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In the cluster randomized crossover trial, a sequence of treatment conditions, rather than just one treatment condition, is assigned to each cluster. This contribution studies the optimal number of time periods in studies with a treatment switch at the end of each time period, and the optimal number of treatment switches in a trial with a fixed number of time periods. This is done for trials with a fixed number of clusters, and for trials in which the costs per cluster, subject, and treatment switch are taken into account using a budgetary constraint. The focus is on trials with a cross-sectional design where a continuous outcome variable is measured at the end of each time period. An exponential decay correlation structure is used to model dependencies among subjects within the same cluster. A linear multilevel mixed model is used to estimate the treatment effect and its associated variance. The optimal design minimizes this variance. Matrix algebra is used to identify the optimal design and other highly efficient designs. For a fixed number of clusters, a design with the maximum number of time periods is optimal and treatment switches should occur at each time period. However, when a budgetary constraint is taken into account, the optimal design may have fewer time periods and fewer treatment switches. The Shiny app was developed to facilitate the use of the methodology in this contribution.

Background Vocational integration of people with mental illness is poor despite their willingness to work. The ‘Individual Placement and Support’ (IPS) model which emphasises rapid and direct job placement and continuing support to patient and employer has proven to be the most effective vocational intervention programme. Various studies have shown that every second patient with severe mental illness was able to find competitive employment within 18 months. However, the goal of taking up employment within two months was rarely achieved. Thus, we aim to test whether the new concept of limited placement budgets increases the effectiveness of IPS. Methods/Design Six job coaches in six out-patients psychiatric clinics in the Canton of Zurich support unemployed patients of their clinic who seek competitive employment. Between June 2010 and May 2011 patients (N=100) are randomly assigned to three different placement budgets of 25h, 40h, or 55h working hours of job coaches. Support lasts two years for those who find a job. The intervention ends for those who fail to find competitive employment when the respective placement budgets run out. The primary outcome measure is the time between study inclusion and first competitive employment that lasted three months or longer. Over a period of three years interviews are carried out every six months to measure changes in motivation, stigmatization, social network and social support, quality of life, job satisfaction, financial situation, and health conditions. Cognitive and social-cognitive tests are conducted at baseline to control for confounding variables. Discussion This study will show whether the effectiveness of IPS can be increased by the new concept of limited placement budgets. It will also be examined whether competitive employment leads in the long term to an improvement of mental illness, to a transfer of the psychiatric support system to private and vocational networks, to an increase in financial independence, to a reduction of perceived and internalized stigma, and to an increase in quality of life and job satisfaction of the patient. In addition, factors connected with fast competitive employment and holding that job down in the long term are being examined (motivation, stigmatization, social and financial situation). Trial register ISRCTN89670872

More than 500 million rural Africans lack safe drinking water. The human right to water and United Nations Sustainable Development Goal SDG6.1 promote a policy shift from building water infrastructure to sustaining water services. However, the financial calculus is bleak with the costs of “safely managed”’ or “basic” water services in rural Africa beyond current government budgets and donor funds. The funding shortfall is compounded by the disappointing results of earlier policy initiatives in Africa. This is partly because of a failure to understand which attributes of water services rural people value. We model more than 11,000 choice observations in rural Kenya by attributes of drinking water quality, price, reliability, and proximity. Aggregate analysis disguises alternative user priorities in three choice classes. The two larger choice classes tolerate lower service levels with higher payments. A higher water service level reflects the smallest choice class favored by women and the lower wealth group. For the lower wealth group, slower repair times are accepted in preference to a lower payment. Some people discount potable water and proximity, and most people choose faster repair times and lower payments. We argue policy progress needs to chart common ground between individual choices and universal rights. Guaranteeing repair times may provide a policy lever to unlock individual payments to complement public investment in water quality and waterpoint proximity to support progressive realization of a universal right.

Uniting diverse stakeholders through communication, education or building a collaborative 'common vision' for biodiversity management is a recommended approach for enabling effective conservation in regions with multiple uses. However, socially focused strategies such as building a collaborative vision can require sharing scarce resources (time and financial resources) with the on-ground management actions needed to achieve conservation outcomes. Here we adapt current prioritisation tools to predict the likely return on the financial investment of building a stakeholder-led vision along with a portfolio of on-ground management strategies. Our approach brings together and analyses expert knowledge to estimate the cost-effectiveness of a common vision strategy and on-ground management strategies, before any investments in these strategies are made. We test our approach in an intensively-used Australian biodiversity hotspot with 179 threatened or at-risk species. Experts predicted that an effective stakeholder vision for the region would have a relatively low cost and would significantly increase the feasibility of on-ground management strategies. As a result, our analysis indicates that a common vision is likely to be a cost-effective investment, increasing the expected persistence of threatened species in the region by 9 to 52%, depending upon the strategies implemented. Our approach can provide the maximum budget that is worth investing in building a common vision or another socially focused strategy for building support for on-ground conservation actions. The approach can assist with decisions about whether and how to allocate scarce resources amongst social and ecological actions for biodiversity conservation in other regions worldwide.

Heart failure is a widespread and costly malady. It represents the leading single diagnosis for hospitalized patients. For many heart failure patients, angiotensin-converting enzyme (ACE) inhibitors are either not tolerated or contraindicated, but angiotensin receptor blockers such as valsartan may be a therapeutic option for them. The aim of this study was to prepare a budget impact analysis to assist health plans in evaluating the financial impact of adding valsartan therapy to usual care for heart failure patients not receiving ACE inhibitors. A budget impact analysis was developed for a hypothetical US health plan. Model inputs included demographic data, estimates of the prevalence of heart failure and proportion of heart-failure patients not on ACE inhibitors, prevalence of heart failure-related hospitalization, cost data, and resultant health care utilization from the Valsartan Heart Failure Trial (Val-HeFT). Costs and cost savings were reported as year-2001 US dollars. An estimated 1207 of hypothetical 250,000 enrollees were projected to have heart-failure diagnoses, with 603 (50.0%) not receiving ACE inhibitors, and 160 (26.5%) of such patients being hospitalized each year. For valsartan-treated patients, savings due to reduced hospitalizations and shorter length of hospital stay were $1,083,938 and $221,364, respectively. Subtracting the cost of valsartan treatment ($629,472) from savings yielded projected net savings of $675,830 per year. Varying patient, treatment, and payer-mix characteristics resulted in projected net savings of $409,598 to $1,350,617 per year. Addition of valsartan therapy to usual care in this model analysis resulted in net cost savings among hypothetical heart-failure patients not receiving ACE inhibitors. Substantial cost savings were realized, regardless of variation in model parameters.

ObjectivesIn many countries, the healthcare sector is dealing with important challenges such as increased demand for healthcare services, capacity problems in hospitals and rising healthcare costs. Therefore, one of the aims of the Dutch government is to move care from in-hospital to out-of-hospital care settings. An example of an innovation where care is moved from a more specialised setting to a less specialised setting is the performance of an antenatal cardiotocography (aCTG) in primary midwife-led care. The aim of this study was to assess the budget impact of implementing aCTG for healthy pregnant women in midwife-led care compared with usual obstetrician-led care in the Netherlands.MethodsA budget impact analysis was conducted to estimate the actual costs and reimbursement of aCTG performed in midwife-led care and obstetrician-led care (ie, base-case analysis) from the Dutch healthcare perspective. Epidemiological and healthcare utilisation data describing both care pathways were obtained from a prospective cohort, survey and national databases. Different implementation rates of aCTG in midwife-led care were explored. A probabilistic sensitivity analysis was conducted to estimate the uncertainty surrounding the budget impact estimates.ResultsShifting aCTG from obstetrician-led care to midwife-led-care would increase actual costs with €311 763 (97.5% CI €188 574 to €426 072) and €1 247 052 (97.5% CI €754 296 to €1 704 290) for implementation rates of 25% and 100%, respectively, while it would decrease reimbursement with −€7 538 335 (97.5% CI −€10 302 306 to −€4 559 661) and −€30 153 342 (97.5% CI −€41 209 225 to −€18 238 645) for implementation rates of 25% and 100%, respectively. The sensitivity analysis results were consistent with those of the main analysis.ConclusionsFrom the Dutch healthcare perspective, we estimated that implementing aCTG in midwife-led care may increase the associated actual costs. At the same time, it might lower the healthcare reimbursement.

Theoretical approaches to the formation of the budget mechanism as a form of practical implementation of budget policy are made more profound; budget decentralization as a budget regulating and stimulating mechanism in the current situation in Ukraine is studiedl and perspective directions of introducing various budget mechanism are outlined. The mechanistic concept was applied to budgetary relations, thus becoming the basis for highlighting the main features of the budgetary mechanism, determining the main provisions of forming the budgetary mechanism. Emphasis is placed on the relationship between budget policy, which is manifested through the dialectical unity of budget strategy and tactics, and the budget mechanism. The budgetary mechanism is defined as a system of measures aimed at influencing the mobilization of optimal funds, their efficient distribution and rational use in order to ensure macroeconomic balance, sustainable development and preservation of state sovereignty, as defined by state policy. It is suggested to integrate the constituent elements of the budgetary mechanism into the appropriate subsystems within its framework, through which the main functions of the budgetary mechanism aimed at achieving the goal are manifested. In order to study a subsystem of the budgetary mechanism, namely the regulatory mechanism, the peculiarities of the manifestation of budgetary decentralization in Ukraine are analyzed. It is proved that the introduction of the subsidiarity principle while constructing the decentralized model of inter-budgetary relations in the unitary Ukraine is currently the best option for it to find a balance between the advantages of budgetary federalism and the unitary form of budgetary relations. Systemic problems of budget decentralization have been identified, namely: decentralization occurs by bringing in new persons to act on the national level; it does not affect the mechanisms of autonomy in decision-making on taxation and the formation of additional sources of local budget revenues; statutory tax benefits for the local tax mobilization significantly reduce the financial resources of local budgets; local budgets remain significantly dependant from the state; in the regulation of local budget revenues, preference is given to transfer instruments, and the share of budget-generating taxes is reduced. Given the theoretical construct of the public sector theory, which gives grounds to the formation of local budget revenues, and the results of the research on budget regulation in Ukraine, budget decentralization processes are only proven to be pretentious, and the need to improve the division of budget authority is identified, while emphasis is made on financial self-sufficiency.

We examine two possible approaches to reducing residential mortgage default using a dynamic model of heterogeneous infinitely-lived agents acting optimally subject to uninsurable idiosyncratic earnings shocks and systemic house price shocks. We find higher down payments are very effective in minimizing residential mortgage foreclosures, even in periods of house price declines and recessions. In contrast, the length of the credit exclusionary period for people who experience bankruptcy or foreclosure has a much smaller impact on mortgage defaults. Thus, it is much more effective to prevent mortgage default before the mortgage closes than to pressure homeowners not to default once they are in financial trouble. This also suggests a major aspect of credit scores and credit policy is non-productive and punitive, harming people in return for little societal gain.

Priority setting is necessary where competing demands exceed the finite resources available. The aim of the study was to develop and test a prioritization framework based upon programme budgeting and marginal analysis (PBMA) as a tool to assist National Health Service (NHS) commissioners in their management of resources for local NHS dental services. Twenty-seven stakeholders (5 dentists, 8 commissioners and 14 patients) participated in a case-study based in a former NHS commissioning organization in the north of England. Stakeholders modified local decision-making criteria and applied them to a number of different scenarios. The majority of financial resources for NHS dental services in the commissioning organization studied were allocated to primary care dental practitioners' contracts in perpetuity, potentially constraining commissioners' abilities to shift resources. Compiling the programme budget was successful, but organizational flux and difficulties engaging local NHS commissioners significantly impacted upon the marginal analysis phase. NHS dental practitioners' contracts resemble budget-silos which do not facilitate local resource reallocation. 'Context-specific' factors significantly challenged the successful implementation and impact of PBMA. A local PBMA champion embedded within commissioning organizations should be considered. Participants found visual depiction of the cost-value ratio helpful during their initial priority setting deliberations.

Non-invasive prenatal testing (NIPT) based on cell-free fetal DNA (cffDNA) is highly accurate in the detection of common fetal autosomal trisomies. Aim of this project was to investigate short-term costs and clinical outcomes of the contingent use of cffDNA for prenatal screening of trisomies 21, 18, 13 within a national health service (NHS). An economic analysis was developed from the perspective of the Italian NHS to compare two possible scenarios for managing pregnant women: women managed according to the Standard of Care screening (SoC) vs a cffDNA scenario, where Harmony Prenatal Test was introduced as a second line screening choice for women with an \"at risk\" result from SoC screening. The introduction of cffDNA as a second line screening test, conditional to a risk ≥ 1:1,000 from SoC screening, showed a 3% increase in the detection of trisomies, with a 71% decrease in the number of invasive tests performed. Total short-term costs (pregnancy management until childbirth) decreased by € 19 million (from € 84.5 to 65.5 million). The adoption of the Harmony Prenatal Test in women resulting at risk from SoC screening, implied a greater number of trisomies detection, together with a reduction of the healthcare costs.