to deal with morbidly obese patients with acetabular fractures, we have not seen an increased reimbursement in this challenging patient population. This could be a disincentive for many centers to treat these challenging injuries. Further efforts are needed to convince government payer sources to increase compensation in these situations. Level IV, economic and decision analyses. See Instructions for Authors for a complete description of levels of evidence.

Navigating Financial and Supply Reliability Tradeoffs in Regional Drought Portfolios

NASA Astrophysics Data System (ADS)

Zeff, H. B.; Herman, J. D.; Characklis, G. W.; Reed, P. M.

2013-12-01

Rising development costs and growing concerns over environmental impacts have led many communities to explore more diversified regional portfolio-type approaches to managing their water supplies. These strategies coordinate existing supply infrastructure with other ';assets' such as conservation measures or water transfers, reducing the capacity and costs required to meet demand by providing greater adaptability to changing hydrologic conditions. For many water utilities, however, this additional flexibility can also cause unexpected reductions in revenue (i.e. conservation) or increased costs (i.e. transfers), fluctuations that can be very difficult for a regulated entity to manage. Thus, despite the advantages, concerns over the resulting financial disruptions provide a disincentive for utilities to develop more adaptive methods, potentially limiting the role of some very effective tools. This study seeks to design portfolio strategies that employ financial instruments (e.g. contingency funds, index insurance) to reduce fluctuations in revenues and costs and therefore do not sacrifice financial stability for improved performance (e.g. lower expected costs, high reliability). This work describes the development of regional water supply portfolios in the ';Research Triangle' region of North Carolina, an area comprising four rapidly growing municipalities supplied by nine surface water reservoirs in two separate river basins. Disparities in growth rates and the respective individual storage capacities of the reservoirs provide the region with the opportunity to increase the efficiency of the regional supply infrastructure through inter-utility water transfers, even as each utility engages in its own conservation activities. The interdependence of multiple utilities navigating shared conveyance and treatment infrastructure to engage in transfers forces water managers to consider regional objectives, as the actions of any one utility can affect the others. Results indicate the inclusion of inter-utility water transfers allows the water utilities to improve on regional operational objectives (i.e. higher reliability and lower restriction frequencies) at a lower expected cost, while financial mitigation tools introduce a tradeoff between expected costs and cost variability. Financial mitigation schemes, including both third-party financial insurance contracts and contingency funds (i.e. self-insurance), were able to reduce cost variability at a lower expected cost than mitigation schemes which use self-insurance alone. The dynamics of the Research Triangle scenario (e.g. rapid population growth, constrained supply, and sensitivity to cost/revenue swings) suggest that this work may have the potential to more generally inform utilities on the effects of coordinated regional water supply planning and the resulting financial implications of more flexible, portfolio-type management techniques.

Does access to a colorectal cancer screening website and/or a nurse-managed telephone help line provided to patients by their family physician increase fecal occult blood test uptake?: A pragmatic cluster randomized controlled trial study protocol.

PubMed

Clouston, Kathleen; Katz, Alan; Martens, Patricia J; Sisler, Jeff; Turner, Donna; Lobchuk, Michelle; McClement, Susan

2012-05-17

Fecal occult blood test screening in Canada is sub-optimal. Family physicians play a central role in screening and are limited by the time constraints of clinical practice. Patients face multiple barriers that further reduce completion rates. Tools that support family physicians in providing their patients with colorectal cancer information and that support uptake may prove useful. The primary objective of the study is to evaluate the efficacy of a patient decision aid (nurse-managed telephone support line and/or colorectal cancer screening website) distributed by community-based family physicians, in improving colorectal cancer screening rates. Secondary objectives include evaluation of (dis)incentives to patient FOBT uptake and internet use among 50 to 74 year old males and females for health-related questions. Challenges faced by family physicians in engaging in collaborative partnerships with primary healthcare researchers will be documented. A pragmatic, two-arm, randomized cluster controlled trial conducted in 22 community-based family practice clinics (36 clusters) with 76 fee-for-service family physicians in Winnipeg, Manitoba, Canada. Each physician will enroll 30 patients attending their periodic health examination and at average risk for colorectal cancer. All physicians will follow their standard clinical practice for screening. Intervention group physicians will provide a fridge magnet to each patient that contains information facilitating access to the study-specific colorectal cancer screening decision aids (telephone help-line and website). The primary endpoint is patient fecal occult blood test completion rate after four months (intention to treat model). Multi-level analysis will include clinic, physician and patient level variables. Patient Personal Health Identification Numbers will be collected from those providing consent to facilitate analysis of repeat screening behavior. Secondary outcome data will be obtained through the Clinic Characterization Form, Patient Tracking Form, In-Clinic Patient Survey, Post-Study Follow-Up Patient Survey, and Family Physician Survey. Study protocol approved by The University of Manitoba Health Research Ethics Board. The study intervention has the potential to increase patient fecal occult blood test uptake, decrease colorectal cancer mortality and morbidity, and improve the health of Manitobans. If utilization of the website and/or telephone support line result in clinically significant increases in colorectal cancer screening uptake, changes in screening at the policy- and system-level may be warranted. Clinical trials.gov identifier NCT01026753.

Population policy.

PubMed

1987-03-01

Participants in the Seminar on Population Policies for Top-level Policy Makers and Program Managers, meeting in Thailand during January 1987, examined the challenges now facing them regarding the implementation of fertility regulation programs in their respective countries -- Bangladesh, China, India, Indonesia, Malaysia, Nepal, Pakistan, the Philippines, the Republic of Korea, and Thailand. This Seminar was organized to coincide with the completion of an Economic and Social Commission for Asia and the Pacific (ESCAP) study investigating the impact and efficiency of family planning programs in the region. Country studies were reviewed at the Seminar along with policy issues about the status of women, incentive and disincentive programs, and socioeconomic factors affecting fertility. In Bangladesh the government recognizes population growth as its top priority problem related to the socioeconomic development of the country and is working to promote a reorientation strategy from the previous clinic-oriented to a multidimensional family welfare program. China's family planning program seeks to postpone marraige, space the births of children between 3-5 years, and promote the 1-child family. Its goal is to reduce the rate of natural increase from 12/1000 in 1978 to 5/1000 by 1985 and 0 by 2000. India's 7th Five-Year-Plan (1986-90) calls for establishing a 2-child family norm by 2000. In Indonesia the government's population policy includes reducing the rate of population growth, achieving a redistribution of the population, adjusting economic factors, and creating prosperous families. The government of Indonesia reversed its policy to reduce the population growth rate in 1984 and announced its goal of achieving a population of 70 million by 2100 in order to support mass consumption industries. It has created an income tax deduction system favoring large families and maternity benefits for women who have up to 5 children as incentives. Nepal's official policy is to decrease fertility, control international migration, and modify the spatial distribution of the population. To reduce its population growth rate, Pakistan has adopted a multi-sectoral, multidimensional approach to family planning. The policy of the government of the Philippines is to bring the population growth rate in line with the availability of natural resources and employment opportunities. In its 5-year plan covering 1982-86, the government of the Republic of Korea emphasized social development, attempting to more fully integrate population and development policies and programs within relevant sectors. To reduce its population growth rate to 1.3% by 1992, the government of Thailand is expanding the reach of its family planning program.

Regulatory Incentives and Disincentives for Utility Investments in Grid Modernization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kihm, Steve; Beecher, Janice; Lehr, Ronald L.

Electric power is America's most capital-intensive industry, with more than $100 billion invested each year in energy infrastructure. Investment needs are likely to grow as electric utilities make power systems more reliable and resilient, deploy advanced digital technologies, and facilitate new services to meet some consumers' expectations for greater choice and control. But do current regulatory approaches provide the appropriate incentives for grid modernization investments? This report presents three perspectives: -Financial analyst Steve Kihm begins by explaining that any major investor-owned electric utility that wants to raise capital today can do so at a reasonable cost. The question is whethermore » utility managers want to raise capital for grid modernization. Specifically, they look for investments that create the most value for their existing shareholders. In cases where grid modernization investments are not the best choice in terms of shareholder value, Kihm describes shareholder incentive mechanisms that regulators could consider to encourage such investments when they are in the public interest. -From an institutional perspective, Dr. Janice Beecher finds that the traditional rate-base/rate of return regulatory model provides powerful incentives for utilities to pursue investments, cost control, efficiency and even innovation, and it is well suited to the policy objectives of grid modernization. Prudence of grid modernization investments (fair returns) depends on careful evaluation of the specific asset, and any special incentives (bonus returns) should be used only if they promote economic efficiency consistent with the core goals of economic regulation. According to Beecher, realizing the promises of grid modernization depends on effective implementation of the traditional regulatory model and ratemaking tools to serve the public interest. -Conversely, former commissioner and clean energy consultant Ron Lehr says that rapid electric industry changes require a better alignment of utility investment incentives with changes challenging the electricity sector, emerging grid modernization options and benefits, and public policies. For example, investor-owned utilities typically have an incentive to make capital investments, but rarely to employ expense-based solutions, since utilities do not earn profits on expenses. Further, Lehr cites a variety of factors that stand in the way of creating well targeted and well aligned utility incentives, including litigated regulatory processes. These may be a poor choice for finding the right balance among competing interests, establishing rules of prospective application, justifying demonstrations of new technologies and approaches to meeting emerging consumer demands, and keeping pace with rapid change.« less

NASA's New Technology Reporting System: A Review and Future Prospects

NASA Technical Reports Server (NTRS)

Chapman, Richard L.

1985-01-01

This report represents a systematic effort to describe how NASA's new technology reporting system operates today, and how that system might be enhanced. Although the system has run for more than two decades, it is not well documented in terms of organization, operational practices, or other program benchmarks. The study seeks to identify and assess incentives or disincentives to reporting, program management, program follow through, and the feasibility of various means for improving the general process. Initially, it was hoped that the study team might uncover the kind of information that would permit the determination of some 'average' sequence of events (or a time line) from the point of identifying a solution to technical 'need' to the point where its solution was actually reported to NASA. Information regarding this objective proved to be too elusive, primarily because early probes revealed that con- tractor awareness of the new technology requirements generally was too poor to provide useful information. The report that follows is based primarily upon documents furnished by NASA Headquarters, by Field Center technology utilization officers, and interviews with persons knowledgeable about the system. Visits were made to seven Field Centers: Ames Research Center, Goddard Space Flight Center, Jet Propulsion Laboratory, Johnson Space Center, Langley Research Center, Lewis Research Center, and Marshall Space Flight Center. Other documents were furnished by officials of major aerospace corporations. Detailed interviews were conducted with Field Center technology utilization officials, project engineers or scientists, patent counsels, and other Field Center officials who had knowledge about the new technology reporting system. Interviews also were conducted with knowledgeable officials from a number of the primary aerospace companies. Numeric data was obtained from regular NASA reports, from original sources such as, NASA Tech Briefs, or from contractor reports. I am indebted to dozens of persons in both NASA and industry who took time to assist in the data collection by being interviewed, and through answering follow up questions on the telephone. Individuals interviewed and their affiliations are shown in Appendix A. I am most grateful to them for their kind assistance. A note of thanks is due to the other members of the DRI study team: Jody Briles, Kathy Hirst, and Joel Johnson. The responsibility for this report, its accuracy, and the nature of the observations and conclusions rest solely with the author. Text or citations in the numbered footnotes are to be found at the end of each chapter.

Can Economic Analysis Contribute to Disease Elimination and Eradication? A Systematic Review

PubMed Central

Sicuri, Elisa; Evans, David B.; Tediosi, Fabrizio

2015-01-01

Background Infectious diseases elimination and eradication have become important areas of focus for global health and countries. Due to the substantial up-front investments required to eliminate and eradicate, and the overall shortage of resources for health, economic analysis can inform decision making on whether elimination/eradication makes economic sense and on the costs and benefits of alternative strategies. In order to draw lessons for current and future initiatives, we review the economic literature that has addressed questions related to the elimination and eradication of infectious diseases focusing on: why, how and for whom? Methods A systematic review was performed by searching economic literature (cost-benefit, cost-effectiveness and economic impact analyses) on elimination/eradication of infectious diseases published from 1980 to 2013 from three large bibliographic databases: one general (SCOPUS), one bio-medical (MEDLINE/PUBMED) and one economic (IDEAS/REPEC). Results A total of 690 non-duplicate papers were identified from which only 43 met the inclusion criteria. In addition, only one paper focusing on equity issues, the “for whom?” question, was found. The literature relating to “why?” is the largest, much of it focusing on how much it would cost. A more limited literature estimates the benefits in terms of impact on economic growth with mixed results. The question of how to eradicate or eliminate was informed by an economic literature highlighting that there will be opportunities for individuals and countries to free-ride and that forms of incentives and/or disincentives will be needed. This requires government involvement at country level and global coordination. While there is little doubt that eliminating infectious diseases will eventually improve equity, it will only happen if active steps to promote equity are followed on the path to elimination and eradication. Conclusion The largest part of the literature has focused on costs and economic benefits of elimination/eradication. To a lesser extent, challenges associated with achieving elimination/eradication and ensuring equity have also been explored. Although elimination and eradication are, for some diseases, good investments compared with control, countries’ incentives to eliminate do not always align with the global good and the most efficient elimination strategies may not prioritize the poorest populations. For any infectious disease, policy-makers will need to consider realigning contrasting incentives between the individual countries and the global community and to assure that the process towards elimination/eradication considers equity. PMID:26070135

Science for Society Workshop Summary Report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wolfe, Amy K; Bjornstad, David J; Lenhardt, W Christopher

Science for Society, a workshop held at the Oak Ridge National Laboratory (ORNL) on September 27, 20111, explored ways to move Laboratory science toward use. It sought actionable recommendations. Thus the workshop focused on: (1) current practices that promote and inhibit the translation of science into use, (2) principles that could lead to improving ORNL's translational knowledge and technology transfer efforts, and (3) specific recommendations for making these principles operational. This highly interactive workshop struck a positive chord with participants, a group of 26 ORNL staff members from diverse arenas of science and technology (S and T), technology transfer, andmore » external laboratory relations, who represented all levels of science, technology, and management. Recognizing that the transformation of fundamental principles into operational practices often follows a jagged path, the workshop sought to identify key choices that could lead to a smoother journey along this path, as well as choices that created roadblocks and bottlenecks. The workshop emphasized a portion of this pathway, largely excluding the marketplace. Participants noted that research translation includes linkages between fundamental and applied research and development (R and D), and is not restricted to uptake by manufacturers, consumers, or end users. Three crosscutting ideas encapsulate workshop participants observations: (1) ORNL should take more action to usher the translation of its S and T products toward use, so as to make a positive national and global impact and to enhance its own competitiveness in the future; (2) ORNL (and external entities such as DOE and Congress) conveys inconsistent messages with regard to the importance of research translation and application, which (a) creates confusion, (b) poses disincentives to pursue research translation, (c) imposes barriers that inhibit cross-fertilization and collaboration, and (d) diminishes the effectiveness of both the science mission and the translation of that science for use; and (3) ORNL should design its commitments and actions for helping move science from the Laboratory toward use to align with one another and should integrate them into its institutional culture in such a way as to elevate research translation and application to coequal status with scientific excellence. Participants made several actionable recommendations for enhancing research translation at ORNL, some of which were particular to specific S and T domains. Among the recommendations that participants agreed apply Lab-wide are to: align metrics and incentives with research translation goals; manage risks and conflicts of interest instead of avoiding them; and create programs (e.g., entrepreneurial leave) that promote interactions between key ORNL staff and industry in ways that complement careers at ORNL.« less

Population education and China: prospects for the one child family.

PubMed

Fraser, S E

1980-01-01

With China's population approaching the billion mark much publicity has been given to promoting the 1 child family, including a massive educational campaign with a series of incentives and disincentives being introduced in some provinces. China needs to immediately achieve and maintain a growth rate of less than 1%. Demographic figures for 1978 suggested that 11 of China's most populous provinces had already reached the target of less than 1% growth rate per annum. Some incentives being recommended to encourage the 1 child family include: 1) working parents who promise not to have a 2nd child receive 6 yuan/month in child welfare subsidies until the child is 14 years old, 2) they will be entitled to an equal amount of living space as a family of 4, 3) the child will have priority of admission to schools and factories provided they meet the entrance requirements, and 4) medical benefits will be available free for the child in a single child family. Sterilization as a means of reducing fertility presents social and medical problems in China and is not being publicized to the same extent as the 1 child family. Incentives for 2 child families include: 1) priority in housing, 2) waiver of compulsory rustication, and 3) priority in getting city jobs for rural youth. There are also measures which discourage parents from trying to have a son when they already have 2 daughters since a daughter may replace her father in his job when he retires. Other incentives include subsidized schooling, priority to move from rural to urban areas and more equal pay for women for equal work. Traditional attitudes towards the transitory value of a daughter and the supposed enduring worth of a son is being challenged with daughters now being encouraged to persuade their husbands to become part of the daughters' households. Longterm implications of the new programs are more equitable food and job supply for the future. In addition, there are guarantees that the standard of living of the elderly will be high regardless of the fact that they have few children to support them. Population growth rates are falling as a result of these programs. The following are some of the economic sanctions levied against couples who produce a second child after being rewarded for only having one: deduction from welfare expenses, nonpayment of medical expenses, and no food coupons. China has taken a great social leap forward in promoting the 1 child family and the call for population education and family planning information dissemination has been established in public schools.

The chicken or the egg? Exploring bi-directional associations between Newcastle disease vaccination and village chicken flock size in rural Tanzania.

PubMed

de Bruyn, Julia; Thomson, Peter C; Bagnol, Brigitte; Maulaga, Wende; Rukambile, Elpidius; Alders, Robyn G

2017-01-01

Newcastle disease (ND) is a viral disease of poultry with global importance, responsible for the loss of a potential source of household nutrition and economic livelihood in many low-income food-deficit countries. Periodic outbreaks of this endemic disease result in high mortality amongst free-ranging chicken flocks and may serve as a disincentive for rural households to invest time or resources in poultry-keeping. Sustainable ND control can be achieved through vaccination using a thermotolerant vaccine administered via eyedrop by trained "community vaccinators". This article evaluates the uptake and outcomes of fee-for-service ND vaccination programs in eight rural villages in the semi-arid central zone of Tanzania. It represents part of an interdisciplinary program seeking to address chronic undernutrition in children through improvements to existing poultry and crop systems. Newcastle disease vaccination uptake was found to vary substantially across communities and seasons, with a significantly higher level of vaccination amongst households participating in a longitudinal study of children's growth compared with non-participating households (p = 0.009). Two multivariable model analyses were used to explore associations between vaccination and chicken numbers, allowing for clustered data and socioeconomic and cultural variation amongst the population. Results demonstrated that both (a) households that undertook ND vaccination had a significantly larger chicken flock size in the period between that vaccination campaign and the next compared with those that did not vaccinate (p = 0.018); and (b) households with larger chicken flocks at the time of vaccination were significantly more likely to participate in vaccination programs (p < 0.001). Additionally, households vaccinating in all three vaccination campaigns held over 12 months were identified to have significantly larger chicken flocks at the end of this period (p < 0.001). Opportunities to understand causality and complexity through quantitative analyses are limited, and there is a role for qualitative approaches to explore decisions made by poultry-keeping households and the motivations, challenges and priorities of community vaccinators. Evidence of a bi-directional relationship, however, whereby vaccination leads to greater chicken numbers, and larger flocks are more likely to be vaccinated, offers useful insights into the efficacy of fee-for-service animal health programs. This article concludes that attention should be focused on ways of supporting the participation of vulnerable households in ND vaccination campaigns, and encouraging regular vaccination throughout the year, as a pathway to strengthen food security, promote resilience and contribute to improved human nutrition.

Reimbursement for pediatric diabetes intensive case management: a model for chronic diseases?

PubMed

Beck, Joni K; Logan, Kathy J; Hamm, Robert M; Sproat, Scott M; Musser, Kathleen M; Everhart, Patricia D; McDermott, Harrold M; Copeland, Kenneth C

2004-01-01

Current reimbursement policies serve as potent disincentives for physicians who provide evaluation and management services exclusively. Such policies threaten nationwide availability of care for personnel-intensive services such as pediatric diabetes. This report describes an approach to improving reimbursement for highly specialized, comprehensive pediatric diabetes management through prospective contracting for services. The objective of this study was to determine whether pediatric diabetes intensive case management services are cost-effective to the payer, the patient, and a pediatric diabetes program. A contract with a third-party payer was created to reimburse for 3 key pediatric diabetes intensive case management components: specialty education, 24/7 telephone access to an educator (and board-certified pediatric endocrinologist as needed), and quarterly educator assessments of self-management skills. Data were collected and analyzed for 15 months after signing the contract. Within the first 15 months after the contract was signed, 22 hospital admissions for diabetic ketoacidosis (DKA) occurred in 16 different patients. After hospitalizations for DKA, all 16 patients were offered participation in the program. All were followed during the subsequent 1 to 15 months of observation. Ten patients elected to participate, and 6 refused participation. Frequency of rehospitalization, emergency department visits, and costs were compared between the 2 groups. Among the 10 participating patients, there was only 1 subsequent DKA admission, whereas among the 6 who refused participation, 5 were rehospitalized for DKA on at least 1 occasion. The 10 patients who participated in the program had greater telephone contact with the team compared with those who did not (16 crisis-management calls vs 0). Costs (education, hospitalization, and emergency department visits) per participating patient were approximately 1350 dollars less than those for nonparticipating patients. Differences between participating and nonparticipating groups included age (participants were of younger age), double-parent households (participants were more likely to be from double parent households), and number of medical visits kept (participants kept more follow-up visits). No differences in duration of diabetes, months followed in the program, sex, or ethnicity were observed. Contracting with third-party payers for pediatric diabetes intensive case management services reduces costs by reducing emergency department and inpatient hospital utilizations, likely a result of intensive education and immediate access to the diabetes health care team for crisis management. Such strategies may prove to be cost saving not only for diabetes management but also for managing other costly and personnel-intensive chronic diseases.

"First, do no harm": legal guidelines for health programmes affecting adolescents aged 10-17 who sell sex or inject drugs.

PubMed

Conner, Brendan

2015-01-01

There is a strong evidence base that the stigma, discrimination and criminalization affecting adolescent key populations (KPs) aged 10-17 is intensified due to domestic and international legal constructs that rely on law-enforcement-based interventions dependent upon arrest, pre-trial detention, incarceration and compulsory "rehabilitation" in institutional placement. While there exists evidence and rights-based technical guidelines for interventions among older cohorts, these guidelines have not yet been embraced by international public health actors for fear that international law applies different standards to adolescents aged 10-17 who engage in behaviours such as selling sex or injecting drugs. As a matter of international human rights, health, juvenile justice and child protection law, interventions among adolescent KPs aged 10-17 must not involve arrest, prosecution or detention of any kind. It is imperative that interventions not rely on law enforcement, but instead low-threshold, voluntary services, shelter and support, utilizing peer-based outreach as much as possible. These services must be mobile and accessible, and permit alternatives to parental consent for the provision of life-saving support, including HIV testing, treatment and care, needle and syringe programmes, opioid substitution therapy, safe abortions, antiretroviral therapy and gender-affirming care and hormone treatment for transgender adolescents. To ensure enrolment in services, international guidance indicates that informed consent and confidentiality must be ensured, including by waiver of parental consent requirements. To remove the disincentive to health practitioners and researchers to engaging with adolescent KPs aged 10-17 government agencies and ethical review boards are advised to exempt or grant waivers for mandatory reporting. In the event that, in violation of international law and guidance, authorities seek to involuntarily place adolescent KPs in institutions, they are entitled to judicial process. Legal guidelines also provide that these adolescents have influence over their placement, access to legal counsel to challenge the conditions of their detention and regular visitation from peers, friends and family, and that all facilities be subject to frequent and periodic review by independent agencies, including community-based groups led by KPs. Controlling international law specifies that protective interventions among KPs aged 10-17 must not only include low-threshold, voluntary services but also "protect" adolescent KPs from the harms attendant to law-enforcement-based interventions. Going forward, health practitioners must honour the right to health by adjusting programmes according to principles of minimum intervention, due process and proportionality, and duly limit juvenile justice and child protection involvement as a measure of last resort, if any.

Bending the urban flow: a construction-migration strategy.

PubMed

Shaw, R P

1980-01-01

The excess rate of migration to urban centers is a problem affecting over 50 developing countries and 18 developed ones (68% of the world's population). Policies that rely on compulsion or disincentives have mostly failed because they do not deal with the cause of the problem. This paper proposes a strategy of increasing or decreasing the rate of housing construction in different urban areas as a means of stimulating or reducing migration to those areas; in most developing areas priority is given to residential construction in already congested metropolitan areas. 5 assumptions are the basis for this approach: 1) migrants tend to gravitate to the most powerful growth poles; 2) residential construction is a leading sector of regional and urban economies; 3) the encouragement of construction activity will make itself felt indirectly via its effect on construction-related employment; 4) rates of residential construction may be manipulated through government policy affecting the cost of materials, availability of loans, level of unionization, and price of housing; and 5) residential construction is amenable to quick policy action. The central idea of the strategy is that an increase in residential construction will exercise a pull on migrants, increasing job opportunities, raising incomes, lowering housing costs, and improving the chances of home ownership. This idea has been verified by various projects in Hong Kong, Ghana, Venezuela, Brazil, Bahrain, Mexico, Colombia, Poland, USSR, and the UK. In Bahrain low-income housing programs have been used to relocate Bahraini nationals in new outlying suburbs and to promote population growth in rural villages. In Mexico self-help and low-income housing programs have helped to redirect migrants headed for small towns toward smaller communities. There is also evidence to show that building construction has the potential to expand and contribute to economic growth. Some problems of implementation might be finding an adequate economic base, the need to place new communities close to primate cities, the use of large portions of the national budget, and profit-maximizing plans have been detrimental to the speed and development of construction migration. Some benefits for smaller urban areas of construction migrants in developing countries are: 1) emphasis on the development of a labor-intensive industry, 2) little training of workers as needed, 3) it can provide the housing required by industries planning to move to smaller areas, 4) this housing will be cheaper, and 5) incentives will exist to save and invest in the smaller areas.

If 'atypical' neuroleptics did not exist, it wouldn't be necessary to invent them: perverse incentives in drug development, research, marketing and clinical practice.

PubMed

Charlton, Bruce G

2005-01-01

Perverse incentives in drug development, research, marketing and clinical usage can be illustrated by considering the example of the so-called 'atypical' neuroleptics which have grown to become a standard - indeed expanding - part of psychiatric practice despite their probable inferiority to older sedative agents. There is now ample evidence to suggest that neuroleptics (aka. anti-psychotics and major tranquillizers) are dangerous drugs, and patients' exposure to them should be minimized wherever possible. This clinical imperative applies whether neuroleptics are of the traditional type or atypical variety, albeit for different reasons since the traditional agents are neurotoxic, while atypicals are mainly metabolic poisons. Usage of traditional neuroleptics seems indeed to be declining progressively, but the opposite seems to be happening for 'atypicals', and new indications for these drugs are being promoted. Yet the atypical neuroleptics are a category of pharmaceuticals which are close to being un-necessary since there are safer, cheaper and pleasanter substitutes, such as benzodiazepines and the sedative antihistamines (e.g. promethazine). If 'atypical' neuroleptics did not exist, it would not be necessary to invent them. Analysis of how such expensive, dangerous and inferior drugs as the 'atypicals' have nevertheless come to dominate clinical practice casts light on the perverse incentives which now motivate the pharmaceutical industry in an era of massive state regulation. The lack of positive incentives to deploy off-patent drugs is longstanding, but there is a new disincentive in the widespread but erroneous belief that only randomized controlled trials (RCTs) can provide valid 'evidence' of effectiveness. Consequently, those who control RCTs now control clinical practice. It sometimes makes commercial sense to develop and market new drugs that are inferior to existing agents, since new drugs are patent-protected and can be promoted on the back of a mass of new RCTs funded and 'owned' by the pharmaceutical corporations. The current regulatory and patenting situation, therefore, requires major reform if drug efficacy and patient safety are to become higher priorities. Given that psychiatric practice is apparently 'locked-in' to prescribing atypicals, and if (as seems likely) most informed individuals would wish to avoid neuroleptics for themselves and their loved-ones except as a last resort; then in the short-term it may be wise for patients and their families to explore the possibilities of increased self-management of psychiatric problems using over-the-counter drugs, such as the sedative antihistamines. In the long-term, there need to be legal reforms to change the regulatory and commercial framework of incentives relating to drug development. These might include new forms of short-term re-patenting of old drugs.

“First, do no harm”: legal guidelines for health programmes affecting adolescents aged 10–17 who sell sex or inject drugs

PubMed Central

Conner, Brendan

2015-01-01

Introduction There is a strong evidence base that the stigma, discrimination and criminalization affecting adolescent key populations (KPs) aged 10–17 is intensified due to domestic and international legal constructs that rely on law-enforcement-based interventions dependent upon arrest, pre-trial detention, incarceration and compulsory “rehabilitation” in institutional placement. While there exists evidence and rights-based technical guidelines for interventions among older cohorts, these guidelines have not yet been embraced by international public health actors for fear that international law applies different standards to adolescents aged 10–17 who engage in behaviours such as selling sex or injecting drugs. Discussion As a matter of international human rights, health, juvenile justice and child protection law, interventions among adolescent KPs aged 10–17 must not involve arrest, prosecution or detention of any kind. It is imperative that interventions not rely on law enforcement, but instead low-threshold, voluntary services, shelter and support, utilizing peer-based outreach as much as possible. These services must be mobile and accessible, and permit alternatives to parental consent for the provision of life-saving support, including HIV testing, treatment and care, needle and syringe programmes, opioid substitution therapy, safe abortions, antiretroviral therapy and gender-affirming care and hormone treatment for transgender adolescents. To ensure enrolment in services, international guidance indicates that informed consent and confidentiality must be ensured, including by waiver of parental consent requirements. To remove the disincentive to health practitioners and researchers to engaging with adolescent KPs aged 10–17 government agencies and ethical review boards are advised to exempt or grant waivers for mandatory reporting. In the event that, in violation of international law and guidance, authorities seek to involuntarily place adolescent KPs in institutions, they are entitled to judicial process. Legal guidelines also provide that these adolescents have influence over their placement, access to legal counsel to challenge the conditions of their detention and regular visitation from peers, friends and family, and that all facilities be subject to frequent and periodic review by independent agencies, including community-based groups led by KPs. Conclusions Controlling international law specifies that protective interventions among KPs aged 10–17 must not only include low-threshold, voluntary services but also “protect” adolescent KPs from the harms attendant to law-enforcement-based interventions. Going forward, health practitioners must honour the right to health by adjusting programmes according to principles of minimum intervention, due process and proportionality, and duly limit juvenile justice and child protection involvement as a measure of last resort, if any. PMID:25724508

At the Edge of US Immigration’s “Halt of Folly:” Data, Information, and Research Needs in the Event of Legalization

PubMed Central

Riosmena, Fernando

2014-01-01

Executive Summary Virtually all accounts of the state of the US immigration system point to its patently broken condition, with the presence of almost 12 million people without legal status paramount to this characterization. Because of several recent developments including continued and renewed interest in regularizing the status of most unauthorized migrants in executive and legislative branch agendas, the Center for Migration Studies of New York, with support from the John D. and Catherine T. MacArthur Foundation, convened a group of immigration specialists, researchers, scholars, and advocates in Washington, DC in September 2013 to discuss potential data, information, and research needs in the event of the enactment of large-scale legalization programs for the unauthorized population. This paper describes the results of this one-and-a-half day discussion. It begins with a description of the contours of a legalization program if it were to follow a similar form as S. 744, the Border Security, Economic Opportunity, and Immigration Modernization Act passed by the Senate in June 2013. In addition to being the most recent effort in this area, S. 744 includes a relatively complex set of conditions for “earning” legalization. A number of data, information, and research needs would need to be met to ensure the proper implementation of such a program. First, planning for effective local outreach and service delivery efforts requires estimating the eligible population at finer-scale geographies; understanding financial and time disincentives to apply and adhere to the program and skill levels required; assessing capacity in service delivery relative to the size and service needs of the local eligible population; tracking the progress of applicants through the legalization process; and understanding effective forms of outreach and service delivery. Second, assessing the effects of legalization on immigrant integration, future immigration, and fiscal and economic life in the United States would include anticipating the effects of legalization on eligibility and use of locally- and state-provided services by the legalized and their families. Within the discussion of these issues, the paper describes recent and potential efforts to develop methodologies, partnerships, and evaluation and tracking systems by different stakeholders and organizations to ensure and assess the short- and long-term effectiveness of legalization efforts. In doing this, a highly volatile climate make a full-fledged legalization program unlikely in the near future, waiting to plan for such a possibility until after legislation passes would be ill-advised. Because such a discussion may also help shape the parameters of how legalization takes place, fora like that provided by this meeting are valuable vehicles to organize and mobilize knowledge, and should be thus continued and expanded. PMID:25411658

A methodology for optimal MSW management, with an application in the waste transportation of Attica Region, Greece

DOE Office of Scientific and Technical Information (OSTI.GOV)

Economopoulou, M.A.; Economopoulou, A.A.; Economopoulos, A.P., E-mail: eco@otenet.gr

2013-11-15

Highlights: • A two-step (strategic and detailed optimal planning) methodology is used for solving complex MSW management problems. • A software package is outlined, which can be used for generating detailed optimal plans. • Sensitivity analysis compares alternative scenarios that address objections and/or wishes of local communities. • A case study shows the application of the above procedure in practice and demonstrates the results and benefits obtained. - Abstract: The paper describes a software system capable of formulating alternative optimal Municipal Solid Wastes (MSWs) management plans, each of which meets a set of constraints that may reflect selected objections and/ormore » wishes of local communities. The objective function to be minimized in each plan is the sum of the annualized capital investment and annual operating cost of all transportation, treatment and final disposal operations involved, taking into consideration the possible income from the sale of products and any other financial incentives or disincentives that may exist. For each plan formulated, the system generates several reports that define the plan, analyze its cost elements and yield an indicative profile of selected types of installations, as well as data files that facilitate the geographic representation of the optimal solution in maps through the use of GIS. A number of these reports compare the technical and economic data from all scenarios considered at the study area, municipality and installation level constituting in effect sensitivity analysis. The generation of alternative plans offers local authorities the opportunity of choice and the results of the sensitivity analysis allow them to choose wisely and with consensus. The paper presents also an application of this software system in the capital Region of Attica in Greece, for the purpose of developing an optimal waste transportation system in line with its approved waste management plan. The formulated plan was able to: (a) serve 113 Municipalities and Communities that generate nearly 2 million t/y of comingled MSW with distinctly different waste collection patterns, (b) take into consideration several existing waste transfer stations (WTS) and optimize their use within the overall plan, (c) select the most appropriate sites among the potentially suitable (new and in use) ones, (d) generate the optimal profile of each WTS proposed, and (e) perform sensitivity analysis so as to define the impact of selected sets of constraints (limitations in the availability of sites and in the capacity of their installations) on the design and cost of the ensuing optimal waste transfer system. The results show that optimal planning offers significant economic savings to municipalities, while reducing at the same time the present levels of traffic, fuel consumptions and air emissions in the congested Athens basin.« less

Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care.

PubMed

Rueda-Clausen, C F; Benterud, E; Bond, T; Olszowka, R; Vallis, M T; Sharma, A M

2014-02-01

Obesity counselling in primary care is positively associated with self-reported behaviour change in patients with obesity. Obesity counselling is rare, and when it does occur, it is often of low quality because of poor training and/or competency of providers' obesity management, lack of time and economical disincentives, and negative attitude towards obesity and obesity management. 5As frameworks are routinely used for behaviour-change counselling and addiction management (e.g. smoking cessation), but few studies have examined its efficacy for weight management. This study presents pilot data from the implementation and evaluation of an obesity management tool (5As of Obesity Management developed by the Canadian Obesity Network) in a primary care setting. Results show that the tool facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care. Obesity remains poorly managed in primary care. The 5As of Obesity Management is a theory-driven, evidence-based minimal intervention designed to facilitate obesity counselling and management by primary care practitioners. This project tested the impact of implementing this tool in primary care clinics. Electronic self-administered surveys were completed by pre-screened obese subjects at the end of their appointments in four primary care clinics (over 25 healthcare providers [HCPs]). These measurements were performed before (baseline, n = 51) and 1 month after implementing the 5As of Obesity Management (post-intervention, n = 51). Intervention consisted of one online training session (90 min) and distribution of the 5As toolkit to HCPs of participating clinics. Subjects completing the survey before and after the intervention were comparable in terms of age, sex, body mass index, comorbidities, satisfaction and self-reported health status (P > 0.2). Implementing the 5As of Obesity Management resulted in a twofold increase in the initiation of obesity management (19 vs. 39%, P = 0.03), and caused a statistically significant increase in the perceived follow-up/coordination efforts (self-reported Patient Assessment of Chronic Illness Care components, 45 ± 22 vs. 67 ± 12 points, P = 0.002), as well as two components of the 5As framework: Assess (50 ± 29 vs. 66 ± 15 points, P = 0.03) and Assist (54 ± 26 vs. 72 ± 13 points, P = 0.01). Our results suggest that using the 5As of Obesity Management facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care. © 2013 The Authors. Clinical Obesity © 2013 International Association for the Study of Obesity.

Laparoscopic versus open nephrectomy for live kidney donors.

PubMed

Wilson, Colin H; Sanni, Aliu; Rix, David A; Soomro, Naeem A

2011-11-09

Waiting lists for kidney transplantation continue to grow and live organ donation has become more important as the number of brain stem dead cadaveric organ donors continues to fall. The major disincentive to potential kidney donors is the pain and morbidity associated with open surgery. To identify the benefits and harms of using laparoscopic compared to open nephrectomy techniques to recover kidneys from live organ donors. We searched the online databases CENTRAL (in The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to January 2010) and EMBASE (January 1980 to January 2010) and handsearched textbooks and reference lists. Randomised controlled trials comparing laparoscopic donor nephrectomy (LDN) with open donor nephrectomy (ODN). Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Six studies were identified that randomised 596 live kidney donors to either LDN or ODN arms. All studies were assessed as having low or unclear risk of bias for selection bias, allocation bias, incomplete outcome data and selective reporting bias. Four of six studies had high risk of bias for blinding. Various different combinations of techniques were used in each study, resulting in heterogeneity in the results. The conversion rate from LDN to ODN ranged from 1% to 1.8%. LDN was generally found to be associated with reduced analgesia use, shorter hospital stay, and faster return to normal physical functioning. The extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) with no associated short-term consequences. ODN was associated with shorter duration of procedure. For those outcomes that could be meta-analysed there were no significant differences between LDN or ODN for perioperative complications (RR 0.87, 95% CI 0.47 to 4.59), reoperations (RR 0.57, 95% CI 0.09 to 3.64), early graft loss (RR 0.31, 95% CI 0.06 to 1.48), delayed graft function (RR 1.09, 95% CI 0.52 to 2.30), acute rejection (RR 1.41, 95 % CI 0.87 to 2.27), ureteric complications (RR 1.51, 95% CI 0.69 to 3.31), kidney function at one year (SMD 0.15, 95% CI -0.11 to 0.41) or graft loss at one year (RR 0.76, 95% CI 0.15 to 3.85). LDN is associated with less pain compared with open surgery; however, there are equivalent numbers of complications and occurrences of perioperative events that require further intervention. Kidneys obtained using LDN procedures were exposed to longer warm ischaemia periods than ODN-acquired grafts, although this has not been reported as being associated with short-term consequences.

Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of Primary Health Care? Perspectives of key stakeholders in northern Ghana.

PubMed

Awoonor-Williams, John Koku; Tindana, Paulina; Dalinjong, Philip Ayizem; Nartey, Harry; Akazili, James

2016-08-30

In 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana's health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC. Using qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers. A stakeholders' workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from participants for the achievement of the goals of UHC and PHC. The key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS, inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC. This study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC.

Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of Primary Health Care? Perspectives of key stakeholders in northern Ghana.

PubMed

Awoonor-Williams, John Koku; Tindana, Paulina; Dalinjong, Philip Ayizem; Nartey, Harry; Akazili, James

2016-09-05

In 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana's health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC. Using qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers. A stakeholders' workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from respondents for the achievement of the goals of UHC and PHC. The key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS; inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC. This study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC.

The population problem and policy in Mainland China 1949-1980: a demographic and anthropological observation.

PubMed

Yin, C C

1981-12-01

This research focuses on Mainland China's population problems and the formation of population policy. It attempts to analyze the relationships between economy and population and between modernization and Communist party decisionmaking. The second hand data used from 4 sources: related newspapers, magazines, official reports and documents from Mainland China; some related Western studies; some Communist China watchers' reports and studies from Hong Kong and the Republic of China; and some related studies of demographic, social, and economic theory. The analysis covers: population growth the Mainland China; sociocultural background of population growth; Communist China's point of view of population problems; Communist China's economy and population problems; and a diachronic approach to population policy. The August 1979 article "For the Realization of the Four Modernizations" suggests that Communist China faces a crisis. First, from the macroeconomic viewpoint Marxian ideology must be reconciled with Malthus' theory. As a result of the increasingly ambitious mainlandwide goals of trimming population growth, the Communit regime set a goal of lowering the natural population growth rate to 0.5% by 1985 and zero population growth at 2000. It also established an incentive/disincentive policy to reach the goal of a 1-child family. In the sphere of economic development, they turn to a nonsocialist model which seems to be a revision back to Liu Shao-chi's line. Finally, it seems at this time that the top officianls realize the need to raise the standard of living for the people. Yet, the question remains as to how long this policy can survive. 30 years after Mainland China became the biggest human laboratory for Communism the Communists have failed to solve most of the salient problems, including educational and scientific development, cultural development, socioeconomic development, and the population problem. They also have created many unprecedented problems, including a low standard of living and a low per capita income, a lack of incentive among the working people, and numerous power struggles and economic policy vacillations. To carry out the 4 modernizations Mainland China is giving up the Maoist and Marxist line. The policy is shifting to revisionism. It is also necessary to reconcile with the Malthusian theory in order to carry out the birth control campaign. The population is 80% rural. More than 50% of the total populations is in the 0-21 age group. The Communist Party always attempts political solutions to solve the population problem, and it now uses the reward and penalty system. The regime attempts to create the image that the 1-child family policy will decide the success or failure of the 4 modernizations. It is believed that the success or failure of the 4 modernizations depends upon the reformation of the regime's institution as a whole rather than a single policy -- the 1-child family.

Singapore.

PubMed

1982-09-01

Attention in this discussion of Singapore is directed to the following: history of the country's demographic situation; government's overall approach to population problems; population data systems and development planning; institutional arrangements for the integration of population within development planning; government's view of the importance of population policy in achieving development objectives; population size, growth and natural increase; morbidity and mortality; fertility; international migration; and spatial distribution. The Republic of Singapore has experienced high population growth rates for some time, with its population of 1.02 million in 1950 increasing to an estimated 2.39 million in 1980. In recent years the rate has declined significantly, decreasing from nearly 5% per year in the early 1950s to 2.8 in 1960-65 and 1.5 in 1970-75. At the present growth rate of about 1.2% per annum, and anticipating the further declines that have been projected for 1995-2000, the population of Singapore is expected to reach about 2.97 million by the end of this century. The government considers the stabilization of the country's population to be 1 of its important objectives. In 1961 population growth was recognized as a serious problem. Singapore has a long history of census taking, having recently conducted its 11th decennial census. Because of the rapid decline in fertility in recent years, the government perceives the nation's current rates of natural increase and fertility as satisfactory, neither constraining development nor inhibiting economic growth. Yet, the government has established as a social norm a goal of a 2 child family and supports policies that discourage early marriage and childbearing at very young ages. The government maintains that Singapore's current rate of population growth is satisfactory, which is a recent change of position that is based on the rapid decline in fertility in the 1960s and 1970s. The crude death rate declined from about 10.6/1000 in 1950-55 to 7.1 in 1960-65 and to 5.1 in both 1970-75 and 1975-80, according to UN estimates. The average life expectancy at birth for both sexes has been improving. To reduce the need for high cost hospital services, the government has recently given more attention to promotive and preventive medicine. The crude birthrate, which was estimated to be around 44 births/1000 in 1950-55, has declined in the past several decades, decreasing to 17.2/1000 in 1975-80 according to UN estimates. The government regards the current level of fertility as satisfactory and has implemented incentive and disincentive schemes to maintain low rates. The government considers levels and trends of immigration to be not significant and satisfactory. The government regards the spatial distribution of the population to be appropriate and has no policies of intervention concerning either internal migration or the rural and urban configuration of settlement.

[Occupational outcome of patients with schizophrenia after first request for disability status: a 2-year follow-up study].

PubMed

Verdoux, H; Goumilloux, R; Monello, F; Cougnard, A

2010-12-01

To assess occupational outcome of persons with schizophrenia over the 2 years following the first request of disability status. This study was carried out in collaboration with the Commission Technique d'Orientation et de Reclassement Professionnel (COTOREP) (technical commission for occupational guidance and rehabilitation of the disabled) de la Gironde (Bordeaux region, South Western France). Persons with schizophrenia or schizoaffective disorder requesting for the first time in 2006 a disability allowance or the status of disabled worker were assessed using a standardized questionnaire collecting data on clinical, occupational and income history. Information on occupational outcome over the 2 years after the first request was collected at the end of the follow-up using multiple sources of information. We used a broad definition of work, including moonlighting and episodic activities (baby-sitting or grape-harvesting), as well as study periods. Of the 121 patients included at baseline, direct or indirect information was available for 108 (90%) at the 24-month assessment. Persons lost to follow-up were less likely to have worked before first request of disability status compared to persons with information available at the end of the follow-up, but did not differ regarding the other characteristics. Nearly half of the persons (41.7%) had worked over the follow-up, irrespective of the type and duration of the occupation. The working periods were of short duration (median duration 14.5 days, interquartile range 6.5-47.5) and most (98%) were done in low-qualified jobs. Nearly half of the persons reported that they had benefitted from support for starting or returning to work, mainly from recruitment agencies specialized in supporting disabled workers. Persons with the status of disabled worker (Reconnaissance de la qualité de travailleur handicapé) (RTH) were more likely to have worked over the follow-up period (66.7% vs 33.3%; OR=3.9; 95%IC 1.3-11.3; p<0.01) as well as persons who had benefitted from institutional support (61.1% vs 38.9%; OR=3.0; 95%IC 1.2-7.8; p=0.02). However, a noteworthy result was that most jobs were obtained by the patient's personal effort. Nearly one out of four patients (23.2%) was involved in vocational training over the follow-up period. This prospective study demonstrates that half of persons with schizophrenia who benefit from the disabled status remain actively engaged in vocational rehabilitation. Hence, giving access to disability status does not act as a disincentive regarding the return or access to work. However, the benefit of being kept involved in vocational rehabilitation has to be weighted against the fact that most patients only obtained low-qualified jobs of short-duration. This precarious situation may be stressful and may have a deleterious impact regarding self-esteem. Copyright © 2010 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.

Opening Data in the Long Tail for Community Discovery, Curation and Action Using Active and Social Curation

NASA Astrophysics Data System (ADS)

Hedstrom, M. L.; Kumar, P.; Myers, J.; Plale, B. A.

2012-12-01

In data science, the most common sequence of steps for data curation are to 1) curate data, 2) enable data discovery, and 3) provide for data reuse. The Sustainable Environments - Actionable Data (SEAD) project, funded through NSF's DataNet program, is creating an environment for sustainability scientists to discover data first, reuse data next, and curate data though an on-going process that we call Active and Social Curation. For active curation we are developing tools and services that support data discovery, data management, and data enhancement for the community while the data is still being used actively for research. We are creating an Active Content Repository, using drop box, semantic web technologies, and a Flickr-like interface for researchers to "drop" data into a repository where it will be replicated and minimally discoverable. For social curation, we are deploying a social networking tool, VIVO, which will allow researchers to discover data-publications-people (e.g. expertise) through a route that can start at any of those entry points. The other dimension of social curation is developing mechanisms to open data for community input, for example, using ranking and commenting mechanisms for data sets and a community-sourcing capability to add tags, clean up and validate data sets. SEAD's strategies and services are aimed at the sustainability science community, which faces numerous challenges including discovery of useful data, cleaning noisy observational data, synthesizing data of different types, defining appropriate models, managing and preserving their research data, and conveying holistic results to colleagues, students, decision makers, and the public. Sustainability researchers make significant use of centrally managed data from satellites and national sensor networks, national scientific and statistical agencies, and data archives. At the same time, locally collected data and custom derived data products that combine observations and measurements from local, national, and global sources are critical resources that have disproportionately high value relative to their size. Sustainability science includes a diverse and growing community of domain scientists, policy makers, private sector investors, green manufacturers, citizen scientists, and informed consumers. These communities need actionable data in order to assess the impacts of alternate scenarios, evaluate the cost-benefit tradeoffs of different solutions, and defend their recommendations and decisions. SEAD's goal is to extend its services to other communities in the "long tail" that may benefit from new approaches to infrastructure development which take into account the social and economic characteristics of diverse and dispersed data producers and consumers. For example, one barrier to data reuse is the difficulty of discovering data that might be valuable for a particular study, model, or decision. Making data minimally discoverable saves the community time expended on futile searches and creates a market, of sorts, for the data. Creating very low barriers to entry to a network where data can be discovered and acted upon vastly reduces this disincentive to sharing data. SEAD's approach allows communities to make small incremental improvements in data curation based on their own priorities and needs.

Value added medicines: what value repurposed medicines might bring to society?

PubMed

Toumi, Mondher; Rémuzat, Cécile

2017-01-01

Background & objectives : Despite the wide interest surrounding drug repurposing, no common terminology has been yet agreed for these products and their full potential value is not always recognised and rewarded, creating a disincentive for further development. The objectives of the present study were to assess from a wide perspective which value drug repurposing might bring to society, but also to identify key obstacles for adoption of these medicines and to discuss policy recommendations. Methods : A preliminary comprehensive search was conducted to assess how the concept of drug repurposing was described in the literature. Following completion of the literature review, a primary research was conducted to get perspective of various stakeholders across EU member states on drug repurposing ( healthcare professionals, regulatory authorities and Health Technology Assessment (HTA) bodies/payers, patients, and representatives of the pharmaceutical industry developing medicines in this field). Ad hoc literature review was performed to illustrate, when appropriate, statements of the various stakeholders. Results : Various nomenclatures have been used to describe the concept of drug repurposing in the literature, with more or less broad definitions either based on outcomes, processes, or being a mix of both. In this context, Medicines for Europe (http://www.medicinesforeurope.com/value-added-medicines/) established one single terminology for these medicines, known as value added medicines, defined as 'medicines based on known molecules that address healthcare needs and deliver relevant improvements for patients, healthcare professionals and/or payers'. Stakeholder interviews highlighted three main potential benefits for value added medicines: (1) to address a number of medicine-related healthcare inefficiencies related to irrational use of medicines, non-availability of appropriate treatment options, shortage of mature products, geographical inequity in medicine access; (2) to improve healthcare system efficiency; and (3) to contribute to sustainability of healthcare systems through economic advantages. Current HTA framework, generic stigma, and pricing rules, such as internal reference pricing or tendering processes in place in some countries, were reported as the current key hurdles preventing the full recognition of value added medicines' benefits, discouraging manufacturers from bringing such products to the market. Discussion & conclusions : There is currently a gap between increasing regulatory authority interest in capturing value added medicines' benefits and the resistance of HTA bodies/payers, who tend to ignore this important segment of the pharmaceutical field. This situation calls for policy changes to foster appropriate incentives to enhance value recognition of value added medicines and deliver the expected benefit to society. Policy changes from HTA perspective should include: absence of any legislative barriers preventing companies from pursuing HTA; HTA requirements proportionate to potential reward; HTA decision-making framework taking into account the specific characteristics of value added medicines; eligibility for early HTA dialogues; Policy changes from pricing perspective should encompass: tenders/procurement policies allowing differentiation from generic medicines; eligibility for early entry agreement; non-systematic implementation of external and internal reference pricing policies; recognition of indication-specific pricing. At the same time, the pharmaceutical industry should engage all the stakeholders (patients, healthcare providers, HTA bodies/payers) in early dialogues to identify their expectations and to ensure the developed value added medicines address their needs.

Safety assessment of biotechnology-derived pharmaceuticals: ICH and beyond.

PubMed

Serabian, M A; Pilaro, A M

1999-01-01

Many scientific discussions, especially in the past 8 yr, have focused on definition of criteria for the optimal assessment of the preclinical toxicity of pharmaceuticals. With the current overlap of responsibility among centers within the Food and Drug Administration (FDA), uniformity of testing standards, when appropriate, would be desirable. These discussions have extended beyond the boundaries of the FDA and have culminated in the acceptance of formalized, internationally recognized guidances. The work of the International Committee on Harmonisation (ICH) and the initiatives developed by the FDA are important because they (a) represent a consensus scientific opinion, (b) promote consistency, (c) improve the quality of the studies performed, (d) assist the public sector in determining what may be generally acceptable to prepare product development plans, and (e) provide guidance for the sponsors in the design of preclinical toxicity studies. Disadvantages associated with such initiatives include (a) the establishment of a historical database that is difficult to relinquish, (b) the promotion of a check-the-box approach, i.e., a tendancy to perform only the minimum evaluation required by the guidelines, (c) the creation of a disincentive for industry to develop and validate new models, and (d) the creation of state-of-the-art guidances that may not allow for appropriate evaluation of novel therapies. The introduction of biotechnology-derived pharmaceuticals for clinical use has often required the application of unique approaches to assessing their safety in preclinical studies. There is much diversity among these products, which include the gene and cellular therapies, monoclonal antibodies, human-derived recombinant regulatory proteins, blood products, and vaccines. For many of the biological therapies, there will be unique product issues that may require specific modifications to protocol design and may raise additional safety concerns (e.g., immunogenicity). Guidances concerning the design of preclinical studies for such therapies are generally based on the clinical indication. Risk versus benefit decisions are made with an understanding of the nature of the patient population, the severity of disease, and the availability of alternative therapies. Key components of protocol design for preclinical studies addressing the risks of these agents include (a) a safe starting dose in humans, (b) identification of potential target organs, (c) identification of clinical parameters that should be monitored in humans, and (d) identification of at-risk populations. One of the distinct aspects of the safety evaluation of biotechnology-derived pharmaceuticals is the use of relevant and often nontraditional species and the use of animal models of disease in preclinical safety evaluation. Extensive contributions were made by the Center for Biologics Evaluation and Research to the ICH document on the safety of biotherapeutics, which is intended to provide worldwide guidance for a framework approach to the design and review of preclinical programs. Rational, scientifically sound study design and early identification of the potential safety concerns that may be anticipated in the clinical trial can result in preclinical data that facilitate use of these novel therapies for use in humans without duplication of effort or the unnecessary use of animals.

Value added medicines: what value repurposed medicines might bring to society?

PubMed Central

Toumi, Mondher; Rémuzat, Cécile

2017-01-01

ABSTRACT Background & objectives: Despite the wide interest surrounding drug repurposing, no common terminology has been yet agreed for these products and their full potential value is not always recognised and rewarded, creating a disincentive for further development. The objectives of the present study were to assess from a wide perspective which value drug repurposing might bring to society, but also to identify key obstacles for adoption of these medicines and to discuss policy recommendations. Methods: A preliminary comprehensive search was conducted to assess how the concept of drug repurposing was described in the literature. Following completion of the literature review, a primary research was conducted to get perspective of various stakeholders across EU member states on drug repurposing (healthcare professionals, regulatory authorities and Health Technology Assessment (HTA) bodies/payers, patients, and representatives of the pharmaceutical industry developing medicines in this field). Ad hoc literature review was performed to illustrate, when appropriate, statements of the various stakeholders. Results: Various nomenclatures have been used to describe the concept of drug repurposing in the literature, with more or less broad definitions either based on outcomes, processes, or being a mix of both. In this context, Medicines for Europe (http://www.medicinesforeurope.com/value-added-medicines/) established one single terminology for these medicines, known as value added medicines, defined as ‘medicines based on known molecules that address healthcare needs and deliver relevant improvements for patients, healthcare professionals and/or payers’. Stakeholder interviews highlighted three main potential benefits for value added medicines: (1) to address a number of medicine-related healthcare inefficiencies related to irrational use of medicines, non-availability of appropriate treatment options, shortage of mature products, geographical inequity in medicine access; (2) to improve healthcare system efficiency; and (3) to contribute to sustainability of healthcare systems through economic advantages. Current HTA framework, generic stigma, and pricing rules, such as internal reference pricing or tendering processes in place in some countries, were reported as the current key hurdles preventing the full recognition of value added medicines’ benefits, discouraging manufacturers from bringing such products to the market. Discussion & conclusions: There is currently a gap between increasing regulatory authority interest in capturing value added medicines’ benefits and the resistance of HTA bodies/payers, who tend to ignore this important segment of the pharmaceutical field. This situation calls for policy changes to foster appropriate incentives to enhance value recognition of value added medicines and deliver the expected benefit to society. Policy changes from HTA perspective should include: absence of any legislative barriers preventing companies from pursuing HTA; HTA requirements proportionate to potential reward; HTA decision-making framework taking into account the specific characteristics of value added medicines; eligibility for early HTA dialogues; Policy changes from pricing perspective should encompass: tenders/procurement policies allowing differentiation from generic medicines; eligibility for early entry agreement; non-systematic implementation of external and internal reference pricing policies; recognition of indication-specific pricing. At the same time, the pharmaceutical industry should engage all the stakeholders (patients, healthcare providers, HTA bodies/payers) in early dialogues to identify their expectations and to ensure the developed value added medicines address their needs. PMID:28265347

A brief introduction to China's family planning programme.

PubMed

Shen, G

1984-08-01

China's family planning program is described in reference to its goals, approaches, and achievements. Between 1949-83, China's population increased from 541 million to 1,024,950,000. The population has a young age structure, and the median age is 22.9 years. 80% of the population is rural, and 90% of the population lives in the southeastern region of the country. In view of this demographic situation, the government recognizes the need to control population growth. China's goals for the year 2000 are to increase industrial and agricultural input by 400% and to keep population size below 1.2 billion in order to ensure that per capita income increases. In accordance with these goals, the government, in 1979, began advocating a 1-child policy. To ensure the survival of single children, the government also launched a program to upgrade maternal and child health (MCH). In some rural areas and among certain minority groups, the 1-child restriction is not applied. Family size goals will vary with time. These variations will reflect the need to maintain a balance between economic growth and population growth. A variety of incentives are used to promote the 1-child family. For example, single children receive medical and educational benefits, and in some rural areas, the parents of single children can obtain additional land contracts. Economic disincentives are also used. The government seeks to obtain compliance with the policy primarily through educating the public about the consequences of uncontrolled population growth. All channels of the mass media are used to deliver the messages, and the publicity campaign is especially intensive in rural areas. A comprehensive plan to provided family planning and population education for middle school students is currently being implemented. Each local area develops its own fertility control plan. This plan is then incorporated into the nation's overall plan and the overall plan is implemented from above. Family planning workers bring free contraceptives directly to the people, and family planning motivators are found in almost all villages, neighborhood committees, factories, and military units. As a result of these efforts, China made great strides in controlling population growth and improving MCH during the last decade. The birth rate declined from 27.93 to 18.62, and the total fertility rate declined from 4.01 to 2.48. 124 million couples were practicing contraception by the end of 1983. 41% used IUDs, 37.4% relied on tubal ligation, 12.9% relied on vasectomy, 5.1% on oral contraceptives, and 1% on other methods. The quality of maternal and child care also improved. 92.7% of all deliveries are now performed by trained midwifes. Infant and maternal mortality rates declined considerablely in recent years. Currently the respective rates are 35.68/1000 live births and 0.5/1000 live births. In 1983 alone, the gross national agricultural and industrial output increased by 46.1%. Since 1979 per capita income increased annually by 18.3% among rural residents and by 10.7% among urban workers. China controls and operates its own population program, but in recent years, it increased its cooperation with UN Fund for Population Activities, other UN agencies, and nongovernment agencies. China recently completed its 3rd national census, and demographic research institutes have been established in 10 universities.

Challenges to student transition in allied health undergraduate education in the Australian rural and remote context: a synthesis of barriers and enablers.

PubMed

Spiers, M C; Harris, M

2015-01-01

The optimum supply of an allied health workforce in rural and remote communities is a persistent challenge. Despite previous indicative research and government investment, the primary focus for rural and remote recruitment has been on the medical profession. The consequent shortage of allied health professionals leaves these communities less able to receive appropriate health care. This comprehensive review incorporates a literature analysis while articulating policy and further research implications. The objective was to identify drivers to recruitment and retention of an allied health workforce in rural and remote communities. This issue was observed in two parts: identification of barriers and enablers for students accessing allied health undergraduate tertiary education, and barriers and enablers to clinical placement experience in rural and remote communities. A search of empirical literature was conducted together with review of theoretical publications, including public health strategies and policy documents. Database searches of CINAHL, Medline, ERIC, PsychInfo and Scopus were performed. Selection criteria included Australian research in English, full text online, keywords in title or abstract, year of publication 1990 to 2012 and research inclusive of rural and remote context by application of the Australian Standard Geographical Classication (ASGC) Remoteness Structure. Theoretical publications, or grey literature, were identified by broad Google searches utilising a variety of search terms relevant to the review objective. Allied health professions were defined as including audiology, dietetics, occupational therapy, optometry, orthoptics, orthotics and prosthetics, pharmacy, physiotherapy, podiatry, psychology, radiography, social work, speech pathology and Aboriginal and Torres Strait Islander Health Workers. A total of 28 empirical publications met the selection criteria with a further 22 grey literature texts identified with relevance to the research objective. Patterns of barriers and enablers for rural and remote student transition in the allied health professions were identified in the literature. Recruitment pathways to allied health tertiary studies in rural and remote communities are vague and often interrupted, and the return of graduates is haphazard. Students from rural and remote communities face an assembly of barriers. They often experience secondary education disadvantage with inadequate subject choices, pathways and opportunities. Programs designed to facilitate transition to tertiary study are often limited in their capacity to address cumulative concerns. Students also face financial imposts and are confronted by daunting social isolation, and separation from families and support systems. In regard to clinical placement, the disincentives weigh heavily. The financial burdens of a rural placement offer little inducement. Social isolation associated with a placement far from home is more acutely felt by students when there is inadequate administrative support and consequent disillusionment. Students also lack a frame of reference to pursue a rural placement option, and are often discouraged by the cumulative commitments involved. Clear and accessible pathways to allied health training for students from rural and remote communities are pivotal to a stronger representation of this cohort among graduates. Similarly, greater representation of rural and remote clinical placements for allied health undergraduate students is an important facilitator. Despite regional coordination and strategies designed to promote a broader range of placement opportunities, the problems remain. This review has consequences for policy and program development for growth of the rural allied health workforce in Australia, as well as identifying knowledge deficits to guide future research endeavours.

Public participation in data audits.

PubMed

McGarity, T O

1989-09-01

The United States in the early 1980s faced a crisis of confidence in the institutions that it had created to protect public health and the environment from the risks posed by toxic chemicals. Although the political climate of the times had a lot to do with the loss of public confidence in agencies like the Environmental Protection Agency (EPA), the Food and Drug Administration (FDA) and the Occupational Safety and Health Administration (OSHA), perhaps the most profound crack in the institutional edifice was the revelation that much (or at least some, depending upon whom you believed) of the scientific basis for past health and environmental decisions was grounded in invalid and even fraudulent health and safety studies. The IBT scandal (named after the Industrial Biotest Laboratories whose misadventures ultimately resulted in jail sentences for its officers) fueled accusations that the health and environmental agencies could not be trusted to reign in the chemical industry.(1) Public apprehensions were hardly quelled by the revelation in late 1982 that EPA had assigned only one full-time professional to audit the performance of all pesticide testing laboratories for evidence of additional fraud or misreporting.(2) It is fair to conclude that the recent trend toward establishing procedures for independent audits of health and safety data is a direct response to the crisis of public confidence resulting from the IBT scandal. Both EPA and FDA have promulgated "Good Laboratory Practice"; guidelines that serve as a baseline for such audits, and an increasing number of firms have established new "quality assurance"; controls to insure the agencies (and themselves) that the scientific underpinnings of health and safety decisions are sound. There is little reason to conclude, however, that this more-or-less unilateral response to the IBT scandal will by itself stem public distrust in health and safety decisionmaking. Knowledgeable members of the public will not trust the agencies until they know that they can trust the audits, and they will not trust the audits until they begin to trust the auditors. This resurrects the ages-old conundrum: Who shall guard the guardians? Representatives of public interest groups, such as the Natural Resources Defense Council, Inc. and Ralph Nader's Public Citizen Health Research Group, have an easy answer to this question. They strongly believe that the only way to ensure the integrity of the scientific basis for health and safety decisionmaking is to spread all aspects of health and safety studies fully on the public record for all to see.(1) Representatives of the pharmaceutical and chemical industries, however, complain that this solution would expose valuable trade secrets to easy appropriation by unscrupulous competitors, thereby reducing industry incentives to develop new drugs and chemicals. Herein lies the core of a debate that has animated more than one congressional hearing and has reached all the way to the Supreme Court in recent years. This paper will examine the arguments for and against affording trade secrecy protection to health and safety testing data and apply those policies to the specific question of data audits. Finally, it will suggest a way to resolve the problem that enhances public trust in the audits while at the same time minimizing any disincentives to innovate.

System for Secure Integration of Aviation Data

NASA Technical Reports Server (NTRS)

Kulkarni, Deepak; Wang, Yao; Keller, Rich; Chidester, Tom; Statler, Irving; Lynch, Bob; Patel, Hemil; Windrem, May; Lawrence, Bob

2007-01-01

The Aviation Data Integration System (ADIS) of Ames Research Center has been established to promote analysis of aviation data by airlines and other interested users for purposes of enhancing the quality (especially safety) of flight operations. The ADIS is a system of computer hardware and software for collecting, integrating, and disseminating aviation data pertaining to flights and specified flight events that involve one or more airline(s). The ADIS is secure in the sense that care is taken to ensure the integrity of sources of collected data and to verify the authorizations of requesters to receive data. Most importantly, the ADIS removes a disincentive to collection and exchange of useful data by providing for automatic removal of information that could be used to identify specific flights and crewmembers. Such information, denoted sensitive information, includes flight data (here signifying data collected by sensors aboard an aircraft during flight), weather data for a specified route on a specified date, date and time, and any other information traceable to a specific flight. The removal of information that could be used to perform such tracing is called "deidentification." Airlines are often reluctant to keep flight data in identifiable form because of concerns about loss of anonymity. Hence, one of the things needed to promote retention and analysis of aviation data is an automated means of de-identification of archived flight data to enable integration of flight data with non-flight aviation data while preserving anonymity. Preferably, such an automated means would enable end users of the data to continue to use pre-existing data-analysis software to identify anomalies in flight data without identifying a specific anomalous flight. It would then also be possible to perform statistical analyses of integrated data. These needs are satisfied by the ADIS, which enables an end user to request aviation data associated with de-identified flight data. The ADIS includes client software integrated with other software running on flight-operations quality-assurance (FOQA) computers for purposes of analyzing data to study specified types of events or exceedences (departures of flight parameters from normal ranges). In addition to ADIS client software, ADIS includes server hardware and software that provide services to the ADIS clients via the Internet (see figure). The ADIS server receives and integrates flight and non-flight data pertaining to flights from multiple sources. The server accepts data updates from authorized sources only and responds to requests from authorized users only. In order to satisfy security requirements established by the airlines, (1) an ADIS client must not be accessible from the Internet by an unauthorized user and (2) non-flight data as airport terminal information system (ATIS) and weather data must be displayed without any identifying flight information. ADIS hardware and software architecture as well as encryption and data display scheme are designed to meet these requirements. When a user requests one or more selected aviation data characteristics associated with an event (e.g., a collision, near miss, equipment malfunction, or exceedence), the ADIS client augments the request with date and time information from encrypted files and submits the augmented request to the server. Once the user s authorization has been verified, the server returns the requested information in de-identified form.

Kuwait.

PubMed

1988-03-01

The Republic of Kuwait occupies an area of 6,880 square miles at the head of the Persian Gulf, bounded on the north and west by Iraq and on the south by Saudi Arabia. 1.7 million people live in Kuwait, of whom 680,000 are Kuwaitis; the rest are expatriate Arabs, Iranians, and Indians. The annual growth rate of Kuwaitis is 3.8%. The Kuwaitis are 70% Sunni and 30% Shi'a Muslims. Arabic is the official language, but English is widely spoken. Kuwait is a highly developed welfare state with a free market economy. Education is free and compulsory, and literacy is 71%. Infant mortality among Kuwaitis is 26.1/1000, and life expectancy is 70 years. Medical care is free. Kuwait was first settled by Arab tribes from Qatar. In 1899 the ruler, Sheikh Mubarak Al Sabah, whose descendents still rule Kuwait, signed a treaty with Britain; and Kuwait remained a British protectorate until it became independent in 1961. A constitution was promulgated in 1962, and a National Assembly was elected by adult male suffrage in 1963. However, the Assembly has since been suspended due to internal friction. Kuwait and Iraq have been disputing Kuwait's northern border since 1913, and the southern border includes a Divided Zone, where sovereignty is disputed by Kuwait and Saudi Arabia. Despite the fall in oil prices in 1982 and the loss of trade due to the Iran-Iraq war, Kuwait is one of the world's wealthiest countries with a per capita gross domestic product of $10,175. Oil accounts for 85% of Kuwait's exports, which total $7.42 billion; income from foreign investments (about $60 billion) makes up most of the balance. All petroleum-related activities are managed by the Kuwait Petroleum Corporation (KPC), which includes the nationalized Kuwait Oil Company, petrochemical industries, the 22-vessel tanker fleet, and refineries and service stations in Europe, where Kuwaiti oil is marketed under the brand name Q8. Kuwait has more than 66 billion barrels of recoverable oil but limits production to 999,000 barrels per day. Other industrial products include ammonia, chemical fertilizers, fishing and water desalinization (215 million gallons a day). Kuwait imports machinery, manufactured goods, and food. Nevertheless exports exceed imports by $2 billion, and the Kuwaiti dinar is a strong currency (1 KD=US$3.57). About $75 billion is kept in 2 reserve funds: the Fund for Future Generations and the General Reserve Fund. In addition to domestic expenditures and imports, Kuwait has extended $5 billion worth of loans to developing countries, made through the Kuwait Fund for Arab Economic Development. Kuwait has been engaged in continuing border disputes with Iraq since 1961, but the most immediate threat to Kuwait has been the Iran-Iraq war. Kuwait lent Iraq $6 billion, in retaliation for which Iran bombed a Kuwaiti oil depot, and Shi'a Muslim terrorists bombed the French and US embassies and hijacked a Kuwaiti airliner in 1984. Iran also attacked Kuwaiti tankers. In 1987 the US reflagged 11 Kuwaiti tankers to protect them from Iranian attacks. Kuwait has been modernizing its own military forces as well as purchasing sophisticated weapons from the UK, the US, France, and the USSR. In 1981 Kuwait, Saudi Arabia, Bahrain, Qatar, the United Arab Emirates and Oman formed the Gulf Cooperation Council (GCC) for mutual defense, and in 1987 Kuwait was elected chairman of the Organization of the Islamic Conference (OIC). Kuwait has diplomatic relations with the USSR and the People's Republic of China, as well as with the US, which has supplied Kuwait with $1.5 billion of sophisticated weaponry from foreign military sales (FMC). The US is Kuwait's largest supplier (after Japan), and Kuwait is the 5th largest market in the Middle East for US goods, despite the disincentives brought about by the Arab boycott of Israel.

Proceedings for the 5th Asia-Pacific Conference on Disaster Medicine: creating an agenda for action.

PubMed

De Grace, M; Ericson, D; Folz, H; Greene, W; Ho, K; Pearce, L

2001-01-01

Disaster medicine has come to the forefront and has become the focus of interest not only in the medical community, but also in the eyes of the public. The 5th APCDM was convened in Vancouver, Canada, 27-30 September 2000. It brought together over 300 delegates from 32 countries to share their experiences and thoughts regarding disaster events and how to effectively manage them. The conference was devoted to the task of establishing priorities and creating an Agenda for Action. From the discussions, key actions required were defined: COMMUNICATIONS: (1) Identify existing regional telehealth groups and gather lessons to be learned from them; (2) Form a telehealth advisory group to work with regional groups to compile telehealth initiatives, identify international protocols in telehealth already in existence, and solicit feedback before setting international standards; and (3) Increase corporate partnerships in the fields of telehealth and telecommunications, and invite corporations to send delegates to future APCDM meetings. This should be an initiative of the APCDM, the World Association of Disaster and Emergency Medicine (WADEM), or the European Society of Emergency Medicine. EDUCATION AND RESEARCH: (1) Formalize education in disaster medicine and management. The World Health Organization and WADEM should take a leadership role; (2) WADEM is requested to hold a conference with a focus on qualitative research; (3) WHO is requested to continue the provision of international research teams, but to advocate for the development of national disaster research infrastructure; (4) Make research findings and reports available on web sites of such organizations as WHO and PAHO; (5) Develop the translation of research for community utilization. The WHO and PAHO are organizations that are requested to consider this action; and (6) WADEM/APCDM are requested to focus future conferences on applied research. INFORMATION AND DATA: (1) Create an "Information and Data Clearinghouse on Disaster Management" to collect, collate, and disseminate information; (2) Collect data using standardized tools, such as CAR or Hazmat indices; (3) Analyze incentives and disincentives for disaster readiness and establish mechanisms for addressing the obstacles to preparedness; and (4) WADEM is requested to develop a web site providing a resource list of interdisciplinary institutions and response activities, organized by country, topic, and research interests. Links to other pertinent web sites should be provided. INTERDISCIPLINARY DEVELOPMENT: (1) Focus on the interdisciplinary nature of disaster response through more conferences encompassing grassroots efforts and through WADEM publications; (2) Develop and apply a standardized template of Needs Assessment for use by multidisciplinary teams. Team Needs Assessment is essential to determine the following: (a) Local response and international assistance required; (b) Appropriate command system; and (c) Psychosocial impact and support necessary. PSYCHOSOCIAL ASPECTS: (1) Incorporate relief for caregivers into action plans. This should include prime family members who also are caregivers; and (2) Implement measures that give survivors control over the recovery process. RESPONSE MANAGEMENT: (1) Define relationships and roles between governments, military and security personnel, non-governmental organizations (NGOs), and civic groups. Use an international legal framework and liability to reinforce accountability of disaster responders; (2) Establish a more sophisticated use of the media during disasters; (3) Establish standards in key areas. WADEM is requested to write "White Papers" on standards for the following areas: (a) management, (b) health/public health, (c) education/training, (d) psychosocial, and (e) disaster plans; (4) Establish task forces to anticipate and resolve issues around evolving and emerging disasters (e.g., chemical and biological terrorism, landmines, emerging infectious diseases). WADEM was again identified as the vehicle for promoting this action. The responsibility of the next meeting of the Asia-Pacific Conference on Disaster Medicine will be to measure progress made in these areas by assessing how well these collective decisions have been implemented.

The net effects of the Project NetWork return-to-work case management experiment on participant earnings, benefit receipt, and other outcomes.

PubMed

Kornfeld, R; Rupp, K

2000-01-01

The Social Security Administration (SSA) initiated Project NetWork in 1991 to test case management as a means of promoting employment among persons with disabilities. The demonstration, which targeted Social Security Disability Insurance (DI) beneficiaries and Supplemental Security Income (SSI) applicants and recipients, offered intensive outreach, work-incentive waivers, and case management/referral services. Participation in Project NetWork was voluntary. Volunteers were randomly assigned to the "treatment" group or the "control" group. Those assigned to the treatment group met individually with a case or referral manager who arranged for rehabilitation and employment services, helped clients develop an individual employment plan, and provided direct employment counseling services. Volunteers assigned to the control group could not receive services from Project NetWork but remained eligible for any employment assistance already available in their communities. For both treatment and control groups, the demonstration waived specific DI and SSI program rules considered to be work disincentives. The experimental impact study thus measures the incremental effects of case and referral management services. The eight demonstration sites were successful in implementing the experimental design roughly as planned. Project NetWork staff were able to recruit large numbers of participants and to provide rehabilitation and employment services on a substantial scale. Most of the sites easily reached their enrollment targets and were able to attract volunteers with demographic characteristics similar to those of the entire SSI and DI caseload and a broad range of moderate and severe disabilities. However, by many measures, volunteers were generally more "work-ready" than project eligible in the demonstration areas who did not volunteer to receive NetWork services. Project NetWork case management increased average annual earnings by $220 per year over the first 2 years following random assignment. This statistically significant impact, an approximate 11-percent increase in earnings, is based on administrative data on earnings. For about 70 percent of sample members, a third year of followup data was available. For this limited sample, the estimated effect of Project NetWork on annual earnings declined to roughly zero in the third followup year. The findings suggest that the increase in earnings may have been short-lived and may have disappeared by the time Project NetWork services ended. Project NetWork did not reduce reliance on SSI or DI benefits by statistically significant amounts over the 30-42 month followup period. The services provided by Project NetWork thus did not reduce overall SSI and DI caseloads or benefits by substantial amounts, especially given that only about 5 percent of the eligible caseload volunteered to participate in Project NetWork. Project NetWork produced modest net benefits to persons with disabilities and net costs to taxpayers. Persons with disabilities gained mainly because the increases in their earnings easily outweighed the small (if any) reduction in average SSI and DI benefits. For SSA and the federal government as a whole, the costs of Project NetWork were not sufficiently offset by increases in tax receipts resulting from increased earnings or reductions in average SSI and DI benefits. The modest net benefits of Project NetWork to persons with disabilities are encouraging. How such benefits of an experimental intervention should be weighed against costs of taxpayers depends on value judgments of policymakers. Because different case management projects involve different kinds of services, these results cannot be directly generalized to other case management interventions. They are nevertheless instructive for planning new initiatives. Combining case and referral management services with various other interventions, such as longer term financial support for work or altered provider incentives, could produc

Strategies to improve recruitment to randomised trials.

PubMed

Treweek, Shaun; Pitkethly, Marie; Cook, Jonathan; Fraser, Cynthia; Mitchell, Elizabeth; Sullivan, Frank; Jackson, Catherine; Taskila, Tyna K; Gardner, Heidi

2018-02-22

Recruiting participants to trials can be extremely difficult. Identifying strategies that improve trial recruitment would benefit both trialists and health research. To quantify the effects of strategies for improving recruitment of participants to randomised trials. A secondary objective is to assess the evidence for the effect of the research setting (e.g. primary care versus secondary care) on recruitment. We searched the Cochrane Methodology Review Group Specialised Register (CMR) in the Cochrane Library (July 2012, searched 11 February 2015); MEDLINE and MEDLINE In Process (OVID) (1946 to 10 February 2015); Embase (OVID) (1996 to 2015 Week 06); Science Citation Index & Social Science Citation Index (ISI) (2009 to 11 February 2015) and ERIC (EBSCO) (2009 to 11 February 2015). Randomised and quasi-randomised trials of methods to increase recruitment to randomised trials. This includes non-healthcare studies and studies recruiting to hypothetical trials. We excluded studies aiming to increase response rates to questionnaires or trial retention and those evaluating incentives and disincentives for clinicians to recruit participants. We extracted data on: the method evaluated; country in which the study was carried out; nature of the population; nature of the study setting; nature of the study to be recruited into; randomisation or quasi-randomisation method; and numbers and proportions in each intervention group. We used a risk difference to estimate the absolute improvement and the 95% confidence interval (CI) to describe the effect in individual trials. We assessed heterogeneity between trial results. We used GRADE to judge the certainty we had in the evidence coming from each comparison. We identified 68 eligible trials (24 new to this update) with more than 74,000 participants. There were 63 studies involving interventions aimed directly at trial participants, while five evaluated interventions aimed at people recruiting participants. All studies were in health care.We found 72 comparisons, but just three are supported by high-certainty evidence according to GRADE.1. Open trials rather than blinded, placebo trials. The absolute improvement was 10% (95% CI 7% to 13%).2. Telephone reminders to people who do not respond to a postal invitation. The absolute improvement was 6% (95% CI 3% to 9%). This result applies to trials that have low underlying recruitment. We are less certain for trials that start out with moderately good recruitment (i.e. over 10%).3. Using a particular, bespoke, user-testing approach to develop participant information leaflets. This method involved spending a lot of time working with the target population for recruitment to decide on the content, format and appearance of the participant information leaflet. This made little or no difference to recruitment: absolute improvement was 1% (95% CI -1% to 3%).We had moderate-certainty evidence for eight other comparisons; our confidence was reduced for most of these because the results came from a single study. Three of the methods were changes to trial management, three were changes to how potential participants received information, one was aimed at recruiters, and the last was a test of financial incentives. All of these comparisons would benefit from other researchers replicating the evaluation. There were no evaluations in paediatric trials.We had much less confidence in the other 61 comparisons because the studies had design flaws, were single studies, had very uncertain results or were hypothetical (mock) trials rather than real ones. The literature on interventions to improve recruitment to trials has plenty of variety but little depth. Only 3 of 72 comparisons are supported by high-certainty evidence according to GRADE: having an open trial and using telephone reminders to non-responders to postal interventions both increase recruitment; a specialised way of developing participant information leaflets had little or no effect. The methodology research community should improve the evidence base by replicating evaluations of existing strategies, rather than developing and testing new ones.