Lower respiratory tract infections (LRTIs) are the fourth leading cause of death worldwide and, in Sri Lanka, were the third and fourth leading causes of hospital deaths and hospitalization, respectively, in 2022–2023. No prior study has quantified the episode-level economic burden in Sri Lanka. Although the public healthcare system provides services free of charge, patients still incur substantial out-of-pocket (OOP) and productivity costs. We estimated the direct and indirect costs of hospitalized LRTI episodes in southern Sri Lanka from a societal perspective, by phase of care and age group. We conducted a prospective cohort study of 1,268 patients (median age 58.0 years; interquartile range [IQR]: 32.0–69.0) hospitalized with LRTIs at a public tertiary care hospital in Galle, Sri Lanka, from April 2018 to March 2021. Standardized questionnaires at enrollment and approximately four weeks after the date of admission captured direct OOP costs (consultations, medications, laboratory tests, transportation) and indirect costs (productivity losses from missed work or school) across three phases: pre-hospitalization (prior costs related to the current illness), hospitalization, and post-hospitalization (illness-related costs from discharge through around four weeks after index admission). Healthcare system costs were estimated from Sri Lanka–specific World Health Organization Choosing Interventions that are Cost-Effective (WHO-CHOICE) estimates and included in the direct costs. All costs were inflation-adjusted to 2020 Sri Lankan Rupees (LKR) and converted to 2020 United States Dollars (USD). Median total cost per hospitalized LRTI episode was USD 125.25, including median direct costs of USD 106.15 and indirect costs of USD 18.47. Before hospitalization, 69.6
Establishing a reliable arteriovenous fistula (AVF) for haemodialysis (HD) is often complicated by early failure. Utilising regional anaesthesia (brachial plexus block, BPB) for AVF creation has previously been shown to improve short- and long-term AVF patency compared to local anaesthesia (LA). We report a comprehensive economic evaluation of the ACCess multicentre trial (comparing BPB vs LA) from the UK health system perspective. Using ACCess trial data, we conducted a within-trial micro-costing analysis of 12-month resource use and outcomes [1], and a decision-analytic cost-effectiveness model over 5 years [2]. Costs of staff, drugs, equipment and consumables were derived and valued in 2024 prices. Utility values (EQ-5D and SF-6D) from trial respondents were used to estimate quality-adjusted life-years (QALYs) for the within-trial evaluation, supplemented by utility values linked to access modality from literature for the cost-effectiveness model. All costs and benefits were discounted at 3.5
COVID-19 exposed weaknesses in health-system readiness and renewed interest in how reported preparedness changed across countries. This paper describes changes in formal preparedness capacity before and during the pandemic, presents health-expenditure and pandemic-response accounting ratios, and examines cross-country associations between reported preparedness changes, fiscal health measures, and international grants. Preparedness is proxied by country-reported International Health Regulations (IHR) monitoring scores. We combine these scores with capital and operating government health expenditure from the WHO Global Health Expenditure Database, selected respiratory-related medical imports from UN COMTRADE, and above-the-line health-sector measures from the IMF COVID-19 fiscal-response dataset. Cross-sectional ordinary least-squares models examine associations between changes in reported IHR scores, fiscal health measures, and grants; the design does not identify causal effects. The unweighted mean reported IHR score increased from 63 to 66, while the population-weighted mean increased from 76 to 78. Larger increases were observed among countries with lower initial scores and among low- and lower-middle-income groups. Health-expenditure-to-score and response-spending-to-score ratios varied widely across countries. In the cross-sectional specifications, fiscal measures and grants were positively associated with reported score changes only through interactions with below-median initial preparedness; these estimates are sensitive to specification and should not be interpreted causally. Reported formal preparedness capacity improved modestly on average, with larger observed gains among countries that began with lower scores. Because IHR scores are self-reported, the measurement instrument changed over time, and the regressions are observational, the results cannot establish that fiscal support or grants caused these changes. The findings nevertheless support continued attention to preparedness financing, transparent measurement, and the needs of countries with limited fiscal space. (1) Reported IHR scores improved modestly on average, with larger observed increases among countries with lower initial scores. (2) Broad expenditure and response-spending ratios show substantial cross-country differences in the fiscal resources recorded relative to reported preparedness; these ratios are descriptive accounting measures and should not be interpreted as the marginal cost of achieving an IHR point. (3) Fiscal health measures and grants are associated with changes in reported preparedness among countries with lower initial scores in some specifications, but the cross-sectional design does not establish causality.
Ensuring equitable access to innovative drugs is crucial for public health. Despite the inclusion of innovative drugs on China’s National Reimbursement Drug List, disparities in availability persist across regions and healthcare facility levels. This study aims to assess the availability and equity of NRDL-listed innovative drugs in China and analyse regional and institutional disparities. Availability was assessed using the WHO/HAI methodology, whereas equity analysis was conducted using the Gini coefficient and Theil index. We firstly constructed a healthcare resource index S as the core analytical unit for equity evaluation, and adopted a dual-weighting strategy based on population and healthcare facilities to comprehensively measure multidimensional regional drug distribution disparities. This study examined regional variations, hospital-level differences, and intra- and inter-regional disparities in drug availability. The availability of NRDL-listed innovative drugs was low, although tertiary facilities (12.09 ± 12.46)
There is growing interest among insurers and policy makers in the United States in primary care playing an expanded role to improve quality and lower cost. These activities often are not costless for primary care practices or clinics (PCCs) to implement, and the costs are not always reimbursed. Thus, a PCC facing expectations to provide additional, unreimbursed services is likely to consider their return on investment (ROI). Additionally, when private businesses are used to implement government policy, the objectives, resources, and constraints of the businesses need to be carefully considered. We develop a general model for the PCC’s ROI in a tiered cost-sharing health insurance benefit design in which PCCs with lower total risk-adjusted annual per capita cost of care (TCOC) are assigned to a tier with lower consumer cost-sharing, leading to an increase in patient volume. We focus on price discounts as one way to lower the PCC’s TCOC, but the same analysis would apply to any unreimbursed effort to make the PCC more attractive to prospective patients, e.g., in a capitation system with regulated fees. We use data from a large state employee insurance program that uses such a TCOC design. The study finds that discounts of 10–20 percent can have a positive ROI for the PCC, meaning a PCC may generate more income through a gain of patient volume than is lost through lowering their unit prices. These results are sensitive to the model’s parameters. The study finds that primary care clinics offering 10–20 percent price discounts within a tiered cost-sharing insurance model can achieve a positive return on investment. Increased patient volume from lower cost-sharing tiers can offset the revenue loss from discounts. However, the profitability of these strategies depends strongly on specific model parameters and assumptions.
Suicide constitutes a serious public health problem, leaving many more bereaved. It also represents a major economic burden to society, and the aim of this study was to estimate the societal costs of suicide in Norway. This cost-of-illness study included direct suicide-related costs and indirect costs in the form of lost economic productivity. It is the first study of suicide using individual register data on the deceased’s earnings to estimate productivity losses. Estimates incorporated productivity growth and life expectancy adjustments but excluded intangible costs and unpaid work. In 2018, the mean societal costs per suicide were NOK 5,510,518 (USD 634,041). Productivity losses constituted the largest cost component (98.8
Multimorbidity is common among people with diabetes and is associated with healthcare cost concentration. This study aims to quantify multimorbidity burden and evaluates the association between multimorbidity and high-cost (HC) status. We conducted a retrospective cohort study using longitudinal health insurance claims and chronic disease management data from 79,910 diabetic patients in eastern China. Patients in the top 10
Obstructive sleep apnoea (OSA) is a chronic condition characterised by recurrent episodes of apnoea and hypopnoea. People with untreated OSA are at increased risk of excessive daytime sleepiness (EDS), functional impairment and developing cardiovascular conditions, metabolic and neurocognitive diseases. EDS is a key determinant of quality of life (QoL) and is associated with increased healthcare utilisation and accident risk. Untreated OSA can also lead to impaired work productivity, reduced health-related quality of life (HRQoL) and life expectancy, which contribute to the UK economic burden. To review and critically appraise all published economic evaluations that assessed the cost-effectiveness of devices and strategies to diagnose and manage people with moderate-to-severe OSA. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews guidelines and registered in the Prospective Register of Ongoing Systematic Reviews (CRD42024535732). We searched electronic databases up to March 2025. Two reviewers undertook screening, data extraction and quality appraisal using recognised reporting quality and methodological quality appraisal tools. The findings were summarised and discussed narratively. Twenty-nine studies were included. Fifteen studies included an economic evaluation alongside a clinical trial and 14 studies were model-based economic analyses. Although many analyses were methodologically sound in their overall approach, there were concerns regarding choice of time horizon, selection of health states, undertaking pre-model analyses and long-term adherence and efficacy of continuous positive airway pressure treatment (CPAP). Substantial methodological heterogeneity was identified across studies, including variation in diagnostic thresholds and scoring criteria used, model structures and assumptions regarding treatment adherence. Only four of twenty-nine included studies used home respiratory polygraphy (HRP) as a comparator, limiting the direct applicability of much of the evidence to the UK setting. Past economic analyses offer insight into the methods used to assess the cost-effectiveness of strategies to diagnose OSA. These economic analyses are a useful framework to build on, but clear gaps exist in the clinical and economic evidence. Future economic evaluations should prioritise contemporary diagnostic pathways and technologies, use consistent diagnostic definitions, and incorporate more realistic modelling of long-term treatment adherence and benefit. Until such information becomes available, the true cost-effectiveness of these strategies remains unknown.
Health information technology has been widely adopted by hospitals, yet the financial consequences of adoption remain uncertain and may depend on which vendor supplies the system. Despite a highly concentrated electronic medical record (EMR) market, little evidence exists on whether systems from market-dominant vendors are associated with lower hospital costs. This study examines how vendor market position and the depth of Meaningful Use implementation relate to hospital cost performance. We assembled a 2011–2017 panel of California hospitals that links audited financial data from the Department of Health Care Access and Information, Meaningful Use attestation records, and HIMSS installation histories. We defined advanced EMR adoption as the presence of computerized physician order entry or physician documentation, and classified adopters by whether their advanced-module vendor was among the two largest in the market. Using hospital and year fixed-effects models, an event-study specification, and several robustness checks, we estimated associations with three cost outcomes: inpatient cost per discharge, outpatient cost per visit, and operating expense per discharge. Advanced EMR adoption was not associated with immediate reductions in inpatient cost per discharge at any horizon. Estimated reductions emerged with a lag in outpatient costs and in operating expense, broadly consistent with a multi-year adjustment period. Vendor heterogeneity was also important: operating-expense reductions were more evident among hospitals using non-dominant vendors than among hospitals using the two largest vendors, and attaining Stage 2 Meaningful Use was consistently associated with lower costs. These patterns were robust to defining vendor dominance within hospital referral regions and within advanced functionality, to a single-versus-multiple-vendor specification, and to a heterogeneity-robust difference-in-differences estimator. Because the analysis is observational, the estimates are interpreted as associations rather than causal effects. The findings highlight the role of implementation depth and organizational fit, and they caution against treating vendor market concentration as inherently efficiency-enhancing.
Chronic diseases are a leading cause of morbidity and mortality worldwide, with prevalence rising because of lifestyle factors and increasing life expectancy. In developing countries, including Jordan, these conditions pose growing health and economic burdens. This systematic review assessed available literature on the economic burden of chronic diseases in Jordan. Following PRISMA guidelines, we searched Medline PubMed, Embase, PubMed Central, and Scopus, supplemented by Google/Google Scholar and reference lists, for studies reporting direct medical costs of chronic diseases in Jordan. Titles, abstracts, and full texts were screened independently by two reviewers. Study characteristics and mean annual per-patient costs were extracted and verified. Costs were standardized to per-patient, per-year estimates in 2025 USD, including outpatient, inpatient, diagnostic, emergency, and medication expenses. The quality of included studies was assessed using the adapted version of Drummond checklist for economic studies. Database search identified 147 records. After removal of one duplicate record, 146 records were screened, and 19 full-text articles were assessed for eligibility. Ultimately, eleven studies were included. They reported costs for cancers, diabetic retinopathy, severe renal disease, thalassaemia, paediatric asthma, and multiple sclerosis, mostly using retrospective designs. Mean annual costs ranged from 35 to30,567 (2025 USD), and the greatest costs were for end-stage renal disease. Of cancer studied, breast cancer and colorectal cancer were associated with substantial annual direct medical costs, although estimates varied considerably between studies because of differences in disease populations, data sources, and cost methodologies. The mean annual cost for all conditions was 10,035 (2025 USD). When weighted against the sample sizes, the pooled mean cost was6,914 USD. The overall quality of included studies was judged to be moderate, with most studies clearly defining study populations, disease conditions, and data sources used for cost estimation. Chronic kidney disease, breast cancer, and multiple sclerosis imposed substantial medical costs in Jordan. Evidence for other major conditions was limited, highlighting the need for further research to guide health care planning, resource allocation, and cost-effective chronic disease management. • Mean annual costs ranged from 35 to30,567 (2025 USD), and the greatest costs were for end-stage renal disease (29,418) and multiple sclerosis (12,590). • Chronic kidney disease, multiple sclerosis, and colorectal cancer impose substantial medical costs in Jordan.
With the emergence of increasing subtype-specific treatments for breast cancer, the need for subtype-based cost assessments have been highlighted, given the lack of detailed molecular data in prior cost analyses. Therefore, this study aimed to estimate medical costs among Korean patients with breast cancer according to molecular subtypes and stages of disease progression. This retrospective cohort study estimated the annual medical costs of 13,797patients with breast cancer by molecular subtype and disease stage using the Korea-Clinical Data Utilization Network for Research Excellence (K-CURE) dataset, a linked dataset of national insurance claims and cancer registry records (2007–2019). We performed a generalized estimating equations (GEE) analysis to evaluate the impact of clinical characteristics on costs. Furthermore, the compound annual growth rate was calculated to assess cost trends across key treatment modalities (e.g., surgery, radiotherapy, adjuvant chemotherapy, and targeted therapy). Breast cancer expenditures were heavily front-loaded, with annual costs in years 2–5 dropping to 28
Pharmaceutical procurement in public tertiary hospitals is a critical component of healthcare delivery but may be vulnerable to corruption because it involves large financial flows, complex technical decisions and multiple actors. In Nigeria, corruption in health sector hinders access to essential medicines, drives up costs, increases circulation of falsified products and compromises patient care. This study examined which procurement stages staff involved in pharmaceutical procurement in two public tertiary hospitals in Enugu State perceived as most vulnerable to corruption. A cross-sectional quantitative study was conducted in two public tertiary hospitals in Enugu State, Nigeria. Data were collected from 122 hospital staff directly or indirectly involved in pharmaceutical procurement. Trained research assistants administered the structured questionnaire face-to-face and recorded participants’ responses. Descriptive statistics summarised respondents’ characteristics and the proportions identifying each procurement stage as vulnerable. Exploratory binary logistic regression examined associations between reported indicators of potentially problematic procurement practices and perceived vulnerability at different procurement stages. Supplier selection was the stage most frequently perceived as vulnerable, identified by 50.8
We conducted an early health technology assessment (eHTA) of bepirovirsen, an investigational finite-course therapy for chronic hepatitis B. In China, low-cost generic nucleos(t)ide analogues (NAs) create a demanding comparator environment. The value-based price of a potential functional-cure strategy therefore depends on local comparator prices, threshold selection, cure durability, safety, monitoring requirements, and cured-state utility assumptions. A lifetime Markov model simulated bepirovirsen 300 mg/week for 24 weeks plus background NAs against comparator-specific standard-of-care options. Chinese cost inputs were valued in 2024 renminbi (RMB) and converted to US dollars using the 2024 annual average exchange rate of 7.1957 RMB per US dollar. The base case used a China-context cost-effectiveness threshold (CET) of 13,500 per quality-adjusted life-year (QALY), approximating China’s 2024 gross domestic product (GDP) per capita after currency conversion, and compared it with higher threshold scenarios. Because reliable long-term relapse rates were unavailable, a 48-week maintained-response scenario set bepirovirsen efficacy to 9.0
Employer mandates are a central mechanism for expanding universal health coverage (UHC). In Oman, the Dhamani platform a national digital health-insurance system mandates private-sector coverage under Capital Market Authority Resolution 78/2019. Full national rollout commenced in 2025, creating an urgent need for pre-implementation employer-readiness evidence. To describe formal employer health-insurance provision rates across Omani private-sector firms, to identify firm structural factors independently associated with provision, and to assess whether organisational resource capacity mediates the firm size–provision relationship. Cross-sectional employer survey (n = 222) conducted prior to full Dhamani enforcement, using stratified purposive sampling by firm size and sector. Multivariable logistic regression (Hosmer–Lemeshow calibration, ROC AUC discrimination, VIF multicollinearity checks, Box–Tidwell linearity test, Firth penalized sensitivity analysis) and bootstrapped mediation analysis (5,000 resamples; bias-corrected 95
Therapeutic options for patients with poor-prognosis invasive triple-negative breast cancer (TNBC) remain lacking. Although novel treatment strategies have demonstrated improved efficacy, they are frequently associated with substantial financial costs. Consequently, rigorous economic evaluation is essential to inform clinical and policy decisions. A three-state Markov model with a lifetime horizon was developed using clinical efficacy data from the ASCENT-04/KEYNOTE-D19 trial, along with treatment-related cost inputs. Lifetime costs and health outcomes in cases of advanced TNBC for patients undergoing treatment with either sacituzumab govitecan plus pembrolizumab or chemotherapy plus pembrolizumab were estimated with the developed model. Model uncertainty and structural stability were examined via probabilistic and deterministic sensitivity analyses. Total costs, quality-adjusted life-years (QALYs), incremental net health benefit (INHB), incremental net monetary benefit (INMB), and incremental cost-effectiveness ratios (ICERs) were examined at a willingness-to-pay (WTP) threshold of 150,000/QALY in the USA. The estimated lifetime cost was1,831,187 for sacituzumab govitecan plus pembrolizumab and 574,011 for chemotherapy plus pembrolizumab. Corresponding health outcomes were 5.28 QALYs and 4.74 QALYs, respectively. The resulting ICER was2,323,487 per QALY gained. The INHB and INMB were -7.84 QALYs and -1,176,175, respectively. The most influential variables in the model included the utility value assigned to progression-free survival, patient body weight, and the cost-effectivness of sacituzumab govitecan. Sensitivity analysis demonstrated that the model findings were robust. At current market prices, sacituzumab govitecan plus pembrolizumab showed limited cost-effectiveness as a first-line option relative to chemotherapy plus pembrolizumab for treating advanced TNBC.
Empirically, this study focuses on the impact assessment of health insurance uptake on the nutrition of kids under five with special attention to variation in wealth level in Pakistan. Theoretical frameworks argue that health insurance provides a safety net against poor health outcomes. We analyzed 4,499 children from the Pakistan Demographic and Health Survey (2017-18) using Instrumental Variable Quantile Regression (IV-QR) along with logistic and probit models as bassline, with internet access and distance to health facility as instruments. This approach addresses endogeneity while examining heterogeneity across the nutritional distribution. The outcomes of the study are based on probit and logistic estimations. Health insurance in general and the Sehat Sahulat scheme in particular among the poor and most wealthy people in Pakistan greatly increases the positive health outcomes and nutrition of children. The Sehat Sahulat scheme of health insurance coverage of the malnourished children in the low economic class in rural and urban Pakistan provides substantial protection from malnutrition. The IV-QR results reveal that health insurance significantly reduces child malnutrition only for the poorest three wealth quintiles (Q1: OR = 0.64, p < 0.01; Q2: OR = 0.75, p < 0.01; Q3: OR = 0.41, p < 0.01), with no significant effect for wealthier households. The Sehat Sahulat program shows protective effects exclusively for low-income groups, confirming effective targeting. This study assesses the impact of health insurance uptake on child nutrition among children under five in Pakistan, with particular attention to variation across wealth groups. The Sehat Sahulat program effectively targets vulnerable populations, but persistent geographic disparities indicate that insurance alone is insufficient. Policymakers should expand coverage while investing in complementary sanitation, education, and region-specific interventions.
Research on public health insurance (PHI) and human capital has focused on direct pathways through which increased medical utilization improves human health capital. However, a possible indirect pathway may also exist: PHI may expand the budget for nonmedical expenditures, some of which are important human capital inputs. This study uses the New Rural Cooperative Medical Scheme (NRCMS) to examine whether two empirical associations are consistent with a potential indirect pathway: NRCMS participation is associated with higher individual caloric intake, and caloric intake is associated with subsequent labor productivity. Using unbalanced panel data from the 2009 and 2011 waves of the China Health and Nutrition Survey, we examined two hypotheses: NRCMS participation is associated with higher individual caloric intake, and higher caloric intake is associated with higher productivity, as measured by earnings per working day. We used propensity score matching for the first hypothesis and inverse probability weighting regression for the second hypothesis. NRCMS participation was associated with approximately 294 kcal/day higher caloric intake. A caloric difference of this magnitude was associated with 2.97
This study aims to elucidate the role of artificial intelligence (AI) in achieving cost-effectiveness within healthcare services, and to address the challenges that hinder its integration. A hybrid multi-criteria decision-making model based on the DEMATEL and ARAS methods was designed. Data were collected with the participation of ten experts working in the fields of health management, health economics and health policy in Canada, India, Switzerland, USA and Türkiye. The causal relationships between the challenges were analyzed using DEMATEL analysis and the solutions to these challenges were evaluated using the ARAS method. As a result of the DEMATEL analysis, the “Regulatory and ethical concerns (REC)” criterion reached the highest level of importance (13.94
Catastrophic health expenditure (CHE) remains a central challenge to achieving financial protection and equity in health systems. While extensive evidence shows that CHE remains disproportionately concentrated among socioeconomically disadvantaged households, most studies adopt a static perspective and provide limited insights into how CHE inequality evolves over time and through which mechanisms. This study aims to examine changes in socioeconomic inequality in CHE in China and disentangle the underlying channels from a household mobility perspective. Using nationally representative longitudinal data from the 2010 and 2020 waves of the China Family Panel Studies, socioeconomic-related CHE inequality was measured using Erreygers’ corrected concentration index, with household per capita wealth as the ranking variable. An integrated mobility–determinant decomposition framework was employed to quantify the contributions of both mobility processes and socioeconomic, demographic, and health system-related factors to changes in CHE inequality. Robustness analyses were performed using alternative CHE definitions, different specifications of household socioeconomic status, and an alternative decomposition approach. CHE remained disproportionately concentrated among lower-wealth households in both waves, although the magnitude of inequality declined significantly between 2010 and 2020. This reduction was primarily driven by progressive contribution of wealth-related CHE mobility, indicating larger improvements in financial protection among initially poorer households, while the regressive contribution of CHE-related wealth mobility partially offset these gains. Lower wealth quintiles, urban residence, and social health insurance coverage were associated with the reduction in CHE inequality, whereas higher wealth quintiles and household ageing were associated with attenuating the inequality reduction, reflecting heterogenous contributions through distinct mobility channels. Robustness checks confirmed the stability of the main findings. Socioeconomic inequality in CHE in China has narrowed over the past decade, primarily due to progressive improvements in financial protection. However, persistent wealth stratification and population ageing continue to constrain further reductions in CHE inequality. Monitoring progress toward universal health coverage requires attention not only to aggregate CHE incidence but also to the underlying mobility processes and structural determinants that influence distributional change.
Although several studies have evaluated the cost-effectiveness of total knee arthroplasty (TKA) compared with conservative treatment, few have explored how implant revision rates may influence its long-term cost-effectiveness. The objective of this study was to evaluate the impact of implant revision rates on quality of life and cost-effectiveness in patients undergoing TKA. A cost-utility analysis from a healthcare system perspective was conducted using an individualized discrete-event simulation model parameterized with data from a Spanish cohort of patients undergoing TKA. Quality-adjusted life years were calculated with the SF-6D index, and implant alternatives were compared by assigning age- and sex-specific revision rates to each simulated patient while projecting long-term quality of life and life expectancy according to general population standards. The prosthetic models compared were those associated with the highest (WorstKnee) and lowest (BestKnee) revision rates in the UK National Joint Registry. The primary outcome was the incremental cost-effectiveness ratio. Secondary analyses included budget impact and deterministic sensitivity analyses. The projected quality-adjusted life expectancy over 15 years was 9.767 QALYs for WorstKnee, compared with 10.004 QALYs for BestKnee. The incremental cost-effectiveness ratio was €6,219/QALY, which remained below the cost-effectiveness thresholds commonly used in Spain. Use of BestKnee was associated with an additional cost of €332.3 M over 15 years; however, it also led to a substantial reduction in revision surgeries, with 27,878 fewer procedures performed, resulting in gradual cost savings over time. Within the price ranges currently observed in the Spanish National Health System, total knee prostheses associated with lower revision rates provide a favorable long-term cost-effectiveness profile and may reduce future revision burden despite their higher acquisition cost.
