RCTs in primary schools in rural China show frequent personalized teacher feedback improves exam scores for Grade 3 (age 9), including those 'left behind' by migrating parents. Two terms of biweekly feedback increase math and language scores by 0.15 standard deviations, with an RCT texting results to parents giving 0.26 sd extra math improvement for the left-behind. Some math improvements maintain even 30 months later. Direct costs are under $5/student. Yet identical feedback produces nothing for Grade 5. Information feedback interventions thus have excellent potential, but their fall in impact with age suggests efforts must begin early.

Background: Chronic obstructive pulmonary disease is a major contributor to morbidity, mortality and health service costs but is vastly underdiagnosed. Evidence on screening and how best to approach this is not clear. There are also uncertainties around the natural history (prognosis) of chronic obstructive pulmonary disease and how it impacts on work performance. Objectives: Work package 1: to evaluate alternative methods of screening for undiagnosed chronic obstructive pulmonary disease in primary care, with clinical effectiveness and cost-effectiveness analyses and an economic model of a routine screening programme. Work package 2: to recruit a primary care chronic obstructive pulmonary disease cohort, develop a prognostic model [Birmingham Lung Improvement StudieS (BLISS)] to predict risk of respiratory hospital admissions, validate an existing model to predict mortality risk, address some uncertainties about natural history and explore the potential for a home exercise intervention. Work package 3: to identify which factors are associated with employment, absenteeism, presenteeism (working while unwell) and evaluate the feasibility of offering formal occupational health assessment to improve work performance. Design: Work package 1: a cluster randomised controlled trial with household-level randomised comparison of two alternative case-finding approaches in the intervention arm. Work package 2: cohort study – focus groups. Work package 3: subcohort – feasibility study. Setting: Primary care settings in West Midlands, UK. Participants: Work package 1: 74,818 people who have smoked aged 40–79 years without a previous chronic obstructive pulmonary disease diagnosis from 54 general practices. Work package 2: 741 patients with previously diagnosed chronic obstructive pulmonary disease from 71 practices and participants from the work package 1 randomised controlled trial. Twenty-six patients took part in focus groups. Work package 3: occupational subcohort with 248 patients in paid employment at baseline. Thirty-five patients took part in an occupational health intervention feasibility study. Interventions: Work package 1: targeted case-finding – symptom screening questionnaire, administered opportunistically or additionally by post, followed by diagnostic post-bronchodilator spirometry. The comparator was routine care. Work package 2: twenty-three candidate variables selected from literature and expert reviews. Work package 3: sociodemographic, clinical and occupational characteristics; occupational health assessment and recommendations. Main outcome measures: Work package 1: yield (screen-detected chronic obstructive pulmonary disease) and cost-effectiveness of case-finding; effectiveness of screening on respiratory hospitalisation and mortality after approximately 4 years. Work package 2: respiratory hospitalisation within 2 years, and barriers to and facilitators of physical activity. Work package 3: work performance – feasibility and acceptability of the occupational health intervention and study processes. Results: Work package 1: targeted case-finding resulted in greater yield of previously undiagnosed chronic obstructive pulmonary disease than routine care at 1 year [n = 1278 (4%) vs. n = 337 (1%), respectively; adjusted odds ratio 7.45, 95% confidence interval 4.80 to 11.55], and a model-based estimate of a regular screening programme suggested an incremental cost-effectiveness ratio of £16,596 per additional quality-adjusted life-year gained. However, long-term follow-up of the trial showed that at ≈4 years there was no clear evidence that case-finding, compared with routine practice, was effective in reducing respiratory admissions (adjusted hazard ratio 1.04, 95% confidence interval 0.73 to1.47) or mortality (hazard ratio 1.15, 95% confidence interval 0.82 to 1.61). Work package 2: 2305 patients, comprising 1564 with previously diagnosed chronic obstructive pulmonary disease and 741 work package 1 participants (330 with and 411 without obstruction), were recruited. The BLISS prognostic model among cohort participants with confirmed airflow obstruction (n = 1894) included 6 of 23 candidate variables (i.e. age, Chronic Obstructive Pulmonary Disease Assessment Test score, 12-month respiratory admissions, body mass index, diabetes and forced expiratory volume in 1 second percentage predicted). After internal validation and adjustment (uniform shrinkage factor 0.87, 95% confidence interval 0.72 to 1.02), the model discriminated well in predicting 2-year respiratory hospital admissions (c-statistic 0.75, 95% confidence interval 0.72 to 0.79). In focus groups, physical activity engagement was related to self-efficacy and symptom severity. Work package 3: in the occupational subcohort, increasing dyspnoea and exposure to inhaled irritants were associated with lower work productivity at baseline. Longitudinally, increasing exacerbations and worsening symptoms, but not a decline in airflow obstruction, were associated with absenteeism and presenteeism. The acceptability of the occupational health intervention was low, leading to low uptake and low implementation of recommendations and making a full trial unfeasible. Limitations: Work package 1: even with the most intensive approach, only 38% of patients responded to the case-finding invitation. Management of case-found patients with chronic obstructive pulmonary disease in primary care was generally poor, limiting interpretation of the long-term effectiveness of case-finding on clinical outcomes. Work package 2: the components of the BLISS model may not always be routinely available and calculation of the score requires a computerised system. Work package 3: relatively few cohort participants were in paid employment at baseline, limiting the interpretation of predictors of lower work productivity. Conclusions: This programme has addressed some of the major uncertainties around screening for undiagnosed chronic obstructive pulmonary disease and has resulted in the development of a novel, accurate model for predicting respiratory hospitalisation in people with chronic obstructive pulmonary disease and the inception of a primary care chronic obstructive pulmonary disease cohort for longer-term follow-up. We have also identified factors that may affect work productivity in people with chronic obstructive pulmonary disease as potential targets for future intervention. Future work: We plan to obtain data for longer-term follow-up of trial participants at 10 years. The BLISS model needs to be externally validated. Our primary care chronic obstructive pulmonary disease cohort is a unique resource for addressing further questions to better understand the prognosis of chronic obstructive pulmonary disease. Trial registration: Current Controlled Trials ISRCTN14930255. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.

We estimate the intergenerational elasticity (IGE) of income for the Netherlands using complete population data for around 177,000 28-year olds. We find that IGEs are much lower when actual individual income data are used rather than proxies or aggregates for income. Though low, daughters’ IGEs are higher than sons’ indicating lower income mobility for women.

Introduction ‘One-off’ systematic case-finding for COPD using a respiratory screening questionnaire is more effective and cost-effective than routine care at identifying new cases. However, it is not known whether early diagnosis and treatment is beneficial in the longer term. We estimated the long-term cost-effectiveness of a regular case-finding programme in primary care. Methods A Markov decision analytic model was developed to compare the cost-effectiveness of a 3-yearly systematic case-finding programme targeted to ever smokers aged ≥50 years with the current routine diagnostic process in UK primary care. Patient-level data on case-finding pathways was obtained from a large randomised controlled trial. Information on the natural history of COPD and treatment effects was obtained from a linked COPD cohort, UK primary care database and published literature. The discounted lifetime cost per quality-adjusted life-year (QALY) gained was calculated from a health service perspective. Results The incremental cost-effectiveness ratio of systematic case-finding versus current care was £16 596 per additional QALY gained, with a 78% probability of cost-effectiveness at a £20 000 per QALY willingness-to-pay threshold. The base case result was robust to multiple one-way sensitivity analyses. The main drivers were response rate to the initial screening questionnaire and attendance rate for the confirmatory spirometry test. Discussion Regular systematic case-finding for COPD using a screening questionnaire in primary care is likely to be cost-effective in the long-term despite uncertainties in treatment effectiveness. Further knowledge of the natural history of case-found patients and the effectiveness of their management will improve confidence to implement such an approach.

At least half of those with COPD are undiagnosed, but current guidelines do not recommend screening partly because evidence of clinical benefit is not available. We previously conducted the TargetCOPD trial demonstrating that yield from active case-finding was significantly higher compared to routine practice (OR=7.45). We now report on clinical outcomes at 4yr follow up. We obtained data through NHS Digital on mortality and hospitalisations (all-cause and respiratory) for 74,693 participants from all 54 practices in the TargetCOPD case-finding trial. Cox proportional hazard models, using random effects, adjusted for potential confounding factors were used to model time to event outcomes (first respiratory hospital admission, first all cause hospital admission and death) in the case-finding and routine arms. Time to event was censored at death or data extraction (Sept17) if no event occurred. Analyses were adjusted for a range of potential confounders, including age, sex, ethnicity and baseline values for lung function, comorbidities and smoking status. Of the 32,743 participants in the case-finding arm, 1,557 had a respiratory hospitalisation compared to 1,899/ 41,950 in the routine arm over a mean follow up of 4.3 years (adjusted hazard ratio (HR) 1.04; 95% CI: 0.73, 1.47). The corresponding HR for all cause hospitalisation and mortality were 1.06 (0.66, 1.71) and 1.15 (0.82, 1.61) respectively. Thus despite screening resulting in higher yield, there were no differences in clinical outcomes at 4 years. Further research is needed to understand the process of management following screening and the effectiveness of existing treatments in case-found patients.

Prognostic scores could be used to guide management of COPD patients and reduce risk of hospital admission but existing scores do not perform well enough and are not practical for primary care. Using data from the Birmingham primary care COPD cohort we developed and internally validated the new BLISS prognostic score from 23 candidate variables. 1558 patients on COPD registers of 71 GP practices and 331 newly-identified patients from a linked case-finding trial were included and their self-reported and clinical data were combined with routine hospital episode statistics. Primary outcome was the record of at least one respiratory admission within 2 years of cohort entry. The model was developed using backward elimination. Missing data were imputed using chained equations. Discrimination and calibration were assessed. Bootstrapping was used for internal validation. Median (min, max) follow up was 2.9 years (1.8, 3.8). 6 variables were retained in the final model: age, CAT score, respiratory admissions previous 12m, BMI, diabetes, FEV1% predicted. After adjustment for optimism, the model performed well in predicting 2yr respiratory admissions (c statistic=0.75 (95%CI 0.72, 0.79). The BLISS score showed better performance in predicting respiratory admissions than existing published scores. All 6 variables are readily available in primary care records or would be easy to collect, and a simple computer programme could calculate the score. Important next steps are external validation, proposing/evaluating a model of use to guide patient management and exploration of the best ways to implement the score in primary care practice.

This paper tests whether the job security offered by stricter employment protection legislation (EPL) undermines positive compensating wage differentials that would otherwise be paid. Specifically, we ask whether industries with relatively more need for layoffs and labour flexibility have lower wages in countries where stricter EPL protects workers from layoffs. We find this generally to be true for a large sample of industries in the major OECD countries over 1984-2005, particularly for wages of unskilled workers. However, we also find that where workers are well organised, they can take advantage of EPL to secure higher wages.

This study reports a randomized controlled trial to improve teacher-student-parent feedback, conducted in a rural county in China with many left-behind children. Data are collected from over 4,000 primary schoolchildren (8 to 10 years old) over two school terms. We find that bi-weekly student feedbacks using our special scorecard of schoolwork and behavior improve mathematics results by 0.16 to 0.20 standard deviations, with 0.09 for language. Communicating these assessments also to parents produces further large mathematics benefits for young left-behind children, about 0.30 standard deviations. A low-cost investment in better feedback thus brings significant achievement gains especially for disadvantaged children.

Background Patients with chronic obstructive pulmonary disease (COPD) are more likely to take time off work (absenteeism) and report poor performance at work (presenteeism) compared to those without COPD. Little is known about the modifiable factors associated with these work productivity outcomes. Aim To assess the factors associated with work productivity among COPD patients. Methods Cross-sectional analysis of baseline data from a subsample (those in paid employment) of the Birmingham COPD Cohort study. Absenteeism was defined by self-report over the previous 12 months. Presenteeism was assessed using the Stanford Presenteeism Scale. Logistic regression analysis was used to assess the effects of sociodemographic, clinical and occupational characteristics on work productivity. Results Among 348 included participants, increasing dyspnoea was the only factor associated with both absenteeism and presenteeism (p for trend<0.01). Additionally, increasing history of occupational exposure to vapours, gases, dusts or fumes (VGDF) was independently associated with presenteeism (p for trend<0.01). Conclusions This is the first study to identify important factors associated with poor work productivity among patients with COPD. Future studies should evaluate interventions aimed at managing breathlessness and reducing occupational exposures to VGDF on work productivity among patients with COPD.

Background: Employment rates among those with chronic obstructive pulmonary disease (COPD) are lower than those without COPD, but little is known about the factors that affect COPD patients' ability to work. Methods: Multivariable analysis of the Birmingham COPD Cohort Study baseline data was used to assess the associations between lifestyle, clinical, and occupational characteristics and likelihood of being in paid employment among working-age COPD patients. Results: In total, 608 of 1,889 COPD participants were of working age, of whom 248 (40.8%) were in work. Older age (60-64 years vs 30-49 years: odds ratio [OR] = 0.28; 95% confidence interval [CI] = 0.12-0.65), lower educational level (no formal qualification vs degree/higher level: OR = 0.43; 95% CI = 0.19-0.97), poorer prognostic score (highest vs lowest quartile of modified body mass index, airflow obstruction, dyspnea, and exercise (BODE) score: OR = 0.10; 95% CI = 0.03-0.33), and history of high occupational exposure to vapors, gases, dusts, or fumes (VGDF; high VGDF vs no VGDF exposure: OR = 0.32; 95% CI = 0.12-0.85) were associated with a lower probability of being employed. Only the degree of breathlessness of BODE was significantly associated with employment. Conclusion: This is the first study to comprehensively assess the characteristics associated with employment in a community sample of people with COPD. Future interventions should focus on managing breathlessness and reducing occupational exposures to VGDF to improve the work capability among those with COPD.

Background Many individuals with chronic obstructive pulmonary disease (COPD) remain undiagnosed worldwide. Health-care organisations are implementing case-finding programmes without good evidence of which are the most effective and cost-effective approaches. We assessed the effectiveness and cost-effectiveness of two alternative approaches to targeted case finding for COPD compared with routine practice.Methods In this duster-randomised controlled trial, participating general practices in the West Midlands, UK, were randomly assigned (1:1), via a computer -generated block randomisation sequence, to either a targeted case-finding group or a routine care group. Eligible patients were ever-smokers aged 40-79 years without a previously recorded diagnosis of COPD. Patients in the targeted case-finding group were further randomly assigned (1:1) via their household to receive either a screening questionnaire at the general practitioner (GP) consultation (opportunistic) or a screening questionnaire at the GP consultation plus a mailed questionnaire (active). Respondents reporting relevant respiratory symptoms were invited for post-bronchodilator spirometry. Patients, dinicians, and investigators were not masked to allocation, but group allocation was concealed from the researchers who performed the spirometry assessments. Primary outcomes were the percentage of the eligible population diagnosed with COPD within 1 year (defined as post-bronchodilator forced expiratory volume in 1 s [FEV1] to forced vital capacity [FVC] ratio <0.7 in patients with symptoms or a new diagnosis on their GP record) and cost per new COPD diagnosis. Multiple logistic and Poisson regression were used to estimate effect sizes. Costs were obtained from the trial. This trial is registered with ISRCTN, number ISRCTN14930255.Findings From Aug 10, 2012, to June 22, 2014, 74818 eligible patients from 54 diverse general practices were randomly assigned and completed the trial. At 1 year, 1278 (4%) cases of COPD were newly detected in 32 789 eligible patients in the targeted case-finding group compared with 337 (1%) cases in 42 029 patients in the routine care group (adjusted odds ratio [OR] 7.45 [95% CI 4.80-11.55], p<0.0001). The percentage of newly detected COPD cases was higher in the active case-finding group (822 [5%] of 15378) than in the opportunistic case-finding group (370 [2%] of 15387; adjusted OR 2.34 [2-06-2.66], p<0.0001; adjusted risk difference 2.9 per 100 patients [95% CI 2.3-3.6], p<0.0001). Active case finding was more cost-effective than opportunistic case finding (33 pound vs 376 pound per case detected, respectively).Interpretation In this well established primary care system, routine practice identified few new cases of COPD. An active targeted approach to case finding including mailed screening questionnaires before spirometry is a cost-effective way to identify undiagnosed patients and has the potential to improve their health.

Economic AffairsVolume 36, Issue 3 p. 396-398 Book Review Labor Supply and Taxation by Richard Blundell; edited by Andreas Piechl and Klaus Zimmerman as part of the IZA Prize in Labor Economics Series. Oxford University Press (2016), 488 pp. ISBN: 978-0198749806 (hb, £55.00). W. S. Siebert, Corresponding Author W. S. Siebert w.s.siebert@bham.ac.uk University of Birmingham Business SchoolSearch for more papers by this author W. S. Siebert, Corresponding Author W. S. Siebert w.s.siebert@bham.ac.uk University of Birmingham Business SchoolSearch for more papers by this author First published: 21 October 2016 https://doi.org/10.1111/ecaf.12199Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume36, Issue3October 2016Pages 396-398 RelatedInformation

Chronic obstructive pulmonary disease (COPD) affects 5–10% of people worldwide, 1 is rising in prevalence 2 and is the third most common cause of death. 3 The annual burden of COPD regarding healthcare (mainly exacerbations resulting in emergency admissions) and societal (predominantly lost productivity) costs was estimated to be around $49.9 billion in the USA (2010 prices 4 ) and €48.4 billion in the EU (2011 prices 5 ). A substantial proportion of those with COPD are of working age, but there is some evidence that they have poorer employment history, 6 higher rate of sickness absence 7 and poorer work performance (presenteeism) 8 compared with the general population.