How do policy levers shape the quality of a national health system?

Poor quality of care may have a detrimental effect on access and take-up and can become a serious barrier to the universality of health services. This consideration is of particular interest in view of the fact that health systems in many countries must address a growing public-sector deficit and respond to increasing pressures due to COVID-19 and aging population, among other factors. In line with a rapidly emerging literature, we focus on patient satisfaction as a proxy for quality of health care. Drawing on rich longitudinal and cross-sectional data for Spain and multilevel estimation techniques, we show that in addition to individual level differences, policy levers (such as public health spending and the patient-doctor ratio, in particular) exert a considerable influence on the quality of a health care system. Our results suggest that policymakers seeking to enhance the quality of care should be cautious when compromising the level of health resources, and in particular, health personnel, as a response to economic downturns in a sector that traditionally had insufficient human resources in many countries, which have become even more evident in the light of the current health crisis. Additionally, we provide evidence that the increasing reliance on the private health sector may be indicative of inefficiencies in the public system and/or the existence of features of private insurance which are deemed important by patients.     

Re‐framing the Analysis: A 3‐dimensional Perspective of Prisoners’ Children's Well‐being

This article highlights three dimensions to understanding children's well‐being during and after parental imprisonment which have not been fully explored in current research. A consideration of ‘time’ reveals the importance of children's past experiences and their anticipated futures. A focus on ‘space’ highlights the impact of new or altered environmental dynamics. A study of ‘agency’ illuminates how children cope within structural, material and social confines which intensify vulnerability and dependency. This integrated perspective reveals important differences in individual children's experiences and commonalities in broader systemic and social constraints on prisoners’ children. The paper analyses data from a prospective longitudinal study of 35 prisoners’ children during and after their (step) father's imprisonment to illustrate the arguments.     

Vaginal births after caesarean: What does Google think about it?

AimVaginal birth after caesarean (VBAC) is a relatively safe alternative to repeat caesarean birth in the proper context. This important decision to undergo an elective caesarean versus VBAC is ultimately a decision of the mother. The purpose of our study was to assess the quality of online information in relation to VBAC collected using the most common search engine: Google.MethodsThe 10 most common hit sites for the keywords “VBAC” and “Vaginal birth after caesarean” were evaluated using the search engine Google. The quality of websites was rated based on the Silberg scale for accountability, the modified Abbott's criteria for presentation and the SMOG index for readability. The content of each website was compared to the Society of Obstetricians and Gynecologists of Canada (SOGC) guidelines for VBAC.Findings13 out of 20 identified websites met the adequate criteria for accountability, with 85% of the websites indicating authorship. 11 websites were deemed aesthetically agreeable. The target audience, assessed by the readability score, was notably above the non-medical population with an average SMOG index score of 14.75. Only half of the websites contained recommendations, as detailed by the SOGC guidelines.ConclusionAlmost all sites target a higher academic level, making it beyond the comprehension of the general population. Woman friendly web-assessment tools should be provided to enable pregnant women to take an active role in their decision making.     

Towards Uniformly Efficient Trend Estimation Under Weak/Strong Correlation and Non‐stationary Volatility

In this paper, we consider the deterministic trend model where the error process is allowed to be weakly or strongly correlated and subject to non‐stationary volatility. Extant estimators of the trend coefficient are analysed. We find that under heteroskedasticity, the Cochrane–Orcutt‐type estimator (with some initial condition) could be less efficient than Ordinary Least Squares (OLS) when the process is highly persistent, whereas it is asymptotically equivalent to OLS when the process is less persistent. An efficient non‐parametrically weighted Cochrane–Orcutt‐type estimator is then proposed. The efficiency is uniform over weak or strong serial correlation and non‐stationary volatility of unknown form. The feasible estimator relies on non‐parametric estimation of the volatility function, and the asymptotic theory is provided. We use the data‐dependent smoothing bandwidth that can automatically adjust for the strength of non‐stationarity in volatilities. The implementation does not require pretesting persistence of the process or specification of non‐stationary volatility. Finite‐sample evaluation via simulations and an empirical application demonstrates the good performance of proposed estimators.     

Design selection for strong orthogonal arrays

Strong orthogonal arrays (SOAs) were recently introduced and studied as a class of space‐filling designs for computer experiments. An important problem that has not been addressed in the literature is that of design selection for such arrays. In this article, we conduct a systematic investigation into this problem, and we focus on the most useful SOA(n,m,4,2 + )s and SOA(n,m,4,2)s. This article first addresses the problem of design selection for SOAs of strength 2+ by examining their three‐dimensional projections. Both theoretical and computational results are presented. When SOAs of strength 2+ do not exist, we formulate a general framework for the selection of SOAs of strength 2 by looking at their two‐dimensional projections. The approach is fruitful, as it is applicable when SOAs of strength 2+ do not exist and it gives rise to them when they do. The Canadian Journal of Statistics 47: 302–314; 2019 © 2019 Statistical Society of Canada     

Properties of the weighted log‐rank test in the design of confirmatory studies with delayed effects

Proportional hazards are a common assumption when designing confirmatory clinical trials in oncology. This assumption not only affects the analysis part but also the sample size calculation. The presence of delayed effects causes a change in the hazard ratio while the trial is ongoing since at the beginning we do not observe any difference between treatment arms, and after some unknown time point, the differences between treatment arms will start to appear. Hence, the proportional hazards assumption no longer holds, and both sample size calculation and analysis methods to be used should be reconsidered. The weighted log‐rank test allows a weighting for early, middle, and late differences through the Fleming and Harrington class of weights and is proven to be more efficient when the proportional hazards assumption does not hold. The Fleming and Harrington class of weights, along with the estimated delay, can be incorporated into the sample size calculation in order to maintain the desired power once the treatment arm differences start to appear. In this article, we explore the impact of delayed effects in group sequential and adaptive group sequential designs and make an empirical evaluation in terms of power and type‐I error rate of the of the weighted log‐rank test in a simulated scenario with fixed values of the Fleming and Harrington class of weights. We also give some practical recommendations regarding which methodology should be used in the presence of delayed effects depending on certain characteristics of the trial.     

A Bayesian Analysis of Abundance,Trend, and Population Viability for Harbor Seals in Iliamna Lake,Alaska

Harbor seals in Iliamna Lake, Alaska, are a small, isolated population, and one of only two freshwater populations of harbor seals in the world, yet little is known about their abundance or risk for extinction. Bayesian hierarchical models were used to estimate abundance and trend of this population. Observational models were developed from aerial survey and harvest data, and they included effects for time of year and time of day on survey counts. Underlying models of abundance and trend were based on a Leslie matrix model that used prior information on vital rates from the literature. We developed three scenarios for variability in the priors and used them as part of a sensitivity analysis. The models were fitted using Markov chain Monte Carlo methods. The population production rate implied by the vital rate estimates was about 5% per year, very similar to the average annual harvest rate. After a period of growth in the 1980s, the population appears to be relatively stable at around 400 individuals. A population viability analysis assessing the risk of quasi‐extinction, defined as any reduction to 50 animals or below in the next 100 years, ranged from 1% to 3%, depending on the prior scenario. Although this is moderately low risk, it does not include genetic or catastrophic environmental events, which may have occurred to the population in the past, so our results should be applied cautiously.     

互联网深化、信息不确定性与企业出口平稳性

互联网作为信息搜寻和传播的重要渠道,有利于缓解国际市场不确定性对企业出口决策的影响,从而有助于稳定企业出口预期,保障出口企业的持续生存。本文首先基于Fernandes 和 Tang(2014)的研究框架将互联网深化程度和出口集聚同时纳入到异质性贸易企业模型,在剥离出口集聚对企业出口行为影响的基础上,从理论视角揭示了互联网深化程度提高影响企业出口行为特别是出口持续生存的内在机理与方向。研究发现,不同于出口集聚会同时影响企业的需求冲击和成本冲击,互联网深化带来的信息溢出效应会通过贝叶斯法则(Bayesian Rule)使得企业修正其对国际市场不确定性的预期,提高其对目的国市场成本冲击的估计精度,从而在互联网深化程度较高的城市,企业进入出口市场的临界生产率较低,有利于其出口参与度和出口稳定性的提高。然而互联网深化程度提高不影响企业在目的国市场产品出口的集约边际。本文使用2000-2013 年中国工业企业数据库、中国海关数据库和中国城市统计年鉴数据库的匹配数据从企业-目的国-产品层面实证检验了本文的理论命题。研究表明,我国政府应充分发挥互联网发展降低信息不确定性的微观机制,以推动外贸的平稳增长。     

Response strategy to environment context factors using a lean and agile approach: Implications for firm performance

Based on the environment-strategy performance perspective and dynamic capabilities framework, we develop a theoretical model and hypotheses specifying how supply chain collaboration as a response to environment context factors – competitive intensity, supply uncertainty, technological turbulence and market turbulence, using a lean and agile strategy may influence firm performance. We test the model using partial least square structural equation modelling on data collected from a field survey with responses from 152 manufacturing firms representing a variety of industries. Empirical findings generally support the relationship between collaboration and firm performance using a lean and agile strategy. Also, for firms in industries that face environments characterised by high supply uncertainty and competitive intensity with, technological turbulence, the study finds evidence of a direct relationship between these environmental factors and supply chain collaboration. The findings provide an initial strategic response framework for appropriately aligning a lean and agile supply chain strategy through collaboration with environment context factors to achieve firm performance improvements.     

Modifications of sequential designs in bioequivalence trials

Bioequivalence (BE) studies are designed to show that two formulations of one drug are equivalent and they play an important role in drug development. When in a design stage, it is possible that there is a high degree of uncertainty on variability of the formulations and the actual performance of the test versus reference formulation. Therefore, an interim look may be desirable to stop the study if there is no chance of claiming BE at the end (futility), or claim BE if evidence is sufficient (efficacy), or adjust the sample size. Sequential design approaches specially for BE studies have been proposed previously in publications. We applied modification to the existing methods focusing on simplified multiplicity adjustment and futility stopping. We name our method modified sequential design for BE studies (MSDBE). Simulation results demonstrate comparable performance between MSDBE and the original published methods while MSDBE offers more transparency and better applicability. The R package MSDBE is available at https://sites.google.com/site/modsdbe/ . Copyright © 2015 John Wiley & Sons, Ltd.