From molecules to morphology: How food supply influences the larvae of sea urchins across all levels of biological organization.

An important goal of many studies in molecular ecology is to utilize molecular tools to elucidate how critical traits like metabolism and growth are affected by environmental stressors and how organisms offset these stresses by adaptive molecular-level responses. Stress from food deprivation may be critical for early developmental stages that require a continued supply of substrates for energy metabolism and growth if development is to be completed. In a 'From the Cover' article in this issue of Molecular Ecology, Li et al. (2023) examined the effects of withholding food (unicellular algae) on 10 traits of larvae of the purple sea urchin (Strongylocentrotus purpuratus), ranging from the molecular level (gene expression) to morphology. Overall, this study sheds new light on the plasticity of larval development and the tight linkages that exist among traits as they respond to changes in food availability. Importantly, shifts in the sources of food utilized under different dietary treatments show the plasticity of these larvae to alter reliance on endogenous energy stores and dissolved organic matter (DOM) as algae deprivation continues. The effects of global change on the amounts and phenology of productivity in the seas make this type of integrated, multi-level analysis an important tool for predicting the future states of marine ecosystems.

A metabolic perspective on polyploid invasion and the emergence of life histories: Insights from a mechanistic model.

PREMISE: Whole-genome duplication (WGD, polyploidization) has been identified as a driver of genetic and phenotypic novelty, having pervasive consequences for the evolution of lineages. While polyploids are widespread, especially among plants, the long-term establishment of polyploids is exceedingly rare. Genome doubling commonly results in increased cell sizes and metabolic expenses, which may be sufficient to modulate polyploid establishment in environments where their diploid ancestors thrive. METHODS: We developed a mechanistic simulation model of photosynthetic individuals to test whether changes in size and metabolic efficiency allow autopolyploids to coexist with, or even invade, ancestral diploid populations. Central to the model is metabolic efficiency, which determines how energy obtained from size-dependent photosynthetic production is allocated to basal metabolism as opposed to somatic and reproductive growth. We expected neopolyploids to establish successfully if they have equal or higher metabolic efficiency as diploids or to adapt their life history to offset metabolic inefficiency. RESULTS: Polyploid invasion was observed across a wide range of metabolic efficiency differences between polyploids and diploids. Polyploids became established in diploid populations even when they had a lower metabolic efficiency, which was facilitated by recurrent formation. Competition for nutrients is a major driver of population dynamics in this model. Perenniality did not qualitatively affect the relative metabolic efficiency from which tetraploids tended to establish. CONCLUSIONS: Feedback between size-dependent metabolism and energy allocation generated size and age differences between plants with different ploidies. We demonstrated that even small changes in metabolic efficiency are sufficient for the establishment of polyploids.

Global chessboard: Analyzing how geopolitical risk shapes renewable energy technology investments.

The allocation of budgets for renewable energy (RE) technology is significantly influenced by geopolitical risks (GPRs), reflecting the intricate interplay among global political dynamics, social media narratives, and the strategic investment decisions essential for advancing sustainable energy solutions. Against the backdrop of increasing worldwide initiatives to transition to RE sources, it is crucial to understand how GPR affects funding allocations, informing policy decisions, and fostering international collaboration to pursue sustainable energy solutions. Existing work probes the nonlinear effect of GPR on RE technology budgets (RTB) within the top 10 economies characterized by substantial research and development investments in RE (China, USA, Germany, Japan, France, South Korea, India, the United Kingdom, Australia, and Italy). Past research largely focused on panel data techniques to delve the interconnection between GPR and RE technology, overlooking the distinctive characteristics of individual economies. Contrarily, existing investigation implements the "Quantile-on-Quantile" tool to explore this association on an economy-particular basis, enhancing the precision of our analysis and offering both a comprehensive global perspective and nuanced perceptions for entire countries. The findings manifest a significant reduction in funding for RE technology associated with GPR across various quantile levels in the chosen economies. The disparities in results spotlight the necessity for policymakers to perform thorough assessments and carry out competent strategies to address the variations in GPR and RTB.

The risk paradox: Exploring asymmetric nexus between climate policy uncertainty and renewable energy technology budgets.

The ups and downs of climate policy uncertainty (CPU) cast a captivating shadow over the budgets allocated to renewable energy (RE) technologies, where strategic choices and risk assessment will determine the course of our green environmental revolution. The main intention of this investigation is to scrutinize the effect of CPU on the RE technology budgets (RETBs) in the top 10 countries with the highest RE research and development budgets (the USA, China, South Korea, India, Germany, the United Kingdom, France, Japan, Australia, and Italy). Although former researchers have typically employed panel data tools to contemplate the connection between CPU and RE technology, they repeatedly ignored variations in this connection throughout different economies. In contrast, our research adopts a unique approach, "quantile-on-quantile," to check this association at the country-to-country level. This approach offers a comprehensive worldwide perspective while procuring tailor-made perceptions for individual economies. The outcomes suggest that CPU significantly decreases RETBs across several data quantiles in our sample nations. In addition, the outcomes underscore that the connections between our variables differ among nations. These outcomes highlight the significance of policymakers implementing thorough appraisals and skillfully governing plans relevant to CPU and RETBs.

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland.

BACKGROUND: Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease. OBJECTIVE: Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes. DESIGN: Observational cohort study. PARTICIPANTS: One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021. INTERVENTIONS: Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support). MAIN MEASURES: Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations). KEY RESULTS: Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months. CONCLUSIONS: CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries. METHODS: This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions. RESULTS: During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1). CONCLUSIONS: Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.

Effects of provisioning on the activity budget and foraging strategies of black-and-white snub-nosed monkeys (Rhinopithecus bieti) in the Baima Snow Mountain Nature Reserve, Yunnan, China.

Provisioning can significantly affect the ranging patterns, foraging strategies, and time budget of wild primates. In this study, we document for the first time, the effects of provisioning on the activity budget and foraging effort in an Asian colobine. Over 3-years, we used an instantaneous scanning method at 10-min intervals to collect data on the activity budget of a semiprovisioned breeding band (SPB) of black-and-white snub-nosed monkeys (Rhinopithecus bieti) (42-70 individuals) at Xiangguqing (Tacheng), Yunnan, China. We then compared the effects of provisioning in our study band with published data on a sympatric wild nonprovisioned breeding band (NPB) of R. bieti (ca. 360 monkeys) at the same field site. The SPB spent 25.6% of their daytime feeding, 17.1% traveling, 46.9% resting, and 10.3% socializing. In comparison, the NPB devoted more time to feeding (34.9%) and socializing (14.1%), less time to resting (31.3%), and was characterized by a greater foraging effort (1.74 versus 0.96, foraging effort = (feeding + traveling)/resting; see Methods). There was no difference between bands in the proportion of their activity budget devoted to traveling (15.7% vs. 17.1%). In addition, the SPB exhibited a more consistent activity budget and foraging effort across all seasons of the year compared to the NPB. These findings suggest that the distribution, availability, and productivity of naturally occurring feeding sites is a major determinant of the behavioral strategies and activity budget of R. bieti. Finally, a comparison of our results with data on six nonprovisioned R. bieti bands indicates that caution must be raised in meta-analyses or intraspecific comparisons of primate behavioral ecology that contain data generated from both provisioned and nonprovisioned groups.

Behavioral adjustments of endangered Barbary macaques (Macaca sylvanus) living at the edge of an agricultural landscape in Morocco.

Transition zones between natural and human-altered spaces are eroding in most terrestrial ecosystems. The persistence of animals in shared landscapes depends in part on their behavioral flexibility, which may involve being able to exploit human agricultural production. As a forest-dependent species, the Barbary macaque (Macaca sylvanus) is affected by the progressive conversion of forest-adjacent lands into crops. We explore how Barbary macaque behavior differs between groups living in a forest at the edge of agricultural zones (hereafter "disturbed groups") and groups inhabiting undisturbed forests (hereafter "natural groups"). We compare the diets, activity-budgets, home range sizes, daily path lengths, and sleeping site locations of the groups. We also quantify anthropogenic disturbances (i.e., rates of encounter with humans and dogs) and investigate relationships between such disturbances and the diets and activity budgets of macaques through multiple co-inertia analysis. Disturbed groups included high proportions of cultivated food items in their diet and encountered over 0.5/h anthropogenic disturbances. Activity-budgets differed between disturbed and natural groups and were mostly influenced by diets, not anthropogenic disturbances. Disturbed groups spent more time feeding and less time resting than natural ones. Patterns of space use differed markedly between groups, with disturbed groups displaying smaller home ranges, shorter daily path length, and much higher reutilization of sleeping sites than natural groups. This study highlights the dietary and behavioral flexibility of Barbary macaques living in human-altered environments. Their patterns of space use suggest a reduction in energy expenditure in the disturbed groups due to the inclusion of cultivated food items in their diet possibly leading to increased foraging efficiency. However, the high rates of anthropogenic encounters, including aggressive ones, are likely stressful and may potentially induce extra energy costs and lead to macaque injuries. This could result in demographic costs for crop-foraging groups, threatening the conservation of this endangered species.

Reimbursement of care does not equal the distribution of hospital resources: an explorative case study on a missing link among Dutch hospitals.

BACKGROUND: Affordability and accessibility of hospital care are under pressure. Research on hospital care financing focuses primarily on incentives in the financial system outside the hospital. It is notable that little is known about (incentives in) internal funding in hospitals. Therefore, our study focuses on the budget allocation in hospitals: the distribution model. Based on our hypothesis that the reimbursement and distribution models in hospitals might interact, we gain knowledge about-, and insight into, the interaction of different reimbursement and distribution models used in Dutch hospitals, and how they affect the financial output of hospital care. METHODS: An online survey with 22 questions was conducted among financial senior management as an expert group in 49 Dutch hospitals. RESULTS: Ultimately, 38 of 49 approached experts fully completed the survey, which amounts to 78% of the hospitals we approached and 60% of all Dutch hospitals. The results on the reimbursement model indicate price * volume with adjusted prices above a maximum cap as the most common dominant contract type. On the internal distribution model, 75-80% of the experts reported incremental budgeting as the dominant budgeting method. Results on the interaction between the reimbursement and the distribution model show that both general and specific changes in contract agreements are only partially incorporated in hospital budgets. In 28 out of 31 hospitals with self-employed medical specialists, a relation is reported between the reimbursement model and the contracts with the Medical Consultant Group(s) in which the medical specialists are united. CONCLUSIONS: Our results in Dutch setting indicate a limited interaction between the reimbursement model and the distribution model. This lack of congruence between both models might limit the desired effects of incentives in contractual agreements aimed at the financial output. This applies to different reimbursement and distribution models. Further research into the various interactions and incentives, as visualized in our conceptual framework, could result in evidence-based advice for achieving affordable and accessible hospital care.

The Costs of Operating a Student-run Free Clinic.

INTRODUCTION: Free clinics provide care for those who may otherwise not have access. While this care is often free for patients, it is not free to operate such clinics. This review will provide a budget and breakdown of all expenditures at a student-run free clinic along with average costs of services provided to patients. METHODS: Accounting data was used to categorize all expenses and generate an annual budget. An inventory tracking system was developed to measure the costs of all medical supplies and services accurately, providing information on costs per clinic and costs per patient for each provided service. RESULTS: The average cost per clinic was $53.55 (per patient: $2.14) for general clinic supplies, $43.74 (per patient: $7.29) for telehealth, $278.47 (per patient: $12.66) for laboratory services, $247.25 (per patient: $10.75) for pharmacy services, and $8.30 (per patient: $1.19) for social work. These costs contributed to a relative minority (< 33%) of the total costs to run a free clinic, where the highest costs were for volunteer appreciation and administrative overhead. Twelve categories of expenditures (administrative overhead, volunteer appreciation, medical and lab supplies, conferences and special projects, advertising and marketing, telehealth, pharmacy, specialty clinics, chronic care, patient transportation, social work, and accounting services) were ranked in order of necessity, and methods for cost reduction were discussed for each category. CONCLUSIONS: Categorizing costs can show where cost savings and cost-effective additions may be implemented. This study may serve as a financial and budgeting reference for other clinics.

Behaviour and welfare of African lion (Panthera leo) cubs used in contact wildlife tourism.

Lion (Panthera leo) cubs are used in wildlife interaction tourism but the effects on cub welfare are unknown. We assessed the behaviour of three cohorts of lion cubs, twelve animals in total, at three different interaction facilities, using continuous and scan-sampling methodologies for the entire duration of cub utilisation for human interactions. Cubs spent most time inactive (62%), particularly sleeping (38%), but also spent a substantial amount of time playing (13%) and being alert (12%). A generalised linear mixed model revealed that cub behaviour was similar in two facilities but different from cubs in the third. In these two similar facilities, as human interactions increased, the time spent resting, sleeping and playing with other cubs decreased, and alert behaviour, grooming of humans and flight responses increased. In the third facility, cubs had an abnormal activity budget, with high levels of inactivity (80%) accompanied by a lack of response to human interactions. We conclude that in some facilities normal cub behaviour cannot be achieved and may be compromised by a high frequency of human interactions, which therefore needs to be controlled to limit adverse effects on cub behaviour.

Uncovering the spatio-temporal dynamics of crop-specific nutrient budgets in China.

Nitrogen (N) and phosphorus (P) are two critical nutrients for agroecosystems. In meeting food demands, human use of both nutrients has crossed planetary boundaries for sustainability. Further, there has been a dramatic shift in their relative inputs and outputs, which may generate strong N:P imbalances. Despite enormous efforts on agronomic N and P budgets, the spatio-temporal characteristics of different crop types in using nutrients are unknown as are patterns in the stoichiometric coupling of these nutrients. Thus, we analyzed the annual crop-specific N and P budgets and their stoichiometric relations for producing ten major crops at the provincial level of China during 2004-2018. Results show that, China has generally witnessed excessive N and P input over the past 15 years, with the N balance remaining stable while the P balance increasing by more than 170%, thus resulting in a decline in the N:P mass ratios from 10.9 in 2004 to 3.8 in 2018. Crop-aggregated nutrient use efficiency (NUE) of N has increased by 10% in these years while most crops have shown a decreasing trend of this indicator for P, which reduced NUE of P from 75% to 61% during this period. At the provincial level, the nutrient fluxes of Beijing and Shanghai have obviously declined, while the nutrient fluxes of provinces such as Xinjiang and Inner Mongolia have increased significantly. Although N management has made progress, P management should be further explored in the future due to eutrophication concerns. More importantly, N and P management strategies for sustainable agriculture in China should take account of not only the absolute nutrient use, but also their stoichiometric balance for different crops in different locations.

Atmospheric oxidizing capacity in autumn Beijing: Analysis of the O3 and PM2.5 episodes based on observation-based model.

Atmospheric oxidizing capacity (AOC) is the fundamental driving factors of chemistry process (e.g., the formation of ozone (O3) and secondary organic aerosols (SOA)) in the troposphere. However, accurate quantification of AOC still remains uncertainty. In this study, a comprehensive field campaign was conducted during autumn 2019 in downtown of Beijing, where O3 and PM2.5 episodes had been experienced successively. The observation-based model (OBM) is used to quantify the AOC at O3 and PM2.5 episodes. The strong intensity of AOC is found at O3 and PM2.5 episodes, and hydroxyl radical (OH) is the dominating daytime oxidant for both episodes. The photolysis of O3 is main source of OH at O3 episode; the photolysis of nitrous acid (HONO) and formaldehyde (HCHO) plays important role in OH formation at PM2.5 episode. The radicals loss routines vary according to precursor pollutants, resulting in different types of air pollution. O3 budgets and sensitivity analysis indicates that O3 production is transition regime (both VOC and NOx-limited) at O3 episode. The heterogeneous reaction of hydroperoxy radicals (HO2) on aerosol surfaces has significant influence on OH and O3 production rates. The HO2 uptake coefficient (γHO2) is the determining factor and required accurate measurement in real atmospheric environment. Our findings could provide the important bases for coordinated control of PM2.5 and O3 pollution.

Trait phenology and fire seasonality co-drive seasonal variation in fire effects on tree crowns.

The plume of hot gases rising above a wildfire can heat and kill the buds in tree crowns. This can reduce leaf area and rates of photosynthesis, growth, and reproduction, and may ultimately lead to mortality. These effects vary seasonally, but the mechanisms governing this seasonality are not well understood. A trait-based physical model combining buoyant plume and energy budget theories shows the seasonality of bud necrosis height may originate from temporal variation in climate, fire behaviour, and/or bud functional traits. To assess the relative importance of these drivers, we parameterized the model with time-series data for air temperature, fireline intensity, and bud traits from Pinus contorta, Picea glauca, and Populus tremuloides. Air temperature, fireline intensity, and bud traits all varied significantly through time, causing significant seasonal variation in predicted necrosis height. Bud traits and fireline intensity explained almost all the variation in necrosis height, with air temperature explaining relatively minor amounts of variation. The seasonality of fire effects on tree crowns appears to originate from seasonal variation in functional traits and fire behaviour. Our approach and results provide needed insight into the physical mechanisms linking environmental variation to plant performance via functional traits.

The past, present, and future of coral reef growth in the Florida Keys.

Coral-reef degradation is driving global-scale reductions in reef-building capacity and the ecological, geological, and socioeconomic functions it supports. The persistence of those essential functions will depend on whether coral-reef management is able to rebalance the competing processes of reef accretion and erosion. Here, we reconstructed census-based carbonate budgets of 46 reefs throughout the Florida Keys from 1996 to 2019. We evaluated the environmental and ecological drivers of changing budget states and compared historical trends in reef-accretion potential to millennial-scale baselines of accretion from reef cores and future projections with coral restoration. We found that historically, most reefs had positive carbonate budgets, and many had reef-accretion potential comparable to the ~3 mm year-1 average accretion rate during the peak of regional reef building ~7000 years ago; however, declines in reef-building Acropora palmata and Orbicella spp. corals following a series of thermal stress events and coral disease outbreaks resulted in a shift from positive to negative budgets for most reefs in the region. By 2019, only ~15% of reefs had positive net carbonate production. Most of those reefs were in inshore, Lower Keys patch-reef habitats with low water clarity, supporting the hypothesis that environments with naturally low irradiance may provide a refugia from thermal stress. We caution that our estimated carbonate budgets are likely overly optimistic; comparison of reef-accretion potential to measured accretion from reef cores suggests that, by not accounting for the role of nonbiological physical and chemical erosion, census-based carbonate budgets may underestimate total erosion by ~1 mm year-1 (-1.15 kg CaCO3 m-2 year-1 ). Although the present state of Florida's reefs is dire, we demonstrate that the restoration of reef-building corals has the potential to help mitigate declines in reef accretion in some locations, which could allow some key ecosystem functions to be maintained until the threat of global climate change is addressed.

Energy-mediated responses to changing prey size and distribution in marine top predator movements and population dynamics.

Climate change is modifying the structure of marine ecosystems, including that of fish communities. Alterations in abiotic and biotic conditions can decrease fish size and change community spatial arrangement, ultimately impacting predator species which rely on these communities. To conserve predators and understand the drivers of observed changes in their population dynamics, we must advance our understanding of how shifting environmental conditions can impact populations by limiting food available to individuals. To investigate the impacts of changing fish size and spatial aggregation on a top predator population, we applied an existing agent-based model parameterized for harbour porpoises Phocoena phocoena which represents animal energetics and movements in high detail. We used this framework to quantify the impacts of shifting prey size and spatial aggregation on porpoise movement, space use, energetics and population dynamics. Simulated individuals were more likely to switch from area-restricted search to transit behaviour with increasing prey size, particularly when starving, due to elevated resource competition. In simulations with highly aggregated prey, higher prey encounter rates counteracted resource competition, resulting in no impacts of prey spatial aggregation on movement behaviour. Reduced energy intake with decreasing prey size and aggregation level caused population decline, with a 15% decrease in fish length resulting in total population collapse Increasing prey consumption rates by 42.8 ± 4.5% could offset population declines; however, this increase was 21.3 ± 12.7% higher than needed to account for changes in total energy availability alone. This suggests that animals in realistic seascapes require additional energy to locate smaller prey which should be considered when assessing the impacts of decreased energy availability. Changes in prey size and aggregation influenced movements and population dynamics of simulated harbour porpoises, revealing that climate-induced changes in prey structure, not only prey abundance, may threaten predator populations. We demonstrate how a population model with realistic animal movements and process-based energetics can be used to investigate population consequences of shifting food availability, such as those mediated by climate change, and provide a mechanistic explanation for how changes in prey structure can impact energetics, behaviour and ultimately viability of predator populations.

How personalisation programs can exacerbate socio-economic inequities: findings from budget utilisation in the Australian National Disability Insurance Scheme.

BACKGROUND: Researchers and policymakers are increasingly concerned that personalisation schemes in social and health care might be worsening social and health inequities. This has been found internationally, where better outcomes from such schemes have been found amongst those who have higher education and more household income. METHOD: This study looks at one of the world's largest personalisation schemes, the Australian National Disability Insurance Scheme. Using publicly available data we examine the allocation and utilisation of NDIS funds according to social gradient. RESULTS: We find that the rate at which people with disability 'spend' or effectively use their disability care funds follows a social gradient. That is, those in areas of higher socioeconomic disadvantage are not spending as much of their allocated budgets on care services across the year compared to people in areas of higher socioeconomic advantage. This represents a clear issue of equity in the use of public money to people with disability in Australia. CONCLUSION: We argue that this points to the need to provide targeted supports for the use of disability care funds in areas of higher socioeconomic disadvantage. Without effective supports for fund use, the NDIS and other personalisation schemes may be positioned to worsen existing social inequalities.

Increasing the impact of budget impact analysis: incorporating uncertainty for decision-makers in small markets.

For decision-makers considering new medicines for reimbursement and public use, both value for money and affordability are important considerations. Whereas a cost-effectiveness model provides information about value for money, a budget impact assessment (BIA) is customized to a specific context and estimates the total investment needed; one part of affordability. Both analytic approaches have parameter uncertainty within them, yet comparatively little attention is given to parameter uncertainty in BIA. Currently, within BIA, uncertainty exploration is limited to point estimates for plausible scenarios, prompting the question: can a decision-maker be confident in point estimates? Within this paper, our intent is to revitalize the discussion of uncertainty in BIA. In the context of health technology assessments submitted to support reimbursement decision-making, we propose reliance on probabilistic sensitivity analysis conducted in the cost-effectiveness model. If assumptions made in a cost-effectiveness model are valid, probabilistic cost estimates from the model, with the same perspective adopted as the BIA, should also inform BIA. Mean and variance of population outcomes, given parameter uncertainty in model inputs, are estimable from model outputs. As sufficiently large random samples are drawn from a population, the distribution of sample means will follow an approximately normal distribution. Therefore, when drawing samples from the model to inform estimates of budget impact, the assumption of an approximately normal distribution for costs is reasonable. We propose that the variance in mean costs from the cost-effectiveness model also reflects the variance in budget impact estimates and should be used to estimate budget impact confidence intervals.

Supervisory and administrative staff's perspectives of self-directed supports for people with intellectual and developmental disabilities.

BACKGROUND: Self-directed supports (SDS) are a model of disability service delivery that focuses on supporting increased decision-making authority and budget autonomy for people with disabilities and their families. This study identifies supervisory and administrative staff's perspectives within a self-directed, individualised budgeting programme for people with intellectual and developmental disabilities. METHOD: Data were collected through 28 face-to-face interviews with supervisory and fiscal administrative staff in Minnesota, USA. RESULTS: A qualitative analysis of these interviews resulted in four major themes: (1) the benefits of SDS, (2) the relationship between SDS and person-centred strategies, (3) the perception that a natural tension arises when balancing person-centred approaches with the need for consistent and fair state policy-including rules and regulations within state systems and (4) the unique challenges related to SDS benefits and challenges occurring across Minnesota. CONCLUSIONS: The results indicate the importance of providing effective communication and training to all stakeholders.

FINANCING HEALTH CARE FROM LOCAL BUDGETS OF UKRAINE AND THE REPUBLIC OF POLAND.

OBJECTIVE: The aim: This article aims to show the role of local budgets in financing health care in communities, and to initiate a discussion on the possibility of expanding powers of local government bodies in the sphere of health care. PATIENTS AND METHODS: Materials and methods: This study is based on the normative acts of the Republic of Poland and Ukraine, conclusions, reports of the Regional Chambers of Audit (Regionalnych Izb Obrachunkowych) in the Republic of Poland, OECD Indicators and budget gminas. Dialectical, comparative, analytical methods and the method of system analysis were used. CONCLUSION: Conclusions: Health care is among own tasks of gminas. Special legislation in the sphere of health care clarifies and narrows the tasks of gminas to monitoring and assessing public health, as well as to development, implementation and evaluation of special policy programs in the sphere of health care, according to identified needs of community residents and projects aimed at informing people about factors harmful to health and about their consequences. These programs can be financed from the budgets of gminas. This approach reduces and limits potential of local governments in the health care sector. Only in the event of an emergency gminas have the right to assign additional tasks to a medical entity and to finance these tasks from their own budget. In order to improve the quality and clarity of legislation own tasks of gminas in the sphere of health care (point 5, Part 1 Art. 7 of the Law of the Republic of Poland dated 8 March, 1990 "On municipal Government") should be specified taking into account point 1 Art. 2 of the Law of the Republic of Poland dated 11 September, 2015 "On Health Care".