tion’, implying that most patients ‘should’ receive a particular action. In contrast, level 2 guidelines are essentially ‘suggestions’ and are deemed to be ‘weak’ or discretionary, recognising that management decisions may vary in different clinical contexts. Each recommendation was further graded from A to D by the quality of evidence underpinning them, with grade A referring to a high quality of evidence whilst grade D recognised a ‘very low’ evidence base. The overall strength and quality of the supporting evidence is summarised in table 1 . The guidelines focused on 4 key domains: (1) AKI definition, (2) prevention and treatment of AKI, (3) contrastinduced AKI (CI-AKI) and (4) dialysis interventions for the treatment of AKI. The full summary of clinical practice statements is available at www.kdigo.org, but a few key recommendation statements will be highlighted here.

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KDIGO clinical practice guidelines for acute kidney injury.

Cost Effectiveness in Health and Medicine.

Successful innovation depends on the development and integration of new knowledge in the innovation process. Part of this knowledge will reach the firm from external sources. Several authors have documented the existence of these external information flows and have commented on their importance for decisions at the firm level (Adam B. Jaffe, 1986; Jeffrey I. Bernstein and M. Ishaq Nadiri, 1988) and ultimately for economic growth (Paul M. Romer, 1990; Gene M. Grossman and Elhanan Helpman, 1991; Zvi Griliches, 1992). One challenge facing this literature has been the measurement of these information flows or “spillovers” between firms and gauging their effect on different innovation management decisions by the firm. While assessing spillovers, it is important to distinguish between incoming spillovers, which affect the rate of innovation of the firm, and appropriability, which affects the ability of the firm to appropriate the returns from innovation. The information sources for incoming spillovers are usually situated in the public domain, and their usefulness to the firm depend on the firm’s ability to create information flows from this public pool of knowledge. But firms also attempt to appropriate the benefits of their innovations by controlling the information flows out of the company into the pool of publicly available information. The relevance of distinguishing between incoming spillovers and appropriability is revealed when we use these measures to analyze their impact on the decision of firms to engage in cooperative RD Morton I. Kamien et al., 1992; Raymond De Bondt, 1997). On the other hand, imperfect appropriability increases the incentive of firms to free ride on each other’s RD Katrien Kesteloot and Veugelers, 1995) and encourages free-riding on the RD Veugelers: Katholieke Universiteit Leuven and CEPR, Naamsestraat 69, 3000 Leuven, Belgium (e-mail: Reinhilde.Veugelers@econ.kuleuven.ac.be). The authors would especially like to thank an anonymous referee, as well as Raymond De Bondt, Paul Geroski, Mort Kamien, Steve Martin, Marno Verbeek, Gary Charness, James Costain, and Harry Bowen, for very helpful comments. We also thank the seminar participants at the London Business School, IESE Business School, Universidad Carlos III, Universitat Autonoma de Barcelona, Universidad de Zaragoza, Universidad Publica de Navarra, the Universite Libre de Bruxelles, and Paris I and Paris XII, and the participants in ASSET (Bologna), LASEM (Cancun), and EARIE (Turin). The DWTC and IWT generously provided the data for this research. Cassiman acknowledges support from BEC2000-1026 and CIRIT 1997SGR00138, and Veugelers from CNRS, Enjeux Economiques de l’Innovation, and NFWO (G.0131.98). The paper was to a large extent written while Cassiman was assistant professor at the Universitat Pompeu Fabra in Barcelona and Veugelers was visiting the Universitat Autonoma de Barcelona and MIT [Sloan School (ICRMOT)].

R&D cooperation and spillovers: Some empirical evidence from Belgium

People with diabetes are more likely to be hospitalized and to have longer durations of hospital stay than those without diabetes. A recent survey estimated that 22% of all hospital inpatient days were incurred by people with diabetes and that hospital inpatient care accounted for half of the 174 billion USD total U.S. medical expenditures for this disease (1). These findings are due, in part, to the continued expansion of the worldwide epidemic of type 2 diabetes. In the U.S. alone, there are ∼1.6 million new cases of diabetes each year, with an over all prevalence of 23.6 million people (7.8% of the population, with one-fourth of the cases remaining undiagnosed). An additional 57 million American adults are at high risk for type 2 diabetes (2). Although the costs of illness-related stress hyperglycemia are not known, they are likely to be considerable in light of the poor prognosis of such patients (3–6).

There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Cohort studies as well as a few early randomized controlled trials (RCTs) have suggested that intensive treatment of hyperglycemia improved hospital outcomes (5–8). In 2004, this evidence led the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE), in collaboration with the American Diabetes Association (ADA) and other medical organizations, to develop recommendations for treatment of inpatient hyperglycemia (9). In 2005, the ADA added recommendations for treatment of hyperglycemia in the hospitalto itsannual Standards of Medical Care (10). Recommendations from the ACE and the ADA generally endorsed tight glycemic control in critical care units. For patients in general medical and surgical units, where RCT evidence regarding treatment targets was lacking, glycemic goals similar to those advised for outpatients were advocated (9, …

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American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines (‘Adherence to medications’, ‘Management of adherence’) and the discipline that studies those processes (‘Adherence-related sciences’). ‘Adherence to medications’ is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: ‘Initiation’, ‘Implementation’ and ‘Discontinuation’. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

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A new taxonomy for describing and defining adherence to medications

Objective To perform an analysis of healthcare resource utilization with intensive insulin therapy, which has recently been shown to reduce morbidity and mortality rates of mechanically ventilated critically ill patients in a surgical intensive care unit. Design A post hoc cost analysis. Setting Surgical intensive care unit. Patients Patients were 1548 mechanically ventilated patients admitted to a surgical intensive care unit. Interventions A post hoc cost analysis was conducted based on data collected prospectively as part of a large randomized controlled trial. The analysis performed was a healthcare resource utilization analysis in which the cost of hospitalization in the intensive care unit was determined based on length of stay and the frequency of crucial cost-generating morbid events occurring in the intensive and conventional insulin treatment groups. Sensitivity analyses were performed to evaluate the robustness of the findings. Discounting of costs was not performed as treatment was limited to the intensive care stay and follow-up was not continued beyond hospitalization. Measurements and main results In the intensive treatment group, total treatment cost was 109,838 Euros (144 Euros per patient). In the conventional treatment group, total treatment cost was 56,359 Euros (72 Euros per patient). The excess cost of intensive insulin therapy was 72 Euros per patient. The total hospitalization cost in the intensive treatment group was 6,067,237 Euros (7931 Euros per patient) compared with 8,275,394 Euros (10,569 Euros per patient) in the conventional treatment group. The excess cost of intensive care unit hospitalization in the conventional vs. intensive treatment group was 2638 Euros per patient. These intensive care unit benefits were not offset by additional costs for care on regular wards. Conclusions Intensive insulin therapy, which reduces morbidity and mortality rates of mechanically ventilated patients admitted to a surgical intensive care unit, is associated with substantial cost savings compared with conventional insulin therapy.

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Analysis of healthcare resource utilization with intensive insulin therapy in critically ill patients

A typology for provider payment systems in health care.

Purpose The activity-based costing method was used to compute radiotherapy costs. This report describes the model developed, the calculated costs, and possible applications for the Leuven radiotherapy department. Methods and materials Activity-based costing is an advanced cost calculation technique that allocates resource costs to products based on activity consumption. In the Leuven model, a complex allocation principle with a large diversity of cost drivers was avoided by introducing an extra allocation step between activity groups and activities. A straightforward principle of time consumption, weighed by some factors of treatment complexity, was used. The model was developed in an iterative way, progressively defining the constituting components (costs, activities, products, and cost drivers). Results Radiotherapy costs are predominantly determined by personnel and equipment cost. Treatment-related activities consume the greatest proportion of the resource costs, with treatment delivery the most important component. This translates into products that have a prolonged total or daily treatment time being the most costly. The model was also used to illustrate the impact of changes in resource costs and in practice patterns. Conclusion The presented activity-based costing model is a practical tool to evaluate the actual cost structure of a radiotherapy department and to evaluate possible resource or practice changes.

Activity-based costing: a practical model for cost calculation in radiotherapy

The literature on the incentives for R & D cooperation with spillovers typically deals only with the factors affecting cooperative profits. This paper focuses on the incentives to cheat and the stability of such cooperative agreements in a repeated game framework. It is shown that the stability of cooperation is influenced by the nature and magnitude of spillovers, relative to the nature and degree of product market competition. While cooperative profits are higher with large positive (exogenous, unintended) know-how spillovers, such as in fundamental research, our anslysis shows that it may be easier to sustain cooperation in areas with lower spillovers, such as applied research, because of the smaller incenfives to cheat on the initial agreement, at least when firms produce substitutes. Alternatively, the possibility of technology sharing (i.e., intended or endogenous spillovers), besides R&D coordination, not only increases cooperative profits but also reduces the incentives to defect from a cooperative equilibrium.

Katrien Kesteloot

Papers

Analysis of healthcare resource utilization with intensive insulin therapy in critically ill patients

A typology for provider payment systems in health care.

Activity-based costing: a practical model for cost calculation in radiotherapy

Stable R&D Cooperation with Spillovers

A review of the literature on the economics of noncompliance. Room for methodological improvement