The circular economy (CE) is heralded as reducing material use and emissions while providing more jobs and growth. We explored this narrative in a series of expert workshops, basing ourselves on theories, methods and findings from science fields such as global environmental input-output analysis, business modelling, industrial organisation, innovation sciences and transition studies. Our findings indicate that this dominant narrative suffers from at least three inconvenient truths. First, CE can lead to loss of GDP. Each doubling of product lifetimes will halve the related industrial production, while the required design changes may cost little. Second, the same mechanism can create losses of production jobs. This may not be compensated by extra maintenance, repair or refurbishing activities. Finally, ‘Product-as-a-Service’ business models supported by platform technologies are crucial for a CE transition. But by transforming consumers from owners to users, they lose independence and do not share in any value enhancement of assets (e.g., houses). As shown by Uber and AirBNB, platforms tend to concentrate power and value with providers, dramatically affecting the distribution of wealth. The real win-win potential of circularity is that the same societal welfare may be achieved with less production and fewer working hours, resulting in more leisure time. But it is perfectly possible that powerful platform providers capture most added value and channel that to their elite owners, at the expense of the purchasing power of ordinary people working fewer hours. Similar undesirable distributional effects may occur at the global scale: the service economies in the Global North may benefit from the additional repair and refurbishment activities, while economies in the Global South that are more oriented towards primary production will see these activities shrink. It is essential that CE research comes to grips with such effects. Furthermore, governance approaches mitigating unfair distribution of power and value are hence essential for a successful circularity transition.
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OBJECTIVES: Knee osteoarthritis (OA) is characterized by its heterogeneity, with large differences in clinical characteristics between patients. Therefore, a stratified approach to exercise therapy, whereby patients are allocated to homogeneous subgroups and receive a stratified, subgroup-specific intervention, can be expected to optimize current clinical effects. Recently, we developed and pilot tested a model of stratified exercise therapy based on clinically relevant subgroups of knee OA patients that we previously identified. Based on the promising results, it is timely to evaluate the (cost-)effectiveness of stratified exercise therapy compared with usual, "nonstratified" exercise therapy.METHODS: A pragmatic cluster randomized controlled trial including economic and process evaluation, comparing stratified exercise therapy with usual care by physical therapists (PTs) in primary care, in a total of 408 patients with clinically diagnosed knee OA. Eligible physical therapy practices are randomized in a 1:2 ratio to provide the experimental (in 204 patients) or control intervention (in 204 patients), respectively. The experimental intervention is a model of stratified exercise therapy consisting of (a) a stratification algorithm that allocates patients to a "high muscle strength subgroup," "low muscle strength subgroup," or "obesity subgroup" and (b) subgroup-specific, protocolized exercise therapy (with an additional dietary intervention from a dietician for the obesity subgroup only). The control intervention will be usual best practice by PTs (i.e., nonstratified exercise therapy). Our primary outcome measures are knee pain severity (Numeric Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score subscale daily living). Measurements will be performed at baseline, 3-month (primary endpoint), 6-month (questionnaires only), and 12-month follow-up, with an additional cost questionnaire at 9 months. Intention-to-treat, multilevel, regression analysis comparing stratified versus usual care will be performed.CONCLUSION: This study will demonstrate whether stratified care provided by primary care PTs is effective and cost-effective compared with usual best practice from PTs.
ObjectiveTo compare cost effectiveness of endovascular revascularisation (ER) and supervised exercise therapy (SET) as primary treatment for patients with intermittent claudication (IC) due to iliac artery obstruction.MethodsCost utility analysis from a restricted societal perspective and time horizon of 12 months. Patients were included in a multicentre randomised controlled trial (SUPER study, NCT01385774, NTR2648) which compared effectiveness of ER and SET. Health status and health related quality of life (HRQOL) were measured using the Euroqol 5 dimensions 3 levels (EQ5D-3L) and VascuQol-25-NL. Incremental costs were determined per allocated treatment and use of healthcare during follow up. Effectiveness of treatment was determined in quality adjusted life years (QALYs). The difference between treatment groups was calculated by an incremental cost utility ratio (ICER).ResultsSome 240 patients were included, and complete follow up was available for 206 patients (ER 111 , SET 95). The mean costs for patients allocated to ER were €4 031 and €2 179 for SET, a mean difference of €1 852 (95% bias corrected and accelerated [bca] bootstrap confidence interval 1 185 – 2 646). The difference in QALYs during follow up was 0.09 (95% bcaCI 0.04 – 0.13) in favour of ER. The ICER per QALY was €20 805 (95% bcaCI 11 053 – 45 561). The difference in VascuQol sumscore was 0.64 (95% bcaCI 0.39 – 0.91), again in favour of ER.ConclusionER as a primary treatment, results in slightly better health outcome and higher QALYs and HRQOL during 12 months of follow up. Although these differences are statistically significant, clinical relevance must be discussed due to the small differences and relatively high cost of ER as primary treatment.
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