Thermal performance study of a PV-driven innovative solar dryer with and without sensible heat storage for drying of Garcinia Pedunculata

Uneven drying is the key drawback of a conventional multi-tray dryer. Therefore, an improved active solar dryer with and without integrated sensible heat storage (SHS) was proposed. A unique feature of this dryer is its movable walls from the sides of the dryer to transform it to an indirect or mixed-mode as and when necessary. Garcinia Pedunculata (GP) is a local seasonal medicinal fruit in Northeast India. Drying kinetics of GP, the dryer performance and economic analysis of dryer were evaluated in the indirect solar dryer without SHS (Exp. I), mixed-mode solar dryer without SHS (Exp. II), indirect solar dryer with SHS (Exp. III), mixed-mode solar dryer with SHS (Exp. IV), and open sun drying (OSD). The dryer's average efficiencies were 18.12%, 22.37%, 21.74%, and 24.46% for Exp. I, Exp. II, Exp. III, and Exp. IV, respectively. The moisture content of GP was reduced to 12.09% in wet basis (w.b.) from 87.99% (w.b.). The overall drying time for Exp. I, Exp. II, OSD, Exp. III and Exp. IV were 31, 26, 53, 28, and 10 h, respectively. From the eleven drying models, the Two-Term model was the best-fitted model for Exp. I, Exp. II, OSD and Exp. III, and Midilli and Kucuk model was for Exp. IV. The final product's fragrance and colour are better for Exp. IV. Developing this dryer for Exp. I, Exp. II, Exp. III and Exp. IV, the price required was around 25,000, 27,000, 26,000, and 28,000 INR (1 US$ = 74.57 INR), respectively, while the economic payback periods are 1.6 years, 0.9 year, 1.4 years, and 0.59 year, respectively.

Economic impact on local businesses of road safety improvements in Seattle: implications for Vision Zero projects

BACKGROUND

Local transportation agencies implementing Vision Zero road safety improvement projects often face opposition from business owners concerned about the potential negative impact on their sales. Few studies have documented the economic impact of these projects.

METHODS

We examined baseline and up to 3 years of postimprovement taxable sales data for retail, food and service-based businesses adjacent to seven road safety projects begun between 2006 and 2014 in Seattle. We used hierarchical linear models to test whether the change in annual taxable sales differed between the 7 intervention sites and 18 nearby matched comparison sites that had no road safety improvements within the study time frame.

RESULTS

Average annual taxable sales at baseline were comparable at the 7 intervention sites (US$44.7 million) and the 18 comparison sites (US$56.8 million). Regression analysis suggests that each additional year following baseline was associated with US$1.20 million more in taxable sales among intervention sites and US$1.14 million more among comparison sites. This difference is not statistically significant (p=0.64). Sensitivity analyses including a random slope, using a generalised linear model and an analysis of variance did not change conclusions.

DISCUSSION

Results suggest that road safety improvement projects such as those in Vision Zero plans are not associated with adverse economic impacts on adjacent businesses. The absence of negative economic impacts associated with pedestrian and bicycle road safety projects should reassure local business owners and may encourage them to work with transportation agencies to implement Vision Zero road safety projects designed to eliminate traffic-related injuries.

Financial burden of anterior cruciate ligament reconstructions in football (soccer) players: an Australian cost of injury study

OBJECTIVES

To estimate the financial burden of anterior cruciate ligament (ACL) reconstructions in amateur football (soccer) players in Australia over a single year, including both direct and indirect cost.

METHODS

Available national direct and indirect cost data were applied to the annual incidence of ACL reconstructions in Australia. Age-adjusted and sex-adjusted total and mean costs (ACL and osteoarthritis (OA)) were calculated for amateur football (soccer) players in Australia using an incidence-based approach.

RESULTS

The estimated cost of ACL reconstructions for amateur football players is $A69 623 211 with a mean total cost of $A34 079. The mean indirect costs are 19.8% higher than the mean direct costs. The mean indirect costs are lower in female (11.5%, $A28 628) and junior (15.3%, $A29 077) football players. The mean ACL costs are 3-4-fold greater than the mean OA costs ($A27 099 vs $A6450, respectively), remaining consistent when stratified by sex and age group. Our model suggests that for every 10% increase in adherence to injury prevention programmes, which equates to approximately 102 less ACL injuries per year, $A9 460 224 in ACL costs could be saved.

CONCLUSION

While the number of ACL reconstructions per year among football players in Australia is relatively small, the annual financial burden is high. Our study suggests that if injury prevention exercises programmes are prioritised by stakeholders in football, significant cost-savings are possible.

Cost-benefit analysis of a distracted pedestrian intervention

OBJECTIVE

Cellphone ubiquity has increased distracted pedestrian behaviour and contributed to growing pedestrian injury rates. A major barrier to large-scale implementation of prevention programmes is unavailable information on potential monetary benefits. We evaluated net economic societal benefits of StreetBit, a programme that reduces distracted pedestrian behaviour by sending warnings from intersection-installed Bluetooth beacons to distracted pedestrians' smartphones.

METHODS

Three data sources were used as follows: (1) fatal, severe, non-severe pedestrian injury rates from Alabama's electronic crash reporting system; (2) expected costs per fatal, severe, non-severe pedestrian injury-including medical cost, value of statistical life, work-loss cost, quality-of-life cost-from CDC and (3) prevalence of distracted walking from extant literature. We computed and compared estimated monetary costs of distracted walking in Alabama and monetary benefits from implementing StreetBit to reduce pedestrian injuries at intersections.

RESULTS

Over 2019-2021, Alabama recorded an annual average of 31 fatal, 83 severe and 115 non-severe pedestrian injuries in intersections. Expected costs/injury were US$11 million, US$339 535 and US$93 877, respectively. The estimated distracted walking prevalence is 25%-40%, and StreetBit demonstrates 19.1% (95% CI 1.6% to 36.0%) reduction. These figures demonstrate potential annual cost savings from using interventions like StreetBit statewide ranging from US$18.1 to US$29 million. Potential costs range from US$3 208 600 (beacons at every-fourth urban intersection) to US$6 359 200 (every other intersection).

CONCLUSIONS

Even under the most parsimonious scenario (25% distracted pedestrians; densest beacon placement), StreetBit yields US$11.8 million estimated net annual benefit to society. Existing data sources can be leveraged to predict net monetary benefits of distracted pedestrian interventions like StreetBit and facilitate large-scale intervention adoption.

Comparing Costs and Outcomes of Treatments for Irritable Bowel Syndrome With Diarrhea: Cost-Benefit Analysis

BACKGROUND

Irritable bowel syndrome (IBS) is one of the most expensive gastroenterological conditions and is an ideal target for developing a value-based care model. We assessed the comparative cost-benefit of treatments for IBS with diarrhea (IBS-D), the most common IBS subtype from insurer and patient perspectives.

METHODS

We constructed a decision analytic model assessing trade-offs among guideline-recommended and recently FDA-approved drugs, supplements, low FODMAP diet, cognitive behavioral therapy (CBT). Outcomes and costs were derived from systematic reviews of clinical trials and national databases. Health-gains were represented using quality-adjusted life years (QALY).

RESULTS

From an insurer perspective, on-label prescription drugs (rifaximin, eluxadoline, alosetron) were significantly more expensive than off-label treatments, low FODMAP, or CBT. Insurer treatment preferences were driven by average wholesale prescription drug prices and were not affected by health gains in sensitivity analysis within standard willingness-to-pay ranges up to $150,000/QALY-gained. From a patient perspective, prescription drug therapies and neuromodulators appeared preferable due to a reduction in lost wages due to IBS with effective therapy, and also considering out-of-pocket costs of low FODMAP food and out-of-pocket costs to attend CBT appointments. Comparative health outcomes exerted influence on treatment preferences from a patient perspective in cost-benefit analysis depending on a patients' willingness-to-pay threshold for additional health-gains, but health outcomes were less important than out-of-pocket costs at lower willingness-to-pay thresholds.

CONCLUSIONS

Costs are critical determinants of IBS treatment value to patients and insurers, but different costs drive patient and insurer treatment preferences. Divergent cost drivers appear to explain misalignment between patient and insurer IBS treatment preferences in practice.

Methodological Challenges in Estimating the Lifetime Medical Care Cost Externality of Obesity

There is a great deal of variability in estimates of the lifetime medical care cost externality of obesity, partly due to a lack of transparency in the methodology behind these cost models. Several important factors must be considered in producing the best possible estimate, including age-related weight gain, differential life expectancy, identifiability, and cost model selection. In particular, age-related weight gain represents an important new component to recent cost estimates. Without accounting for age-related weight gain, a study relies on the untenable assumption that people remain the same weight throughout their lives, leading to a fundamental misunderstanding of the evolution and development of the obesity crisis. This study seeks to inform future researchers on the best methods and data available both to estimate age-related weight gain and to accurately and consistently estimate obesity's lifetime external medical care costs. This should help both to create a more standardized approach to cost estimation as well as encourage more transparency between all parties interested in the question of obesity's lifetime cost and, ultimately, evaluating the benefits and costs of interventions targeting obesity at various points in the life course.

Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value

BACKGROUND

Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored.

METHODS

Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices.

RESULTS

Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact.

CONCLUSIONS

Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.

Economic Evaluation of Extending Medicare Immunosuppressive Drug Coverage for Kidney Transplant Recipients in the Current Era

BACKGROUND

Kidney transplant recipients must take immunosuppressant drugs to prevent rejection and maintain transplant function. Medicare coverage of immunosuppressant drugs for kidney transplant recipients ceases 36 months after transplantation, potentially increasing the risk of transplant failure. A contemporary economic analysis of extending Medicare coverage for the duration of transplant survival using current costs of immunosuppressant medications in the era of generic equivalents may inform immunosuppressant drug policy.

METHODS

A Markov model was used to determine the incremental cost and effectiveness of extending Medicare coverage for immunosuppressive drugs over the duration of transplant survival, compared with the current policy of 36-month coverage, from the perspective of the Medicare payer. The expected improvement in transplant survival by extending immunosuppressive drug coverage was estimated from a cohort of privately insured transplant recipients who receive lifelong immunosuppressant drug coverage compared with a cohort of Medicare-insured transplant recipients, using multivariable survival analysis.

RESULTS

Extension of immunosuppression Medicare coverage for kidney transplant recipients led to lower costs of -$3077 and 0.37 additional quality-adjusted life years (QALYs) per patient. When the improvement in transplant survival associated with extending immunosuppressant coverage was reduced to 50% of that observed in privately insured patients, the strategy of extending drug coverage had an incremental cost-utility ratio of $51,694 per QALY gained. In a threshold analysis, the extension of immunosuppression coverage was cost-effective at a willingness-to-pay threshold of $100,000, $50,000, and $0 per QALY if it results in a decrease in risk of transplant failure of 5.5%, 7.8%, and 13.3%, respectively.

CONCLUSIONS

Extending immunosuppressive drug coverage under Medicare from the current 36 months to the duration of transplant survival will result in better patient outcomes and cost-savings, and remains cost-effective if only a fraction of anticipated benefit is realized.

Financial Costs Incurred by Living Kidney Donors: A Prospective Cohort Study

BACKGROUND

Approximately 40% of the kidneys for transplant worldwide come from living donors. Despite advantages of living donor transplants, rates have stagnated in recent years. One possible barrier may be costs related to the transplant process that potential willing donors may incur for travel, parking, accommodation, and lost productivity.

METHODS

To better understand and quantify the financial costs incurred by living kidney donors, we conducted a prospective cohort study, recruiting 912 living kidney donors from 12 transplant centers across Canada between 2009 and 2014; 821 of them completed all or a portion of the costing survey. We report microcosted total, out-of-pocket, and lost productivity costs (in 2016 Canadian dollars) for living kidney donors from donor evaluation start to 3 months after donation. We examined costs according to (1) the donor's relationship with their recipient, including spousal (donation to a partner), emotionally related nonspousal (friend, step-parent, in law), or genetically related; and (2) donation type (directed, paired kidney, or nondirected).

RESULTS

Living kidney donors incurred a median (75th percentile) of $1254 ($2589) in out-of-pocket costs and $0 ($1908) in lost productivity costs. On average, total costs were $2226 higher in spousal compared with emotionally related nonspousal donors (P=0.02) and $1664 higher in directed donors compared with nondirected donors (P<0.001). Total costs (out-of-pocket and lost productivity) exceeded $5500 for 205 (25%) donors.

CONCLUSIONS

Our results can be used to inform strategies to minimize the financial burden of living donation, which may help improve the donation experience and increase the number of living donor kidney transplants.

Improvement of Metabolic Control and Diabetes Management in Insulin-Treated Patients Results in Substantial Cost Savings for the German Health System

BACKGROUND

Self-monitoring of blood glucose (SMBG) using the ColourSure™ Technology to visualize target range showed improvement of metabolic control and overall diabetes self-management in insulin-treated patients. This economic analysis aimed to identify cost savings for the German health system resulting from an HbA1c reduction due to the utilization of user-friendly glucose meters.

METHODS

Patient data from a recently published observational study on SMBG were used for risk evaluations using the UKPDS risk engine. These values were integrated in an economic analysis regarding costs of myocardial infarctions (MIs) related to diabetes for the German health system. Based on an earlier assessment these calculations were combined with a 10% reduction of severe hypoglycemic episodes. In the current study, 0% severe hypoglycemic episodes were observed.

RESULTS

An HbA1c reduction of 0.69% over 6 months was associated with a 3% decreased risk of MI in 10 years. In this model the decrease led to cost savings of €4.90 per patient-year. Considering 2.3 million insulin-treated patients in Germany, this 3% reduction of MI could result in annual savings of €11.27 million. Combining this with a 10% reduction in severe hypoglycemic events, the cost savings would increase to €30.61 per patient-year or €70.4 million for 2.3 million insulin-treated patients in Germany.

CONCLUSION

The improvement of metabolic control and diabetes self-management that was achieved with the ColourSure™ Technology has the potential to generate substantial cost savings for the German health system underlining the importance of user-friendly methods for SMBG.

Cost of Dialysis Therapy by Modality in Manitoba

BACKGROUND AND OBJECTIVES

The prevalence of ESKD is increasing worldwide. Treating ESKD is disproportionately costly in comparison with its prevalence, mostly due to the direct cost of dialysis therapy. Here, we aim to provide a contemporary cost description of dialysis modalities, including facility-based hemodialysis, peritoneal dialysis, and home hemodialysis, provided with conventional dialysis machines and the NxStage System One.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We constructed a cost-minimization model from the perspective of the Canadian single-payer health care system including all costs related to dialysis care. The labor component of costs consisted of a breakdown of activity-based per patient direct labor requirements. Other costs were taken from statements of operations for the kidney program at Seven Oaks General Hospital (Winnipeg, Canada). All costs are reported in Canadian dollars.

RESULTS

Annual maintenance expenses were estimated as $64,214 for in-center facility hemodialysis, $43,816 for home hemodialysis with the NxStage System One, $39,236 for home hemodialysis with conventional dialysis machines, and $38,658 for peritoneal dialysis. Training costs for in-center facility hemodialysis, home hemodialysis with the NxStage System One, home hemodialysis with conventional dialysis machines, and peritoneal dialysis are estimated as $0, $16,143, $24,379, and $7157, respectively. The threshold point to achieve cost neutrality was determined to be 9.7 months from in-center hemodialysis to home hemodialysis with the NxStage System One, 12.6 months from in-center hemodialysis to home hemodialysis with conventional dialysis machines, and 3.2 months from in-center hemodialysis to peritoneal dialysis.

CONCLUSIONS

Home modalities have lower maintenance costs, and beyond a short time horizon, they are most cost efficient when considering their incremental training expenses.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_07_18_CJASNPodcast_18_8_F.mp3.

Employment among Patients Starting Dialysis in the United States

BACKGROUND AND OBJECTIVES

Patients with ESRD face significant challenges to remaining employed. It is unknown when in the course of kidney disease patients stop working.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We examined employment trends over time among patients ages 18-54 years old who initiated dialysis in the United States between 1996 and 2013 from a national ESRD registry. We compared unadjusted trends in employment at the start of dialysis and 6 months before ESRD and used linear probability models to estimate changes in employment over time after adjusting for patient characteristics and local unemployment rates in the general population. We also examined employment among selected vulnerable patient populations and changes in employment in the 6 months preceding dialysis initiation.

RESULTS

Employment was low among patients starting dialysis throughout the study period at 23%-24%, and 38% of patients who were employed 6 months before ESRD stopped working by dialysis initiation. However, after adjusting for observed characteristics, the probability of employment increased over time; patients starting dialysis between 2008 and 2013 had a 4.7% (95% confidence interval, 4.3% to 5.1%) increase in the absolute probability of employment at the start of dialysis compared with patients starting dialysis between 1996 and 2001. Black and Hispanic patients were less likely to be employed than other patients starting dialysis, but this gap narrowed during the study period.

CONCLUSIONS

Although working-aged patients in the United States starting dialysis have experienced increases in the adjusted probability of employment over time, employment at the start of dialysis has remained low.

Influence of various levels of milk by-products in weaner diets on growth performance, blood urea nitrogen, diarrhea incidence, and pork quality of weaning to finishing pigs

OBJECTIVE

This study was conducted to evaluate various levels of milk by-product in weaning pig diet on growth performance, blood profiles, carcass characteristics and economic performance for weaning to finishing pigs.

METHODS

A total of 160 weaning pigs ([Yorkshire×Landrace]×Duroc), average 7.01±1.32 kg body weight (BW), were allotted to four treatments by BW and sex in 10 replications with 4 pigs per pen in a randomized complete block design. Pigs were fed each treatment diet with various levels of milk by-product (Phase 1: 0%, 10%, 20%, and 30%, Phase 2: 0%, 5%, 10%, and 15%, respectively). During weaning period (0 to 5 week), weaning pigs were fed experimental diets and all pigs were fed the same commercial feed during growing-finishing period (6 to 14 week).

RESULTS

In the growth trial, BW, average daily gain (ADG), and average daily feed intake (ADFI) in the nursery period (5 weeks) increased as the milk by-product level in the diet increased (linear, p<0.05). Linear increases of pig BW with increasing the milk product levels were observed until late growing period (linear, p = 0.01). However, there were no significant differences in BW at the finishing periods, ADG, ADFI, and gain:feed ratio during the entire growing-finishing periods. The blood urea nitrogen concentration had no significant difference among dietary treatments. High inclusion level of milk by-product in weaner diet decreased crude protein (quadratic, p = 0.05) and crude ash (Linear, p = 0.05) of Longissimus muscle. In addition, cooking loss and water holding capacity increased with increasing milk product levels in the weaner diets (linear, p<0.01; p = 0.05). High milk by-product treatment had higher feed cost per weight gain compared to non-milk by-products treatment (linear, p = 0.01).

CONCLUSION

Supplementation of 10% to 5% milk by-products in weaning pig diet had results equivalent to the 30% to 15% milk treatment and 0% milk by-product supplementation in the diet had no negative influence on growth performance of finishing pigs.

The impact of urban speed reduction programmes on health system cost and utilities

BACKGROUND

Vehicle speed changes impact the probability of injuring a pedestrian in ways that differ from the way that it impacts the probability of a collision or of death. Therefore, return on investment in speed reduction programmes has complex and unpredictable manifests. The objective of this study is to analyse the impact of motor vehicle speed reduction on the collision-related morbidity and mortality rates of urban pedestrians.

METHODS AND FINDINGS

We created a simple way to estimate the public health impacts of traffic speed changes using a Markov model. Our outcome measures include the cost of injury, quality-adjusted life years (QALYs) gained and probability of death and injury due to a road traffic collision. Our two-way sensitivity analysis of speed, both before the implementation of a speed reduction programme and after, shows that, due to key differences in the probability of injury compared with the probability of death, speed reduction programmes may decrease the probability of death while leaving the probability of injury unchanged. The net result of this difference may lead to an increase in injury costs due to the implementation of a speed reduction programme. We find that even small investments in speed reductions have the potential to produce gains in QALYs.

CONCLUSIONS

Our reported costs, effects and incremental cost-effectiveness ratios may assist urban governments and stakeholders to rethink the value of local traffic calming programmes and to implement speed limits that would shift the trade-off to become between minor injuries and no injuries, rather than severe injuries and fatalities.

Home Dialysis in the Prospective Payment System Era

The ESRD Prospective Payment System introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for home dialysis training. We evaluated the effects of the ESRD Prospective Payment System on home dialysis use by patients starting dialysis in the United States from January 1, 2006 to August 31, 2013. We analyzed data on dialysis modality, insurance type, and comorbidities from the United States Renal Data System. We estimated the effect of the policy on home dialysis use with multivariable logistic regression and compared the effect on Medicare Parts A/B beneficiaries with the effect on patients with other types of insurance. The ESRD Prospective Payment System associated with a 5.0% (95% confidence interval [95% CI], 4.0% to 6.0%) increase in home dialysis use by the end of the study period. Home dialysis use increased by 5.8% (95% CI, 4.3% to 6.9%) among Medicare beneficiaries and 4.1% (95% CI, 2.3% to 5.4%) among patients covered by other forms of health insurance. The difference between these groups was not statistically significant (1.8%; 95% CI, -0.2% to 3.8%). Conversely, in both populations, the training add-on did not associate with increases in home dialysis use beyond the effect of the policy. The ESRD Prospective Payment System bundling, but not the training add-on, associated with substantial increases in home dialysis, which were identical for both Medicare and non-Medicare patients. These spill-over effects suggest that major payment changes in Medicare can affect all patients with ESRD.

Consolidation in the Dialysis Industry, Patient Choice, and Local Market Competition

The Medicare program insures >80% of patients with ESRD in the United States. An emphasis on reducing outpatient dialysis costs has motivated consolidation among dialysis providers, with two for-profit corporations now providing dialysis for >70% of patients. It is unknown whether industry consolidation has affected patients' ability to choose among competing dialysis providers. We identified patients receiving in-center hemodialysis at the start of 2001 and 2011 from the national ESRD registry and ascertained dialysis facility ownership. For each hospital service area, we determined the maximum distance within which 90% of patients traveled to receive dialysis in 2001. We compared the numbers of competing dialysis providers within that same distance between 2001 and 2011. Additionally, we examined the Herfindahl-Hirschman Index, a metric of market concentration ranging from near zero (perfect competition) to one (monopoly) for each hospital service area. Between 2001 and 2011, the number of different uniquely owned competing providers decreased 8%. However, increased facility entry into markets to meet rising demand for care offset the effect of provider consolidation on the number of choices available to patients. The number of dialysis facilities in the United States increased by 54%, and patients experienced an average 10% increase in the number of competing proximate facilities from which they could choose to receive dialysis (P<0.001). Local markets were highly concentrated in both 2001 and 2011 (mean Herfindahl-Hirschman Index =0.46; SD=0.2 for both years), but overall market concentration did not materially change. In summary, a decade of consolidation in the United States dialysis industry did not (on average) limit patient choice or result in more concentrated local markets. However, because dialysis markets remained highly concentrated, it will be important to understand whether market competition affects prices paid by private insurers, access to dialysis care, quality of care, and associated health outcomes.

Resource use associated with type 2 diabetes in Africa, the Middle East, South Asia, Eurasia and Turkey: results from the International Diabetes Management Practice Study (IDMPS)

OBJECTIVE

Type 2 diabetes (T2D) and its complications form a global healthcare burden but the exact impact in some geographical regions is still not well documented. We describe the healthcare resource usage (HRU) associated with T2D in Africa, the Middle East, South Asia, Eurasia and Turkey.

RESEARCH DESIGN AND METHODS

In the fifth wave of the International Diabetes Management Practices Study (IDMPS; 2011-2012), we collected self-reported and physician-reported cross-sectional data from 8156 patients from 18 countries across 5 regions, including different types of HRU in the previous 3-6 months. Negative binomial regression was used to identify parameters associated with HRU, using incidence rate ratios (IRRs) to express associations.

RESULTS

Patients in Africa (n=2220), the Middle East (n=2065), Eurasia (n=1843), South Asia (n=1195) and Turkey (n=842) experienced an annual hospitalization rate (mean±SD) of 0.6±1.9, 0.3±1.2, 1.7±4.1, 0.4±1.5 and 1.3±2.7, respectively. The annual number of diabetes-related inpatient days (mean±SD) was 4.7±22.7, 1.1±6.1, 16.0±30.0, 1.5±6.8 and 10.8±34.3, respectively. Despite some inter-regional heterogeneity, macrovascular complications (IRRs varying between 1.4 and 8.9), microvascular complications (IRRs varying between 3.4 and 4.3) and, to a large extent, inadequate glycemic control (IRRs varying between 1.89 and 10.1), were independent parameters associated with hospitalization in these respective regions.

CONCLUSIONS

In non-Western countries, macrovascular/microvascular complications and inadequate glycemic control were common and important parameters associated with increased HRU.

Economic aspects in the management of diabetes in Italy

BACKGROUND

Diabetes mellitus (DM) is a chronic-degenerative disease associated with a high risk of chronic complications and comorbidities. The aim of this study is to estimate the average annual cost incurred by the Italian National Health Service (NHS) for the treatment of DM stratified by patients' comorbidities. Moreover, the model estimates the economic impact of implementing good clinical practice for the management of patients with DM.

METHODS

Data were extrapolated from administrative database of the Marche Region and specific inclusion and exclusion criteria were developed from a clinical board in order to estimate patients with DM only, DM+1, DM+2, DM+3 and DM+4 comorbidities (cardiovascular disease, neuropathy, nephropathy and retinopathy). Regional data were considered a good proxy for implementing a previously developed cost-of-illness (COI) model from Italian NHS perspective already published. A scenario analysis was considered to estimate the economic impact of good clinical practice implementation in the treatment of DM and its comorbidities in Italy.

RESULTS

The model estimated an average number of patients with DM per year in the Marche region of 85.909 (5.5% of population) from 2008 to 2011. The mean costs per patients with DM only, DM+1, DM+2, DM+3 and DM+4 comorbidities were €341, €1,335, €2,287, €5,231 and €7,085 respectively. From the Italian NHS perspective, the total economic burden of DM in Italy amounted to €8.1. billion/year (22% for drugs, 74% for hospitalization and 4% for visits). Scenario analysis demonstrates that the implementation of good clinical practice could save over €700 million per year.

CONCLUSIONS

This model is the first study that considers real world data and COI model to estimate the economic burden of DM and its comorbidities from the Italian NHS perspective. Integrated management of the patients with DM could be a good driver for the reduction of the costs of this disease in Italy.

[Normative-empirical determination of personnel requirements in psychosomatic medicine and psychotherapy]

OBJECTIVES

There is a high degree of misallocated medical care for patients with somatoform disorders and patients with concomitant mental diseases. This complex of problems could be reduced remarkably by integrating psychosomatic departments into hospitals with maximum medical care. Admitting a few big psychosomatic specialist clinics into the calculation basis decreased the Day-Mix Index (DMI). The massive reduction of the calculated costs per day leads to a gap in funding resulting in a loss of the necessary personnel requirements - at least in university psychosomatic departments. The objective of this article is therefore to empirically verify the reference numbers of personnel resources calculated on the basis of the new German lump-sum reimbursement system in psychiatry and psychosomatics (PEPP).

METHODS

The minute values of the reference numbers of Heuft (1999) are contrasted with the minute values of the PEPP reimbursement system in the years 2013 and 2014, as calculated by the Institute for Payment Systems in Hospitals (InEK).

RESULTS

The minute values derived from the PEPP data show a remarkable convergence with the minute values of Heuft's reference numbers (1999).

CONCLUSIONS

A pure pricing system like the PEPP reimbursement system as designed so far threatens empirically verifiable and qualified personnel requirements of psychosomatic departments. In order to ensure the necessary therapy dosage and display it in minute values according to the valid OPS procedure codes, the minimum limit of the reference numbers is mandatory to maintain the substance of psychosomatic care. Based on the present calculation, a base rate of at least 285 e has to be politically demanded. Future developments in personnel costs have to be refinanced at 100 %.

Lamb Production Costs: Analyses of Composition and Elasticities Analysis of Lamb Production Costs

Since lamb is a commodity, producers cannot control the price of the product they sell. Therefore, managing production costs is a necessity. We explored the study of elasticities as a tool for basing decision-making in sheep production, and aimed at investigating the composition and elasticities of lamb production costs, and their influence on the performance of the activity. A representative sheep production farm, designed in a panel meeting, was the base for calculation of lamb production cost. We then performed studies of: i) costs composition, and ii) cost elasticities for prices of inputs and for zootechnical indicators. Variable costs represented 64.15% of total cost, while 21.66% were represented by operational fixed costs, and 14.19% by the income of the factors. As for elasticities to input prices, the opportunity cost of land was the item to which production cost was more sensitive: a 1% increase in its price would cause a 0.2666% increase in lamb cost. Meanwhile, the impact of increasing any technical indicator was significantly higher than the impact of rising input prices. A 1% increase in weight at slaughter, for example, would reduce total cost in 0.91%. The greatest obstacle to economic viability of sheep production under the observed conditions is low technical efficiency. Increased production costs are more related to deficient zootechnical indexes than to high expenses.

The costs associated with the evaluation of rotator cuff tears before surgical repair

BACKGROUND

Patients undergoing rotator cuff repair typically have a diagnostic evaluation and trial of nonoperative therapy before surgery. Recent studies have evaluated the cost-effectiveness of surgery, but none have attempted to estimate the costs associated with the preoperative evaluation. This study used available data to examine major expenditures during the preoperative period.

MATERIALS AND METHODS

We conducted a search using an insurance company database to identify patients undergoing rotator cuff repair from 2004 to 2009. Patients were identified by the common Current Procedural Terminology codes for rotator cuff repair. The associated charge codes for the 90-day period before surgery were categorized as outpatient physician visits, diagnostic imaging studies, injections, physical therapy, laboratory and other preoperative studies, prior surgeries, and miscellaneous. The frequency of each code and the associated charges were noted.

RESULTS

In total, 92,688 patients were identified in the study period. A total of $161,993,100 was charged during the preoperative period, for an average of $1,748 per patient. Diagnostic imaging charges totaled $104,510,646 (65%); injections, $5,145,227 (3%); outpatient visits, $29,723,751 (18%); physical therapy, $13,844,270 (8.5%); preoperative studies, $6,792,245 (4.2%); and miscellaneous, $1,164,688 (<1%).

CONCLUSIONS

The costs for preoperative evaluation of rotator cuff tears are substantial, and the majority of the costs are associated with magnetic resonance imaging. To help reduce costs, future studies should attempt to identify the factors that predict which patients might not respond to nonoperative management and might benefit from early surgical intervention. In addition, magnetic resonance imaging should perhaps be reserved for patients in whom the diagnosis cannot be achieved by other modalities.

Preparing for the bundled-payment initiative: the cost and clinical outcomes of reverse shoulder arthroplasty for the surgical treatment of advanced rotator cuff deficiency at an average 4-year follow-up

BACKGROUND

The purpose of this study is to report on cost, outcomes, reliability, and safety of reverse shoulder arthroplasty (RSA) in patients with symptomatic advanced rotator cuff deficiency.

METHODS

Fifty-five primary RSA patients operated on at a single institution by a single surgeon were prospectively studied for a mean of 48 months (range, 31-71 months). For each patient, validated subjective and independently evaluated objective outcome data were collected to determine clinical reliability. In addition, safety, defined as major complications, as well as direct costs specific to each patient, were collected and analyzed.

RESULTS

There were significant improvements (P < .05) in all clinical measures with the exception of the general health and vitality components as well as the mental component summary scores of the Short Form 36 version 2 (SF-36v2). In addition, the majority of the patients met the criteria set forth for clinical reliability (53 of 55 [96%]) and safety (49 of 55 [89%]). The mean total 4-year cost was $24,661, with the hospitalization accounting for 92% of this cost. Fiscal year was found to be responsible for the greatest fluctuation in total cost (P < .001). In addition, a lower comorbidity burden (P < .001), a higher preoperative extremity impairment rating (P < .001), higher postoperative role-emotional component scores on the SF-36v2 (P = .001), and lower postoperative social functioning component scores on the SF-36v2 (P = .005) were correlated with less cost.

CONCLUSION

The mean 4-year total cost of $24,661 allowed the purchase of treatment with RSA, leading to a greater than 5-fold reduction in pain and a 70% improvement in shoulder function with a small risk of harm.