Sector Perspective Research Articles

Cost-effectiveness of semaglutide for secondary prevention of cardiovascular disease in the United States

Abstract Background In the SELECT trial, semaglutide produced a 20% reduction in the composite of cardiovascular death, non-fatal myocardial infarction (MI), and non-fatal stroke in individuals with overweight or obesity who did not have diabetes but had established pre-existing cardiovascular disease (CVD). Cost is an important barrier to widespread uptake of semaglutide, particularly in the US, and the cost-effectiveness for the secondary prevention of CVD is uncertain. Purpose To evaluate the cost-effectiveness of semaglutide vs. no obesity treatment for the secondary prevention of CVD from a US healthcare sector perspective. Methods The CVD Policy Model is an established, validated simulation model of fatal and non-fatal CVD outcomes and costs in the US population. Using data from the National Health and Nutrition Examination Survey, we created a nationally representative cohort of SELECT-eligible individuals (age ≥45, BMI ≥27kg/m2, no diabetes, pre-existing CVD). Healthcare costs associated with acute and chronic CVD were estimated from national survey and claims data and inflated to 2023 US dollars. The simulated control arm received usual care; the intervention arm received weekly semaglutide 2.4mg injections (assuming 8% discontinuation, which occurs year one). We reproduced the effectiveness of semaglutide based on results of the SELECT trial primary cardiovascular composite endpoint (non-fatal MI, non-fatal strokes and CVD death). The base case assumed 7% of patients receiving semaglutide developed injection-site reactions. Monthly cost of semaglutide was assumed to be $717 (US price net of rebates and discounts), but this was varied in sensitivity analyses. The analysis adopted a health system perspective over lifetime horizon. Results Approximately 4.7 million US adults would meet SELECT trial eligibility criteria. Over a lifetime horizon, semaglutide is projected to avert 538,000 major adverse cardiovascular events (241,000 nonfatal MIs; 80,000 nonfatal stokes, and 217,000 cardiovascular deaths) at an incremental cost of $613 billion. The incremental cost effectiveness ratio for semaglutide was $443,000 per quality-adjusted life year (QALY) gained. In order to meet cost-effectiveness thresholds of $50,000/QALY, $100,000/QALY, $150,000/QALY, drug costs would have to decline 90%, 79%, and 69% respectively. In sensitivity analyses, lowering drug cost to the current UK price (~ $220 per patient per month) would improve the incremental cost-effectiveness of semaglutide to <$150,000 per QALY gained, a potential upper threshold for cost-effectiveness in the US. Conclusion Widespread uptake of semaglutide in the SELECT-eligible U.S. population would prevent a large number of cardiovascular events, but its use would be low economic value at current US prices. Lowering prices in line with those in Europe (e.g., monthly price from $717 to $223) would make the therapy cost-effective at a threshold of $150,000 per QALY gained.

Cost-Effectiveness Analysis Comparing Conventional and Digital Software Supported Management for Hypothyroidism.

Wearable devices can now leverage the established correlation between thyroid function and heart rate to monitor thyroid function alongside exercise levels and heart rate. The objective was to assess the cost-effectiveness of introducing a wearable/mobile-based thyroid function digital monitoring solution for the management of hypothyroidism compared to the conventional management approach. A decision-analytic Markov state-transition simulation model employed for utilizing a simulated cohort of 10,000 40-year-old patients with hypothyroidism to estimate costs and health outcomes. Cost-effectiveness from the healthcare sector perspective was evaluated using a 4.5% annual discount rate and the costs adjusted to 2022 levels, and lifetime outcomes were presented through incremental cost-effectiveness 49 ratios (ICERs). Deterministic and probabilistic sensitivity analyses evaluated the robustness of the results. The digital monitoring solution supported group yielded an additional 0.65 QALYs with an incremental cost of $11700.87, resulting in an ICER value of $17988.97 per QALY gained. Digital-powered software could be an optimal strategy in 99% of iterations against willingness-to-pay thresholds of $32,255/QALY gained. The ICER was most sensitive to the annual cost of a digital monitoring solution for hypothyroidism. The incorporation of the digital monitoring solution has demonstrated positive cost-effectiveness in hypothyroidism management when compared to the standard care. The cost of the digital monitoring solution and its sensitivity are key factors in determining cost-effectiveness. Striking a balance among the cost of digital monitoring support, the precision of hormonal level monitoring, and its effectiveness for the specific group of hypothyroid patients in real-world clinical practice is essential.

Health and Economic Outcomes of Offering Buprenorphine in Homeless Shelters in Massachusetts

Overdose is the leading cause of death among people experiencing homelessness (PEH), but engagement in medication treatment is low in this population. Shelter-based buprenorphine may be a strategy for increasing initiation and retention on lifesaving medications. To estimate clinical outcomes and conduct an economic analysis of statewide shelter-based opioid treatment in Massachusetts. This economic evaluation study in Massachusetts used a cohort state-transition simulation model. Two cohorts were modeled starting in 2013, including (1) a closed cohort of a fixed population of PEH with history of high-risk opioid use over their lifetimes and (2) an open cohort in which membership could change over time, allowing assessment of population-level trends over a 10-year period. Data analysis occurred from January 2023 to April 2024. Model exposures included (1) no shelter-based buprenorphine (status quo) and (2) offering buprenorphine in shelters statewide. Outcomes included overdose deaths, quality-adjusted life-years (QALYs) gained, and health care and modified societal perspective costs. Sensitivity analyses were conducted on key parameters. In the closed cohort analysis of 13 800 PEH (mean [SD] age, 40.4 [13.1] years; 8749 male [63.4%]), shelter-based buprenorphine was associated with an additional 65.4 person-weeks taking buprenorphine over an individual's lifetime compared with status quo. Shelter-based buprenorphine was cost saving when compared with the status quo, with a discounted lifetime cost savings from the health sector perspective of $1300 per person, and 0.2 additional discounted QALYs per person and 0.9 additional life-years per person. In the population-level simulation, 254 overdose deaths were averted over the 10-year period with the shelter-based buprenorphine strategy compared with the status quo (a 9.2% reduction of overdose deaths among PEH in Massachusetts). Overdose-related and other health care utilization undiscounted costs decreased by $3.0 million and $66.4 million, respectively. Shelter-based opioid treatment generated $44.7 million in additional medication and clinical costs, but saved $69.4 million in overdose and other health costs. In this economic evaluation of clinical and economic outcomes among PEH, shelter-based buprenorphine was associated with fewer overdose deaths and was cost saving. These findings suggest that broad rollout of shelter-based buprenorphine may be an important tool in addressing the overdose crisis.

Gendering Ocean Management for Sustainable Ocean Care in Ghana

UNESCO presently offers a universal regime and policy environment for the identification and management of natural and cultural heritages. However, heritage does not merely signify cultural diversity; it can also facilitate greater equity and equality. The research problem addressed in this article is that in Ghana, the national government perceives and treats the small-scale fishing (SSF) sector as a masculine space and endeavour, ignoring the gendered aspects of this environment, of SSF practice and ocean care. In the article, it is hypothesized that if the SSF sector is treated as a socially differentiated space, and if the concern of ocean care is prioritized as a key imperative in Ghanaian ocean management, it is likely that a more inclusive and sustainable ocean management process and SSF sector will emerge in Ghana. Mindful of the socially differentiated nature of the SSF sector in Ghana, the goal of the research presented in this article is to use mixed qualitative research methods (participant-observation and semi-structured interviews) to investigate gendered knowledge forms and gendered practices in ocean care in the central region of Ghana. A key finding of the research is that gendered ritual practices, including canoe building and use in Ghana, are critical to long-term, sustainable, and inclusive ocean management in the country. Recognition of the gendered dimensions of ocean management in Ghana may also result in more inclusive ocean governance policies and nature management policies in Ghana in general. The conclusion of the article is that ocean governance in Ghana should consider and mainstream a gendered perspective of the SSF sector, to advance transformative, sustainable, and inclusive ocean care. The article draws on theories of intersectionality, African indigenous feminist thought, and critical heritage studies to analyse the data gathered, to support the discussion, and to propose the way forward for the national government.

Cost-effectiveness of screening with transcriptional signatures for incipient TB among U.S. migrants.

Host-response-based transcriptional signatures (HrTS) have been developed to identify "incipient tuberculosis (TB)". No study has reported the cost-effectiveness of HrTS for post-arrival migrant screening programs in low-incidence countries. To assess the potential health impact and cost-effectiveness of HrTS for post-arrival TB infection screening among new migrants in the United States. We used a discrete-event simulation model to compare four strategies: (1) no screening for TB infection or incipient TB; (2) 'IGRA-only', screen all with interferon gamma release assay (IGRA), provide TB preventive treatment for IGRA-positives; (3) 'IGRA-HrTS', screen all with IGRA followed by HrTS for IGRA-positives, provide incipient TB treatment for individuals testing positive with both tests; and (4) 'HrTS-only', screen all with HrTS, provide incipient TB treatment for HrTS-positives. We assessed outcomes over the lifetime of migrants entering the U.S. in 2019, assuming HrTS met the WHO Target Product Profile (TPP) optimal criteria. We conducted sensitivity analyses to evaluate the robustness of results. The IGRA-only strategy dominated the HrTS-based strategies under both healthcare sector and societal perspectives, with an incremental cost-effectiveness ratio of $78,943 and $89,431 per quality-adjusted life-years (QALY) gained, respectively. This conclusion was robust to varying costs ($15-300) and characteristics of HrTS, and the willingness-to-pay threshold ($30,000-150,000/ QALY gained), but sensitive to the rate of decline in TB progression risk after U.S. entry. Our findings suggest that HrTS meeting the WHO TPP is unlikely to be a cost-effective component of post-arrival screening for migrants entering the U.S.

Cost of care associated with utilization of telehealth in clinical trials

ObjectiveDue to COVID-19 pandemic restrictions, telehealth was incorporated into standard oncologic care and clinical trial operations. We sought to analyze whether telehealth changed cost of care compared to traditional clinical trial operations. MethodsWe conducted a retrospective cohort study of gynecologic oncology patients enrolled in therapeutic clinical trials at a National Cancer Institute designated center, comparing the cost of cancer care on trial pre-TELEhealth (9/30/2019 to 3/15/2020) versus during TELEhealth (3/16/2020 to 8/20/2020). Inclusion required trial participation during both study periods, ≥1 telehealth visit, and identifiable billing records. The analysis was from a healthcare sector perspective. Cost per patient per month on trial was calculated for scheduled (per protocol) and unscheduled (non-protocol) encounters using 2020 national Medicare reimbursement rates, not institution-specific prices. Pairwise t-tests between pre-TELE and TELE periods were performed. ResultsTwenty-eight patients were included in the study. The majority of patients (93 %) had ovarian cancer. One patient (4 %) had uterine and 1 (4 %) had concurrent ovarian/uterine cancer. Most patients had advanced-stage disease at diagnosis (93 %). Mean cost per patient per month was similar in pre-TELE and TELE periods ($3797 vs. $4720, p = 0.064). There were no cost differences among scheduled or unscheduled encounters, office or ED visits, admissions, outpatient procedures, nor those billed to study sponsors or patient’s insurer. ConclusionsIncorporating telehealth in gynecologic cancer clinical trials during the COVID-19 pandemic did not increase cost of care and may be a mechanism for decentralizing clinical trials, reducing barriers to trial participation, and improving the value of cancer care.

Cost-Effectiveness And Health Impact Of Increasing Emergency Department Pediatric Readiness In The US.

The quality of emergency department (ED) care for children in the US is highly variable. The National Pediatric Readiness Project aims to improve survival for children receiving emergency services. We conducted a cost-effectiveness analysis of increasing ED pediatric readiness, using a decision-analytic simulation model. Previously published primary analyses of a nationally representative, population-based cohort of children receiving emergency services at 747 EDs in eleven states provided clinical and cost parameters. From a health care sector perspective, we used a 3percent annual discount rate and quantified lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We performed probabilistic, one-way, and subgroup sensitivity analyses. Increasing ED pediatric readiness yields 69,100 QALYs for the eleven-state cohort, costing $9,300 per QALY gained. Achieving high readiness nationally yields 179,000 QALYs at the same ICER (with implementation costs of approximately $260million). Implementing high ED pediatric readiness for all EDs in the US is highly cost-effective.

Continuous Glucose Monitoring With Geriatric Principles in Older Adults With Type 1 Diabetes and Hypoglycemia: A Randomized Controlled Trial.

Continuous glucose monitoring (CGM) use in older adults with type 1 diabetes (T1D) has shown benefits. However, the impact of CGM use, coupled with simplified treatment regimens and personalized glycemic goals that are better suited for older patients with multiple comorbidities and hypoglycemia, is not known. Older adults (≥65 years) with T1D with hypoglycemia (two or more episodes of hypoglycemia [blood glucose <70 mg/dL for ≥20 min over 2 weeks]) who were CGM naïve or CGM users were randomized to intervention and control groups. The intervention consisted of the combined use of CGM with geriatric principles (i.e., adjusting goals based on overall health, and simplification of regimens based on CGM patterns and clinical characteristics) over 6 months. The control group received usual care by their endocrinologist. The primary end point was change in time when blood glucose was <70 mg/dL from baseline to 6 months. Cost-effectiveness was calculated using a health care sector perspective. We randomized 131 participants (aged 71 ± 5 years; 21% ≥75 years old) to the intervention (n = 68; CGM users = 33) or the control (n = 63; CGM users = 40) group. The median change in hypoglycemia from baseline to 6 months was -2·6% in the intervention group and -0.3% in the control group (median difference, -2.3% [95% CI -3.7%, -1.3%]; P < 0.001). This improvement was seen in both CGM naïve (-2.8%; 95% CI -5.6%, -0.8%) and CGM users (-1.2%; 95% CI -2.7%, -0.1%). The HbA1c did not differ between the groups (7.5% vs 7.3%). The intervention was cost-effective (incremental cost-effectiveness ratio $71,623 per quality adjusted life-year). In older adults with T1D and high risk of hypoglycemia, CGM use enhanced by geriatric principles can lower hypoglycemia without worsening glycemic control in a cost-effective fashion.

Addressing the limitation of Operational Flexibility in Power Generation with Pumped Hydro Energy Storage System – Indian Perspective

The global climate change scenario has impacted and taken corrective measures in shifting the sourcing of primary energy and efficient end-use pattern with more focus to utilise renewable energy resources to replace the depleting fossil fuels. Electric power generation capacity in the Indian subcontinent has gradually been improved to substantially contribute to intermittent and variable renewable power generation mix up to 40% of grid demand. However, the injection of grid-integrated renewable power as per the availability of generation potential will necessitate limiting the power generation from generating plants running on fossil fuel. But the operational flexibility of fossil fuel power plants is mostly designed to run efficiently with a 55% minimum technical load on the machines. In the above situation, stable grid availability and operation with a desirable spinning reserve may be taken care of suitably with an on-grid energy storage system, and in the Indian context, a pumped hydro energy storage system may play a critical role to take care of grid operational variability with adequate measures on frequency and voltage correction through periodic power generation and power draw. In this paper, the feasibility of a pumped hydro storage system from an Indian power sector perspective has been reviewed about the present national power scenario.

Cost-effectiveness of a primary care-based Healthy Weight Clinic compared with usual care.

The objective of this study was to project the cost-effectiveness of implementing the Healthy Weight Clinic (HWC), a primary care-based intervention for 6- to 12-year-old children with overweight or obesity, at federally qualified health centers (FQHCs) nationally. We estimated intervention costs from a health care sector and societal perspective and used BMI change estimates from the HWC trial. Our microsimulation of national HWC implementation among all FQHCs from 2023 to 2032 estimated cost per child and per quality-adjusted life year (QALY) gained and projected impact on obesity prevalence by race and ethnicity. Probabilistic sensitivity analyses assessed uncertainty around estimates. National implementation is projected to reach 888,000 children over 10 years, with a mean intervention cost of $456 (95% uncertainty interval [UI]: $409-$506) per child to the health care sector and $211 (95% UI: $175-$251) to families (e.g., time participating). Assuming effect maintenance, national implementation could result in 2070 (95% UI: 859-3220) QALYs gained and save $14.6 million (95% UI: $5.6-$23.5 million) in health care costs over 10 years, yielding a net cost of $278,000 (95% CI: $177,000-$679,000) per QALY gained. We project greater reductions in obesity prevalence among Hispanic/Latino and Black versus White populations. The HWC is relatively low-cost per child and projected to reduce obesity disparities if implemented nationally in FQHCs.

Optimal malarial screening strategy in Australian blood donors: A cost-effectiveness analysis.

The risk of transfusion-transmitted malaria (TTM) infections is extremely low in Australia, and the cost-effectiveness of the current screening strategy has not been assessed. This study aims to conduct a cost-effectiveness analysis of different malaria screening strategies in blood donors as part of the risk-based decision-making framework. A decision tree model was developed to assess the cost-effectiveness of five alternative malaria screening strategies from a healthcare sector perspective. Screening strategies combining total or partial removal of malaria testing with different deferral periods were considered. The probabilities of developing severe and uncomplicated TTM were based on a literature review of cases in non-endemic areas since 2000. The health outcomes were quantified using disability-adjusted life years. The costs of non-returning donors due to deferral were also included. Deterministic and probabilistic sensitivity analyses were conducted to account for data uncertainty. The residual risks for all strategies were so low that the costs, mortality and morbidity associated with TTM are almost negligible. The overall costs were predominantly influenced by the costs of non-returning blood donors. As a result, removal of malaria testing and applying a 28-day deferral for at-risk donors were the least costly and most cost-effective of all the options considered. The current screening strategy for malaria in blood donors in Australia is not an efficient use of healthcare resources. Partial or total removal of malaria testing would bring significant cost savings without significantly compromising blood safety.

Accelerating power grid interconnectivity in Southeast Asia: a private sector perspective

Abstract Integrating the power systems between member states of the Association of Southeast Asian Nations (ASEAN) can facilitate economic growth for the region and enable businesses to cost-effectively procure reliable, clean electricity. As corporations strengthen their clean energy commitments, the grid becomes an important enabler of power sector emissions reductions as well as economic development. This paper offers perspectives from the Asia Clean Energy Coalition (ACEC) on the importance of renewing the Memorandum of Understanding (MOU) on the ASEAN Power Grid, focusing on accelerated implementation to expand multilateral power trade and cross-border grid interconnections. ACEC consists of clean energy buyers, sellers, and financiers that can drive economic growth. It supports strengthening the ASEAN Power Grid MOU to recognise the importance of holistic regional grid planning, prioritising interconnectors that scale up clean energy, harmonising regulatory and technical frameworks, and making data accessible to facilitate multilateral power trade and clean energy tracking.

Abstract P333: Predicted Nationwide Health and Economic Impacts of the AMA MAP TM Hypertension Program to Improve Hypertension Control

Introduction: Lack of actionable blood pressure (BP) measurements, therapeutic inertia, and suboptimal patient self-management are three key barriers to better BP control. To help address these barriers, the American Medical Association developed the Measure Accurately, Act Rapidly, and Partner with Patients Hypertension (MAP TM HTN) quality improvement program. Methods: To estimate the 10-year health and economic outcomes achieved when healthcare delivery systems adopt MAP HTN, HealthPartners Institute's ModelHealth™: Cardiovascular disease (CVD) microsimulation model was applied to conduct “what if” analyses for adopting MAP HTN nationwide and in care delivery systems of varying size. MAP HTN targets patients aged 18 to 85 years with diagnosed hypertension. To account for newly diagnosed hypertensive patients over time and outcomes that follow exposure to the program after age 85, the simulation model predicted outcomes for a dynamic cross-section of U.S. adults aged 18 to 100 years. This study was conducted from the health care sector perspective, including that of the payers for medical services and the health care delivery system that provides these services. Risk equations to predict the incidence of CVD events were derived from Framingham Heart Study data and are based upon the following risk factors: age, sex, body mass index, systolic BP (SBP), lipid levels, smoking status, diabetes status, and CVD history. Modeled outcomes over 10 years included prevalence of SBP ≥140 mmHg; incidence of cardiovascular disease (CVD) events and CVD-related mortality; averted medical costs in 2021 U.S. dollars; and net costs. Results: Nationwide adoption of MAP HTN was predicted to improve mean BP control by 4.3% and prevent 601000 CVD events, with 85000 fewer myocardial infarctions, 164000 fewer strokes and 120000 fewer CVD deaths over 10 years as compared to usual care. The majority (93%) of the estimated $17.9 billion in averted costs were among Medicare beneficiaries. Total costs of implementing MAP HTN was $12.6 billion, resulting in a predicted $5.3 billion in net savings to the health care sector over 10 years. Small and large care delivery organizations could economically benefit from implementing MAP HTN at varying levels (5-50%) of shared cost savings from payers. Conclusions: The model demonstrates that AMA’s MAP HTN has the potential to improve population health and provide a positive business case by averting future myocardial infarctions, strokes, and CVD deaths.

Developing collaborative ecosystem platforms to trigger sustainable “place-based” value creation: a dynamic performance governance approach

PurposeThis paper aims to illustrate how service ecosystem governance may provide a suitable ground to pursue holistic resilience to “wicked” socio-economic and ecological problems, for enhancing “place-based” sustainable performance outcomes through an organizational, interorganizational and context setting.Design/methodology/approachThis work suggests the use of “place-based” collaborative ecosystem platforms driven by a dynamic performance governance approach as a setting where facilitated performance dialogue is carried out among networked stakeholders. This fosters a holistic view of performance sustainability where intangibles, inertial, cultural and behavioral factors play a key role in policy analysis.FindingsThe paper illustrates how different research streams framing stakeholder relationships under a business, hybrid organization and public sector perspective converge toward the “service ecosystem” construct, as a common field for sustainable “place-based” value creation. This performance governance perspective frames accountability for achieving sustainable outcomes through interconnected viewpoints, i.e. (1) time (short vs long-term), (2) subject (single organization, “theme-focused” service ecosystem and “place-based” service ecosystem) and (3) field (socio-economic, cultural and ecological).Originality/valueThis work has an interdisciplinary track. It recommends feedback and “stock-and-flow” modeling to enhance framing counterintuitive patterns of behavior of dynamic complex socio-economic, cultural and ecological subsystems within “place-based” collaborative ecosystem platforms. Combining an inside-out with an outside-in view triggers sustainable outcome-based dynamic performance governance through an organizational, interorganizational and context setting.

Budget impact and cost per responder analysis of upadacitinib for the treatment of moderate to severe atopic dermatitis from the perspective of the social security and the private sector in Argentina

ABSTRACT Objectives Our study assessed the budget impact and cost per responder of upadacitinib15mg and 30 mg for moderate to severe atopic dermatitis (MS-AD) treatment from social security and private health sector perspective in Argentina. Methods A budget impact model was adapted to depict clinical and economic aspects of treatment over a 5-years horizon time. Scenario analyses and deterministic sensitivity analyses were performed. A 16-weeks cost per responder model was adapted based on a network meta-analysis. Primary analyses assessed the cost per Eczema Area and Severity Index 50, 75 and 90 at week 16. Results The inclusion of upadacitinib 15 mg and 30 mg in the biological treatment mix for MS-AD was associated with an average budget saving per-member per-month ofU$S0.062 (social security) and U$S0.064 (private sector). Percentage of patients with access to treatment, acquisition cost of upadacitinib 30 mg and prevalence of MS-AD were the most influential parameters in the budget impact results. At week 16, upadacitinib 30 mg was associated with the lowest number needed to treat and the lowest cost per responder for all outcomes. Conclusion The introduction of upadacitinib in MS-AD treatment was associated with modest savings for the social security and private payer budget in Argentina.

Government promotion and city image: visitor intentions in Macao

PurposeThis study aims to critically evaluate the impact of government tourism promotion methods on city image and visiting intentions and to explore the moderating effect of tourism experience on two of the conceptualized relationships, using Macao as a case study.Design/methodology/approachThe research analyzed responses from 407 Macao visitors during the pandemic to determine the effects of tourism promotion methods on the city’s image and visiting intention using structural equation modeling (SEM) to test the hypotheses.FindingsThis study revealed that tourism promotion methods positively impact the city’s image and visiting intentions. City image also mediates the relationship between tourism promotion methods and visiting intentions. Furthermore, tourism experience moderates the relationships between promotion methods and city image and between promotion methods and visiting intentions.Research limitations/implicationsThe study’s findings on the effects of promotion methods utilized by local governments support and expand upon existing theoretical frameworks within the realm of nonprofit organizations’ management and marketing for destination marketing organizations (DMOs). However, the cross-sectional design limits causality, and findings may not be generalizable beyond Macao without further comparative research.Practical implicationsThis study provides valuable insights for policymakers and marketers to design promotional campaigns that deliver authentic and memorable experiences, aligning with their promotional promises, especially in postpandemic contexts.Social implicationsThis research contributes to the theoretical and methodological advancement of management and marketing for DMOs from a public sector perspective, highlighting the critical role of government involvement in urban tourism promotion.Originality/valueThe research offers valuable insights into how promotional activities influence visiting intentions, advancing tourism management and marketing for DMOs from a nonprofit perspective. The study validates theories and adds unique insights by focusing on Macao’s postpandemic recovery, offering practical implications for similar urban settings.

Clinical and cost-effectiveness of remote-delivered, online lifestyle therapy versus psychotherapy for reducing depression: results from the CALM non-inferiority, randomised trial

We conducted the first non-inferiority, randomised controlled trial to determine whether lifestyle therapy is non-inferior to psychotherapy with respect to mental health outcomes and costs when delivered via online videoconferencing. An individually randomised, group treatment design with computer-generated block randomisation was used. Between May 2021-April 2022, 182 adults with a Distress Questionnaire-5 score=≥8 (indicative depression) were recruited from a tertiary mental health service in regional Victoria, Australia and surrounds. Participants were assigned to six 90-min sessions over 8-weeks using group-based, online videoconferencing comprising: (1) lifestyle therapy (targeting nutrition, physical activity) with a dietitian and exercise physiologist (n=91) or (2) psychotherapy (Cognitive Behavioural Therapy) with psychologists (n=91). The primary outcome was Patient Health Questionnaire-9 (PHQ-9) depression at 8-weeks (non-inferiority margin ≤2) using Generalised Estimating Equations (GEE). Cost-minimisation analysis estimated the mean difference in total costs from health sector and societal perspectives. Outcomes were assessed by blinded research assistants using Computer Assisted Telephone Interviews. Results are presented per-protocol (PP) and Intention to Treat (ITT) using beta coefficients with 95% Confidence Intervals (CIs). The sample was 80% women (mean: 45-years [SD:13.4], mean PHQ-9:10.5 [SD:5.7]. An average 4.2 of 6 sessions were completed, with complete data for n=132. Over 8-weeks, depression reduced in both arms (PP: Lifestyle (n=70) mean difference:-3.97, 95% CIs:-5.10,-2.84; and Psychotherapy (n=62): mean difference:-3.74, 95% CIs:-5.12,-2.37; ITT: Lifestyle (n=91) mean difference:-4.42, 95% CIs:-4.59,-4.25; Psychotherapy (n=91) mean difference:-3.82, 95% CIs:-4.05,-3.69) with evidence of non-inferiority (PP GEE β:-0.59; 95% CIs:-1.87, 0.70, n=132; ITT GEE β:-0.49, 95% CIs:-1.73, 0.75, n=182). Three serious adverse events were recorded. While lifestyle therapy was delivered at lower cost, there were no differences in total costs (health sector adjusted mean difference: PP AUD$156 [95% CIs-$182, $611, ITT AUD$190 [95% CIs-$155, $651] ]; societal adjusted mean difference: PP AUD$350 [95% CIs:-$222, $1152] ITT AUD$ 408 [95% CIs-$139, $1157]. Remote-delivered lifestyle therapy was non-inferior to psychotherapy with respect to clinical and cost outcomes. If replicated in a fully powered RCT, this approach could increase access to allied health professionals who, with adequate training and guidelines, can deliver mental healthcare at comparable cost to psychologists. This trial was funded by the Australian Medical Research Future Fund (GA133346) under its Covid-19 Mental Health Research Grant Scheme.

Cost-effectiveness analysis of a digital diabetes-prevention programme versus an in-person diabetes-prevention programme in people with prediabetes in the United States.

To assess the cost-effectiveness of a digital diabetes prevention programme (d-DPP) compared with a diabetes prevention programme (DPP) for preventing type 2 diabetes (T2D) in individuals with prediabetes in the United States. A Markov cohort model was constructed, simulating a 10-year period starting at the age of 45 years, with a societal and healthcare sector perspective. The effectiveness of the d-DPP intervention was evaluated using a meta-analysis, with that of the DPP as the comparator. The initial cycle represented the treatment period, and transition probabilities for the post-treatment period were derived from a long-term lifestyle intervention meta-analysis. The onset of T2D complications was estimated using microsimulation. Quality-adjusted life years (QALYs) were calculated based on health utility measured by short form (SF)-12 scores, and a willingness-to-pay threshold of $100 000 per QALY gained was applied. The d-DPP intervention resulted in cost savings of $3,672 from a societal perspective and $2,990 from a healthcare sector perspectiveand a gain of 0.08 QALYs compared with the DPP. The dropout rate was identified as a significant factor influencing the results. Probabilistic sensitivity analysis showed that the d-DPP intervention was preferred in 85.8% in the societal perspective and 85.2% in the healthcare sector perspective. The d-DPP is a cost-effective alternative to in-person lifestyle interventions for preventing the development of T2D among individuals with prediabetes in the United States.

Fusing domain knowledge with machine learning: A public sector perspective

Machine learning (ML) offers widely-recognized, but complex, opportunities for both public and private sector organizations to generate value from data. A key requirement is that organizations must find ways to develop new knowledge by merging crucial ‘domain knowledge’ of experts in relevant fields with ‘machine knowledge’, i.e., data that can be used to inform predictive models. In this paper, we argue that understanding the process of generating such knowledge is essential to strategically develop ML. In efforts to contribute to such understanding, we examine the generation of new knowledge from domain knowledge through ML via an exploratory study of two cases in the Swedish public sector. The findings reveal the roles of three mechanisms – dubbed consolidation, algorithmic mediation, and naturalization – in tying domain knowledge to machine knowledge. The study contributes a theory of knowledge production related to organizational use of ML, with important implications for its strategic governance, particularly in the public sector.

Design principles for MOOC platforms: a public sector perspective

Purpose One impediment of e-government implementation is the lack of e-(government) competences among public officials, especially because foundational education programs fail to teach them. Therefore, this study suggests massive open online course (MOOC)-based continuous education. This study aims to design and evaluate a MOOC and MOOC platform for acquiring e-competence in the public sector and principles for such platforms to capture their inherent design knowledge. Design/methodology/approach This study uses design science research incorporating qualitative and quantitative methods and draws on established patterns of formulating design principles (DPs). Findings The core results are a physically instantiated MOOC platform and six DPs: DP of 1) easy access and easy use, 2) professional exchange, 3) protected space, 4) domain focus, 5) cooperation with higher education institutions and 6) promotion from higher government level. Research limitations/implications This study contributes to e-government research by extending the design knowledge for the construction of domain-specific MOOC platforms. Moreover, the study contributes to platform economics by discussing existing theses and outlining new opportunities. The research also entails limitations, as the authors have solely considered MOOCs and neglected complimentary offers to sustain learning success. Practical implications This study provides practitioners with design principles they can use in their efforts to construct education platforms for the public sector. Moreover, the study presents a working MOOC platform instantiating these DPs, and thus provides an exemplary reference. Social implications Not fulfilling expectations regarding digital public services comes with a risk of decreasing trust in public organizations and the overall government. The results of this study contribute to enabling public officials fulfilling stakeholders’ expectations and generating public value. Originality/value By linking e-government competence education with MOOC platform design, this research approximates an important research gap. Scholars previously investigated e-competences and focused on alone-standing MOOCs to convey those. The results of this study offer the potential to construct platforms to centralize such fragmented solutions, maximizing their impact among public officials.