Nitrogen Application Timing and Levels Affect the Fate and Budget of Fertilizer Nitrogen in the Apple-Soil System.

This study aimed to determine the effects of the nitrogen (N) application period and level on the fate of fertilizer N and the contribution of N absorption and translocation to apple organ N. Two N application periods (labeled by the 15N tracer technique in spring and summer, represented by SP and SU, respectively) and three N levels (N0, MN, and HN) were used to determine the physiological indexes and aboveground, root, and soil 15N content of 4-year-old dwarf ('Red Fuji'/M9T337) and arborized ('Red Fuji'/Malus hupehensis Rehd.) apple trees. The results showed that HN led to shoot overgrowth, which was not conducive to the growth of the apple root system (root length, root tips, root surface area, and root volume) or the improvement of root activity. The contribution of soil N to apple organ N accounted for more than 50%, and the contribution of N application in summer to fruit N was higher than that in spring. Under HN treatment, the proportion of soil N absorbed by trees decreased, while that of fertilizer N increased; however, the highest proportion was still less than 50%, so apple trees were highly dependent on soil N. Under MN treatment, fertilizer N residue was similar to soil N consumption, and soil N fertility maintained a basic balance. Under HN treatment, fertilizer N residue was significantly higher than soil N consumption, indicating that excessive N application increased fertilizer N residue in the soil. Overall, the 15N utilization rate of arborized trees (17.33-22.38%) was higher than that of dwarf trees (12.89-16.91%). A total of 12.89-22.38% of fertilizer 15N was absorbed by trees, 30.37-35.41% of fertilizer 15N remained in the soil, and 44.65-54.46% of fertilizer 15N was lost. The 15N utilization rate and 15N residual rate of summer N application were higher than those of spring N application, and the 15N loss rate was lower than that of spring N application. High microbial biomass N (MBN) may be one of the reasons for the high N utilization rate and the low loss rate of N application in summer.

Socioeconomic inequalities in healthcare system efficiency in Japan during COVID-19 pandemic: an analysis of the moderating role of vaccination.

Background: In the context of the COVID-19 pandemic, limited research has focused on socioeconomic disparities in Local Healthcare System Efficiency (LHSE) among Japanese prefectures. This study seeks to investigate the moderating impact of vaccination on the relationship between LHSE and socioeconomic characteristics and endowments. Methods: To explore these relationships, we first utilized the Data Envelopment Analysis with Slack-Based Measure to measure the LHSE, based on data from Japanese prefectures during waves 2 to 5 of the pandemic. Then estimating the impact of socioeconomic variables on LHSE. Finally, we assessed the changes in the way socioeconomic variables affect LHSE before and after vaccine deployment using the Seemingly Unrelated Estimation t-test methodology. Results: The research findings suggest an overall reduction in LHSE disparities across various regions due to the utilization of vaccines. Particularly in areas with relatively nsufficient bed resources, a significant improvement in LHSE was observed in most regions. However, there was no evidence supporting the role of vaccine deployment in mitigating socioeconomic inequalities in LHSE. Conversely, the utilization of vaccines showed a positive correlation between the improvement in LHSE and the proportion of older adult population in regions with sufficient bed resources. In regions facing bed shortages, the enhancement of LHSE became more reliant on reducing the occupancy rate of secured beds for severe cases after the introduction of vaccination. Discussion: In regions facing bed shortages, the enhancement of LHSE became more reliant on reducing the occupancy rate of secured beds for severe cases. This underscores the importance for policymakers and implementers to prioritize the treatment of severe cases and ensure an effective supply of medical resources, particularly secured beds for severe cases, in their efforts to improve LHSE, in the post-COVID-19 era with rising vaccine coverage.

Exploring pre-MRI imaging tests: patient survey reveals potential implications for healthcare efficiency in Israel.

BACKGROUND: Medical imaging tests are vital in healthcare but can be costly, impacting national health expenditures. Magnetic resonance imaging (MRI) is a crucial diagnostic tool for assessing medical conditions. However, the rising demand for MRI scans has frequently strained available resources. This study aimed to estimate the prevalence of different imaging tests in individuals who eventually had an MRI, in the Israeli public health system. METHODS: An online survey of patient experience of scheduling an MRI was conducted in January-February 2023, among 557 Israeli adults, representing all four health maintenance organizations (HMOs). All participants had undergone an MRI in the public health system within the past year. RESULTS: Results showed that 60% of participants underwent other imaging tests before their MRI scan. Of those, computed tomography (CT) scans (43%), X-rays (39%), and ultrasounds (32%) were the most common additional imaging procedures. In addition, of the 60% of participants, 23% had undergone more than one prior imaging examination. CONCLUSIONS: These findings highlight the high prevalence of preliminary imaging tests prior to MRI, with many patients undergoing multiple tests for the same problem. The health system may need to evaluate whether current clinical guidelines defining the use of various imaging tests are cost-effective.

An energy efficiency assessment of Yttrium-aluminum-garnet laser in vitro.

To study the effect range of the Nd:YAG laser through various levels of cloudy medium for targets with varying grayscale values in vitro. The coated paper cards with grayscale values of 0, 50, 100, and 150 were used as the laser's targets, which were struck straightly with varying energies using three burst modes (single pulse, double pulse, and triple pulse). Six filters (transmittances of 40, 50, 60, 70, 80, and 90) were applied to simulate various levels of cloudy refractive medium. Image J software was used to measure the diameters and regions of the laser spots. The ranges of the Nd:YAG laser spots increased with energy in the same burst mode (P < 0.05). Under the same amount of energy, the ranges of the Nd:YAG laser spot increased with the grayscale value of the targets (P < 0.05). The greater the transmittance of the filters employed, the larger the range of the Nd: YAG laser spots produced. Assuming that the total pulse energy is identical, the effect ranges of multi-pulse burst modes were significantly larger than those of single-pulse burst mode (P < 0.05). The effect range of a Nd:YAG laser grows with increasing energy and the target's grayscale value. A cloudy refractive medium has a negative impact on the effect range of the Nd: YAG laser. The single pulse mode has the narrowest and safest efficiency range.

Investigating the effects of ICT, education, and R&D on economic efficiency and technology heterogeneity: A cross-country analysis.

This study explores the impact of information and communication technology (ICT), education, and research and development (R&D) on countries' economic efficiency and technology heterogeneity. A panel of 52 countries, classified into developed (31 sample countries) and developing (21 sample countries) during 2011-2019, were the data sources for the analysis. We obtained relative country-level economic efficiency and technology gap inefficiency estimates from a novel Bayesian data envelopment analysis (DEA) approach. Bias-corrected estimates yielded by this technique have proven to be valid. We then regressed the estimates on ICT, education, and R&D proxy variables using a two-step and an iterative generalized method of moments (GMM) for linear dynamic panel data. Our analysis mitigates possible feedback effects between the explanatory and response variables, as well as possible endogeneity. The novelty of this work goes beyond the use of a new data analysis technique, investigating the impact of the three factors mentioned above and the country classification on technology heterogeneity caused by differences in countries' market structures, regulatory frameworks, economic and knowledge ecosystems, and cultures. Based on this study's findings, fixed broadband subscriptions have the most significant effect on economic efficiency improvement, while R&D is the main driver for reducing technology gap inefficiency. Specifically, ICT-facilitated knowledge spillovers within and across country groups through R&D cooperation play a significant positive role in closing the technology gap. This finding is consistent with the catch-up theory.

[Cost-effectiveness analysis of fracture liaison services in Catalonia]. / Análisis de coste-efectividad de las Unidades de Coordinación de Fracturas en Cataluña.

OBJECTIVE: To assess the cost-effectiveness of Fracture Liaison Service (FLS) compared to the standard of care for secondary prevention of fragility fractures form the perspective of the Catalan Health Service. METHODS: Cost-utility assessment through a Markov model that simulated disease progression of a patients' cohort candidates to initiate antiosteoporotic treatment after a fragility fracture. A time horizon of 10 years and a 6-month duration per cycle was established. Clinical, economics and quality of life parameters were obtained from the literature and derived from four Catalan FLS. The Catalan Health Service perspective was adopted, considering direct health costs expressed in 2022 euros. A 3% discount rate was applied on costs and outcomes. Uncertainty was assessed through multiple sensitivity analyses. RESULTS: Compared to the standard of care, FLS would promote antiosteoporotic initiation and persistence, reducing the incidence and mortality associated with subsequent fragility fractures. This incremental clinical benefit was estimated at 0.055 years and 0.112 quality-adjusted life years (QALYs) per patient. A higher cost (€1,073.79 per patient) was estimated, resulting into an incremental cost-utility ratio of €9,602.72 per QALYs gained. The sensitivity analyses performed were consistent, corroborating the robustness and conservative approach of the base-case. CONCLUSIONS: The introduction of FLS for the secondary prevention of FF would represent a cost-effective strategy from the Catalan Health Service perspective.

Service Quality and Residents' Preferences for Facilitated Self-Service Fundus Disease Screening: Cross-Sectional Study.

BACKGROUND: Fundus photography is the most important examination in eye disease screening. A facilitated self-service eye screening pattern based on the fully automatic fundus camera was developed in 2022 in Shanghai, China; it may help solve the problem of insufficient human resources in primary health care institutions. However, the service quality and residents' preference for this new pattern are unclear. OBJECTIVE: This study aimed to compare the service quality and residents' preferences between facilitated self-service eye screening and traditional manual screening and to explore the relationships between the screening service's quality and residents' preferences. METHODS: We conducted a cross-sectional study in Shanghai, China. Residents who underwent facilitated self-service fundus disease screening at one of the screening sites were assigned to the exposure group; those who were screened with a traditional fundus camera operated by an optometrist at an adjacent site comprised the control group. The primary outcome was the screening service quality, including effectiveness (image quality and screening efficiency), physiological discomfort, safety, convenience, and trustworthiness. The secondary outcome was the participants' preferences. Differences in service quality and the participants' preferences between the 2 groups were compared using chi-square tests separately. Subgroup analyses for exploring the relationships between the screening service's quality and residents' preference were conducted using generalized logit models. RESULTS: A total of 358 residents enrolled; among them, 176 (49.16%) were included in the exposure group and the remaining 182 (50.84%) in the control group. Residents' basic characteristics were balanced between the 2 groups. There was no significant difference in service quality between the 2 groups (image quality pass rate: P=.79; average screening time: P=.57; no physiological discomfort rate: P=.92; safety rate: P=.78; convenience rate: P=.95; trustworthiness rate: P=.20). However, the proportion of participants who were willing to use the same technology for their next screening was significantly lower in the exposure group than in the control group (P<.001). Subgroup analyses suggest that distrust in the facilitated self-service eye screening might increase the probability of refusal to undergo screening (P=.02). CONCLUSIONS: This study confirms that the facilitated self-service fundus disease screening pattern could achieve good service quality. However, it was difficult to reverse residents' preferences for manual screening in a short period, especially when the original manual service was already excellent. Therefore, the digital transformation of health care must be cautious. We suggest that attention be paid to the residents' individual needs. More efficient man-machine collaboration and personalized health management solutions based on large language models are both needed.

Smoothing the Phosphorus Resource Stress under the Socioeconomic Development in China.

Phosphorus (P) is the key in maintaining food security and ecosystem functions. Population growth and economic development have increased the demand for phosphate rocks. China has gradually developed from zero phosphate mining to the world's leading P miner, fertilizer, and agricultural producer since 1949. China released policies, such as designating phosphate rock as a strategic resource, promoting eco-agricultural policies, and encouraging the use of solid wastes produced in mining and the phosphorus chemical industry as construction materials. However, methodological and data gaps remain in the mapping of the long-term effects of policies on P resource efficiency. Here, P resource efficiency can be represented by the potential of the P cycle to concentrate or dilute P as assessed by substance flow analysis (SFA) complemented by statistical entropy analysis (SEA). P-flow quantification over the past 70 years in China revealed that both resource utilization and waste generation peaked around 2015, with 20 and 11 Mt of mined and wasted P, respectively. Additionally, rapidly increasing aquaculture wastewater has exacerbated pollution. The resource efficiency of the Chinese P cycle showed a U-shaped change with an overall improvement of 22.7%, except for a temporary trough in 1975. The driving force behind the efficiency decline was the roaring phosphate fertilizer industry, as confirmed by the sharp increase in P flows for both resource utilization and waste generation from the mid-1960s to 1975. The positive driving forces behind the 30.7% efficiency increase from 1975 to 2018 were the implementation of the resource conservation policy, downstream pollution control, and, especially, the circular agro-food system strategy. However, not all current management practices improve the P resource efficiency. Mixing P industry waste with construction materials and the development of aquaculture to complement offshore fisheries erode P resource efficiency by 2.12% and 9.19%, respectively. With the promotion of a zero-waste society in China, effective P-cycle management is expected.

Temporal and geographical variations in diagnostic imaging in Norway.

BACKGROUND: Unwarranted temporal and geographical variations are acknowledged as a profound problem for equal access and justice in the provision of health services. Even more, they challenge the quality, safety, and efficiency of such services. This is highly relevant for imaging services. OBJECTIVE: To analyse the temporal and geographical variation in the number of diagnostic images in Norway from 2013 to 2021. METHODS: Data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and inpatient data afforded by fourteen hospital trusts and hospitals in Norway. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics. RESULTS: More than 37 million examinations were performed in Norway during 2013-2021 giving an average of 4.2 million examinations per year. In 2021 there was performed and average of 0.8 examinations per person and 2.2 examinations per person for the age group > 80. There was a 9% increase in the total number of examinations from 2013 to 2015 and a small and stable decrease of 0.5% per year from 2015 to 2021 (with the exception of 2020 due to the pandemic). On average 71% of all examinations were outpatient examinations and 32% were conducted at private imaging centres. There were substantial variations between the health regions, with Region South-East having 53.1% more examinations per inhabitant than Region West. The geographical variation was even more outspoken when comparing catchment areas, where Oslo University Hospital Trust had twice as many examinations per inhabitant than Finnmark Hospital Trust. CONCLUSION: As the population in Norway is homogeneous it is difficult to attribute the variations to socio-economic or demographic factors. Unwarranted and supply-sensitive variations are challenging for healthcare systems where equal access and justice traditionally are core values.

Construction and evolutionary factors of spatial correlation network of China's provincial tourism resource conversion efficiency.

Research objective: To explore the spatial correlation network characteristics and formation mechanisms of tourism resource conversion efficiency, and provide reference for the collaborative improvement of tourism resource conversion efficiency at the provincial level in China. Research methods: Non parametric SBM efficiency measurement method and social network analysis method. Research hypothesis: The spatial network correlation characteristics of tourism resource conversion efficiency are obvious, and regional connections are close. Research findings: (i) during the research period, the spatial connection strength of China's tourism resource conversion efficiency continued to increase and the spatial network structure of tourism resource conversion efficiency tended to become more complex and significantly more stable. (ii) A spatially linked network with a stable tourism resource conversion efficiency structure formed in China. The number of network relations and density of the network fluctuated and increased, while the network efficiency continued to decrease; however, a strong small-world nature was observed. (iii) The economic development level difference matrix, tourism industry agglomeration difference matrix, human capital difference matrix, and marketization degree difference matrix significantly and positively affected spatial association relationship establishment, while the provincial adjacency matrix significantly and negatively affected such relationships.

Improving new energy subsidy efficiency considering learning effect: A case study on wind power.

Subsidy policies are instrumental in driving the development of new energy. However, the effective allocation of new energy subsidies over time is challenging given fiscal constraints. This study addresses this challenge by considering the learning effect associated with the new energy industry. A two-stage dynamic programming model is proposed to capture the investment decision-making process of companies under new energy subsidy policies and government subsidy setups. Theoretical findings suggest that company investment decisions in new energy are influenced by a guiding principle: The subsidy rate should be negatively correlated with the variation rate of production scale increment (VRPSI). We calibrate this investment decision principle using wind power data from 14 countries. According to this principle, excessive subsidy rates may result in a low VRPSI, thereby diminishing future investment profitability in the new energy industry and leading to subsidy inefficiency. Upon investigating the efficiency of annual subsidy allocation, we find that the subsidy rates were potentially set too high in 2014, 2016, and 2017. Furthermore, the government should exercise caution regarding an inefficient subsidy pattern whereby companies invest in new energy only when the subsidy rate exceeds a certain threshold, neglecting traditional power sources. It is crucial to note that although this study uses wind power industry data for calibration and simulation, the theoretical model can be broadly applied to other new energy industries and emerging industries with increasing marginal net profit.

Evaluating health systems' efficiency towards universal health coverage: A data envelopment analysis.

To estimate the technical efficiency of health systems toward achieving universal health coverage (UHC) in 191 countries. We applied an output-oriented data envelopment analysis approach to estimate the technical efficiency of the health systems, including the UHC index (a summary measure that captures both service coverage and financial protection) as the output variable and per capita health expenditure, doctors, nurses, and hospital bed density as input variables. We used a Tobit simple-censored regression with bootstrap analysis to observe the socioeconomic and environmental factors associated with efficiency estimates. The global UHC index improved from the 2019 estimates, ranged from 48.4 (Somalia) to 94.8 (Canada), with a mean of 76.9 (std. dev.: ±12.0). Approximately 78.5% (150 of 191) of the studied countries were inefficient (ϕ < 1.0) with respect to using health system resources toward achieving UHC. By improving health system efficiency, low-income, lower-middle-income, upper-middle-income, and high-income countries can improve their UHC indices by 4.6%, 5.5%, 6.8%, and 4.1%, respectively, by using their current resource levels. The percentage of health expenditure spent on primary health care (PHC), governance quality, and the passage of UHC legislation significantly influenced efficiency estimates. Our findings suggests health systems inefficiency toward achieving UHC persists across countries, regardless of their income classifications and WHO regions, as well as indicating that using current level of resources, most countries could boost their progress toward UHC by improving their health system efficiency by increasing investments in PHC, improving health system governance, and where applicable, enacting/implementing UHC legislation.

Can the digitalization level of agriculture improve its ecological efficiency under carbon constraints: Evidence from China.

The interplay between digitalization and economic development constitutes a pivotal global issue, yet empirical research on agricultural ecological efficiency in developing countries remains limited. This study initially establishes a measurement system and a comprehensive index for the level of agricultural digitalization. Subsequently, it delineates the relationship between agricultural digitalization level and agroecological efficiency using the spatial Durbin model, and ultimately explores the enhancing effect of agricultural digitalization level on agroecological efficiency using China as a case study. Research reveals that the agricultural ecological efficiency across the 31 mainland Chinese provinces demonstrates a generally linear upward trajectory, embodying both agglomeration and heterogeneity. The level of agricultural digitization exerts a significant, positive direct impact and facilitates a spatial spillover effect on agricultural ecological efficiency. Other control variables, such as financial support for agriculture and local economic development, impart a positive direct impact on regional agricultural ecological efficiency, while rural household operating income propels a positive spatial spillover effect on adjacent areas. The findings furnish guidance for developing countries to adeptly execute digital rural construction, aiming to enhance agricultural ecological efficiency amidst carbon constraints.

Analyzing the relationship between the efficiency and safety of a turbo roundabout by the factor analysis method.

The construction of cities and economic development lead to more and more serious environmental pollution, and the concept of green and low-carbon city has been proposed. Therefore, a series of requirements have been put forward for transportation. CO and other pollutants will be produced in the exhaust of conventional fuel vehicles, which will seriously affect the urban environment, especially at intersections with large passenger and vehicle flows. When multiple roads, especially more than 4 roads, intersect on urban roads, traffic organization can usually be achieved by using a roundabout. However, due to the limited capacity of the conventional roundabout, with the rapid increase of the traffic volume, and there are many vehicles in the circle lane change and interweaving behavior. This has caused serious congestion at the roundabout, the significantly increase in pollutants emissions and the decline in air quality. As an unconventional design, the turbo roundabouts use canalized traffic to allowed drivers to select the appropriate lanes in advance depending on their destinations so that different lanes within the circle do not interfere with one another, which improves the safety of the intersection while ensuring capacity. The main purpose of this paper is to analyze the traffic efficiency and safety of the conventional roundabout scheme and turbo roundabout scheme for five-way intersections. Using VISSIM to simulate different forms of roundabout and analyzing the six selected evaluation indicators. The number of vehicles in different entrance lanes and the diameter of the circle are selected as sensitivity factors for sensitivity analysis. Finally, the factor analysis method (FAM) is used to classify the six indicators into two categories: traffic efficiency and traffic safety, so as to comprehensively evaluate the different schemes. The results show that the difference in performance between the two schemes was not significant at low traffic volumes. At high traffic volumes, the turbo roundabout was better than the conventional roundabout in terms of emissions, safety and throughput efficiency. CO emissions from vehicles on conventional roundabout are generally higher than those on turbo roundabout, up to 53.62%. Therefore, the turbo roundabout is more appropriate for heavy traffic conditions.

Empirical analysis of factors influencing industrial eco-efficiency in the Yellow River Basin from a social embeddedness perspective.

Measuring industrial eco-efficiency (IEE) is essential to improve environmental quality and industrial restructuring. However, most studies ignore the influence of embeddedness on industrial eco-efficiency and lack analysis of the pathways of influence factors. Therefore, this study assesses industrial eco-efficiency in the Yellow River Basin (YRB) using a super-efficiency model slacks-based measure (Super-SBM) that considers non-desired outputs, outlines the social embeddedness of IEE, and empirically analyzes the driving mechanism of IEE from the perspective of embeddedness by constructing hierarchical linear modeling (HLM) to address the pathways of action of the influencing factors of industrial eco-efficiency. The results showed that 50.79% of the overall differences in IEE in the YRB were caused by social embeddedness. Economic development level, industrial agglomeration, and environmental regulation (ER) are significant direct influencing factors. Increasing cognitive and cultural embeddedness will enhance the positive relationship between economic development level and IEE. Political and relational embeddedness significantly moderates the positive relationship between industrial agglomeration and eco-efficiency. Cultural embeddedness can significantly and directly affect industrial eco-efficiency and weaken the positive relationship between ERs and industrial eco-efficiency. Therefore, improving IEE should consider both fundamental and embedded factors. Our findings are conducive to promoting high-quality development in the YRB and support the government in formulating differentiated policies. In addition, this paper tries to establish an empirical analysis method suitable for social embeddedness theory, and the empirical results help to improve the situation due to the lack of empirical analysis of social embeddedness theory.

[Efficiency Characteristics and Evolution Patterns of Urban Carbon Metabolism of Production-Living-Ecological Space in Beijing-Tianjin-Hebei Region].

This study explored the carbon metabolism efficiency of a production-living-ecological space system, which is of great significance for regional factor integration and spatial optimization. In this study, the material flow analysis method was introduced to establish a framework for evaluating the carbon metabolism efficiency of the production-living-ecological space system, and the super-efficiency DEA model and Malmquist index were used to empirically analyze the spatio-temporal distribution, dynamic change, and evolution patterns of the carbon metabolism efficiency of production-living-ecological space in the Beijing-Tianjin-Hebei Region, China, from 2000 to 2020 on the basis of the urban metabolic perspective. The results showed that:① the carbon metabolism efficiency of the production-living-ecological space showed a fluctuating growth trend, indicating the significant spatial differentiation of carbon metabolism efficiency in each city. There was a low overall carbon metabolism efficiency level, with a distribution pattern of being high in the middle and low in the north and south. ② The Malmquist index showed that the Total Factor Productivity (TFP) of carbon metabolism efficiency was greater than 1, and both the Technical Change (TC) and Pure Efficiency Change (PEC) were less than 1, in which the TFP showed an increasing trend, whereas there was no significant contribution of technological progress or pure technical efficiency to carbon metabolism efficiency. The total factor productivity of more than 50% of the cities showed an improving trend, only 38.46% of which made technological progress in improving carbon metabolism efficiency, and more than half of the urban pure technical efficiency showed a decreasing trend, in which the technical efficiency change and scale efficiency change were greater than 1 in most cities. ③ There were different types of carbon efficiency characteristics in each city, and according to the movement rules of the corresponding points in the quartile map, the evolution patterns of tourism industry efficiency were classified into stable, reciprocating, progressive, and abrupt. Therefore, local governments should adopt differentiated strategies to reasonably allocate spatial resources of production-living-ecological space and improve the technical level and scale efficiency, so as to improve the efficiency of urban carbon metabolism.

Aligning opportunity cost and net benefit criteria: the health shadow price.

Given constrained healthcare budgets and many competing demands, public health decision-making requires comparing the expected cost and health outcomes of alternative strategies and associated adoption and financing actions. Opportunity cost (comparing outcomes from the best alternative use of budgets or actions in decision making) and more recently net benefit criteria (relative valuing of effects at a threshold value less costs) have been key concepts and metrics applied toward making such decisions. In an ideal world, opportunity cost and net benefit criteria should be mutually supportive and consistent. However, that requires a threshold value to align net benefit with opportunity cost assessment. This perspective piece shows that using the health shadow price as the ICER threshold aligns net benefit and opportunity cost criteria for joint adoption and financing actions that arise when reimbursing any new strategy or technology under a constrained budget. For an investment strategy with ICER at the health shadow price Bc = 1/(1/n + 1/d-1/m), net benefit of reimbursing (adopting and financing) that strategy given an incremental cost-effectiveness ration (ICER) of actual displacement, d, in financing, is shown to be equivalent to that of the best alternative actions, the most cost-effective expansion of existing programs (ICER = n) funded by the contraction of the least cost-effective programs (ICER = m). Net benefit is correspondingly positive or negative if it is below or above this threshold. Implications are discussed for creating pathways to optimal public health decision-making with appropriate incentives for efficient displacement as well as for adoption actions and related research.

Cost-efficiency and budget-neutral expanded access modeling of the novel PD-1 inhibitor toripalimab versus pembrolizumab in recurrent or metastatic nasopharyngeal carcinoma.

AIMS: To estimate, in the setting of recurrent or metastatic nasopharyngeal carcinoma (R/M NPC) for an assumed 1,207 incident US cases in 2024, (1) the cost-efficiency of a toripalimab-gemcitabine-cisplatin regimen compared to a similar pembrolizumab regimen; and (2) the budget-neutral expanded access to additional toripalimab cycles and regimens afforded by the accrued savings. METHODS: Simulation modeling utilized two cost inputs (wholesale acquisition cost (WAC) at market entry and an ex ante toripalimab price point of 80% of pembrolizumab average sales price (ASP)) and drug administration costs over 1 and 2 years of treatment with treatment rates ranging from 45% to 90%. In the absence of trial data for pembrolizumab-gemcitabine-cisplatin in R/M NPC, it is assumed that such a regimen would be comparable to toripalimab-gemcitabine-cisplatin in efficacy and safety. RESULTS: In the models utilizing the WAC, toripalimab saves $2,223 per patient per cycle and $40,014 over 1 year of treatment ($77,805 over 2 years). Extrapolated to the 1,207-patient panel, estimated 1-year savings range from $21,733,702 (45% treatment rate) to $43,467,404 (90% rate). Reallocating these savings permits budget-neutral expanded access to an additional 2,359 (45% rate) to 4,717 (90% rate) toripalimab maintenance cycles or to an additional 126 (45% rate) to 252 (90%) full 1-year toripalimab regimens with all agents. Two-year savings range from $42,259,976 (45% rate) to $84,519,952 (90% rate). Reallocating these efficiencies provides expanded access, ranging from an additional 4,586 (45% rate) to 9,172 (90% rate) toripalimab cycles or to an additional 128-257 full 2-year toripalimab regimens. The ex ante ASP model showed similar results. CONCLUSION: This simulation demonstrates that treatment with toripalimab generates savings that enable budget-neutral funding for up to an additional 252 regimens with toripalimab-gemcitabine-cisplatin for one full year, the equivalent of approximately 21% of the 2024 incident cases of R/M NPC in the US.

An estimated 1,207 patients will be diagnosed with late-stage nasopharyngeal cancer in the US in 2024. Toripalimab is a novel PD-1 inhibitor drug approved by the US Food and Drug Administration on October 27, 2023 as first-line treatment for patients with recurrent or metastatic nasopharyngeal cancer when used in combination with gemcitabine and cisplatin. We conducted economic evaluations of the costs of this toripalimab regimen versus the costs of a similar regimen with the PD-1 inhibitor pembrolizumab. Our simulation models used two pricing scenarios: the wholesale acquisition cost (WAC) or "list price" at market entry and, as no average sales price (ASP) will be available for toripalimab for several quarters, an estimated toripalimab price point of 80% of the pembrolizumab ASP. We compared the savings in each scenario when between 45% and 90% of the 1,207 patients are treated with the toripalimab regimen. We then evaluated how these savings could be re-allocated, on a budget-neutral basis and without requiring extra cash outlays, to provide more patients with access to toripalimab treatment; specifically, how many toripalimab doses and how many full toripalimab regimens could be purchased to provide more patients with treatment. We found that, if 90% of new cases of recurrent or metastatic nasopharyngeal cancer were treated with toripalimab over 1 year, these savings are enough to purchase up to 4,717 additional doses on a budget-neutral basis, which could provide up to an additional 252 newly diagnosed patients with 1 year of treatment with toripalimab. In combination with gemcitabine and cisplatin, toripalimab can markedly improve access to care for patients with recurrent or metastatic nasopharyngeal cancer in a cost-responsible way.

Can digital finance development drive green transformation in manufacturing? Evidence from China.

Digital finance is a product of emerging technology-enabled innovation in financial services and has a critical impact on the green transformation of the manufacturing industry. We propose a new efficiency measurement model based on the slacks-based measure (SBM) to measure the efficiency of green transformation on regional manufacturing. Chinese interprovincial data from 2010 to 2019 were obtained for the study. In addition, we estimated the effect of digital finance on green transformation of manufacturing using a benchmark panel model. Finally, considering the regional heterogeneity and spatial effects of green transformation efficiency in the manufacturing industry, we constructed a spatial Durbin model based on an economic-geographic nested spatial weight matrix to analyze the spatial influence of digital finance on green transformation in the manufacturing industry. The results show that the green transformation of the manufacturing industry has significant positive spatial spillover effects owing to the existence of competition, demonstration, and economic correlation effects among regions.