Transradial versus transfemoral access routes for diagnostic cerebral angiography: a large single-center comparative cost-analysis study

OBJECTIVE

Recently, the transradial (TR) approach has become a common alternative because of its safety profile and increased patient satisfaction compared with the transfemoral (TF) route. Both routes are associated with their respective associated costs, and differences typically emerge on the basis of patient anatomy, operator expertise, and occurrence of complications. The authors' objective was to compare the overall costs of diagnostic cerebral angiography via both routes and to shed light on the individual equipment costs of each route.

METHODS

This retrospective single-center study of 926 elective diagnostic angiograms was performed between December 2019 and March 2022.

RESULTS

The study comprised of 314 and 612 angiograms performed through the TF and TR routes, respectively. A significantly greater proportion of female patients were included in the TF cohort (79.3% vs 67.8%, p < 0.001), and most other demographic characteristics and baseline modified Rankin Scale scores were comparable between cohorts. The overall cost of patients utilizing the TR route was comparable to that of the TF route (mean ± SD $12,591.80 ± $19,128.00 vs $12,789.50 ± 18,424.00, p = 0.88). However, the median cost of catheters was significantly higher in TR group ($55.20 vs $12.40, p = 0.03), while the median costs of closure devices ($87.00 vs $20.20 p < 0.001) and sheaths ($44.60 ± 11.3 vs $41.10 ± 3.10, p < 0.001) were significantly higher in the TF group.

CONCLUSIONS

Overall, the authors' study showed that the TR approach can be a less expensive option for patients undergoing diagnostic cerebral angiography, especially if complications occur. Future studies may corroborate these findings and potentially lead to the adoption of TR as a low-cost, efficient, gold-standard technique for cerebral angiography.

Refresh Rate-Based Caching and Prefetching Strategies for Internet of Things Middleware

One of the research directions in Internet of Things (IoT) is the field of Context Management Platforms (CMPs) which is a specific type of IoT middleware. CMPs provide horizontal connectivity between vertically oriented IoT silos resulting in a noticeable difference in how IoT data streams are processed. As these context data exchanges can be monetised, there is a need to model and predict the context metrics and operational costs of this exchange to provide relevant and timely context in a large-scale IoT ecosystem. In this paper, we argue that caching all transient context information to satisfy this necessity requires large amounts of computational and network resources, resulting in tremendous operational costs. Using Service Level Agreements (SLAs) between the context providers, CMP, and context consumers, where the level of service imperfection is quantified and linked to the associated costs, we show that it is possible to find efficient caching and prefetching strategies to minimize the context management cost. So, this paper proposes a novel method to find the optimal rate of IoT data prefetching and caching. We show the main context caching strategies and the proposed mathematical models, then discuss how a correctly chosen proactive caching strategy and configurations can help to maximise the profit of CMP operation when multiple SLAs are defined. Our model is accurate up to 0.0016 in Root Mean Square Percentage Error against our simulation results when estimating the profits to the system. We also show our model is valid using the t-test value tending to 0 for all the experimental scenarios.

Telehealth Impact in Frontier Critical Access Hospitals: Mixed Methods Evaluation

BACKGROUND

Frontier areas are sparsely populated counties in states where 65% of the counties have 6 or fewer residents per square mile. Residents access primary care at critical access hospitals (CAHs) located in these rural communities but must travel great distances for specialty care. Telehealth could address access challenges; however, there are barriers to broader use, including reimbursement and the need for practical implementation support. The Centers for Medicare & Medicaid Services implemented the Frontier Community Health Integration Project (FCHIP) Demonstration to assess the impact of telehealth payment change and technical assistance to adopt and sustainably use telehealth for CAHs treating Medicare fee-for-service patients in frontier regions.

OBJECTIVE

We evaluated the impact of the FCHIP Demonstration telehealth payment change and technical assistance on telehealth adoption and ongoing use using a mixed methods approach.

METHODS

We conducted a mixed methods evaluation of the 8 CAHs in Montana, Nevada, and North Dakota that participated in the FCHIP program. Key informant interviews and FCHIP program document review were conducted and analyzed using thematic analysis to understand how CAHs implemented their telehealth programs and the facilitators of program adoption and maintenance. Medicare fee-for-service claims were analyzed from August 2013 to July 2019 relative to a group of CAHs that did not participate in the demonstration project to understand the frequency of telehealth use for Medicare fee-for-service beneficiaries receiving care at the participating CAHs before and during the Demonstration program.

RESULTS

CAH staff noted several key factors for establishing and sustaining a telehealth program: clinical and administrative staff champions, infrastructure changes, training on telehealth processes, and establishing strong relationships with specialists at distant facilities to deliver telehealth services to patients of CAH. There was a modest increase in telehealth services billed to Medicare during the FCHIP Demonstration that were limited to a handful of CAHs.

CONCLUSIONS

The frontier setting is characterized by a low population; and thus, the volumes of telehealth services provided in both the CAHs and comparison sites are low. Overall, CAHs reported that patient satisfaction was high and expressed the desire for more virtual services. Telehealth service selection was informed by perceived community needs and specialist availability. CAHs made infrastructure changes to support telehealth and expressed the desire for more virtual services. Implementation support services helped CAHs integrate telehealth into clinical and operational workflows. There was some increase in telehealth services billed to Medicare, but the volume billed was low and not enough to substantially improve hospital revenue. Future work to inform policy and practice could include standardized, formal community need assessments and assistance finding distant providers to meet those needs and further technical assistance around billing, service selection, and ongoing use to support sustainability.

Optimising ambulance conveyance rates and staff costs by adjusting proportions of rapid-response vehicles and dual-crewed ambulances: an economic decision analytical modelling study

AIM

To model optimum proportions of dual-crewed ambulances (DCAs) and rapid-response vehicles (RRVs) in Ambulance Trusts with a view to generating a policy brief for one Ambulance Trust and a modelling tool for other Trusts on the strategic procurement and allocation of emergency vehicle (EV) resources.

METHODS

Historical EV assignments for 12 months of emergency calls in 2019 were provided by an NHS Ambulance Trust and analysed for backup, see and treat, and patient to hospital conveyance. Unit costs were derived for paramedics and technicians using Agenda for Change pay rates. Time cycles were assigned for RRV and DCA attendances and unit costs assigned to these. Information was put into a decision analytical model to estimate the costs and numbers of vehicles attending incidents based on relative proportions of available RRVs and DCAs.

RESULTS

Of 711 992 calls attended by 837 107 EVs, 514 766 (72.3%) required at least one emergency department conveyance. The rate of conveyance was significantly lower when RRVs arrived first on the scene. 27 883 out of 529 693 (5.3%) DCAs first arriving at an incident required some backup, and this was also factored into the model. Modelling demonstrated high conveyance rates were counterproductive when increasing the relative proportions of RRVs to DCAs. For example, with conveyance rates of 65%, increasing the RRVs increased the cost and numbers of vehicles attending per incident. At lower conveyance rates, however, there was a levelling around 30% where it could become cost-effective to increase the relative proportions of RRVs to DCAs.

CONCLUSION

At current overall conveyance rates, there is no benefit in increasing the relative proportions of RRVs to DCAs unless additional benefits can be realised that bring the conveyance rates down.

Evaluation of Strong Cation Ion-Exchange Resin Cost Efficiency in Manufacturing Applications-A Case Study

The effective ionic capacities of strong cation ion-exchange resins were investigated and compared using conditions similar to those found in white goods, in order to establish behavioral differences between commercial products and evaluate their capacity in a broader business context. Nine different products of equivalent TDS (Technical Data Sheet) capacity were observed to examine their differences in approximately real-life conditions. For a broader context of applicability analysis, besides the absolute ionic operating capacity, the following additional factors were included in the evaluation: the standard deviation in the resins’ performances and their relative prices. A complete method for material applicability evaluation was hereby proposed and shown to offer cost factor benefits of up to 21.1% within the range of products examined, in comparison to a cost-only evaluation for equivalent materials.

The impact of public acceptance on cost efficiency and environmental sustainability in decentralized energy systems

Local resistance often hinders renewable energy technology developments, especially for onshore wind. In decentralized energy systems, the landscape impact of wind turbines or transmission lines is a key barrier to public acceptance. By using landscape scenicness as a proxy for public acceptance, we quantify its impact on the optimal energy systems of 11,131 German municipalities. In municipalities with high scenicness, it is likely that onshore wind will be rejected, leading to higher levelized costs of energy by up to about 7 €-cent/kWh. Onshore wind would be replaced mainly by solar photovoltaics and imports, and the cost-optimal energy systems would be associated with higher CO₂ emissions of up to about 200 gCO₂/kWh compared with an average of around 50 gCO₂/kWh. The findings help to identify municipalities where public resistance to onshore wind could be particularly high and support the scientific and policy debate about the location of onshore wind farms.

•

Determine cost-optimal energy systems of 11,131 German municipalities in 2050

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Combine cluster and regression analyses with mathematical optimization methods

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Apply nationwide scenicness data to estimate the landscape impact of onshore wind

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Rejecting onshore wind leads to a significant increase in costs and CO₂ emissions

Renewable energy technologies are necessary to maintain secure energy supplies and limit the impacts of climate change. Developments of these technologies are mostly planned purely based on economic criteria, but this can lead to resistance in local communities. Among the diverse renewable technologies, especially onshore wind turbines may negatively affect the scenicness of beautiful landscapes. We analyze how cost-efficient local energy systems could be impacted through public opposition toward onshore wind. In doing so, we draw on a database of public evaluation of landscape beauty across Germany. In the energy systems of German municipalities with high scenicness, onshore wind would mainly be replaced by solar photovoltaics. Depending on the location, the local energy systems may be associated with a significant increase in costs and CO₂ emissions. These insights can support local and national stakeholders in making decisions relating to energy and climate policy.

Reimagining Innovation Amid the COVID-19 Pandemic: Insights From the WISH Innovation Programme

The World Innovation Summit for Health (WISH) hosts two innovation competitions as part of its biennial healthcare conference. During the COVID-19 pandemic, WISH received more than 350 applications for both competitions, of which 31 were shortlisted to showcase at the WISH 2020 virtual summit. Of the 31 showcasing innovations, 11 (35.5%) had suggested an alternative use to their innovation as a contribution to the global fight against COVID-19. As such, this article explores the apparent and urgent need for the repurposing of healthcare innovations to reduce the costs and time associated with the conventional approach, in order to best respond to the demands of the global pandemic.

The Energy Impact of Building Materials in Residential Buildings in Turkey

In Turkey, heat loss from existing and new buildings constitutes a large part of energy waste, so usage of suitable construction material is quite important. The building selected in this study was analyzed by applying different building materials considering the annual energy consumption allowed, and according to the different heat zones and different thicknesses of insulation material in relation to demand. The most suitable building material in terms of energy and cost uptake and cost given to the regions was determined; the results were measured in the study in terms of the maximum allowable annual heating energy requirement and the optimum values were determined. Comparison of the optimum values and the total energy consumption rates was conducted for the analyzed cities.

Evaluating long-term success in grassland restoration: an ecosystem multifunctionality approach

It is generally assumed that restoring biodiversity will enhance diversity and ecosystem functioning. However, to date, it has rarely been evaluated whether and how restoration efforts manage to rebuild biodiversity and multiple ecosystem functions (ecosystem multifunctionality) simultaneously. Here, we quantified how three restoration methods of increasing intervention intensity (harvest only < topsoil removal < topsoil removal + propagule addition) affected grassland ecosystem multifunctionality 22 yr after the restoration event. We compared restored with intensively managed and targeted seminatural grasslands based on 13 biotic and abiotic, above- and belowground properties. We found that all three restoration methods improved ecosystem multifunctionality compared to intensively managed grasslands and developed toward the targeted seminatural grasslands. However, whereas higher levels of intervention intensity reached ecosystem multifunctionality of targeted seminatural grasslands after 22 yr, lower intervention missed this target. Moreover, we found that topsoil removal with and without seed addition accelerated the recovery of biotic and aboveground properties, and we found no negative long-term effects on abiotic or belowground properties despite removing the top layer of the soil. We also evaluated which ecosystem properties were the best indicators for restoration success in terms of accuracy and cost efficiency. Overall, we demonstrated that low-cost measures explained relatively more variation of ecosystem multifunctionality compared to high-cost measures. Plant species richness was the most accurate individual property in describing ecosystem multifunctionality, as it accounted for 54% of ecosystem multifunctionality at only 4% of the costs of our comprehensive multifunctionality approach. Plant species richness is the property that typically is used in restoration monitoring by conservation agencies. Vegetation structure, soil carbon storage and water-holding capacity together explained 70% of ecosystem multifunctionality at only twice the costs (8%) of plant species richness, which is, in our opinion, worth considering in future restoration monitoring projects. Hence, our findings provide a guideline for land managers how they could obtain an accurate estimate of aboveground-belowground ecosystem multifunctionality and restoration success in a highly cost-efficient way.

Cost-per-remitter with esketamine nasal spray versus standard of care for treatment-resistant depression

Aim: Estimate the cost-per-remitter with esketamine nasal spray plus an oral antidepressant (ESK + oral AD) versus oral AD plus nasal placebo (oral AD + PBO) among patients with treatment-resistant depression. Patients & methods: An Excel-based model was developed to estimate the cost-per-remitter for ESK + oral AD versus oral AD + PBO over 52 weeks from multiple US payer perspectives. Clinical end points and cost inputs were derived from clinical trials and the literature, respectively. Results: Under the base-case scenario, the cost-per-remitter for ESK + oral AD and oral AD + PBO were as follows: Commercial: US$85,808 versus US$100,198; Medicaid: US$76,236 versus US$96,067; Veteran's Affairs: US$77,765 versus US$104,519; and Integrated Delivery Network: US$103,924 versus US$142,766. Conclusion: The findings suggest that ESK + oral AD is a cost-efficient alternative treatment for treatment-resistant depression compared with oral AD + PBO.

IUI needs fairer appraisal to improve patient and stakeholder choices

Information supporting IVF at the expense of intrauterine insemination (IUI) has become commonplace, but it lacks critical analyses. Data from poorly practiced IUI, without an equivalent comparison to IVF, has been generalised to recommend a total abandonment of IUI in favour of IVF treatment. Our intention with this paper is to reappraise and balance arguments so that patients and stakeholders can have an unbiased informed choice. We provide information that reveals IUI to predominate over IVF in terms of integrated success, risks and cost to deliver one live birth whilst obviating the maternal and neonatal costs. Exceptional cost savings are demonstrated for IUI over IVF for fee-paying agencies and patients with lowered risks of maternal and neonatal care along with other risks including OHSS, fetal reduction and termination of pregnancies. This analysis supports the view that patients and stakeholders can choose IUI instead of IVF in most instances, except with bilateral tubal blockage and severe male factor infertility. It is apparent that fertility clinics need to re-evaluate and reconsider this field, and IUI can be of benefit to both subfertile patients and the stakeholders.

Cost-Efficiency Analysis of the Improved Web-Based Planning, Budgeting, and Reporting System (PlanRep) in Tanzania

Background

Information systems offer unlimited potential for innovation and digitalization of management functions to facilitate citizen participation and improve accountability, transparency, and efficiency in government operations and service delivery. In line with this, for more than one decade, Tanzania implemented an integrated planning, budgeting, and reporting system (PlanRep) that was used to prepare plans and budgets at the local government authorities (LGAs) using a desktop application. In 2017, PlanRep was upgraded to a Web-based system to address several challenges, including poor coordination and high cost involved in the preparation of plans and budgets. However, operational evidence regarding the cost-efficiencies and benefits of shifting to Web-based PlanRep has not been explored. This study aims to address this gap by assessing efficiency gains (in terms of cost and time) of shifting to a Web-based PlanRep system as a tool for the preparation of LGA plans and budgets.

Methods

The study applied a retrospective before-and-after study design whereby quantitative data was used to assess the amount of time and the cost incurred by LGAs when preparing their budget 1 year before the introduction of PlanRep and 1 year after. Parallelly, qualitative data were collected through key informant interviews with selected LGA officials, Regional Secretariats (RSs), President's Office Regional Administration and Local Government (PORALG), and system end-users such as heads of health facilities and schools (primary and secondary). Secondary data was analyzed by comparing time and cost used before and after Web-based PlanRep, while thematic analysis was employed for qualitative data.

Results

The analysis showed a 53% reduction (from USD 3.8 million in 2017/18 to USD 1.8 million in 2018/19) in the total costs LGAs incurred during planning and budgeting after introducing the Web-based PlanRep. The main efficiency gain was related to per diem costs. The analysis also showed significant time saving from an average of 87 days in 2017/18 to only 8 days in 2018/19. PlanRep system end-users also acknowledged that the introduction of Web-based PlanRep has significantly saved their time and costs in preparation of LGA plans and budget.

Conclusion

The introduction of the Web-based planning, budgeting, and reporting systems has resulted in tremendous cost reduction, time savings, transparency, accountability, and workload reduction. The findings offer operational evidence to guide the implementation and scale up of similar systems in countries that share equivalent circumstances like Tanzania.

Organization of chemotherapeutic preparations in advance: Do we save or waste money?

OBJECTIVE

The development of oncology day-hospital activities contributes to increase quality of life of patients and consequently have changed their perception about waiting. The extemporaneous preparation of antineoplastic has become difficult to achieve given the increasing activity, and hospital pharmacists have taken up the challenge by the implementation of the antineoplastic preparation in anticipation. Because anticipation can lead to an important number of preparations to be discarded, we also develop a recycled process for other patients to limit these waste extra costs. We aim to demonstrate the positive balance of anticipated preparation in this 4-year study report.Data sources: This prospective study was conducted in a major European oncology day-hospital from January, 2012 to December, 2015. The data were extracted from our software WinSimbad™ and updated as needed. The number and cost-associated of preparation ungiven chemotherapy doses (recycled or discarded) were compared to the global drug budget of our hospital in order to not exceed 2%.Data summary: 303,100 antineoplastic have been prepared. Approximately 35% of them were anticipated with an average of 5,431±984 that were finally ungiven. Two-third was recycled and the cost of the ungiven preparations finally discarded represents 1.7±0.15% of the global drug budget.

CONCLUSIONS

This study assesses the drug wastage and its associated cost of this concept through a prospective study and discusses the cost of ungiven antineoplastic preparations. With prior consideration of the need to define the acceptable rate of discarded ungiven preparation, the hospitals with an high oncology day-hospital activity should implement this approach.

Hospital referrals of patients with acute poisoning by the Belgian Poison Centre: analysis of characteristics, associated factors, compliance and costs

OBJECTIVE

Aims were (1) to assess the characteristics, associated factors and compliance of patients with acute poisoning advised by the Belgian Poison Centre (BPC) to go (conditionally) to the hospital, (2) to assess the compliance and potential health-economic impact.

METHODS

Three types of referrals to the hospital of patients who called the BPC between 1 January and 30 June 2018 were analysed: referrals in case of deterioration in the patient's condition (Hosp-watchful-wait), referrals (Hosp-referral) or urgent referrals (Hosp-urgent-referral). Factors associated with type of recommendation were registered. A survey was conducted on a second dataset of patients who called the BPC between 1 March and 15 May 2019 and referred (conditionally) to the hospital.

RESULTS

5476 referrals were included: 72.4% accidental poisoning, 25.3% intentional self-harm, 1.2% substance abuse and 1.1% unclear intentionality. There were 2368 (43.2%) Hosp-watchful-wait cases, 2677 (48.9%) Hosp-referrals and 431 (7.9%) Hosp-urgent-referrals. In Hosp-watchful-wait cases, soaps and detergents were represented most (20.5%). In Hosp-referrals and Hosp-urgent-referrals, benzodiazepines (12.7% and 15.1%, respectively) predominated. Factors associated with hospitalisation type were number of symptoms, intentionality, type of agent(s) involved and advising antidotes. The survey showed that 7.8% of Hosp-watchful-wait patients went to the hospital versus 57.3% of Hosp-referrals and 59.6% of Hosp-urgent-referrals. The mean cost for Hosp-watchful-wait patients, Hosp-referrals and Hosp-urgent-referrals was estimated at €127, €767 and €796, respectively.

CONCLUSION

Only a small proportion of patients followed the advice of the BPC to go (conditionally) to the hospital. A systematic follow-up of cases is warranted to examine the appropriateness of referrals and the compliance of patients.

Evaluating the efficiency of specimen pooling for PCR-based detection of COVID-19

In the age of a pandemic, such as the ongoing one caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), the world faces a limited supply of tests, personal protective equipment, and factories and supply chains are struggling to meet the growing demands. This study aimed to evaluate the efficacy of specimen pooling for testing of SARS‐CoV‐2 virus, to determine whether costs and resource savings could be achieved without impacting the sensitivity of the testing. Ten previously tested nasopharyngeal and throat swab specimens by real‐time polymerase chain reaction (PCR), were pooled for testing, containing either one or two known positive specimens of varying viral concentrations. Specimen pooling did not affect the sensitivity of detecting SARS‐CoV‐2 when the PCR cycle threshold (Ct) of original specimen was lower than 35. In specimens with low viral load (Ct > 35), 2 of 15 pools (13.3%) were false negative. Pooling specimens to test for Coronavirus Disease 2019 infection in low prevalence (≤1%) areas or in low risk populations can dramatically decrease the resource burden on laboratory operations by up to 80%. This paves the way for large‐scale population screening, allowing for assured policy decisions by governmental bodies to ease lockdown restrictions in areas with a low incidence of infection, or with lower‐risk populations.

Specimen pooling did not affect the sensitivity of detecting SARS‐CoV.

Pooling specimens to test for COVID‐19 infection can dramatically decrease the resource burden on laboratory operations.

Specimen pooling in samples whose cycle threshold (Ct) value is greater than 35 may yield false‐negative results.

Pooling specimens is especially useful for large‐scale population screening.

Rethinking Food Production: Nexus of Mobile Phones and Production Cost Minimization

Information and communication technologies are a ready tool for all strata of society and are indeed redefining the way almost everything is done. Mobile phone technology, in particular, plays a vital role in expediting improvement in the efficiency of the household resource through access to information on various available technologies. Can mobile phones improve the cost efficiency of agricultural production? Comprehension of such effect is critical, especially in the context of the Sustainable Development Goals. We addressed this topic using cross-sectional data from smallholder maize producers in Zambia. The Stochastic Frontier Analysis was applied to estimate cost efficiency. The results indicate that mobile phone use improves the cost efficiency of maize production significantly and as such, adopters have made a rational decision to adopt mobile phone use for information access. Precisely, we found a 10.2% efficiency gap in favor of users. Nevertheless, if non-users were to adopt mobile phones for agricultural information access, maize production per hectare would increase by 21.38%. Eventually, food production would be increased in an environmentally friendly manner and the price of maize would be set at a competitive price within the region because agricultural inputs would be allocated cost efficiently. Therefore, in an attempt to minimize production cost in food production, this study strongly endorses the use of mobile phones for agricultural information access.

Observational retrospective study of UK national success, risks and costs for 319,105 IVF/ICSI and 30,669 IUI treatment cycles

OBJECTIVE

To compare success rates, associated risks and cost-effectiveness between intrauterine insemination (IUI) and in vitro fertilisation (IVF).

DESIGN

Retrospective observational study.

SETTING

The UK from 2012 to 2016.

PARTICIPANTS

Data from Human Fertilisation and Embryology Authority's freedom of information request for 2012-2016 for IVF/ICSI (intracytoplasmic sperm injection)and IUI as practiced in 319 105 IVF/ICSI and 30 669 IUI cycles. Direct-cost calculations for maternal and neonatal expenditure per live birth (LB) was constructed using the cost of multiple birth model, with inflation-adjusted Bank of England index-linked data. A second direct-cost analysis evaluating the incremental cost-effective ratio (ICER) was modelled using the 2016 national mean (baseline) IVF and IUI success rates.

OUTCOME MEASURES

LB, risks from IVF and IUI, and costs to gain 1 LB.

RESULTS

This largest comprehensive analysis integrating success, risks and costs at a national level shows IUI is safer and more cost-effective than IVF treatment.IVF LB/cycle success was significantly better than IUI at 26.96% versus 11.49% (p<0.001) but the IUI success is much closer to IVF at 2.35:1, than previously considered. IVF remains a significant source of multiple gestation pregnancy (MGP) compared with IUI (RR (Relative Risk): 1.45 (1.31 to 1.60), p<0.001) as was the rate of twins (RR: 1.58, p<0.001).In 2016, IVF maternal and neonatal cost was £115 082 017 compared with £2 940 196 for IUI and this MGP-related perinatal cost is absorbed by the National Health Services. At baseline tariffs and success rates IUI was £42 558 cheaper than IVF to deliver 1LB with enhanced benefits with small improvements in IUI. Reliable levels of IVF-related MGP, OHSS (ovarian hyperstimulation syndrome), fetal reductions and terminations are revealed.

CONCLUSION

IUI success rates are much closer to IVF than previously reported, more cost-effective in delivering 1 LB, and associated with lower risk of complications for maternal and neonatal complications. It is prudent to offer IUI before IVF nationally.

The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery

Background

This paper aims to review the introduction of an enhanced recovery after surgery (ERAS) service within complex spinal surgery, with an aim to assess if this is a cost effective way to improve the overall experience of such complex surgery.

Methods

The ERAS model was defined and followed within a regional centre for complex spinal surgery in the UK. Outcomes such as length of stay (LOS) and satisfaction were measured before and after implementation of the service.

Results

LOS was reduced and both patient and staff satisfaction improved following the implementation of the ERAS service.

Conclusions

The ERAS model can successfully be implemented within complex spinal surgery, to help improve satisfaction and reduce cost.

From ED overcrowding to jail overcrowding: a cautionary tale of a Serial Inebriate Programme (SIP)

INTRODUCTION

Community-based programmes have been implemented to curtail ED use by individuals with chronic public intoxication. Among these programmes is the Serial Inebriate Programme (SIP), which aims to reduce use of ED and emergency medical services. We present the results of an evaluation of the SIP in Santa Cruz, California, including data on the participants' police and jail history, information not considered in prior analyses of SIPs.

METHODS

In the present study, we used a retrospective cohort to evaluate the effectiveness of the SIP in Santa Cruz, California from 2013 to 2015. Specifically, we looked at the programme effects on participants' arrests, nights in jail, use of the local ED and ambulance services after programme adjudication.

RESULTS

The median number of visits to the ED for participants before and after adjudication was reduced from 4 to 1, and participants showed a significant decrease in their number of jail bookings following adjudication (-4.5 bookings; p=0.004). However, the average number of nights in jail served by participants after adjudication was 2.1 times the average number of nights spent in jail spent before programme adjudication (58.5 vs 27.6 nights in jail for postadjudication and preadjudication groups, respectively; p=0.009).

CONCLUSIONS

Our findings suggest that the Santa Cruz SIP had some impact in reducing participants' use of emergency services, but at the cost of increased jail time. The burdens of placing chronically intoxicated individuals in jail for extended periods of time are not trivial and should not be overlooked when designing and implementing a SIP.

Impact of Precision Medicine on Drug Repositioning and Pricing: A Too Small to Thrive Crisis

The pricing of targeted medicines continues to be a major area of contention in healthcare economics. This issue is further complicated by redefining the role of molecular testing in precision medicine. Currently, whilst pricing of clinical laboratory diagnostics is cost-based, drug pricing is value-based. The pricing for molecular testing is under pressure to change the traditional business model, for it has a critical subsidiary role in determining the final value of targeted medicines. The market size for drugs is reduced by molecular testing when patients with the same disease are stratified based on their genetics, it is critical to determine the value of this new enhanced drug specificity to realize its full pricing potential. However, these value-based pricing strategies require a careful understanding of changing market conditions, especially, in the context of stratified patient segments made possible by precision medicine. In this article, we discuss the various factors impacting pricing decisions, and consider evolving economic trends in precision medicine.

Cost Description and Comparative Cost Efficiency of Post-Exposure Prophylaxis and Canine Mass Vaccination against Rabies in N'Djamena, Chad

Rabies claims approximately 59,000 human lives annually and is a potential risk to 3.3 billion people in over 100 countries worldwide. Despite being fatal in almost 100% of cases, human rabies can be prevented by vaccinating dogs, the most common vector, and the timely administration of post-exposure prophylaxis (PEP) to exposed victims. For the control and prevention of human rabies in N'Djamena, the capital city of Chad, a free mass vaccination campaign for dogs was organized in 2012 and 2013. The campaigns were monitored by parallel studies on the incidence of canine rabies based on diagnostic testing of suspect animals and the incidence of human bite exposure recorded at selected health facilities. Based on the cost description of the campaign and the need for PEP registered in health centers, three cost scenarios were compared: cumulative cost-efficiency of (1) PEP alone, (2) dog mass vaccination and PEP, (3) dog mass vaccination, PEP, and maximal communication between human health and veterinary workers (One Health communication). Assuming ideal One Health communication, the cumulative prospective cost of dog vaccination and PEP break even with the cumulative prospective cost of PEP alone in the 10th year from the start of the calculation (2012). The cost efficiency expressed in cost per human exposure averted is much higher with canine vaccination and One Health communication than with PEP alone. As shown in other studies, our cost-effectiveness analysis highlights that canine vaccination is financially the best option for animal rabies control and rabies prevention in humans. This study also provides evidence of the beneficial effect of One Health communication. Only with close communication between the human and animal health sectors will the decrease in animal rabies incidence be translated into a decline for PEP. An efficiently applied One Health concept would largely reduce the cost of PEP in resource poor countries and should be implemented for zoonosis control in general.

Robotic surgery in gynecology

Robotic surgery is the most dynamic development in the sector of minimally invasive operations currently. It should not be viewed as an alternative to laparoscopy, but as the next step in a process of technological evolution. The advancement of robotic surgery, in terms of the introduction of the Da Vinci Xi, permits the variable use of optical devices in all four trocars. Due to the new geometry of the "patient cart," an operation can be performed in all spatial directions without re-docking. Longer instruments and the markedly narrower mechanical elements of the "patient cart" provide greater flexibility as well as access similar to those of traditional laparoscopy. Currently, robotic surgery is used for a variety of indications in the treatment of benign gynecological diseases as well as malignant ones. Interdisciplinary cooperation and cooperation over large geographical distances have been rendered possible by telemedicine, and will ensure comprehensive patient care in the future by highly specialized surgery teams. In addition, the second operation console and the operation simulator constitute a new dimension in advanced surgical training. The disadvantages of robotic surgery remain the high costs of acquisition and maintenance as well as the laborious training of medical personnel before they are confident with using the technology.

Comparisons of risk prediction methods using nested case-control data

Using both simulated and real datasets, we compared two approaches for estimating absolute risk from nested case-control (NCC) data and demonstrated the feasibility of using the NCC design for estimating absolute risk. In contrast to previously published results, we successfully demonstrated not only that data from a matched NCC study can be used to unbiasedly estimate absolute risk but also that matched studies give better statistical efficiency and classify subjects into more appropriate risk categories. Our result has implications for studies that aim to develop or validate risk prediction models. In addition to the traditional full cohort study and case-cohort study, researchers designing these studies now have the option of performing a NCC study with huge potential savings in cost and resources. Detailed explanations on how to obtain the absolute risk estimates under the proposed approach are given. Copyright © 2016 John Wiley & Sons, Ltd.

A Systematic Approach to the Comparison of Cost Efficiency of Endopeptidases for the Hydrolysis of Atlantic Salmon (Salmo salar) By-Products

The hydrolytic and cost efficiencies of five endopeptidases (Alcalase 2.4L, Corolase 7089, Neutrase 0.8L, Promod 671L and Protex 7L) to hydrolyze Atlantic salmon by-products were compared at standardized activity levels based on a casein assay. The substrate was characterized prior to the hydrolytic experiments (pH=6.5, t=50 °C) to obtain substrate--specific constants for nitrogen to protein mass (in g) ratio, i.e. conversion factor f_N=5.23 and total amount of peptide bonds (h_tot)=9.3 mmol per g of protein. At low enzyme activity to substrate ratio, all enzymes were equally efficient in hydrolyzing the substrate. At highest enzyme activity to substrate ratio, Protex 7L, Alcalase 2.4L and Promod 671L gave higher degree of hydrolysis (DH=14.2-14.6%) than Corolase 7089 (13.2%) and Neutrase 0.8L (11.6%) after 120 min of hydrolysis. No differences were observed in protein recovery (yield of solubilized protein) relative to DH. Determination of DH was followed by the pH-STAT and o-phthaldialdehyde methods. Based on pH-STAT data, response surface regression models were established based on the combined effects of hydrolysis time and enzyme activity to substrate ratio on DH and protein recovery. The modelling approach was combined with enzyme cost to identify the most cost-efficient enzyme (Protex 7L).

Estimated cost per HIV infection diagnosed through routine HIV testing offered in acute general medical admission units and general practice settings in England

OBJECTIVES

Following national guidelines to expand HIV testing in high-prevalence areas in England, a number of pilot studies were conducted in acute general medical admission units (ACUs) and general practices (GPs) to assess the feasibility and acceptability of testing in these settings. The aim of this study was to estimate the cost per HIV infection diagnosed through routine HIV testing in these settings.

METHODS

Resource use data from four 2009/2010 Department of Health pilot studies (two ACUs; two GPs) were analysed. Data from the pilots were validated and supplemented with information from other sources. We constructed possible scenarios to estimate the cost per test carried out through expanded HIV testing in ACUs and GPs, and the cost per diagnosis.

RESULTS

In the pilots, cost per test ranged from £8.55 to £13.50, and offer time and patient uptake were 2 minutes and 90% in ACUs, and 5 minutes and 60% in GPs, respectively. In scenario analyses we fixed offer time, diagnostic test cost and uptake rate at 2 minutes, £6 and 80% for ACUs, and 5 minutes, £9.60 and 40% for GPs, respectively. The cost per new HIV diagnosis at a positivity of 2/1000 tests conducted was £3230 in ACUs and £7930 in GPs for tests performed by a Band 3 staff member, and £5940 in ACUs and £18 800 in GPs for tests performed by either hospital consultants or GPs.

CONCLUSIONS

Expanded HIV testing may be more cost-efficient in ACUs than in GPs as a consequence of a shorter offer time, higher patient uptake, higher HIV positivity and lower diagnostic test costs. As cost per new HIV diagnosis reduces at higher HIV positivity, expanded HIV testing should be promoted in high HIV prevalence areas.

Performance and Cost Comparisons for Continuous Rearing of Arma chinensis (Hemiptera: Pentatomidae: Asopinae) on a Zoophytogenous Artificial Diet and a Secondary Prey

The impact of a zoophytogenous, insect-free artificial diet and a secondary prey, pupae of Chinese oak silk moth Antheraea pernyi (Guérin-Méneville) (Lepidoptera: Saturniidae), on the developmental rate, life history parameters, and fertility was examined for F6, F9, and F12 consecutive generations for domesticated Arma chinensis (Fallou) (Heteroptera: Pentatomidae). This study showed that when fed an insect-free artificial diet during both the nymphal and adult stages, developmental times were prolonged, and fecundity, egg viability, net reproductive rates (R0), and intrinsic rates of increase (rm) declined. As a result, the cost to rear A. chinensis on the artificial diet approached 1.7 times the cost of rearing A. chinensis on pupae of A. pernyi. Future diet improvements should attempt to reduce developmental time, increase fecundity, and egg viability and use less costly nutrient sources.

Financial and quality impacts of the Medicare physician group practice demonstration

OBJECTIVE

To examine the impact of the Medicare Physician Group Practice (PGP) demonstration on expenditure, utilization, and quality outcomes.

DATA SOURCE

Secondary data analysis of 2001-2010 Medicare claims for 1,776,387 person years assigned to the ten participating provider organizations and 1,579,080 person years in the corresponding local comparison groups.

STUDY DESIGN

We used a pre-post comparison group observational design consisting of four pre-demonstration years (1/01-12/04) and five demonstration years (4/05-3/10). We employed a propensity-weighted difference-in-differences regression model to estimate demonstration effects, adjusting for demographics, health status, geographic area, and secular trends.

PRINCIPAL FINDINGS

The ten demonstration sites combined saved $171 (2.0%) per assigned beneficiary person year (p<0.001) during the five-year demonstration period. Medicare paid performance bonuses to the participating PGPs that averaged $102 per person year. The net savings to the Medicare program were $69 (0.8%) per person year. Demonstration savings were achieved primarily from the inpatient setting. The demonstration improved quality of care as measured by six of seven claims-based process quality indicators.

CONCLUSIONS

The PGP demonstration, which used a payment model similar to the Medicare Accountable Care Organization (ACO) program, resulted in small reductions in Medicare expenditures and inpatient utilization, and improvements in process quality indicators. Judging from this demonstration experience, it is unlikely that Medicare ACOs will initially achieve large savings. Nevertheless, ACOs paid through shared savings may be an important first step toward greater efficiency and quality in the Medicare fee-for-service program.

Levosimendan

We designed this review to examine the mechanism of action of levosimendan (Simdax^®, Orion Pharma, Espoo, Finland) and its current clinical application in critically ill adults and children with acutely decompensated severe congestive heart failure and who require inotropic support. We applied Pubmed (primarily) and Google search engines for English-language papers whose main topic was the use of levosimendan in the general population and those that concentrated on pediatric cohorts aged 0 to 18-year-old. Levosimendan increases contractile force of the heart and improves vasodilation. It increases the heart's sensitivity to calcium, thereby increasing cardiac contractility. Its mechanism of action is via the increased calcium sensitivity of myocytes by binding to cardiac troponin C in a calcium-dependent manner. Its opening of adenosine triphosphate-sensitive potassium channels in vascular smooth muscle leads to a vasodilatory effect and smooth muscle relaxation. Levosimendan was shown to be effective in the treatment of acute decompensated heart failure, rescue therapy for septic shock, weaning patients from assisted devices and weaning patients from inotropic therapy. Neonates with hypoplastic left heart syndrome who were treated by levosimendan showed improvement in systemic perfusion following cardiac surgery. Cost-effectiveness of this new drug is discussed.

Comparison of the costs of care during acute illness by two community children's nursing teams

OBJECTIVE

To compare the costs associated with care by two community children's nursing teams (CCNT).

DESIGN

A case study incorporating questionnaire survey, analysis of routinely collected data and analysis of costs in the north-west England.

PATIENTS

Children with acute illness referred for CCNT care.

INTERVENTIONS

Two CCNT provided care for 273 children during acute illness in order to reduce the number and duration of hospital admissions.

MAIN OUTCOME MEASURES

Costs of CCNT, other services and costs to families.

RESULTS

The objectives of both CCNT included shortening and avoiding hospitalisations. Most (45 (58%) in case A and 150 (77%) in case B) children were referred for infections. There were differences in the proportion of children who had been hospitalised (45 (57.7%) and 78 (40%)), the mean number of services used before referral to CCNT (1.6 and 2.2) and the staffing profile of the CCNT. There was a statistically significant difference in the overall mean cost to the NHS of CCNT care (£146 and £238, 95% CI for difference of means 7 to 184), associated with higher proportions of children having telephone-only contact (two (3%) and 46 (24%)) and children using almost twice as many other health services during care by one CCNT (means 0.27 and 0.51).

CONCLUSIONS

Costs of CCNT care can vary widely when all health service use is taken into account. Differences in the way CCNT are integrated with the urgent care system, and the way in which CCNT care is organised, could contribute to variations in costs.

Comparative cost efficiency across the European G5 countries of originators and a biosimilar erythropoiesis-stimulating agent to manage chemotherapy-induced anemia in patients with cancer

OBJECTIVES

To evaluate the comparative cost efficiency across the European Union G5 countries of the erythropoiesis-stimulating agents (ESAs) epoetin α (originator [Eprex®] and biosimilar [Binocrit®]; once weekly), epoetin β (NeoRecormon®; once weekly), and darbepoetin α (Aranesp®; once weekly or once every 3 weeks) under different scenarios of fixed and weight-based dosing in the management of chemotherapy-induced anemia.

METHODS

Direct costs of ESA treatment were calculated for one patient with cancer undergoing chemotherapy (six cycles at 3-week intervals) with ESA initiated at week 4 and continued for 15 weeks. Five scenarios were developed under fixed and weight-based dosing: continuous standard dose for 15 weeks; sustained dose escalation to 1.5× or double the standard dose at week 7, continued for 12 weeks; and discontinued dose escalation to 1.5× or double the standard dose at week 7 for a 3-week period, then 9 weeks of standard dose.

RESULTS

Under fixed dosing, the average cost of biosimilar epoetin α treatment across scenarios was €4643 (30,000 IU) or €6178 (40,000 IU). Corresponding estimates were €7168 for originator epoetin α, €7389 for epoetin β, €8299 for darbepoetin α once weekly, and €9221 for darbepoetin α once every 3 weeks. Under weight-based dosing, the average cost of biosimilar epoetin α treatment across scenarios was €4726. Corresponding estimates were €5484 for originator epoetin α, €5652 for epoetin β, and €8465 for both darbepoetin α once weekly and once every three weeks.

CONCLUSION

Managing chemotherapy-induced anemia with biosimilar epoetin α is consistently cost efficient over treatment with originator epoetin α, epoetin β, and darbepoetin α under both fixed and weight-based dosing scenarios.

Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries

OBJECTIVES

To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability.

SUBJECTS AND SETTING

Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury.

METHODS

Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: "low" (NPDS<10 (n=83)); "medium" (NPDS10-24 (n=112)); "high" (NPDS>24 (n=102)).

RESULTS

Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in "weekly cost of care" was greatest in the high dependency group at pound639 per week (95% CI 488 to 789)), as compared with the medium (pound323/week (95% CI 217 to 428)), and low (pound111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups.

CONCLUSIONS

The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients.

Can severely disabled patients benefit from in-patient neurorehabilitation for acquired brain injury?

Neurorehabilitation may be most cost efficient in those with the most severe disability