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Tourism consumption as a typical representative of service consumption, has strong comprehensiveness and driving force, continuously expanding new consumption upgrade space. In the context of the digital economy, the development of the mobile internet has opened up new opportunities for the tourism industry acting as an important factor influencing the consumer behaviour of the residents. Based on 9007 resident survey data from the China General Social Survey (CGSS) in 2017, this paper explores the relationship between Internet use, access to information and residents' travel consumption behavior by means of probit model and mediating effect model. First, according to the findings, Internet use has a positive impact on residents' travel consumption behavior, increasing residents' tourism expenditure. Second, the mechanism suggests that access to information plays a partially mediating role between Internet use and travel consumption behavior. Third, further analysis revealed that, for the retired population, the more frequently they use the Internet, the more likely they are to spend on travel. Compared to those with lower incomes, those with higher incomes will spend less on travel after retirement. With this in mind, in order to promote residents' tourism consumption, speed and fee reduction should be continuously promoted, urban and rural information infrastructure should be strengthened, and accessibility of tourism information for residents should be improved. At the same time, there is a need to innovate the way tourism products are promoted, improve the types of tourism products and launch diversified tourism products., Competing Interests: NO authors have competing interests Enter: The authors have declared that no competing interests exist., (Copyright: © 2024 Lei, Yang. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Car-sharing is a travel mode that can serve as an alternative to private cars, helping to reduce urban pollution. However, currently, there is a low willingness among travelers to use car-sharing, which is reflected in both low market penetration and user frequency. Therefore, it is essential for the government to encourage the use of car-sharing by providing subsidies. To better encourage the usage of car-sharing, this paper applies a two-fold evolutionary game model involving travelers and the government to explore the impact of subsidies on travelers' choices, and the factors that could affect the subsidies' efficiency. A simulation, using data from Beijing, was conducted to determine the implications of subsidy policies. The results show that a mileage-based subsidy and a fixed subsidy are applicable to travel of high and low mileages respectively, and under both subsidy modes, subsidies for trips with short duration or short pick-up and return time are more effective. Furthermore, we find that the efficiency of subsidies increases as the scale of car-sharing users, demand elasticity, or total number of travelers increases. Additionally, the subsidy levels should be lower than the environmental benefits of car-sharing but higher than the difference in travel costs between private cars and car-sharing. Future work will involve other game players such as car-sharing operators in order to draw deeper conclusions, and will involve the collection of data from more countries and cities to develop the robustness of the conclusions., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To quantify differences in hospital-associated costs, and accompanying travel costs and productivity losses, before and after withdrawing TNF-α inhibitors (TNFi) in JIA patients., Methods: This was a retrospective analysis of prospectively collected data from electronic medical records of paediatric JIA patients treated with TNFi, which were immediately discontinued, spaced (increased treatment interval) or tapered (reduced subsequent doses). Costs of hospital-associated resource use (consultations, medication, radiology procedures, laboratory testing, procedures under general anaesthesia, hospitalization) and associated travel costs and productivity losses were quantified during clinically inactive disease until TNFi withdrawal (pre-withdrawal period) and compared with costs during the first and second year after withdrawal initiation (first and second year post-withdrawal)., Results: Fifty-six patients were included of whom 26 immediately discontinued TNFi, 30 spaced and zero tapered. Mean annual costs were €9165/patient on active treatment (pre-withdrawal) and decreased significantly to €5063/patient (-44.8%) and €6569/patient (-28.3%) in the first and second year post-withdrawal, respectively (P < 0.05). Of these total annual costs, travel costs plus productivity losses were €834/patient, €1180/patient, and €1320/patient in the three periods respectively. Medication comprised 80.7%, 61.5% and 72.4% of total annual costs in the pre-withdrawal, first and second year post-withdrawal period, respectively., Conclusion: In the first two years after initiating withdrawal, the total annual costs were decreased compared with the pre-withdrawal period. However, cost reductions were lower in the second year compared with the first year post-withdrawal, primarily due to restarting or intensifying biologics. To support biologic withdrawal decisions, future research should assess the full long-term societal cost impacts, and include all biologics., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Purpose: Patients who undergo growth-friendly (GF) treatment for early-onset scoliosis (EOS) undergo multiple clinical and surgical encounters. We sought to quantify the associated temporal and travel burden and estimate subsequent cost., Methods: Four centers in an international study group combined data on EOS patients who underwent surgical GF treatment from 2006 to 2021. Data collected included demographics, scoliosis etiology, GF implant, encounter type, and driving distance. We applied 2022 IRS and BLS data or $0.625/mile and $208.2/day off work to calculate a relative financial burden., Results: A total of 300 patients were analyzed (55% female). Etiologies were: congenital (33.3%), idiopathic (18.7%), neuromuscular (30.7%), and syndromic (17.3%). The average age at the index procedure was 5.5 years. For the 300 patients, 5899 encounters were recorded (average 18 encounters/patient). Aggregate encounter types were 2521 clinical office encounters (43%), 2045 surgical lengthening encounters (35%), 1157 magnetic lengthening encounters (20%), 149 spinal fusions (3%), and 27 spinal fusion revisions (0.5%). When comparing patients by scoliosis etiology or by GF implant type, no significant differences were noted in the total number of encounters or average travel distance. Patients traveled a median round trip distance of 158 miles/encounter between their homes and treating institutions (range 2.4-5654 miles), with a cumulative median distance of 2651 miles for the entirety of their treatment (range 29-90,552 miles), at an estimated median cost of $1656.63. The mean number of days off work was 18 (range 3-75), with an associated loss of $3643.50 in income., Conclusion: Patients with EOS averaged 18 encounters for GF surgical treatment. These patients and their families traveled a median distance of 158 miles/encounter, with an estimated combined mileage and loss of income of $5300., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Enhancing access to healthcare remains a formidable challenge in rural regions of low- and lower-middle-income countries. Amid evolving healthcare challenges, telerheumatology provides opportunities to bridge gaps and expand access to rheumatology care, particularly in remote areas. We describe a pilot telerheumatology program and its cost-, time-, and travel-saving potential in a remote rural setting in northern Pakistan. The telerheumatology program commenced at the Pakistan Institute of Medical Sciences Islamabad, providing services through video consultations to a basic health unit in the Gilgit-Baltistan region. Patients visiting from the Gilgit-Baltistan region willing to participate were recruited in the program. Demographics and logistical metrics were recorded in a dedicated registry. A total of 533 consultations were carried out from April 2022 to April 2023. The majority of the patients were female (318/533, 59.7%). The median age of patients was 50 ± 15.7 years. The average wait time for consultation was 20 ± 13 min. The average travel time to reach telecentre was 59 ± 53 min. The average travel cost to reach telecentre was 379 ± 780 PKR (1.85 ± 3.81 USD). The average duration of consultation was 15 ± 5 min. The most common diagnosis for consultation was knee osteoarthritis (237, 44.5%), chronic low back pain (118, 22.1%), and rheumatoid arthritis (42, 7.9%). On average, patients saved 787 ± 29 km of distance, 15 ± 1 h of traveling, and 6702 ± 535 PKR (33 ± 3 USD) that would have been required to travel to our tertiary care hospital. Telerheumatology substantially reduced travel time, distance, and cost for patients. It has the potential to deliver outpatient rheumatology consultation in an economically efficient manner, effectively breaking geographical barriers and expanding access to essential services for patients in remote areas., (© 2024. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

The study examined the determinants that affect tourism receipts in Thailand. To this end, quarterly data from eight main provinces of Thailand from the period 2015-2019 were used and constituted a repeated measures design. Accordingly, a generalized linear mixed model was applied for developing two different random intercept models by treating 1) province, and 2) a combination of province and calendar quarter as cluster-specific effects. It was found that determinants that increased tourism receipts were the number of visitors, the average cost per day, the length of stay of visitors, the presence of low-cost airlines, and a relatively low offence rate. Moreover, an increase in the number of visitors in the fourth quarter produced a higher amount of additional receipts as compared to a similar increase in the first quarter. Specifically, for Thailand attracting high-spending tourists and extending tourist visas for more than 30 days is recommended. Beyond Thailand, uncovering interaction effects as described above may help tourism agencies to focus their limited resources on the determinants that matter., Competing Interests: The authors declare that they have no conflict of interest., (Copyright: © 2024 Khemthong et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

To stimulate the regional tourism economy, local governments often seek to increase the number of 5A-rated tourist attractions. However, there have been few analyses examining the economic benefits and influence mechanisms of 5A-rated attraction selection. Using the quality signaling theory and data from 282 prefecture-level cities spanning 2002 to 2019, this study examines the impact of 5A-rated attraction selection on the local tourism economy with the difference-in-differences method. This study's results demonstrate that the selection of 5A-rated attractions significantly contributes to the growth of the local tourism economy. The robustness test results confirm the validity of this conclusion. A mechanism analysis reveals that 5A-rated attractions positively impact the tourism economy via investments in infrastructure, popularization of informatization, and increased external openness. Furthermore, the study suggests that the effect of 5A-rated attractions is more pronounced in economically underdeveloped regions and low-level cities. The results of this study contribute to the sustainable development of China's tourism economy and may provide guidance for the establishment of tourism evaluation systems in other international locations in order to foster economic growth., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Xu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Community-based mask wearing has been shown to reduce the transmission of SARS-CoV-2. However, few studies have conducted an economic evaluation of mask mandates, specifically in public transportation settings. This study evaluated the cost-effectiveness of implementing mask mandates for subway passengers in the United States by evaluating its potential to reduce COVID-19 transmission during subway travel., Materials and Methods: We assessed the health impacts and costs of subway mask mandates compared to mask recommendations based on the number of infections that would occur during subway travel in the U.S. Using a combined box and Wells-Riley infection model, we estimated monthly infections, hospitalizations, and deaths averted under a mask mandate scenario as compared to a mask recommendation scenario. The analysis included costs of implementing mask mandates and COVID-19 treatment from a limited societal perspective. The cost-effectiveness (net cost per averted death) of mandates was estimated for three different periods based on dominant SARS-CoV-2 variants: Alpha, Beta, and Gamma (November 2020 to February 2021); Delta (July to October 2021); and early Omicron (January to March 2022)., Results: Compared with mask recommendations only, mask mandates were cost-effective across all periods, with costs per averted death less than a threshold of $11.4 million (ranging from cost-saving to $3 million per averted death). Additionally, mask mandates were more cost-effective during the early Omicron period than the other two periods and were cost saving in January 2022. Our findings showed that mandates remained cost-effective when accounting for uncertainties in input parameters (e.g., even if mandates only resulted in small increases in mask usage by subway ridership)., Conclusions: The findings highlight the economic value of mask mandates on subways, particularly during high virus transmissibility periods, during the COVID-19 pandemic. This study may inform stakeholders on mask mandate decisions during future outbreaks of novel viral respiratory diseases., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

In the post-epidemic era, the restart of China's inbound tourism is imminent. However, there are gaps in our current understanding of how distance perception dynamically affects inbound tourism in China. In order to understand the past patterns of inbound tourism in China, we mapped the data of 61 countries of origin from 2004 to 2018 into a dynamic expanding gravity model to understand the effects of cultural distance, institutional distance, geographical distance, and economic distance on inbound tourism in China and revealed the dynamic interaction mechanism of non-economic distance perception on inbound tourism in China. Our research results show that cultural distance has a positive impact on China's inbound tourism, while institutional distance has a negative impact. The significant finding is that the dynamic interaction of the above two kinds of perceived distance can still have a positive impact on China's inbound tourism. Its practical significance is that it can counteract the influence of institutional distance by strengthening the cultural distance. Generally speaking, geographical distance and institutional distance restrict China's inbound tourism flow, while cultural distance, economic distance, and interactive perceptual distance promote China's inbound tourism flow., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

An in-depth study of the mechanisms governing the generation, evolution, and regulation of differences in tourism economics holds significant value for the rational utilization of tourism resources and the promotion of synergistic tourism economic development. This study utilizes mathematical statistical analysis and GIS spatial analysis to construct a single indicator measure and a comprehensive indicator measure to analyze tourism-related data in the research area from 2004 to 2019. The main factors influencing the spatial and temporal differences in the tourism economy are analyzed using two methods, namely, multiple linear regression and geodetector. The temporal evolution, overall differences and differences within each city group fluctuate downwards, while the differences between groups fluctuate upwards. Domestic tourism economic differences contribute to over 90% of the overall tourism economic differences. Spatial divergence, the proportion of the tourism economy accounted for by spatial differences is obvious, the comprehensive level of the tourism economy can be divided into five levels. The dominant factors in the formation of the pattern of spatial and temporal differences in the tourism economy are the conditions of tourism resources based on class-A tourist attractions and the level of tourism industry and services based on star hotels and travel agencies. This study addresses the regional imbalance of tourism economic development in city clusters and with the intent of promoting balanced and high-quality development of regional tourism economies., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Telemedicine, a method of healthcare service delivery bridging geographic distances between patients and providers, has gained prominence. This modality is particularly advantageous for outpatient consultations, addressing inherent barriers of travel time and cost., Objective: We aim to describe economical outcomes towards the implementation of a multidisciplinary telemedicine service in a high-complexity hospital in Latin America, from the perspective of patients., Design: A cross-sectional study was conducted, analysing the institutional data obtained over a period of 9 months, between April 2020 and December 2020., Setting: A high-complexity teaching hospital located in Cali, Colombia., Participants: Individuals who received care via telemedicine. The population was categorised into three groups based on their place of residence: Cali, Valle del Cauca excluding Cali and Outside of Valle del Cauca., Outcome Measures: Travel distance, time, fuel and public round-trip cost savings, and potential loss of productivity were estimated from the patient's perspective., Results: A total of 62 258 teleconsultations were analysed. Telemedicine led to a total distance savings of 4 514 903 km, and 132 886 hours. The estimated cost savings were US$680 822 for private transportation and US$1 087 821 for public transportation. Patients in the Outside of Valle del Cauca group experienced an estimated average time savings of 21.2 hours, translating to an average fuel savings of US$149.02 or an average savings of US$156.62 in public transportation costs. Areas with exclusive air access achieved a mean cost savings of US$362.9 per teleconsultation, specifically related to transportation costs., Conclusion: Telemedicine emerges as a powerful tool for achieving substantial travel savings for patients, especially in regions confronting geographical and socioeconomic obstacles. These findings underscore the potential of telemedicine to bridge healthcare accessibility gaps in low-income and middle-income countries, calling for further investment and expansion of telemedicine services in such areas., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Improving travel time prediction for public transit effectively enhances service reliability, optimizes travel structure, and alleviates traffic problems. Its greater time-variance and uncertainty make predictions for short travel times (≤35min) more subject to be influenced by random factors. It requires higher precision and is more complicated than long-term predictions. Effectively extracting and mining real-time, accurate, reliable, and low-cost multi-source data such as GPS, AFC, and IC can provide data support for travel time prediction. Kalman filter model has high accuracy in one-step prediction and can be used to calculate a large amount of data. This paper adopts the Kalman filter as a travel time prediction model for a single bus based on single-line detection: including the travel time prediction model of route (RTM) and the stop dwell time prediction model (DTM); the evaluation criteria and indexes of the models are given. The error analysis of the prediction results is carried out based on AVL data by case study. Results show that under the precondition of multi-source data, the public transportation prediction model can meet the accuracy requirement for travel time prediction and the prediction effect of the whole route is superior to that of the route segment between stops., Competing Interests: The authors have declared that no competing interests exist.

As a typical representative of tourism resources, the spatial distribution of A-level scenic spots has a profound impact on the layout of tourism industry. Scenic spot accessibility is also important for the development of tourism. However, the relationship of regional accessibility and spatial distribution of A-level scenic spots are understudied. The study used quantitative geography and geographic information system spatial analysis methods and analyzed the evolution of spatial distribution and regional accessibility of A-level scenic spots in Guangdong Province from 2001 to 2020. The results present the following: 1. Agglomeration distribution is the main distribution type of A-level scenic spots in Guangdong Province, and the spatial distribution is unbalanced. 2. From 2001 to 2020, the spatial distribution of A-level scenic spots in 21 prefecture-level cities of Guangdong Province has gradually developed from "wide gap" to "relatively reasonable." 3. Distribution density of A-level scenic spots in Guangdong Province has evolved into the main core area of high density. 4. Center of the gravity of A-level scenic spots in Guangdong Province developed from east to west during 2002-2007 and moved to the east after 2007. 5. Accessibility between A-level scenic spots and tourist source areas in Guangdong Province is good, with an evident aggregation phenomenon. This study reveals the spatial distribution evolution law and regional accessibility of A-level scenic spots, which is conducive to healthy, sustainable, and stable development of tourism in Guangdong Province., Competing Interests: The authors have declared that no competing interests exist.

Exploring the spatial pattern of tourism resources and tourism economy is vital to improve the utilization efficiency of tourism resources and promote sustainable tourism development. This research investigated the quantity and types of tourism resources and analyzed the spatial patterns of tourism resources on Hainan Island from the perspectives of spatial variation and spatial association. The spatial and temporal pattern of the number of tourists and tourism revenue during 2010-2019 were further analyzed. The influencing factors of tourism development were explored based on the geographic detector. The results showed that 10425 tourism resources exist on Hainan Island, and the type of buildings and facilities had the largest number of tourism resources. The geological landscape, astronomical phenomena and meteorological landscapes, buildings and facilities, ruins and remains, tourism commodities, and human activities showed significant spatial agglomeration. Domestic tourism was far more developed than inbound tourism in terms of the number of tourists and tourism revenue. However, the spatial difference of tourism resources and tourism economy was apparent on Hainan Island. Factor analysis showed that the quantity of hotels, the proportion of tertiary industry in the GDP, and the regional population were the most influential factors for the distribution of tourism resources, while the density of the road network, the quantity of hotels, the per capita GDP, the proportion of tertiary industry in GDP, the regional population, and the quantity of tourism resources showed obvious influences on the tourism economy of Hainan Island. Interactions of the factors mainly fell into three types: synergistic increases, single factor weakening, and nonlinear weakening. It is suggested that the local government should fully exploit diversity types of tourism resources on Hainan Island to attract more tourists and improve the tourism revenue; improving the inbound tourism, and to strengthen the construction of road network on Hainan Island., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To explore strategies rural Australians use to cope with the financial consequences of their cancer diagnosis and how that impacts on their lives., Methods: Twenty adult cancer patients/survivors residing in regional-remote areas of Australia were purposively sampled and participated in audio-recorded, semi-structured interviews. When data saturation was reached, thematic analysis was employed to analyse the data., Results: Participants were 20-78 years (M=60), 70% female, 35% were undergoing treatment and the remaining 65% had finished treatment within the past 5 years. Three themes provide context to rural financial toxicity-related experiences (travelling to access cancer treatment away from home is expensive, being single or lacking family support exacerbates the financial strain, and no choice other than to adopt cost-saving strategies if wanted to access treatment). Strategies commonly employed to minimise financial toxicity include: accessing travel-related support, changes to lifestyle (buying cheaper food, saving on utilities), accessing savings and retirement funds, missing holidays and social activities, reduced car use and not taking a companion to cancer-related appointments at metropolitan treatment areas. Although cost-saving strategies can effectively increase the ability of rural people to cover cancer treatment-related and other costs, most have broader negative psychological, social and practical consequences for them and their families., Conclusions: Increasing rural cancer patients' and survivors' awareness of various cost-saving strategies and their impact (positive and negative) may decrease their risk of experiencing financial toxicity and unexpected unintended consequences of adopting cost-saving measures., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

While there has been much speculation on how the pandemic has affected work location patterns and home location choices, there is sparse evidence regarding the impacts that COVID-19 has had on amenity visits in American cities, which typically constitute over half of all urban trips. Using aggregate app-based GPS positioning data from smartphone users, this study traces the changes in amenity visits in Somerville, MA from January 2019 to December 2020, describing how visits to particular types of amenities have changed as a result of business closures during the public health emergency. Has the pandemic fundamentally shifted amenity-oriented travel behavior or is consumer behavior returning to pre-pandemic trends? To address this question, we calibrate discrete choice models that are suited to Census block-group level analysis for each of the 24 months in a two-year period, and use them to analyze how visitors' behavioral responses to various attributes of amenity clusters have shifted during different phases of the pandemic. Our findings suggest that in the first few months of the pandemic, amenity-visiting preferences significantly diverged from expected patterns. Even though overall trip volumes remained far below normal levels throughout the remainder of the year, preferences towards specific cluster attributes mostly returned to expected levels by September 2020. We also construct two scenarios to explore the implications of another shutdown and a full reopening, based on November 2020 consumer behavior. While government restrictions have played an important role in reducing visits to amenity clusters, our results imply that cautionary consumer behavior has played an important role as well, suggesting a likely long and slow path to economic recovery. By drawing on mobile phone location data and behavioral modeling, this paper offers timely insights to help decision-makers understand how this unprecedented health emergency is affecting amenity-related trips and where the greatest needs for intervention and support may exist., Competing Interests: The authors have declared that no competing interests exist.

This study aims to explore various barriers in accessing outpatient care among the participants from different age groups and to identify determinants associated with physician visits. The study had adopted Andersen's Behavioral Model (ABM) of Health Services Use. A cross-sectional study design was adopted to collect data from 417 participants through a questionnaire survey. Poisson regression models were used to explore determinants for explaining the differences in outpatient care use. The regression results revealed that divergent relationships existed among age groups. Children and elderly participants tended to decrease the probability of seeking care. Elderly participants confronted more difficulties in access and were dependent on family members. Despite free care provisions, participants visited and spent their out-of-pocket expenditure mostly at non-universal health coverage (non-UHC) facilities. Convenience and the availability of specialist physicians led the higher-income parents to seek care of their children at non-UHC facilities. Highly educated people of working age preferred more self-care or institutionalized care to save time. Children up to the primary level of education were more likely to visit a doctor. We concluded that investments in education or well-informed health services provision would improve health care utilization. Findings of Andersen's Behavioral Model variables suggested that improvements in the quality of services, medical professional skills, and efficient resource allocation may induce seeking care at UHC facilities. Consequently, it will reduce the number of referred cases, caseloads at tertiary care units, and visits to non-UHC facilities at longer distances.

Aims: Heart failure with reduced ejection fraction (HFrEF) is associated with poor outcomes. While several medications are beneficial, achieving optimal guideline-directed medical therapy (GDMT) is challenging. COVID-19 created a need to explore new ways to deliver care., Methods: Fifty consecutive patients were taught to identify fluid congestion and monitor their vital signs using BP monitors and electronic scales with NP-led telephone support. Quantitative data were collected and a patient experience interview was performed., Results: The majority (76%) of the cohort (male, 76%; Māori/Pacific, 58%) had a new diagnosis of HFrEF, with 90% having severe left ventricular (LV) dysfunction. There were 216 contacts (129 (60%) by telephone), which eliminated travelling, (time saved, 2.12 hours per patient), petrol costs ($58.17 per patient), traffic pollution (607 Kg of CO2) and time off work. Most (75%) received contact within two weeks and 75% were optimally titrated within two months. Improvements in systolic BP (SBP) (124mmHg to 116mmHg), pulse (78 bpm to 70 bpm) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (292 to 65) were identified. Of the 43 patients who had a follow-up transthoracic echocardiogram (TTE), 33 (77%) showed important improvement in left ventricular ejection fraction (LVEF)., Conclusions: Patients found the process acceptable and experienced rapid titration with less need for clinic review with titration rates comparable with most real-world reports., Competing Interests: Dr Lund reports other from Amgen inc and personal fees from Novartis outside the submitted work.

Objective: To investigate the association between participation in government subsidies for domestic travel (subsidise up to 50% of all travel expenses) introduced nationally in Japan on 22 July 2020 and the incidence of symptoms indicative of COVID-19 infections., Design: Cross-sectional analysis of nationally representative survey data., Setting: Internet survey conducted between 25 August and 30 September 2020 in Japan. Sampling weights were used to calculate national estimates., Participants: 25 482 survey respondents (50.3% (12 809) women; mean (SD) age, 48.8 (17.4) years)., Main Outcome Measures: Incidence rate of five symptoms indicative of the COVID-19 infection (high fever, sore throat, cough, headache, and smell and taste disorder) within the past month of the survey, after adjustment for characteristics of individuals and prefecture fixed effects (effectively comparing individuals living in the same prefecture)., Results: At the time of the survey, 3289 (12.9%) participated in the subsidy programme. After adjusting for potential confounders, we found that participants in the subsidy programme exhibited higher incidence of high fever (adjusted rate, 4.7% for participants vs 3.7% for non-participants; adjusted OR (aOR) 1.83; 95% CI 1.34 to 2.48; p<0.001), sore throat (19.8% vs 11.3%; aOR 2.09; 95% CI 1.37 to 3.19; p=0.002), cough (19.0% vs 11.3%; aOR 1.96; 95% CI 1.26 to 3.01; p=0.008), headache (29.2% vs 25.5%; aOR 1.24; 95% CI 1.08 to 1.44; p=0.006) and smell and taste disorder (2.6% vs 1.8%; aOR 1.98; 95% CI 1.15 to 3.40; p=0.01) compared with non-participants. These findings remained qualitatively unaffected by additional adjustment for the use of 17 preventative measures (eg, social distancing, wearing masks and handwashing) and fear against the COVID-19 infection., Conclusions: The participation of the government subsidy programme for domestic travel was associated with a higher probability of exhibiting symptoms indicative of the COVID-19 infection., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Based on the data of 812 small towns in Chongqing, China, this paper attempts to conduct an empirical analysis on whether tourist towns with excellent natural environment, policy advantage, and market preference are more ecologically livable than ordinary small towns. It is found that as a whole, tourist towns are indeed more ecologically livable than ordinary small towns. Also, from the perspective of grading, both the national and provincial tourist towns have the advantage of ecological livability, but the advantage of national ones is more prominent. Furthermore, the ecological livability of tourist towns is affected by location advantage and policy inclination. The implications of the results are discussed following the outcomes of the coronavirus disease 2019 outbreak. The suggestions beyond the coronavirus disease 2019 are also provided., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Su and Zhou.)

The emergence and development of car-sharing has not only satisfied people's diverse travel needs, but also brought new solutions for improving urban traffic conditions and achieving low-carbon and green sustainable development. In recent years, car-sharing has had competition with other ways of getting around, as the acceptance of car-sharing has grown, notably taxis. Therefore, it is particularly important to explore car-sharing travel costs advantages from the perspective of consumers and discover the competitive and complementary spaces between car-sharing and other modes. Therefore, taking Beijing as an example, this paper uses GPS trajectory data based on car-sharing orders to design a travel cost framework of car-sharing and taxis. We calculate and compare the travel cost difference between these two modes under different travel characteristics. The results indicate that car-sharing is a more economical way for consumers to travel for short or medium lengths of time, while people are more inclined to take taxis for distances of long duration. Compared with on workdays, at the weekend, the cost advantage of car-sharing is greater for long-distance trips. Moreover, the cost advantage of car-sharing increases gradually with the increase in travel distance. In addition, the travel costs of car-sharing and taxis are also affected by peak and off-peak traffic periods. Compared with off-peak periods, it is more cost-effective for travelers to take taxis during peak traffic periods for various travel distances. From the perspective of the travel cost, it is of great theoretical significance to discuss the substitution (market competition) and complementary relationship (market cooperation) between car-sharing and taxis in a detailed and systematic way. It provides methods and ideas for the comparative cost calculation of car-sharing and other travel modes. This paper also provides enlightenment and guidance for the development of car-sharing. Enterprises should implement differentiated pricing, designing different charging methods for different traffic periods, travel miles, and rental times, and set up additional stations in the surrounding areas of the city. Relevant government departments should also strictly manage the market access of car-sharing, and add or open car-sharing parking lots in centralized areas and for specific periods.

Introduction: Residents of Northern Ontario have limited access to local psychiatric care. To address this, three program models exist: (1) telepsychiatry; (2) psychiatrists traveling to underserved areas; and (3) reimbursing patients for travel to a psychiatrist. Evidence shows that telepsychiatry has comparable outcomes to in-person consultations. The objective of this study was to determine the cost difference between programs., Methods: A cost-minimization analysis estimating cost per visit from a public healthcare payer economic costing perspective was conducted. Data on fixed and variable costs were obtained. Evidence-based assumptions were made where relevant. Base-case scenarios and a break-even analysis were completed, as well as deterministic and probabilistic sensitivity analyses, to explore the effects of parameter variability on program costs., Results: Costs per visit were lowest in telepsychiatry (CAD$360) followed by traveling physicians (CAD$558) and patient reimbursement (CAD$620). Among the 100,000 Monte Carlo simulations, results showed telepsychiatry was the least costly program in 71.2% of the simulations, while the reimbursement and outreach programs were least costly in 15.1% and 13.7% of simulations, respectively. The break-even analysis found telepsychiatry was the least costly program after an annual patient visit threshold of approximately 76 visits (compared to traveling psychiatrists) and 126 visits (compared to reimbursed patients)., Discussion: Our analyses support telepsychiatry as the least costly program. These results have important implications for program planning, including the prioritization of telepsychiatry, increased integration of telepsychiatry with other modalities of outreach psychiatry, and limiting use of the patient remuneration program to where medically necessary, to reduce overall cost.

Gahar Lake is located within Oshtorankooh Protected Area (east of Lorestan Province in Iran), which has extensive potentials for the development of the tourism industry. The aim of the present research was to determine the economic value of the Gohar Lake resort using the zonal travel cost method. Therefore, at first, 380 questionnaires were distributed among the tourists by the simple random sampling method based on appropriate spatiotemporal distribution during the visiting seasons. The questionnaire items were categorized as economic, social, and miscellaneous parts. The calculation results revealed a value of USD 84.538 per visitor and a value of USD 1,986,657.163 per year, indicating the high value and importance of the region. The analysis showed that socio-economic variables have a significant role in the use or non-use of the resort. The obtained R2 coefficient was 0.82, indicating that around 82% of the changes in the number of visitors can be justified by the variables introduced in the model. The results also revealed the need to pay more attention to this region and formulate a tourism development plan., Competing Interests: The authors have declared that no competing interests exist.

The paper explores the travelling behaviour of migrant groups using Facebook audience estimates. Reduced geographical mobility is associated with increased risk of social exclusion and reduced socio-economic and psychological well-being. Facebook audience estimates are timely, openly available and cover most of the countries in the world. Facebook classifies its users based on multiple attributes such as the country of their previous residence, and whether they are frequent travellers. Using these data, we modelled the travelling behaviour of Facebook users grouped by countries of previous and current residence, gender and age. We found strong indications that the frequency of travelling is lower for Facebook users migrating from low-income countries and for women migrating from or living in countries with high gender inequality. Such mobility inequalities impede the smooth integration of migrants from low-income countries to new destinations and their well-being. Moreover, the reduced mobility of women who have lived or currently live in countries with conservative gender norms capture another aspect of the integration which is referring to socio-cultural norms and gender inequality. However, to provide more solid evidence on whether our findings are also valid for the general population, collaboration with Facebook is required to better understand how the data is being produced and pre-processed., Competing Interests: The authors have declared that no competing interests exist.

Background: Neuroblastoma (NB) is notorious in childhood cancer because of its high incidence and poor prognosis. The Children's Oncology Group reported that the 3-year OS in the high-risk (HR) group is 50%, and the HR-NB with bone marrow metastasis in our center is 43.1%. Thousands of families in China suffer from the cost of NB, but the true costs of therapy are unknown; to date, no study has ever performed a detailed therapy costs analysis for NB. The objective of this study was to assess the economic burden of NB treatment in children to the family, to ultimately reduce related expenses for patients and promote the establishment of NB management policy., Materials and Methods: Data in this cross-sectional study were collected via questionnaires completed by parents at the outpatient clinic and was verified via a computer system. Therapy costs of children with NB of differing risks were analyzed through descriptive statistics (1 CNY ≈ 0.1412 USD)., Results: Median direct medical costs of low risk (LR), middle risk (MR), and HR NB during treatment were 180.0 (120.0, 300.0), 200.0 (166.0, 300.0), and 650.0 (415.5, 850.0) thousand Chinese yuan (CNY), respectively. Direct non-medical costs including transportation, food, and accommodation were 60.0 (37.0, 100.0), 80.0 (60.0, 120.0), and 100.0 (80.0, 157.5) thousand CNY in the LR, MR, and HR groups, respectively. Additionally, parents accrued work absences to attend treatment, and lost a total of 100.0 (50.0, 150.0) thousand CNY in indirect costs., Limitations: Families whose children had relapsed or died were excluded from this analysis and therefore limited the conclusions drawn. Parents were asked to recall costs since initial diagnosis (1-6 years in the past), but this extended time period may have introduced recall bias., Conclusions: Direct non-medical and indirect costs play an important role in the total treatment costs of NB. Children with NB treated in local hospitals and followed up in hospital specialized in childhood oncology may save many unnecessary expenses. China's healthcare system should establish mechanisms and provide financial support for children with NB.

Many healthcare workers are "on the road" traveling to and from fixed sites (eg, patients'/clients' homes). Qualitative interviews with nine Nova Scotian managers of mobile healthcare workers explored the conditions of workers' travel. Findings highlight challenges such as changing schedules, as well as positive features including flexibility over the travel schedule. Some managers noted worker mobility-related responsibilities including having to decide if travel is too dangerous due to poor weather. A few managers suggested that workers may not receive adequate economic reimbursement for travel costs (eg, wear and tear on vehicle), and in some instances, workers need to use a benefit (eg, vacation day) or are not paid if they cannot drive due to poor weather. Reported organizational supports for workers' travel were variable. This research indicates a need for supportive mobility-related policies and practices across all organizations, including policies that cover economic costs related to travel for all workers.

In response to the coronavirus disease 2019 (COVID-19) pandemic, several national governments have applied lockdown restrictions to reduce the infection rate. Here we perform a massive analysis on near-real-time Italian mobility data provided by Facebook to investigate how lockdown strategies affect economic conditions of individuals and local governments. We model the change in mobility as an exogenous shock similar to a natural disaster. We identify two ways through which mobility restrictions affect Italian citizens. First, we find that the impact of lockdown is stronger in municipalities with higher fiscal capacity. Second, we find evidence of a segregation effect, since mobility contraction is stronger in municipalities in which inequality is higher and for those where individuals have lower income per capita. Our results highlight both the social costs of lockdown and a challenge of unprecedented intensity: On the one hand, the crisis is inducing a sharp reduction of fiscal revenues for both national and local governments; on the other hand, a significant fiscal effort is needed to sustain the most fragile individuals and to mitigate the increase in poverty and inequality induced by the lockdown., Competing Interests: The authors declare no competing interest., (Copyright © 2020 the Author(s). Published by PNAS.)

The issue of tourism impacts is one that has plagued the tourism industry. This study develops a quantitative approach using hierarchical variance analysis, which deals with the exploration of the relevant factors and the confirmation of their significant contribution to analyze the residents' perception of tourism impacts. Hierarchical variance analysis includes three mathematical procedures: Cronbach's alpha tests, the exploration of relevant factors, and a hierarchical factor confirmation. Data are collected using a structured questionnaire completed by 452 surveyed residents living in Ly Son Island, Vietnam. The significant effects of socio-demographic variables on the overall impact assessment are observed. The bilateral and simultaneous relationships are analyzed using a one-factor ANOVA. A two-factor ANOVA shows the significant contribution of each socio-demographic variable on the economic, socio-cultural, and environmental impacts. Interaction between factors such as "Education level", "Type of work", etc. are hierarchically confirmed. The findings allow a better understanding of the residents' perception of the effects of tourism on society, the economy, and the environment. This provides a scientific basis to help define problems and promote legal regulations for community participation in tourism planning in a small island destination.

Background: Children's habitual physical activity, including active travel and catching public transit (walking and cycling to and from destinations), and independent mobility (mobility without an adult) have decreased. Public transit trips are physically active and can provide access to hobbies independent of parents, but there is no device-measured data about children's total physical activity time following the introduction of free public transit. Our aim is to compare physical activity and independent mobility between children living in two Finnish towns, one with a recently introduced free public transit system, and the other without free public transit., Methods: The city of Mikkeli has provided free public transit for all comprehensive school children since 2017. Various districts from Mikkeli, and the reference town of Kouvola (towns from South-Eastern Finland with a comparative population size and geographical structure), are selected based on their accessibility and the availability of public transit services. Samples of 10-12-year-old children will be recruited through primary schools. We will compare moderate-to-vigorous physical activity time, sitting time (a thigh-worn Fibion® device) and independent mobility (a participatory mapping method, PPGIS) of children: 1) who live in towns with and without free public transit, 2) who live and go to school in districts with high vs. low perceived and objective access to free public transit, and 3) who report using vs. not using free public transit. In addition, ethnography will be used to get insights on the social and cultural effects of the free public transit on children's and parent's everyday life., Discussion: There is a need for scalable solutions that can increase children's physical activity independent of their socioeconomic background or place of residence. This project will give information on how a political action to provide free public transit for children is associated with their total physical activity time and independent mobility patterns, therefore providing highly relevant information for political decision-making and for promoting independent physical activity in children.

After the recession in Japan in the 1990s, Japanese art exhibitions began to appear. The purpose of these exhibitions was to revitalize these areas through the presentation of art (attracting visitors and tourists). Correspondingly, this study explores the significance of exhibition-driven tourism in Japan. The Echigo-Tsumari Art Triennial (ETAT) was used as a case to study how exhibition-driven tourism has impacted sustainable tourism, economics, and the population. The current paper collected panel data from 1900 to 2018. These panel data were analyzed by descriptive statistics and a correlation analysis (a one-way ANOVA and a Pearson correlation analysis in SPSS26). The empirical analysis showed that the Echigo-Tsumari Art Triennial (exhibition-driven tourism) had positive impacts on sustainable tourism, economics, and the population; its correlations with Niigata were also clear. This study generated results that are valuable from both academic and industry perspectives (exhibition-driven tourism), as this field has not been extensively researched. The current paper also presents the theoretical and practical implications of the statistical results.

The Asia-Pacific region is known as a favorite destination for global medical travelers due to its medical expertise, innovative technology, safety, attractive tourism destination and cost advantage in the recent decade. This study contributes to propose an approach which effectively assesses performance of medical tourism industry based on considering the economic impact factors as well as provides a conceptual framework for the industry analysis. Grey system theory is utilized as a major analyzing approach. According to that, factors impact on the sustainable development of medical tourism in Asia-Pacific region could be identified. The performance of each destination in this region was simultaneously revealed. The results presented an overall perspective of the medical tourism industry in the scope of the Asia-Pacific region, and in Taiwan particularly. Data was collected on six major destinations including Singapore, Thailand, India, South Korea, Malaysia and Taiwan. The results proved that tourism sources and healthcare medical infrastructures play a crucial role in promoting the healthcare travel industry, while cost advantage and marketing effectiveness were less considered. In addition, performance analyse indicated that Thailand has a good performance and stands in the top ranking, followed by Malaysia, India, Singapore, South Korea and Taiwan, respectively. The revenue of Taiwan has increased slowly in the last six years, with a market worth approximately NT$20.5 billion, and the number of medical travelers is expected to increase to 777,523 by 2025. The findings of this study are expected to provide useful information for the medical tourism industry and related key players in strategic planning., Competing Interests: The authors declare no conflicts of interest.

Background: Hand surgeons can alleviate the burden associated with various congenital anomalies, burn sequelae, and trauma that debilitate individuals in low- and middle-income countries. Because few surgeons in these areas have the necessary resources to perform complex hand surgery, surgical trips provide essential surgical care. The authors aimed to determine the economic benefit of hand surgical trips to low- and middle-income countries to comprehensively determine the economic implications of hand surgery trips in low-resource settings., Methods: The authors collected data from two major global hand surgery organizations to analyze the economic benefit of hand surgery trips in low- and middle-income countries. The authors used both the human capital approach and the value of a statistical life-year approach to conduct this cost-benefit analysis. To demonstrate the economic gain, the authors subtracted the budgeted cost of each trip from the economic benefit., Results: The authors analyzed a total of 15 trips to low- and middle-income countries. The costs of the trips ranged from $3453 to $87,434 (average, $24,869). The total cost for all the surgical trips was $373,040. The authors calculated a net economic benefit of $3,576,845 using the human capital approach and $8,650,745 using the value of a statistical life-year approach., Conclusions: The authors found a substantial return on investment using both the human capital approach and the value of a statistical life-year approach. In addition, the authors found that trips emphasizing education had a net economic benefit. Cost-benefit analyses have substantial financial implications and will aid policy makers in developing cost-reduction strategies to promote surgery in low- and middle-income countries.

The world is currently in the throes of the COVID-19 pandemic which has halted the tourism sector and created an unprecedented global economic crisis. This paper will outline economics pertaining to COVID-19 lockdown, recovery and the inevitable competition that will occur between countries for tourists who will be scarcer and therefore more valuable. Countries are competing with a variety of incentives in order to lure visitors. However, persistent first waves that extend into July will put off tourists, further reducing tourism revenues and accelerate job losses and bankruptcies in affected countries. The example of Sweden's response to COVID-19 in this regard will be described. Countries that have COVID-19 relatively under control but experience second waves will also manifest negative tourism effects. Governments and public health must act in unison so as to exit lockdown as speedily and as safely as feasible, with COVID-19 rises that are as low and brief as possible in order to better compete in the tourism sector with other countries. Websites are already online comparing not only safety for travellers vis-à-vis COVID-19 but also the incentives offered by different countries in their attempts to woo tourists in this difficult market.

Living organ donors face direct costs when donating an organ, including transportation, lodging, meals, and lost wages. For those most in need, the National Living Donor Assistance Center (NLDAC) provides reimbursement to defray travel and subsistence costs associated with living donor evaluation, surgery, and follow-up. While this program currently supports 9% of all US living donors, there is tremendous variability in its utilization across US transplant centers, which may limit patient access to living donor transplantation. Based on feedback from the transplant community, NLDAC convened a Best Practices Workshop on August 2, 2018, in Arlington, VA, to identify strategies to optimize transplant program utilization of this valuable resource. Attendees included team members from transplant centers that are high NLDAC users; the NLDAC program team; and Advisory Group members. After a robust review of NLDAC data and engagement in group discussions, the workgroup identified concrete best practices for administrative and transplant center leadership involvement; for individuals filing NLDAC applications at transplant centers; and to improve patient education about potential financial barriers to living organ donation. Multiple opportunities were identified for intervention to increase transplant programs' NLDAC utilization and reduce financial burdens inhibiting expansion of living donor transplantation in the United States., (© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.)