Cost-effectiveness of dedicated dietitians for hyperphosphatemia management among hemodialysis patients in Lebanon: results from the Nutrition Education for Management of Osteodystrophy trial

Aim: To assess the cost-effectiveness of nutrition education by dedicated dietitians (DD) for hyperphosphatemia management among hemodialysis patients.

Materials and methods: This was a trial-based economic evaluation in 12 Lebanese hospital-based units. In total, 545 prevalent patients were cluster randomized to DD, trained hospital dietitian (THD), and existing practice (EP) groups. During Phase I (6 months), DD (n?=?116) received intensive education by DD trained on renal nutrition, THD (n?=?299) received care from trained hospital dietitians, and EP (n?=?130) received usual care from untrained hospital dietitians. Patients were followed-up during Phase II (6 months).

Results: At baseline, EP had the lowest weekly hemodialysis time, and DD had the highest serum phosphorus and malnutrition-inflammation score. The additional costs of the intervention were low compared with the societal costs (DD: $76.7, $21,007.7; EP: $4.6, $18,675.4; THD: $17.4, $20,078.6, respectively). Between Phases I and II, DD showed the greatest decline in services use and societal costs (DD: –$2,364.0; EP: –$1,727.7; THD: –$1,105.7). At endline, DD experienced the highest decrease in adjusted serum phosphorus (DD: –0.32; EP: +0.16; THD: +0.04?mg/dL), no difference in quality-adjusted life-years (QALY), and the highest societal costs. DD had a cost-effectiveness ratio of $7,853.6 per 1?mg decrease in phosphorus, compared with EP; and was dominated by THD. Regarding QALY, DD was dominated by EP and THD. The results were sensitive to changes in key parameters.

Limitations: The analysis depended on numerous assumptions. Interpreting the results is limited by the significant baseline differences in key parameters, suggestive of higher baseline societal costs in DD.

Conclusions: DD yielded the greatest effectiveness and decrease in societal costs, but did not affect QALY. Regarding serum phosphorus, DD was likely to be cost-effective compared with EP, but had a low cost-effectiveness probability compared with THD. Regarding QALY, DD was not likely to be cost-effective. Assessing the long-term cost-effectiveness of DD, on similar groups, is recommended.     

Sandwich-Course Training in Higher Education as a Major Strategic Thrust Regional Policy of Professional Training： Lessons Learned From the Pioneering Example of the University Institute of Technology Corsica

Corsica is an island economy marked by the complete absence of any of the big holdings and multinationals that fuel and forge the worldwide economy. Equally absent is any of the kind of medium-sized enterprises servicing big business that have spearheaded local economies in other regions like Lombardy. Corsica＇s economic fabric is essentially made up of small and home businesses, farm smallholdings, artisans, and small-scale retail. Given how public-sector capital investment is already hypertrophied, a policy of investment in human capital could be a compelling new opportunity to trigger a dynamic regional development impetus. Leading the way, the University Institute of Technology Corsica, Corsica University＇s affiliated school of applied vocational technologies, is demonstrating its ability to act as a structurally engaged facilitator of island-wide spatial planning and regional branding. As a founding pillar in pioneering the emergence of a sandwich-course training system in higher education in Corsica, in 2010 the university made its entire training curriculum fully accessible to all through the signature of apprenticeship training or vocational qualifications agreements. This grass-roots programme is the outcome of a committed core strategy to develop partnerships with the island＇s key social and economic communities （businesses, community groups, and local authorities）, and it plays a fundamental role in shaping and selling the most vital valued assets that typify a regional territory emerging into a structured destination-brand identity （simultaneous growth in the employability and quality of school-to-work transition shown by its human capital, mass shift in the degree of skill acquisition directly tied to the regional territory＇s own organic needs, fluidity of knowledge transfer fully controlled through sandwich placements, deep sustainable entrepreneurship education etc.）. After highlighting the specific features of the sandwich training policy development process in Corsica as a shaper of the Regional Vocational Development Programme, this paper brings an analysis of the lessons learned from the pioneering example of the University Institute of Technology Corsica as a dynamic engineer of structured future and regional brand for Corsica.     

Specification and estimation of stochastic multiple-output production and technical inefficiency

This paper presents a primal-based approach for specification and estimation of multiple-output production frontiers that allows simultaneous identification and estimation of determinants of technical inefficiency. The proposed model extends the technical efficiency effects model by Battese and Coelli (1995) to general multiple-output technologies. An empirical application using Swedish health care panel data from the years 1989–1994 is included. The key issue is to test for the effects on technical efficiency of an organizational reform implemented with the primary purpose to increase efficiency. The results reveal no significant effect on technical efficiency of the reform, but evidence of overall decreased technical efficiency and technical progress in the provision of health care over the studied time period are found.     

Voter turnout and intergenerational redistribution

Electoral reforms that lead to reduced turnout modify the composition of the electorate, potentially overrepresenting specific interests in policy implementation. Intergenerational redistribution tilts in favor of the elderly when they are sufficiently numerous, but in favor of the young rich otherwise. We exploit a natural experiment provided by the repeal of compulsory voting in Austrian parliamentary elections to study how exogenous turnout decline affects intergenerational redistribution through pro-young public education spending in Austrian municipalities. Empirically, education spending falls when the proportion of elderly voters exceeds 21% of the electorate, but rises when the proportion of elderly voters is below this threshold.     

Physicians’ views on pay-for-performance as a reimbursement model: a quantitative study among Dutch surgical physicians

Objectives:

To assess the views, knowledge, and experience of Dutch physicians with regard to the general objectives and values of the pay-for-performance (P4P) system, as the Dutch healthcare industry might find it useful, in terms of governance, to explore this approach further.

Methods:

A quantitative cross-sectional survey study was conducted among 48 physicians in surgical specialties in the Netherlands between May 2014 and July 2014. The survey questionnaire was designed to gather information regarding the intensity of feelings, on a 7-point Likert scale, toward statements that address the P4P system. Confidence intervals were calculated using the bootstrap technique with 1000 iterations.

Results:

Physicians see a positive value in P4P for their organizations rather than for personal attainment (mean?=?5.00; 95% CI?=?4.62–5.39), even though they feared that P4P might put financial pressure on them (mean?=?5.03; 95% CI?=?4.50–5.54). They strongly share the view that other colleagues will resist adopting P4P as a business model (mean?=?5.74; 95% CI?=?5.43–6.04). Respondents stated that they would not leave their current jobs if P4P were to be incorporated in their organization.

Conclusions:

Physicians see value in P4P for their organizations, and consider that P4P could provide an incentive for improving medical outcomes. There seems to be potential for the P4P system in the Netherlands as participants expressed positive support for its values. There is an intersection of interests between the value of P4P and the physicians’ aim of achieving quality outcomes; however, further studies would be needed to investigate perceptions about specific design features in a larger sample. In addition, prior to implementing P4P, broad education about the system should be provided in order to counteract pre-conceptions and prevent resistance.     

A societal cost-of-illness study of hemodialysis in Lebanon

Aim: Renal failure is a growing public health problem, and is mainly treated by hemodialysis. This study aims to estimate the societal costs of hemodialysis in Lebanon.

Methods: This was a quantitative, cross-sectional cost-of-illness study conducted alongside the Nutrition Education for Management of Osteodystrophy trial. Costs were assessed with a prevalence-based, bottom-up approach, for the period of June–December 2011. The data of 114 patients recruited from six hospital-based units were collected through a questionnaire measuring healthcare costs, costs to patients and family, and costs in other sectors. Recall data were used for the base-case analysis. Sensitivity analyses employing various sources of resources use and costs were performed. Costs were uprated to 2015US$. Multiple linear regression was conducted to explore the predictors of societal costs.

Results: The mean 6-month societal costs were estimated at $9,258.39. The larger part was attributable to healthcare costs (91.7%), while costs to patient and family and costs in other sectors poorly contributed to the total costs (4.2% and 4.1%, respectively). In general, results were robust to sensitivity analyses. Using the maximum value for hospitalization resulted in the biggest difference (+15.5% of the base-case result). Female gender, being widowed/divorced, having hypertension comorbidity, and higher weekly time on dialysis were significantly associated with greater societal costs.

Limitations: Information regarding resource consumption and cost were not readily available. Rather, they were obtained from a variety of sources, with each having its own strengths and limitations.

Conclusion: Hemodialysis represents a high societal burden in Lebanon. Using extrapolation, its total annual cost for the Lebanese society is estimated at $61,105,374 and the mean total annual cost ($18,516.7) is 43.70% higher than the gross domestic product per capita forecast for 2015. Measures to reduce the economic burden of hemodialysis should be taken, by promoting chronic kidney disease’s prevention and encouraging transplantation.     

Labour Costs and the Size of Government

Given inelastic demand for labour‐intensive public services, the size of government depends positively on labour costs. OECD data exhibit a strong statistical association between government size and the business‐sector labour share of income. When the labour share is instrumented with measures of technological change, institutional variation and predetermined data it continues to positively impact government size. In contrast, transfer spending is unaffected by the labour share. The evidence is consistent with the idea that the recent decline in the labour share has contributed to the slowdown in the growth of government witnessed in much of the post‐war era.     

Ideological polarization and the media

Greater media presence may facilitate information transmission and consensus or amplify existing political differences. In the OECD greater media penetration is strongly correlated with reduced ideological polarization. Media penetration increases lead reductions in polarization, suggesting that this relationship is causal.     

New product and service launching in new ventures: a multilevel approach to innovation antecedents

Macro-economic policies such as public financing seek to push the development and introduction of innovations; however, entrepreneurs also need support in their ‘day-to-day’ activities to improve their capability to launch innovations. As this micro-level perspective is rarely studied, we analyze both the micro and macro levels by examining the effects of the entrepreneurs’ individual intention to innovate and public financing. Additionally, we include the meso level, representing entrepreneurs’ network. Entrepreneurs are embedded in social spheres in which they capture resources and identify opportunities. But not all entrepreneurs are equally well supported, and some tend to be completely isolated. We thus focus on multilevel factors explaining new product or service launching in new ventures. Drawing on data of 48,251 French new ventures, we reveal that innovation intention and public financing positively impact new ventures’ product and service innovation launching, while entrepreneurs’ isolation has a negative effect. We also highlight two interaction effects that enhance the multilevel effects of innovation antecedents.