Sleep duration differences between children of migrant and native origins.

AIM: To explore whether primary school children of migrant and native Dutch origins differ regarding their sleep duration per night, a risk for overweight and obesity, and to determine to what degree differences in parenting styles contribute to these differences. SUBJECTS AND METHODS: A cross-sectional survey, including 1,943 children aged 8-9 years old and their primary caregivers, was performed. Data were collected from primary schools in cities and adjacent municipalities in The Netherlands: Eindhoven and Rotterdam. The outcome measure was mean sleep duration per night. The main independent variable was migrant background, based on the country of birth of the parents. A possible mediating variable was parenting style (rejecting, neglecting, permissive, authoritarian, authoritative). Age and sex of the child as well as parental socioeconomic status, as indicated by educational level, were added as confounders. RESULTS: Dutch children have the highest sleep duration: more than 11 h (mean = 670.1; SD = 27.7). All migrant children show less than 11 h of sleep per night. Migrant children of non-Western origin, especially Turkish and Moroccan children, show the lowest sleep duration per night. Parenting styles do not contribute to these differences. CONCLUSION: Migrant background is associated with sleep duration. As children of migrant origin are, in general, at higher risk for overweight and obesity and sleep duration is regarded as a risk factor for overweight and obesity, further investigation of this association is needed.

[Collaborative care for co-morbid major depressive disorder in chronically ill outpatients in a general hospital]. / Collaborative care voor de behandeling van comorbide depressieve stoornis bij chronisch lichamelijk zieke patiënten op een polikliniek van een algemeen ziekenhuis.

BACKGROUND: Depression is highly prevalent in patients with chronic physical illnesses. A promising intervention for this group of patients is the collaborative care treatment as developed in the us. AIM: To demonstrate the prevalence of depression and the risk factors of depression in diabetes patients, to describe how the screening for depression can be carried out and to assess whether the collaborative care treatment in the Netherlands is effective. METHOD: A questionnaire was completed every three months in order to determine whether there was an improvement in patients' depression and physical symptoms. The outcomes were analysed by means of the multilevel logistic regression analyses. RESULTS: On the basis of the Patient Health Questionnaire, about 26% of the diabetes patients were found to have a depression. This questionnaire was validated for the measurement of depression in diabetes patients, the best results being found at a cut-off point of 12. In cases of fairly severe depression, collaborative care had no effect on depressive symptoms but did reduce severe physical complications. In cases of more severe depression, collaborative care only had an effect on depressive symptoms, but was not found to have any effect on physical complications. CONCLUSION: There is evidence that collaborative care can reduce depression and physical complications in chronically ill patients. However, more research is needed to find out whether collaborative care can become more effective if it is supplemented with digital methods and group therapy.

Differences in overweight and obesity among children from migrant and native origin: a systematic review of the European literature.

To review the prevalence regarding overweight and obesity among children and adolescents from migrant and native origin within Europe, a systematic review (1999-2009) was performed, using Embase, PubMed and citation snowballing. Literature research resulted in 19 manuscripts, reporting studies in six countries, mostly situated in Western and Central Europe. From this review, it appears that, in most of the European countries for which data are available, especially non-European migrant children are at higher risk for overweight and obesity than their native counterparts. The prevalence of overweight in migrant children ranged from 8.9% to 37.5% and from 8.8% to 27.3% in native children. The prevalence of obesity in migrant children ranged from 1.2% to 15.4% and from 0.6% to 11.6% in native children. Some limitations of the review are discussed, especially the problematic classification of migrant and native children. Apparently, migrant children display an even more sedentary way of life or adverse dietary patterns, as compared with native children. To what degree these differences can be explained by socioeconomic and cultural factors remains to be investigated. As overweight and obese children are at risk for many chronic health problems, further research is urgently needed in order to develop preventive interventions.

More co-morbid depression in patients with Type 2 diabetes with multiple complications. An observational study at a specialized outpatient clinic.

AIMS: The impact of depression on patients with chronic medical illnesses such as diabetes is well documented. Depression is relatively common in diabetes patients with diabetes-related complications and they are more likely to be referred to specialized outpatient facilities. Only a few studies have addressed the association between depression and multiple diabetes-related complications at these specialized outpatient facilities. The aim of this study was to determine the association between diabetes with multiple complications and depression in patients with Type 2 diabetes at a specialized outpatient clinic. METHODS: After giving informed consent, 1194 patients were screened for depression using the Patient Health Questionnaire (PHQ-9). Additional data on the type of diabetes and complications were taken from the medical records. Logistic regression analysis was conducted, with complications as the predictor variable and the probability of depression as the dependent variable. RESULTS: A total of 596 (63%) patients with Type 2 diabetes participated in the study. The presence of two or more complications (OR 2.23, 95% CI 1.02­2.94) was significantly associated with depression. Neuropathy (OR 1.7, 95% CI 1.10­2.77) and nephropathy (OR 1.68, 95% CI 1.00­2.48) were especially related to depression. CONCLUSIONS: Patients with Type 2 diabetes with two or more complications, especially neuropathy or nephropathy, are at high risk of depression. Knowing this can help clinicians identify patients at risk for depression and facilitate timely and adequate treatment.

Comparing methodologies for the cost estimation of hospital services.

The aim of the study was to determine whether the total cost estimate of a hospital service remains reliable when the cost components of bottom-up microcosting were replaced by the cost components of top-down microcosting or gross costing. Total cost estimates were determined in representative general hospitals in the Netherlands for appendectomy, normal delivery, stroke and acute myocardial infarction for 2005. It was concluded that restricting the use of bottom-up microcosting to those cost components that have a great impact on the total costs (i.e., labour and inpatient stay) would likely result in reliable cost estimates.

Cost assessment and price setting of inpatient care in The Netherlands. the DBC case-mix system.

In February 2005, a case-mix system based on 'diagnosis treatment combinations' (DBCs) was introduced in The Netherlands for the registration and reimbursement of hospital and medical specialist care. This paper describes the characteristics of the DBC system and how it is used for the reimbursement of hospitals. Prices for reimbursement are either based on fixed tariffs ('list A') or negotiated between health insurers and hospitals ('list B') and are partly based on information about unit costs of health care services. Because the DBC system is still under development we will describe the current situation (March 2006), but also focus on the most likely future developments.

Medical consumption and costs during a one-year follow-up of patients with LUTS suggestive of BPH in six european countries: report of the TRIUMPH study.

OBJECTIVE: To determine the medical consumption and associated treatment costs of patients with LUTS suggestive of BPH. METHODS: A prospective, cross-sectional, observational survey in six European countries: France, Germany, Italy, Poland, Spain and the United Kingdom, with a one-year follow-up of incident and prevalent patients. RESULTS: Treatment costs were estimated for 5,057 patients with a mean age of 66 years and a mean IPSS score at inclusion of 11.5. In 30% of patients watchful waiting was the therapy of choice for the full follow-up period, 57% were prescribed alpha-lockers, 11% finasteride and 10% phytotherapy at any moment during the follow-up (including switches and combination of treatment). Surgery rate was 4.9%. Mean one-year treatment costs were 858 per patient, three quarters of which concerned medication costs. Multivariate regression analysis showed that medication choice, complications and undergoing surgery were associated with higher costs. CONCLUSIONS: Treatment costs for patients with LUTS suggestive of BPH were moderate and largely consisted of medication costs. Daily practice and associated costs varied considerably across the six countries.

The societal costs and quality of life of patients suffering from bipolar disorder in the Netherlands.

OBJECTIVE: To assess the societal costs and quality of life of patients suffering from bipolar disorder in the Netherlands. METHOD: Forty persons with a lifetime diagnosis of bipolar disorder (SCID/DSM-IV) and representative for the Dutch general population were interviewed to collect data on direct (use of medical resources) and indirect (productivity losses because of absence from work and reduced efficiency at work) costs of illness. Respondents' quality of life was also assessed. Prevalence (5.2%) of bipolar disorder was used to estimate total costs. RESULTS: Total costs of bipolar disorder were estimated at US 1.83 billion dollars (total direct costs = US 454 million dollars; total indirect costs = US 1.37 billion dollars). Participants' quality-of-life scores were lower than those of the general population. CONCLUSION: The societal costs form patients suffering of bipolar disorder in the Netherlands were high, especially the indirect costs because of absence from work. The quality of life of bipolar patients was lower than the general population.

A cost study of a general practitioner hospital in the Netherlands.

OBJECTIVE: To perform a cost study of the first general practitioner (GP) hospital in the Netherlands. METHODS: We conducted a cost study in a GP hospital in the Netherlands. Data on healthcare utilisation from 218 patients were collected for a period of one year. The costs of admission to the GP hospital were compared with the expected costs of the alternative mode of care. In the GP hospital three types of bed categories were distinguished: GP beds (admission and discharge by GPs, n=131), rehabilitation beds (recovery from hospital surgery, n=62) and nursing home beds (hospital patients awaiting a vacancy in a nursing home, n=25). GPs were interviewed to indicate the best alternative form of healthcare for the GP bed patients in the absence of a GP hospital (dichotomised for this study into "hospital" or "home care"). For the "rehabilitation" and "nursing home" patients the alternative care mode was admission to a hospital. RESULTS: The mean length of stay was 15 days for the GP beds, 31 days for the rehabilitation beds and 90 days for the nursing home beds. For the GP bed patients the costs were 2533 euros per admission compared with 3792 euros for hospital stay. For the group of GP bed patients for whom "home care" was the best alternative, the costs were 2494 euros for GP hospital days compared with 2814euros , the average cost for home care of patients of 65 years and older. For rehabilitation patients the costs per patient were 4744 euros compared with 8041 euros in a hospital. For patients waiting for admission to a nursing home, these costs were 13,143 euros and 22,670 euros respectively. CONCLUSION: The GP hospital might be a cost-saving alternative for elderly patients in need of intermediate medical and nursing care between hospital and home care. Further research on the cost-effectiveness of the GP hospital compared with home care and nursing home care is needed.

[More care for a limited budget; a case for a better use of the efficiency criteria]. / Meer zorg bij beperkt budget; een pleidooi voor een betere inzet van het doelmatigheidscriterium.

A systematic consideration of the cost-effectiveness in decisions concerning the financing and implementation of healthcare technologies would contribute to the efficiency of the Dutch healthcare system. This consideration applies to the initial decision to finance a project, the periodic testing of this on the basis of practice data and the policy to promote a cost-effective approach in daily practice (via practice guidelines). Bearing in mind that the government has decided to allocate few additional resources to healthcare, it should undertake measures to ensure the systematic use of such information in these steps. The National Institute for Clinical Excellence (NICE) in the United Kingdom can serve as an example, where broadly supported guidelines are drawn up with systematic attention for the cost-effectiveness and the implications for healthcare. Within this context the question arises as to whether a Dutch variant of NICE is needed.

Incidence and prevalence of lower urinary tract symptoms suggestive of benign prostatic hyperplasia in primary care--the Triumph project.

OBJECTIVE: Benign prostatic hyperplasia (BPH) is one of the most common conditions associated with ageing in men. BPH often presents as lower urinary tract symptoms (LUTS) due to difficulties in voiding and irritability of the bladder. We conducted a retrospective cohort study within the Integrated Primary Care Information (IPCI) database, a general practitioners database in The Netherlands, to assess the incidence of LUTS suggestive of BPH (LUTS/BPH) in the general population. MATERIALS: Our study population comprised all males, 45 years or older who were registered for at least 6 months prior to start of follow-up. The study period lasted from 1 January 1995 to 31 December 2000. Cases of LUTS/BPH were defined as persons with a diagnosis of BPH, treatment or surgery for BPH, or urinary symptoms suggestive of BPH that could not be explained by other co-morbidity. RESULTS: The study cohort comprised 80,774 males who contributed 141,035 person-years of follow-up. We identified 2181 incident and 5605 prevalent LUTS/BPH cases. The overall incidence rate of LUTS/BPH was 15 per 1000 man-years (95% CI: 14.8-16.1). The incidence increased linearly (r(2) = 0.99) with age from three cases per 1000 man-years at the age of 45-49 years (95% CI: 2.4-3.6) to a maximum of 38 cases per 1000 man-years at the age of 75-79 years (95% CI: 34.1-42.9). After the age of 80 years, the incidence rate remained constant. For a symptom-free man of 46 years, the risk to develop LUTS/BPH over the coming 30 years, if he survives, is 45%. The overall prevalence of LUTS/BPH was 10.3% (95% CI: 10.2-10.5). The prevalence rate was lowest among males 45-49 years of age (2.7%) and increased with age until a maximum at the age of 80 years (24%). CONCLUSIONS: The incidence rate of LUTS/BPH increases linearly with age and reaches its maximum at the age of 79 years.

Productivity costs before and after absence from work: as important as common?

Traditionally, production losses are estimated using the human capital or friction cost method. These methods base estimations of productivity costs on data on absence from work. For some diseases, like migraine, productivity losses without absence are occasionally calculated by estimating the production losses from reduced productivity at work. However, diseases typically only associated with absence may also be expected to cause reduced productivity before and after absence. In a previous study, Brouwer et al. concluded that productivity losses without absence are also very relevant in common diseases, like influenza, common cold or neck-problems. Studying a new sample of employees of a Dutch trade-firm (n = 51), who completed the questionnaire 'Ill and Recovered' upon return to work after absence due to illness, it was revealed that about 25% of the respondents experienced production losses before absence and about 20% of the respondents experience production losses after absence. This leads to an increase in estimated production losses of about 16% compared with only considering absence data. Current productivity costs estimates based solely on absence data may, therefore, underestimate real productivity costs. Compensation mechanisms in firms may reduce the underestimation.

Analysis of costs and cost-effectiveness in multinational trials.

OBJECTIVES: the number of economic evaluations alongside multinational trials is increasing. Pooling of health effects of patients from different countries may be possible, but simply pooling costs does not give valid results and may not address national health policy issues properly. How should costs be handled in multinational economic evaluations? METHODS: a range of factors is discussed, that determine the (un)comparability of medical consumption and costs between countries; patient characteristics, epidemiology, patterns of medical practice, absolute and relative prices of medical services and cost estimation procedures. RESULTS: as an empirical example we investigated a clinical trial on breast cancer therapy in three European countries, focusing on the relationship between differences in medical practice and hospital medical consumption and costs. Correcting for differences in patient mix a multivariate analysis showed that differences in the number of laboratory procedures, day care treatments and outpatient visits between countries appear to be related to differences in medical practice. We calculated the costs of medical consumption as if all patients were treated in one country, correcting for these differences in medical practice. CONCLUSIONS: although the extent of the correction in this particular example was not very substantial, this approach seems a sensible way of analysis in order to investigate cost differences between countries in multinational trials. This provisional approach should be further developed and compared with alternative methods of correcting medical consumption and costs.

The cost effectiveness of tapered versus abrupt discontinuation of oral cyclosporin microemulsion for the treatment of psoriasis.

OBJECTIVE: To assess the cost effectiveness of tapered versus abrupt discontinuation of a microemulsion formulation of cyclosporin in patients with chronic plaque psoriasis. METHODS: A cost-effectiveness analysis was performed in parallel with a non-blind, multicentre, international clinical trial of the safety and efficacy of intermittent short courses of cyclosporin. Direct and indirect costs were considered within a 1-year period following randomisation. PATIENTS: Patients with chronic plaque psoriasis inadequately controlled with topical treatment. STUDY PERSPECTIVE: The study was conducted from a societal perspective and was performed using data from Canada, Spain, Turkey and the UK. MAIN OUTCOMES MEASURES: The health outcome used was the total number of systemic therapy-free days (STFDs) over the first year. The mean incremental cost-effectiveness ratio (ICER) was determined by dividing the differences in average cost per patient by the differences in average STFDs per patient. RESULTS: The overall ICER was dominant because tapered discontinuation was associated with both lower costs and improved efficacy in comparison with abrupt discontinuation. Further analyses showed that tapered discontinuation was a cost-effective alternative to abrupt discontinuation therapy, even when a conservative definition for cost effectiveness was adopted. CONCLUSION: This cost-effectiveness analysis demonstrated that tapering cyclosporin was more cost effective than abruptly stopping cyclosporin in patients with chronic plaque psoriasis.

The cost of treatment of Alzheimer's disease in The Netherlands: a regression-based simulation model.

OBJECTIVE: To examine the potential economic impact of treatment of Alzheimer's disease. DESIGN: Regression-based simulation estimation of the long term costs of Alzheimer's disease under a number of treatment scenarios. Data from an epidemiological study conducted in Rotterdam, The Netherlands, was used to simulate disease progression. Comparison of the costs and effectiveness experienced by the patients were used to measure the impact of treatment. PATIENTS AND INTERVENTION: 2 theoretical cohorts of patients with Alzheimer's disease, one of which receives standard treatment, while the other receives a treatment which slows cognitive decline as measured by the Mini-Mental State Examination (MMSE). MAIN OUTCOME MEASURES AND RESULTS: Under one of the scenarios examined, the baseline cost of Alzheimer's disease was 97,866 euro (EUR; 1996 values) per patient over 10 years' follow-up; the cost was almost EUR100,000 under all scenarios. Life expectancy following onset was about 4.5 years and MMSE decline was approximately 2 points per year for a typical prevalent (existing) patient and almost twice as much for incident (newly diagnosed) patients (1.82 vs 3.42 points per year, respectively). Slowing the rate of cognitive decline results in a slightly increased life expectancy, with more time being spent at home and less in a nursing home. Total costs (excluding those of therapy) will decrease, but savings will be modest and may well be less than the cost of therapy. Under the same scenario, total savings were EUR1,571 per patient which corresponds to an annual break-even cost of just EUR453. Decisions regarding the initiation or termination of therapy will affect both the number of patients treated and the costs and potential savings of treatment. CONCLUSIONS: The savings made in treating Alzheimer's disease will almost certainly be small in comparison with total costs and may well be offset by the cost of the treatment itself. Simulation models can be used to estimate the effect of therapy on the costs of care and can be useful tools in clinical decision-making and allocation of resources. These results show the need for further research into the costs and effects of treatment of Alzheimer's disease.

Cost effectiveness of continuous terbinafine compared with intermittent itraconazole in the treatment of dermatophyte toenail onychomycosis: an analysis of based on results from the L.I.ON. study. Lamisil versus Itraconazole in Onychomycosis.

OBJECTIVE: To compare the costs and effectiveness of 2 oral antifungal treatment regimens in patients with dermatophyte toenail onychomycosis. DESIGN AND METHODS: A cost-effectiveness analysis using a model based on data from the Lamisil versus Itraconazole in Onychomycosis (L.I.ON.) study, a randomised controlled trial comparing continuous terbinafine with intermittent itraconazole. The trial included 4 treatment arms: terbinafine 250 mg/day for 12 or 16 weeks (T12, T16) and itraconazole 400 mg/day for 1 week in every 4 weeks for 12 or 16 weeks (I3, I4). Cost calculations for 6 countries (Finland, Germany, Iceland, Italy, The Netherlands, UK) included costs for medication, physician visits, laboratory tests, management of adverse events and management of relapse. Effectiveness was based on complete cure rates (mycological cure plus 100% toenail clearing). Costs per complete cure were determined and both average and incremental cost-effectiveness ratios were calculated. PERSPECTIVE: Healthcare system. MAIN OUTCOME MEASURES AND RESULTS: In the L.I.ON. study, terbinafine was seen to be more effective than itraconazole (cure rates, 45.8 vs 23.4%). In most comparisons (5 of the 6 countries), the costs of T12 were statistically significantly lower than those of I3 [range: -37 to -173 euros (EUR); 1998 values; 1.172 US dollars = EUR1], indicating that T12 was the dominant strategy (i.e. less expensive and more effective). One exception (Finland) showed an incremental cost-effectiveness ratio of EUR524 per additional cure. In the other 5 countries, T16 and 14 were essentially equal in cost, but the greater effectiveness of T16 (cure rates, 55.1 vs 25.9%) resulted in a situation of extended dominance. CONCLUSION: From a healthcare system perspective, continuous terbinafine is less costly and more effective than intermittent itraconazole in the treatment of dermatophyte toenail onychomycosis.

Quality of life and clinical outcome in psoriasis patients using intermittent cyclosporin.

BACKGROUND: Psoriasis causes considerable patient morbidity and can seriously affect a patient's quality of life (QoL). OBJECTIVES: To investigate the relationships between changes in QoL and measures of severity and extent of disease, and itch, in patients with chronic plaque psoriasis receiving intermittent short courses of cyclosporin (Neoral). METHODS: This study was performed as part of an international trial investigating the safety, efficacy and total costs of intermittent short courses of cyclosporin (the PISCES study). All patients received cyclosporin until clearance and were then followed up until relapse. On relapsing, patients received another course. Patients were followed up for a minimum of 1 year during which they could receive as many courses of treatment as necessary. In a subgroup (n = 255) of patients in the trial, the Dermatology Life Quality Index (DLQI) was used to assess the impact of psoriasis and its treatment on the patients' health status at the beginning and end of each treatment period. At the beginning and end of each treatment period, as well as at 2-weekly visits, the extent and severity of disease, together calculated into a modified Psoriasis Area and Severity Index (PASI), and itch were recorded. Data were analysed using the Wilcoxon matched pairs test, multivariate Hotelling's T2 tests, and Spearman's rank correlation coefficients (rs). RESULTS: During treatment, a clear impact on the overall DLQI scores and in the scores in all six DLQI headings was found (i.e. an improvement in QoL; P < 0.001 in all scores). Also, significant decreases in PASI and itch scores were found (P < 0.001). Multivariate analyses confirmed that a decrease in PASI and itch scores was accompanied by an impact on the DLQI scores during and between the two treatment periods (P < 0.0001). Statistically significant but weak correlations were found between changes in QoL and changes in PASI (rs = 0.40 and 0.24 for the first and second treatment periods, respectively) and itch scores (rs = 0.31 and 0.42, respectively). CONCLUSIONS: Intermittent short courses of cyclosporin clearly improve the QoL of the patients and decrease the extent and severity of disease and itch. Changes in clinical outcome scores are accompanied by changes in QoL. The weak correlations between changes in QoL and clinical measures may suggest that no clear relationship between QoL and clinical outcomes exists. However, due to the inclusion and exclusion criteria of the study, both QoL and clinical outcome measures do not show much variation among this homogeneous group of patients. As long as the relationship between clinical outcome parameters and measures of QoL is not completely clear, both measures of health should be considered in adequate, patient-orientated clinical decision making.

Lower urinary tract symptoms suggestive of benign prostatic obstruction--Triumph: health-economical analysis.

Given the ageing of western populations, the cost burden associated with the treatment of LUTS suggestive of BPO will increase substantially over the next few decades. Therefore, from the economic perspective, the primary objective of the Triumph project is the assessment of the cost-effectiveness of treatment options for lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO), formerly referred to as symptomtic benign prostatic hyperplasia (BPH), in medical practice in initially six European countries. All modalities of LUTS treatment used in these countries will be considered. The effectiveness and costs associated with these treatments will be assessed in each country. Data will be gathered from observed medical practice rather than in the setting of a trial. Country-specific aspects will be studied and the outcome of country-specific policies can be predicted. Patient quality of life will also be measured using the I-PSS score as a basis. A number of treatment scenarios will be assessed in terms of both their costs and long-term effects, using a computer simulation. These economic analyses will provide greatly improved insight into the most cost-effective treatments for LUTS suggestive of BPO.

Healthcare resource utilisation and costs of treating NSAID-associated gastrointestinal toxicity. A multinational perspective.

OBJECTIVE: The aim of the study was to perform an economic analysis of a new therapy in 11 countries (Australia, Belgium, Finland, France, Germany, Italy, The Netherlands, Spain, Sweden, Switzerland and the UK) to assess the cost of treating the gastrointestinal (GI) events associated with the use of nonsteroidal anti-inflammatory drugs in patients with osteoarthritis and rheumatoid arthritis. METHODS: Estimates of GI event-related costs were based on the results of resource utilisation questionnaires. Resources required for the treatment and follow-up of GI events were identified and converted into costs from society and payer perspectives. RESULTS: From the perspective of society, the total per-event cost of managing GI-related events varies from $US51 to $US772 for GI discomfort, from $US108 to $US1100 for anaemia, from $US145 to $US1200 for ulcer and from $US1923 to $US5473 for serious GI events requiring hospitalisation. From the payer perspective, the total per-event cost varies from $US47 to $US680 for GI discomfort, from $US144 to $US762 for anaemia, from $US229 to $US795 for ulcer and from $US1787 to $US6729 for serious GI events requiring hospitalisation. The total cost is driven by hospital expenses for those events requiring hospital admission. For GI discomfort, physician consultations are generally the cost driver, whereas for ulcer and anaemia, cost is primarily driven by the rate of endoscopy. CONCLUSIONS: Costs associated with nonsteroidal anti-inflammatory drug-related GI events differ significantly across countries as a result of variations in resources consumed and price/tariff policies.