34427105
The reliability of willingness to pay for changes in health status
One of the most common means to test for the temporal reliability of willingness-to-pay (WTP) values is the ‘test-retest’ method. However, few such tests have been conducted in healthcare, and the few that are focus on specific patient or professional groups, limiting their generalisability. In this article, a test-retest analysis of WTP for changes in health status from a general population sample found good reliability overall, with the level of reliability increasing with the overall amount of WTP and/or level of WTP as a proportion of income. The possible implications for the design and use of WTP studies in healthcare are outlined.
26796548
Medical tourism: a review of the literature and analysis of a role for bi-lateral trade.
OBJECTIVES
With increasing globalization, many countries are considering opening their health systems to greater cross-border movement of patients. This is usually done from the viewpoint of a multi-lateral trade relationship. This paper considers the issues that arise from this debate from a bi-lateral perspective.


METHODS
A systematic literature review was carried out on 'Medical Tourism' from the perspective of a bi-lateral trade relationship, using the UK and India as a case study.


RESULTS
There is a dearth of data and discussion on such bi-lateral trade. This limited evidence offers some suggestions. Exporting countries may benefit from medical tourism by generating foreign exchange and reversing the brain drain, but run the risk of creating a dual system, where the local population is crowded out. Importing countries can benefit from alleviating waiting lists and lowering healthcare costs, but may risk quality of care and legal liability. However, evidence from a bi-lateral perspective suggests that the positive aspects can be capitalised, and the negative ones reduced.


CONCLUSIONS
The key recommendations from this paper are for more evidence to be collected at the country and international level, and for countries to consider trade in health services from a bi-lateral rather than multi-lateral perspective.
7096884
Foreign direct investment and trade in health services: a review of the literature.
Globalization is a key challenge facing health policy-makers. A significant aspect of this is direct trade in health services, a result of the rise of transnational corporations, challenges in health care financing, porous borders and improved technology creating the scope for increased 'foreign direct investment' (FDI) in health care. This has gathered momentum with the General Agreement on Trade in Services (GATS), which aims to further liberalize trade in services, and within which FDI has been noted as perhaps the most critical area for trade negotiation. Given the rapid development of this area, there are little empirical data. This paper therefore seeks to provide the first comprehensive and systematic review of evidence concerning FDI and health services. This process included electronic bibliographic database searches, website searches and correspondence with experts in the area of trade in health services, from which 76 papers, books and reports were reviewed. Perhaps due to the rapid developments in this area, most of the literature is speculative, polarized between those arguing for the benefits of liberalization and those arguing against. However, there seem to be three issues which emerge as of most importance: (i) the extent to which a national health system is commercialized per se is of more significance than whether investment in it is foreign or domestic; (ii) the national regulatory environment and its 'strength' will significantly determine the economic and health impact of FDI, the effectiveness of safeguard measures, and the stability of GATS commitments; and (iii) any negotiations will depend upon parties having a common understanding of what is being negotiated, and the interpretation of key definitions is thus critical. Each of these issues is explored in some depth, with the overall conclusion that countries should take a step back and first think through the risks and benefits of commercialization of their health sector, rather than being sidetracked in to considering the level of foreign investment.
39397016
The relationship between reliability and size of willingness-to-pay values: a qualitative insight.
In a previous paper, the reliability of willingness-to-pay (WTP) values was found to be an increasing function of the size of WTP expressed. Here, the results of a qualitative exercise conducted alongside this quantitative study are presented. The results of this exercise suggest that higher WTP values may require more thought from the respondent which, in turn, gives them greater stability. At low levels of WTP, values appear to be taken from a 'discretionary account', where expenditure is more volatile. Caveats to this result, and suggestions for future research, are considered in the discussion.
18066304
Macroeconomic impact of a mild influenza pandemic and associated policies in Thailand, South Africa and Uganda: a computable general equilibrium analysis
Background Previous research has demonstrated the value of macroeconomic analysis of the impact of influenza pandemics. However, previous modelling applications focus on high‐income countries and there is a lack of evidence concerning the potential impact of an influenza pandemic on lower‐ and middle‐income countries. Objectives To estimate the macroeconomic impact of pandemic influenza in Thailand, South Africa and Uganda with particular reference to pandemic (H1N1) 2009. Methods A single‐country whole‐economy computable general equilibrium (CGE) model was set up for each of the three countries in question and used to estimate the economic impact of declines in labour attributable to morbidity, mortality and school closure. Results Overall GDP impacts were less than 1% of GDP for all countries and scenarios. Uganda's losses were proportionally larger than those of Thailand and South Africa. Labour‐intensive sectors suffer the largest losses. Conclusions The economic cost of unavoidable absence in the event of an influenza pandemic could be proportionally larger for low‐income countries. The cost of mild pandemics, such as pandemic (H1N1) 2009, appears to be small, but could increase for more severe pandemics and/or pandemics with greater behavioural change and avoidable absence.
13856154
Macroeconomic impact of pandemic influenza and associated policies in Thailand, South Africa and Uganda
BACKGROUND
Research has shown the value of conducting a macroeconomic analysis of the impact of influenza pandemics. However, previous modelling applications focus on high-income countries, and there is a lack of evidence concerning the potential impact of an influenza pandemic on lower- and middle-income countries.


OBJECTIVES
To estimate the macroeconomic impact of pandemic influenza in Thailand, South Africa and Uganda with particular reference to pandemic (H1N1) 2009.


METHODS
A single-country whole-economy Computable General Equilibrium (CGE) model was set up for each of the three countries in question and used to estimate the economic impact of declines in labour attributable to morbidity, mortality and school closure.


RESULTS
Overall GDP impacts were less than 1% of GDP for all countries and scenarios. Uganda's losses were proportionally larger than those of Thailand and South Africa. Labour-intensive sectors suffer the largest losses.


CONCLUSION
The economic cost of unavoidable absence in the event of an influenza pandemic could be proportionally larger for low-income countries. The cost of mild pandemics, such as pandemic (H1N1) 2009, appears to be small, but could increase for more severe pandemics and/or pandemics with greater behavioural change and avoidable absence.
44367961
Recent advances in understanding the endocrinology of human birth
The timing of human birth has a crucial impact upon the survival of the fetus. New knowledge on the regulation of human birth includes the role of endogenous retroviruses in the formation of the syncytiotrophoblast cells and consequently the secretion of corticotrophin releasing hormone, a hormone linked to gestational length determination. miRNAs have been identified that mediate progesterone withdrawal at labor by suppressing progesterone-induced transcription factors. Progress has also been made in understanding how the contractile machinery of the uterine myocytes is activated at labor and the role of small heat-shock proteins in this process. From this work, new therapeutic targets have been identified that may be used to regulate the onset of labor and improve neonatal mortality.
27058025
Mammalian labor: variations on a theme by amniota.
In this month’s issue of Endocrinology, Wada et al (1) report on the “Role of vascular endothelial growth factor (VEGF) in maintenance of pregnancy in mice.” It’s a beautifully written report of a carefully performed series of experiments that strongly implicate a fall in the corpus luteum production of VEGF in the onset of labor in mice. However, the most intriguing and insightful aspect is the focus within the title on pregnancy maintenance. Maintaining the fertilized egg within the reproductive tract is a key issue for all amniotes. Before the evolution of the amniote egg, most vertebrate females laid their eggs in water and fertilization was achieved by the male depositing sperm in the vicinity (2). The ability to be fully terrestrial required the evolution of the amniote egg that was covered with membranes that were impervious to water so they did not dry out, yet permeable to oxygen and carbon dioxide allowing respiration. However, the membranes and shell of the amniote egg are formed inside the reproductive tract and the formed coverings are impermeable not only to water but also to sperm. The physiological consequence of the internal creation of the egg coverings is the need also for internal fertilization before the formation of the impenetrable membranes. Movement of the ovum from the ovary to the exterior down the reproductive tract is seen in fish and amphibians in anticipation of external fertilization. This transport is effected by both peristaltic contraction and cilial motion (3). In contrast, for all amniotes, a central requirement is a female reproductive tract that allows the penetration of the sperm against the usual peristaltic and cilial transport toward the exterior. Once fertilization has occurred within the reproductive tract of the amniote, the fertilized ovum must be retained to allow formation of the membranes and in some species the shell or outer covering. A critical evolutionary step for the amniote is the development of a mechanism to retain the zygote within the reproductive tract. Although direct studies of early amniotes are impossible, the physiology of extant members of the group may provide clues. Extant amniotes include birds, reptiles, and mammals. In these diverse classes of vertebrates, the endocrinological processes that arrest contractions of the reproductive tract or uterus have been examined. In the chicken, progesterone plays a key role in retaining the egg within the oviduct. Equally, in the lizard and other reptiles, corpus luteum production of progesterone is critical (4). Within mammalia, the role of progesterone has been examined in many species. In the sheep, murides, marsupials (5), and in humans, progesterone withdrawal is associated with the onset of labor indicating a role for progesterone in reducing contractile activity of the myometrium. Therefore, progesterone as an agent for the inhibition of uterine or reproductive tract activity is found in members of all extant classes of amniotes. This is evidence that progesterone was used to maintain reproductive tract quiescence in the ancestral root amniote. This view is also supported by genome comparison studies that support the evolution of the progesterone receptor (PR) before the evolution of amniotes (6). The data indicate that progesterone allows the amniote to delay the passage of the zygote through the reproductive passage to permit additional parental investment. In some amniotes, the investment of the mother is in the form of egg yolk and the formation of a shell. In placental mammals, retention of the zygote allows additional development of the embryo and fetal growth before release into the exter-
11517691
Pathological interactions with the timing of birth and uterine activation.
The physiological processes that regulate the onset of parturition and birth are slowly being elucidated, and the points at which pathology can intervene are becoming more apparent. The data support the view that multiple pathways lead to myometrial activation. The clinical corollary is that combinations of tocolytics that operate via different mechanisms may be more effective than single agents. It may also be necessary to divide preterm labour into groups based on underlying mechanisms and to tailor therapy accordingly.
3109318
A general model for continuous noninvasive pulmonary artery pressure estimation
Elevated pulmonary artery pressure (PAP) is a significant healthcare risk. Continuous monitoring for patients with elevated PAP is crucial for effective treatment, yet the most accurate method is invasive and expensive, and cannot be performed repeatedly. Noninvasive methods exist but are somewhat inaccurate, expensive, and cannot be used for continuous monitoring. We present a machine learning model based on heart sounds that estimates pulmonary artery pressure with enough accuracy to exclude an invasive diagnostic operation, allowing for consistent monitoring of heart condition in suspect patients without the cost and risk of invasive monitoring. We conduct a greedy search through 38 possible features using a 109-patient cross-validation to find the most predictive features. Our best general model has a standard estimate of error (SEE) of 8.3mmHg, which outperforms the previous best performance in the literature on a general set of unseen patient data.
23247928
Unexplained antepartum stillbirth: a consequence of placental aging?
Unexplained antepartum stillbirth is a major obstetric health problem. Data demonstrate a rapid rise in risk per 1000 continuing pregnancies as gestation advances beyond 40 weeks. We review the evidence that such stillbirths are a consequence of aging related changes in the late gestation placenta. We suggest that the relatively small number of continuing pregnancies after 40 completed weeks means that negative effects of genes that produce aging affect so few pregnancies that polymorphisms in genes that produce these effects are retained in the population. Aging related changes likely represent a consequence of the damaging effects of oxidative stress, increased by cigarette smoking counteracted by the mitigating effects of oxidative defence pathways. The aging related changes are likely downstream from nutrient sensing units such as mTOR and include effects on production of telomerase and consequent shortening of telomere length. The late gestation changes occur in the context of increasing fetal growth and nutrient supply demands that can produce the rapid development of a mismatch between placental supply and fetal need resulting in fetal demise. Premature aging may also play an important role in antepartum stillbirth occurring earlier in pregnancy, especially in the context of growth restriction.