A model-based cost-utility analysis of an automated notification system for deteriorating patients on general wards

BACKGROUND

Delayed response to clinical deterioration of hospital inpatients is common. Deployment of an electronic automated advisory vital signs monitoring and notification system to signal clinical deterioration is associated with significant improvements in clinical outcomes but there is no evidence on the cost-effectiveness compared with routine monitoring, in the National Health Service (NHS) in the United Kingdom (UK).

METHODS

A decision analytic model was developed to estimate the cost-effectiveness of an electronic automated advisory notification system versus standard care, in adults admitted to a district general hospital. Analyses considered: (1) the cost-effectiveness of the technology based on secondary analysis of patient level data of 3787 inpatients in a before-and-after study; and (2) the cost-utility (cost per quality-adjusted life-year (QALY)) over a lifetime horizon, extrapolated using published data. Analysis was conducted from the perspective of the NHS. Uncertainty in the model was assessed using a range of sensitivity analyses.

RESULTS

The study population had a mean age of 68 years, 48% male, with a median inpatient stay of 6 days. Expected life expectancy at discharge was assumed to be 17.74 years. (1) Cost-effectiveness analysis: The automated notification system was more effective (-0.027 reduction in mean events per patient) and provided a cost saving of -£12.17 (-182.07 to 154.80) per patient admission. (2) Cost-utility analysis: Over a lifetime horizon the automated notification system was dominant, demonstrating a positive incremental QALY gain (0.0287 QALYs, equivalent to ~10 days of perfect health) and a cost saving of £55.35. At a threshold of £20,000 per QALY, the probability of automated monitoring being cost-effective in the NHS was 81%. Increased use of cableless sensors may reduce cost-savings, however, the intervention remains cost-effective at 100% usage (ICER: £3,107/QALY). Stratified cost-effectiveness analysis by age, National Early Warning Score (NEWS) on admission, and primary diagnosis indicated the automated notification system was cost-effective for most strategies and that use representative of the patient population studied was the most cost-saving strategy.

CONCLUSION

Automated notification system for adult patients admitted to general wards appears to be a cost-effective use in the NHS; adopting this technology could be good use of scarce resources with significance for patient safety.

Pandemic effects to autonomous vehicles test operations in California

Companies developing automated driving system (ADS) technologies have spent heavily in recent years to conduct live testing of autonomous vehicles operating in real world environments to ensure their reliable and safe operations. However, the unexpected onset and ongoing resurgent effects of the Covid-19 pandemic starting in March 2020 has serve to halt, change, or delay the achievement of these new product development test objectives. This study draws on data obtained from the California automated vehicle test program to determine the extent that testing trends, test resumptions, and test environments have been affected by the pandemic. The importance of government policies to support and enable autonomous vehicles development during pandemic conditions is highlighted.

The interaction effects of automation and population aging on labor market

Automation and population aging are two major forces that will shape the nature of works in the future. However, it is not clear how these forces will interact with each other and affect the labor market. This paper examines the interaction effects of computerization and population aging on the labor market. We found that computerization and population aging have large and statistically significant effects on employment growth but not earnings growth. Also, their interaction terms are statistically significant only for employment growth but not for earnings growth.

Comparison of four commercial, automated antigen tests to detect SARS-CoV-2 variants of concern

A versatile portfolio of diagnostic tests is essential for the containment of the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic. Besides nucleic acid-based test systems and point-of-care (POCT) antigen (Ag) tests, quantitative, laboratory-based nucleocapsid Ag tests for SARS-CoV-2 have recently been launched. Here, we evaluated four commercial Ag tests on automated platforms and one POCT to detect SARS-CoV-2. We evaluated PCR-positive (n = 107) and PCR-negative (n = 303) respiratory swabs from asymptomatic and symptomatic patients at the end of the second pandemic wave in Germany (February–March 2021) as well as clinical isolates EU1 (B.1.117), variant of concern (VOC) Alpha (B.1.1.7) or Beta (B.1.351), which had been expanded in a biosafety level 3 laboratory. The specificities of automated SARS-CoV-2 Ag tests ranged between 97.0 and 99.7% (Lumipulse G SARS-CoV-2 Ag (Fujirebio): 97.03%, Elecsys SARS-CoV-2 Ag (Roche Diagnostics): 97.69%; LIAISON^® SARS-CoV-2 Ag (Diasorin) and SARS-CoV-2 Ag ELISA (Euroimmun): 99.67%). In this study cohort of hospitalized patients, the clinical sensitivities of tests were low, ranging from 17.76 to 52.34%, and analytical sensitivities ranged from 420,000 to 25,000,000 Geq/ml. In comparison, the detection limit of the Roche Rapid Ag Test (RAT) was 9,300,000 Geq/ml, detecting 23.58% of respiratory samples. Receiver-operating-characteristics (ROCs) and Youden’s index analyses were performed to further characterize the assays’ overall performance and determine optimal assay cutoffs for sensitivity and specificity. VOCs carrying up to four amino acid mutations in nucleocapsid were detected by all five assays with characteristics comparable to non-VOCs. In summary, automated, quantitative SARS-CoV-2 Ag tests show variable performance and are not necessarily superior to a standard POCT. The efficacy of any alternative testing strategies to complement nucleic acid-based assays must be carefully evaluated by independent laboratories prior to widespread implementation.

Regional development potentials of Industry 4.0: Open data indicators of the Industry 4.0+ model

This paper aims to identify the regional potential of Industry 4.0 (I4.0). Although the regional background of a company significantly determines how the concept of I4.0 can be introduced, the regional aspects of digital transformation are often neglected with regard to the analysis of I4.0 readiness. Based on the analysis of the I4.0 readiness models, the external regional success factors of the implementation of I4.0 solutions are determined. An I4.0+ (regional Industry 4.0) readiness model, a specific indicator system is developed to foster medium-term regional I4.0 readiness analysis and foresight planning. The indicator system is based on three types of data sources: (1) open governmental data; (2) alternative metrics like the number of I4.0-related publications and patent applications; and (3) the number of news stories related to economic and industrial development. The indicators are aggregated to the statistical regions (NUTS 2), and their relationships analyzed using the Sum of Ranking Differences (SRD) and Promethee II methods. The developed I4.0+ readiness index correlates with regional economic, innovation and competitiveness indexes, which indicates the importance of boosting regional I4.0 readiness.

Covid-19 driven advances in automation and artificial intelligence risk exacerbating economic inequality

Anton Korinek and Joseph E Stiglitz make the case for a deliberate effort to steer technological advances in a direction that enhances the role of human workers

Research on the energy-saving control strategy of a belt conveyor with variable belt speed based on the material flow rate

Aiming at solving the problem of high energy consumption in the rated belt speed operation of a belt conveyor system when the material flow rate is reduced, the power consumption of the frequency converter, motor, and belt conveyor is analyzed, a power consumption model of the belt conveyor system is established, the relationship between the power consumption of the belt conveyor system and belt speed is obtained, and a energy-saving control strategy of the belt conveyor with variable belt speed based on the material flow rate is put forward. The energy consumption of the belt conveyor is analyzed for a practical case. Results show that the power consumption model is accurate and the control strategy effectively reduces energy consumption. The model has high application value in coal, ports, power, mine, metallurgy, chemical, and other industries.

People versus machines in the UK: Minimum wages, labor reallocation and automatable jobs

This study follows the Lordan and Neumark (2018) analysis for the US, and examines whether minimum wage increases affect employment opportunities in automatable jobs in the UK for low-skilled low-wage workers. Overall, I find that increasing the minimum wage decreases the share of automatable employment held by low-skilled low-wage workers, and increases the likelihood that workers in automatable jobs become dis-employed. On aggregate the effect size is modest, but I also provide evidence that these effects are larger in more recent years. The study also highlights significant heterogeneity by industry and demographic group, including more substantive adverse effects for older low-skilled workers in manufacturing, as well as effects at the intensive margin.

[Automated Driving Cuts the Future]

There are strong expectations for automated driving. Whether the purpose is accident prevention or driver shortage, it is technically difficult to move fully automatically anywhere, and it is also difficult to establish business potential and merchantability through reasonable cost. In this paper, to properly understand automated driving, I will explain the current conditions and prospects.

Comparative Cost-Effectiveness Analysis of Three Different Automated Medication Systems Implemented in a Danish Hospital Setting

INTRODUCTION

Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice.

METHODS

The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period.

RESULTS

With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation.

CONCLUSION

The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.

Cost and benefit estimates of partially-automated vehicle collision avoidance technologies

Many light-duty vehicle crashes occur due to human error and distracted driving. Partially-automated crash avoidance features offer the potential to reduce the frequency and severity of vehicle crashes that occur due to distracted driving and/or human error by assisting in maintaining control of the vehicle or issuing alerts if a potentially dangerous situation is detected. This paper evaluates the benefits and costs of fleet-wide deployment of blind spot monitoring, lane departure warning, and forward collision warning crash avoidance systems within the US light-duty vehicle fleet. The three crash avoidance technologies could collectively prevent or reduce the severity of as many as 1.3 million U.S. crashes a year including 133,000 injury crashes and 10,100 fatal crashes. For this paper we made two estimates of potential benefits in the United States: (1) the upper bound fleet-wide technology diffusion benefits by assuming all relevant crashes are avoided and (2) the lower bound fleet-wide benefits of the three technologies based on observed insurance data. The latter represents a lower bound as technology is improved over time and cost reduced with scale economies and technology improvement. All three technologies could collectively provide a lower bound annual benefit of about $18 billion if equipped on all light-duty vehicles. With 2015 pricing of safety options, the total annual costs to equip all light-duty vehicles with the three technologies would be about $13 billion, resulting in an annual net benefit of about $4 billion or a $20 per vehicle net benefit. By assuming all relevant crashes are avoided, the total upper bound annual net benefit from all three technologies combined is about $202 billion or an $861 per vehicle net benefit, at current technology costs. The technologies we are exploring in this paper represent an early form of vehicle automation and a positive net benefit suggests the fleet-wide adoption of these technologies would be beneficial from an economic and social perspective.

Seeking an Explanation for the Poor Uptake of In-Hospital AED Programs

The automated external defibrillator (AED) has been adopted by emergency service personnel as a first-line intervention in the management of out-of-hospital cardiac arrest (OHCA). AED leads to more successful Advanced Cardiac Life Support; consequently, national resuscitation organisations worldwide have recommended that nurses and doctors also integrate AEDs as a component of their basic life-support response to cardiac arrest. Despite these recommendations, the implementation of AED programs within hospitals has been generally sporadic and isolated. A continuation of this situation will most likely disturb and perplex nurses and patients, as they are key stakeholders with respect to upholding recommended BLS practices. In the absence of any explanation from change agents within hospitals, this paper seeks, by way of a pilot study and a review of the literature, to identify the extent of the problem and identify factors contributing to the relatively slow uptake of this device. We argue that nurses and other first responders to in-hospital cardiac arrest (CA) have much to gain, in the context of Occupational Health Safety and Welfare (OHS and W), from ready access to AEDs. Cost factors are also considered, with initial cost of AED purchase likely to be a major concern for managers of hospital budgets. The issues we discuss in this paper clearly support the need for further research to (a) explain the nature of public hospital resistance to AEDs and (b) to consider whether AEDs will provide practical advantages to public hospitals from an occupational, social and economic perspective.

Can automation in radiotherapy reduce costs?

BACKGROUND

Computerized automation is likely to play an increasingly important role in radiotherapy. The objective of this study was to report the results of the first part of a program to implement a model for economical evaluation based on micro-costing method. To test the efficacy of the model, the financial impact of the introduction of an automation tool was estimated. A single- and multi-center validation of the model by a prospective collection of data is planned as the second step of the program.

MATERIAL AND METHODS

The model was implemented by using an interactive spreadsheet (Microsoft Excel, 2010). The variables to be included were identified across three components: productivity, staff, and equipment. To calculate staff requirements, the workflow of Gemelli ART center was mapped out and relevant workload measures were defined. Profit and loss, productivity and staffing were identified as significant outcomes. Results were presented in terms of earnings before interest and taxes (EBIT). Three different scenarios were hypothesized: baseline situation at Gemelli ART (scenario 1); reduction by 2 minutes of the average duration of treatment fractions (scenario 2); and increased incidence of advanced treatment modalities (scenario 3). By using the model, predicted EBIT values for each scenario were calculated across a period of eight years (from 2015 to 2022).

RESULTS

For both scenarios 2 and 3 costs are expected to slightly increase as compared to baseline situation that is particularly due to a little increase in clinical personnel costs. However, in both cases EBIT values are more favorable than baseline situation (EBIT values: scenario 1, 27%, scenario 2, 30%, scenario 3, 28% of revenues).

CONCLUSION

A model based on a micro-costing method was able to estimate the financial consequences of the introduction of an automation tool in our radiotherapy department. A prospective collection of data at Gemelli ART and in a consortium of centers is currently under way to prospectively validate the model.

Reducing the risk of injury from table saw use: the potential benefits and costs of automatic protection

The use of table saws in the United States is associated with approximately 28,000 emergency department (ED) visits and 2,000 cases of finger amputation per year. This article provides a quantitative estimate of the economic benefits of automatic protection systems that could be designed into new table saw products. Benefits are defined as reduced health-care costs, enhanced production at work, and diminished pain and suffering. The present value of the benefits of automatic protection over the life of the table saw are interpreted as the switch-point cost value, the maximum investment in automatic protection that can be justified by benefit-cost comparison. Using two alternative methods for monetizing pain and suffering, the study finds switch-point cost values of $753 and $561 per saw. These point estimates are sensitive to the values of inputs, especially the average cost of injury. The various switch-point cost values are substantially higher than rough estimates of the incremental cost of automatic protection systems. Uncertainties and future research needs are discussed.

Automated and electronically assisted hand hygiene monitoring systems: a systematic review

BACKGROUND

Hand hygiene is one of the most effective ways to prevent transmission of health care-associated infections. Electronic systems and tools are being developed to enhance hand hygiene compliance monitoring. Our systematic review assesses the existing evidence surrounding the adoption and accuracy of automated systems or electronically enhanced direct observations and also reviews the effectiveness of such systems in health care settings.

METHODS

We systematically reviewed PubMed for articles published between January 1, 2000, and March 31, 2013, containing the terms hand AND hygiene or hand AND disinfection or handwashing. Resulting articles were reviewed to determine if an electronic system was used.

RESULTS

We identified 42 articles for inclusion. Four types of systems were identified: electronically assisted/enhanced direct observation, video-monitored direct observation systems, electronic dispenser counters, and automated hand hygiene monitoring networks. Fewer than 20% of articles identified included calculations for efficiency or accuracy.

CONCLUSIONS

Limited data are currently available to recommend adoption of specific automatic or electronically assisted hand hygiene surveillance systems. Future studies should be undertaken that assess the accuracy, effectiveness, and cost-effectiveness of such systems. Given the restricted clinical and infection prevention budgets of most facilities, cost-effectiveness analysis of specific systems will be required before these systems are widely adopted.

High-level endoscope disinfection processes in emerging economies: financial impact of manual process versus automated endoscope reprocessing

BACKGROUND

The use of flexible endoscopes is growing rapidly around the world. Dominant approaches to high-level disinfection among resource-constrained countries include fully manual cleaning and disinfection and the use of automated endoscope reprocessors (AERs). Suboptimal reprocessing at any step can potentially lead to contamination, with consequences to patients and healthcare systems.

AIM

To compare the potential results of guideline-recommended AERs to manual disinfection along three dimensions - productivity, need for endoscope repair, and infection transmission risk in India, China, and Russia.

METHODS

Financial modelling using data from peer-reviewed published literature and country-specific market research.

FINDINGS

In countries where revenue can be gained through productivity improvements, conversion to automated reprocessing has a positive direct impact on financial performance, paying back the capital investment within 14 months in China and seven months in Russia. In India, AER-generated savings and revenue offset nearly all of the additional operating costs needed to support automated reprocessing.

CONCLUSION

Among endoscopy facilities in India and China, current survey-reported practices in endoscope reprocessing using manual soaking may place patients at risk of exposure to pathogens leading to infections. Conversion from manual soak to use of AERs, as recommended by the World Gastroenterology Organization, may generate cost and revenue offsets that could produce direct financial gains for some endoscopy units in Russia and China.

High-fidelity, low-cost, automated method to assess laparoscopic skills objectively

BACKGROUND

We sought to define the extent to which a motion analysis-based assessment system constructed with simple equipment could measure technical skill objectively and quantitatively.

METHODS

An "off-the-shelf" digital video system was used to capture the hand and instrument movement of surgical trainees (beginner level = PGY-1, intermediate level = PGY-3, and advanced level = PGY-5/fellows) while they performed a peg transfer exercise. The video data were passed through a custom computer vision algorithm that analyzed incoming pixels to measure movement smoothness objectively.

RESULTS

The beginner-level group had the poorest performance, whereas those in the advanced group generated the highest scores. Intermediate-level trainees scored significantly (p < 0.04) better than beginner trainees. Advanced-level trainees scored significantly better than intermediate-level trainees and beginner-level trainees (p < 0.04 and p < 0.03, respectively).

CONCLUSIONS

A computer vision-based analysis of surgical movements provides an objective basis for technical expertise-level analysis with construct validity. The technology to capture the data is simple, low cost, and readily available, and it obviates the need for expert human assessment in this setting.

A new screening method for proteinuria using Erythrosin B and an automated analyzer--rapid, sensitive and inexpensive determination

BACKGROUND

In spite of the urgent necessity for a screening test of urinary protein for the early diagnosis of kidney diseases, a rapid, accurate and cost-effective method for their detection has yet to be developed.

METHODS

A solution containing a buffer agent (pH 2.3) and surfactants and a solution of Erythrosin B are added to a urine sample. After letting the mixture stand for 5 min at 37°C, the dye-bound protein is measured by a spectrophotometer at 546 nm using a Hitachi 7170S automated analyzer.

RESULTS

The calibration curve was linear with human serum albumin concentration in the range of 2.4-200 mg/l. The detection limit, 2.4 mg/l was superior to conventional dye-binding methods by one order of magnitude and comparable to the turbidimetric immunoassay (TIA). Spot urine samples from 70 patients who showed (-) or (±) in the dip-stick screening test for proteinuria and 79 healthy volunteers were analyzed. There was an excellent correlation (r=0.978, n=149) between the results given by the proposed method and those by the TIA.

CONCLUSIONS

This method provides a viable alternative to the conventional immunoassay-based methods for urinary protein measurement, and will be useful in the diagnosis of early stage kidney disease.

Curbing infections via electronic surveillance

Infection control programs can generate a wealth of data, but many professionals become overwhelmed when trying to translate the data into actionable knowledge. Automated surveillance systems have the potential to greatly streamline these efforts, but many questions arise about how to evaluate these systems, their costs, benefits and more. Here are answers to some of the most important questions on this issue.

[On machines and instruments (II): the world in the eye of the work of E. T. A. Hoffmann]

Continuing with the subject of the previous work, this article considers the whole series of problems connected to the question of vision provoked by the mere existence of the body of the automaton. The eyes of the android and, above all, the reactions aroused by looking at these human-shaped machines are the object of Hoffman's reflections, from a viewpoint apparently firmly set within the Goethean concept of the <<world of the eye>> - Welt des Auges. Similarly, there is as it had been perceived in science since the seventeenth century.

AutoCPAP initiation at home: optimal trial duration and cost-effectiveness

BACKGROUND

The duration of automatic computer-controlled continuous positive airway pressure device (autoCPAP) initiation at home varies largely between sleep centers. Our objectives were to evaluate the cost-effectiveness and to find the optimal trial duration.

METHODS

Of the 206 consecutive CPAP-naive patients with obstructive sleep apnea syndrome, who were referred to our hospital, 166 received autoCPAP for a 5-day trial at home.

RESULTS

Of the 166 patients, 89 (15 women) showed a successful 5-day autoCPAP trial (normalized oximetry and mask-on time exceeding 4 h/day for at least 4 days). For the first trial day, 88 (53%) patients had normalized oximetry and a mask-on time exceeding 4 h. A 1-day autoCPAP trial EUR 668 was less cost-effective than a 5-day trial EUR 653, with no differences in values of efficient CPAP pressure or residual apnea-hypopnea index (AHI). The systematic requirement of oximetry monitoring raised the cost considerably from EUR 481 to EUR 668.

CONCLUSIONS

In selected patients with obstructive sleep apnea, the optimal duration for initiating CPAP therapy at home by autoCPAP is 5 days. Although a 1-day trial was sufficient to determine the CPAP pressure requirement, it was not cost-effective and had a high rate of failure.

Guidelines for implementing automation in a hospital laboratory setting--part II

Laboratories entering into a discussion regarding automation of their facility have a number of key issues that need to be considered right away. What is the financial impact going to be? How do we know which processes we should automate and which ones we shouldn't? Which vendor is going to best align with the goals of our organization? Developing a thorough and robust plan at the start of the automation process is vital to the overall success of the project. It requires dedicated staff members who are willing to do the research, crunch the numbers, and present the data effectively. In Part II of this manuscript, issues such as cost analyses, business plans, and purchasing decisions are each covered thoroughly.

Breaking down barriers to electronic claims settlement

Past attempts to transition payer and provider environments to electronic claims settlements have faced several obstacles. However, technological advances, the development of more secure databases, bank-independent approaches to electronic funds transfer and electronic remittance advice, and the availability of secure archives are now making electronic settlement increasingly practical, cost-effective, and attainable.

[Equipment components and system board for an automated microscopy system]

Characteristics of modern equipment components for general- or special-purpose modular systems of automated microscopy are considered. Medical, technical, and economic assessment of various configurations of automated microscopy systems is performed. These systems can be used in telemedicine and hematological, cytological, and parasitologic analysis. Schemes for optimization of the configuration of automated microscopy systems are described. The structure of MECOS-Ts2 automated microscopy systems is considered. The system board of MECOS-Ts2 systems makes it possible to use a wide variety of equipment components and software from different manufacturers.

The Profitability of Automatic Milking on Dutch Dairy Farms

Several studies have reported on the profitability of automatic milking based on different simulation models, but a data-based study using actual farm data has been lacking. The objective of this study was to analyze the profitability of dairy farms having an automatic milking system (AMS) compared with farms using a conventional milking system (CMS) based on real accounting data. In total, 62 farms (31 using an AMS and 31 using a CMS) were analyzed for the year 2003 in a case control study. Differences between the years 2002 and 2003 also were analyzed by comparing a subgroup of 16 farms with an AMS and 16 farms with a CMS. Matching was based on the time of investment in a milking system (same year), the total milk production per year, and intensity of land use (kg/ha). Results from 2003 showed that the farms with an AMS used, on average, 29% less labor than farms with a CMS. In contrast, farms using a CMS grew faster (37,132 kg of milk quota and 5 dairy cows) than farms with an AMS (-3,756 kg milk quota and 0.5 dairy cows) between 2002 and 2003. Dairy farmers with a CMS had larger (euro7,899) revenues than those with an AMS. However, no difference in the margin on dairy production was detected, partly because of numerically greater (euro6,822) variable costs on CMS farms. Dairy farms were compared financially based on the amount of money that was available for rent, depreciation, interest, labor, and profit (RDILP). The CMS farms had more money (euro15,566) available for RDILP than the AMS farms. This difference was caused by larger fixed costs (excluding labor) for the AMS farms, larger contractor costs (euro6,422), and larger costs for gas, water, and electricity (euro1,549). Differences in costs for contractors and for gas, water, and electricity were statistically significant. When expressed per full-time employee, AMS farms had greater revenues, margins, and gross margins per full-time employee than did CMS farms. This resulted in a substantially greater (but not statistically significant) RDILP per full-time employee (euro12,953) for AMS farms compared with CMS farms. Depreciation and interest costs for automatic milking were not available but were calculated based on several assumptions. Assuming larger purchase costs and a shorter depreciation time for AMS than for CMS, costs for depreciation and interest were larger for AMS farms than for CMS farms. Larger fixed costs should be compensated for by the amount of labor that has become available after introducing the milking robot. Therefore, farm managers should decide whether the extra time acquired by automatic milking balances against the extra costs associated with an AMS.

Culture without the petri-dish

Automation of oocyte maturation and embryo production techniques is a new and exciting development in the field of reproductive technologies. There are two areas where increased automation is having an impact: in the area of embryo diagnostics and in the process of embryo production itself. Benefits include decreased staffing and skill requirements for production and assessment of embryos, as well as increasing quality management systems by removing the "human" factor. However, the uptake of new technologies is likely to be slow, as costs and the conservative nature of the Assisted Reproduction Technology industry to adopt new techniques.

Cost-effectiveness analysis of medical documentation alternatives

OBJECTIVES

The delay between patient discharge and the completion of the final discharge note have prompted hospitals to consider new information technologies. This study compared the relative cost-effectiveness of an automated medical documentation system to the current system in place at a Canadian hospital. There are significant expenditures associated with the choice of medical documentation system, yet the benefit to the patient population has not been studied.

METHODS

A systematic review of the literature was carried out. Cost data for the current documentation system were obtained from the study hospital. The costs of purchasing the automated system were obtained from the manufacturer. Other resource cost implications of the automated system were estimated based on information obtained from the Centre for Applied Health Informatics at the study hospital. The outcome was determined to be the average time (days) between patient discharge and note completion. A cost-effectiveness analysis was conducted. Sensitivity analyses were used to determine the robustness of the results.

RESULTS

The automated documentation system was associated with higher costs but better outcomes than the current system. The incremental cost-effectiveness ratio used for comparing the automated medical documentation system with the traditional system indicated that the incremental daily cost for decreasing a day in average note completion time per discharge note was 0.331 Canadian $/day over the study period (4 years).

CONCLUSIONS

Although the automated documentation system was more expensive than the current system, it also provided qualitative benefits that were not considered in the cost-effectiveness analysis.

Automated Screening for Biological Weapons in Homeland Defense

Biological threat detection programs that collect air samples and monitor for large-scale release of biowarfare agents generate large numbers of samples that must be quickly and accurately screened for the presence of biological agents. An impediment to the rapid analysis of large numbers of environmental biological samples is that manual laboratory processes are time-consuming and require resources to maintain infrastructure, trained personnel, and adequate supplies of testing reagents. An ideal screening system would be capable of processing multiple samples rapidly, cost-effectively, and with minimal personnel. In the present study, we evaluated the Automated Biological Agent Testing System (ABATS) to explore the capability of automation to increase sample throughput, maximize system accuracy, and reduce the analysis costs associated with biological threat agent screening in environmental samples. This study demonstrates the utility of this concept and the potential of an automated system to address the growing environmental monitoring needs of the United States.

Driving affinity selection by centrifugal force

We describe a new approach to affinity selection based on the application of centrifugal force to macromolecules in solution. The method relies on the well known macromolecular hydrodynamic principles of centrifugation. It can be automated and operated in a centralized fashion, or it can be decentralized and used by single researchers or networks of researchers with a minimal additional capital investment. In this method, a centrifugal driving force is used to establish a differential and selective concentration gradient between a therapeutic target and potential ligands in compound libraries. This concentration gradient, in turn, drives the binding of ligands. Once formed, the differential concentration gradient of target macromolecules and ligands is fractionated to capture the self-sorting binding events. Ligand binding is defined by the individual ligand binding constants, so tight binding ligands will essentially distribute identically with the protein target, and weaker binding ligands will not. The level of affinity needed to operationally define tight binding can be adjusted by selecting the initial concentration conditions or centrifugal force. A variety of rapid, commonly available, detection methods can be used to assess binding in the fractionated samples. The method can be broadly applied in drug discovery efforts to examine most types of cell-cell, protein-protein, and protein-small molecule interactions. We describe the application of this method to systems of small molecule interactions with several macromolecules of therapeutic interest.

Impact of the New Beckman Coulter Cytomics FC 500 5-Color Flow Cytometer on a Regional Flow Cytometry Clinical Laboratory Service

Calgary Laboratory Services (CLS) in Alberta, Canada, is the regional reference laboratory providing flow cytometry services for southern Alberta and southeastern British Columbia. As a busy reference flow laboratory we provide flow cytometry immunophenotyping for investigation and diagnosis of acute and chronic leukemias, lymphomas, immunodeficiencies, neuroblastoma, platelet disorders, and interstitial lung disease (ILD). Because of increasing workload and the continual effort to improve the service to our health care providers, CLS invested in the new Beckman Coulter Cytomics FC 500 5-color flow cytometer. In addition to time and labor savings due to reduced maintenance and operating system design, this new flow cytometer automates many of the previous manual steps involved in quality control and flow cytometric analysis. It also incorporates 2 lasers and is capable of measuring 5-color antibody combinations in a single tube, enabling us to reduce the number of tubes and overall costs, giving us better gating options for minimal residual disease analysis. We present the first published evaluation, an assessment of the overall productivity and cost impact of the new state-of-the-art Cytomics FC 500 flow cytometer. Implementation of the Cytomics FC 500 has resulted in a 20% reduction in reagent costs and shorter turnaround time for analysis and diagnosis. This instrument has allowed us to reduce our acute leukemia panel from 17 to 13 tubes, our lymphoma panel from 13 to 7 tubes, and our ILD panel from 4 to 2 tubes. The availability of 2 lasers provides more flexibility in choosing antibodies and conjugates to customize immunophenotyping panels. It also allows us to use the DRAQ5 dye and simultaneously analyze the immunophenotype and DNA content of cells with very little compensation. Many of the arduous, time-consuming flow operator tasks often associated with previous generation flow cytometry instruments, such as color compensation, list mode analysis, sample repeats, and interpretations, have been substantially reduced with the Cytomics FC 500 5-color flow cytometer. In conclusion the Cytomics FC 500 5-color flow cytometer is a major advance in flow cytometry instrumentation and has reduced our overall reagent costs by 20%, provided better information and speedier turnaround time to our health care professionals. It is an ideal flow cytometer for any busy clinical or research flow cytometry service.

Workflow Improvement and Impact of the New Beckman Coulter LH 1500 High Throughput Automated Hematology Workcell

Our core laboratory at St. Joseph's Medical Center (SJMC) recently installed the new Beckman Coulter LH 1500 fully automated hematology workcell. Like many laboratories in North America and other parts of the world, we are under significant pressure to improve productivity, reduce costs, and improve service provision to our hospital and clinician bases. The difficulty of meeting this challenge is often further compounded by an increasing shortage of qualified technologist personnel. We recently reported on the significant productivity gains with the introduction of the LH 750 hematology system into the core laboratory, including a 23% reduction in slide review rate, automation of reticulocyte and nucleated red blood cell counts, and an 82% increase in the pass-through rate. Evolution to the next stage of automation has come much quicker than anticipated owing to a steep rise in workload and an ever increasing shortage of trained and experienced technologists to fill vacancies in the 24-hour core laboratory operation. We chose to upgrade our LH 750 analyzers to the newly introduced LH 1500 hematology workcell in order to cope with the increased workload and shortage of available experienced hematology technologists. The LH 1500 is a compact, high throughput, fully automated hematology workcell. It is designed to automate all manual process and handling steps associated with hematology analyses, including sample sorting, loading and unloading of cassettes, automatic rerun and reflex testing, sample storage, and tracking of samples. The LH 1500 is comprised of a minimum of 2, and up to 4, LH 750 instruments (with or without integrated slidemaker/stainers). The instruments are bidirectionally interfaced and linked to a fully automated conveyor track, specimen inlet and outlet stations, a sample stockyard, and a line controller. The configuration we chose at SJMC incorporates 1 LH 750 and 1 LH 755. We report that the upgrade to the LH 1500 was a relatively straightforward process and required no redesign of the core laboratory. Based on our evaluation, we estimate cost savings with the LH 1500 of between three quarters to 1 full-time equivalent, which eliminated or decreased many manual handling steps. In addition, this increase in efficiency has freed up our technologist resources to concentrate on the more difficult and clinically important samples. This is the first published report on the new LH 1500 hematology workcell. Our research indicates that the LH 1500 is the first hematology workcell to offer hematology laboratories the next level of automation and virtually eliminate preanalytical and postanalytical sample handling and sorting. For core laboratories and high-throughput hematology laboratories that face similar pressures to ours, the LH 1500 would appear as an attractive solution to maximize hematology productivity and improve service delivery.

Laboratory evaluation of a fully automated chemiluminescence immunoassay for rapid detection of HBsAg, antibodies to HBsAg, and antibodies to hepatitis C virus

The performance of a fully automated, random access, enhanced chemiluminescence immunoassay (Ortho/ECi) for the detection of antibody to hepatitis C virus (HCV) (anti-HCV), HBsAg, and antibody to HBsAg (anti-HBsAg), in human serum was compared to a Abbott second-generation enzyme immunoassay (EIA 2.0). The Ortho/ECi assays employ an immunometric technique with enhanced chemiluminescence for optimal assay performance. With regard to the study of clinical laboratory performance, six groups of sera prescreened with Abbott EIAs were assayed: anti-HCV-negative samples (n = 318), anti-HCV-positive samples (n = 177), anti-HBsAg-negative samples (n = 241), anti-HBsAg-positive samples (n = 239), HBsAg-positive samples (n = 158), and HBsAg-negative samples (n = 312). Sera with discrepant results in the two serological assays were resolved by confirmatory tests. Sera with indeterminate results by one or more confirmatory tests were evaluated by reviewing medical records. The overall concordance between the Ortho/ECi assay and the Abbott EIA were 97.78, 93.54, and 97.66% for anti-HCV antibodies, anti-HBsAg antibodies, and HBsAg, respectively. After resolving the discrepancies, the specificities of the new assay for anti-HCV and anti-HBsAg antibodies and HBsAg were 98.1, 92.8, and 100%, respectively. The sensitivities of the new assay for anti-HCV, anti-HBsAg, and HBsAg were 100, 98.8, and 97.4%, respectively. In conclusion, The Ortho/ECi assays for diagnosis of HCV and hepatitis B virus (HBV) infections are highly specific and sensitive assays. The rapid turnaround time, random access, full automation, and high throughput make it an effective assay system for clinical laboratory diagnosis of HCV and HBV infections.

Automated tissue engineering: a major paradigm shift in health care

The tissue engineering product market is projected to rise to US $80 billion by 2012. However, the technology must become an automated process to enable predictions to become reality.

The effects of total laboratory automation on the management of a clinical chemistry laboratory. Retrospective analysis of 36 years

BACKGROUND

Thirty-six years of data and history of laboratory practice at our institution has enabled us to follow the effects of analytical automation, then recently pre-analytical and post-analytical automation on productivity, cost reduction and enhanced quality of service.

METHODS

In 1998, we began the operation of a pre- and post-analytical automation system (robotics), together with an advanced laboratory information system to process specimens prior to analysis, deliver them to various automated analytical instruments, specimen outlet racks and finally to refrigerated stockyards. By the end of 3 years of continuous operation, we compared the chemistry part of the system with the prior 33 years and quantitated the financial impact of the various stages of automation.

RESULTS

Between 1965 and 2000, the Consumer Price Index increased by a factor of 5.5 in the United States. During the same 36 years, at our institution's Chemistry Department the productivity (indicated as the number of reported test results/employee/year) increased from 10,600 to 104,558 (9.3-fold). When expressed in constant 1965 dollars, the total cost per test decreased from 0.79 dollars to 0.15 dollars. Turnaround time for availability of results on patient units decreased to the extent that Stat specimens requiring a turnaround time of <1 h do not need to be separately prepared or prioritized on the system.

CONCLUSIONS

Our experience shows that the introduction of a robotics system for perianalytical automation has brought a large improvement in productivity together with decreased operational cost. It enabled us to significantly increase our workload together with a reduction of personnel. In addition, stats are handled easily and there are benefits such as safer working conditions and improved sample identification, which are difficult to quantify at this stage.

OR automation systems

An operating room (OR) automation system is a combination of hardware and software designed to address efficiency issues in the OR by controling multiple devices via a common interface. Systems range from the relatively basic--allowing control of a few devices within a single OR--to advanced designs that are capable of not only controlling a wide range of devices within the OR but also exchanging information with remote locations.

Automated transport and sorting system in a large reference laboratory: part 1. Evaluation of needs and alternatives and development of a plan

BACKGROUND

Our laboratory, a large, commercial, esoteric reference laboratory, sought some form of total laboratory automation to keep pace with rapid growth of specimen volumes as well as to meet competitive demands for cost reduction and improved turnaround time.

METHODS

We conducted a systematic evaluation of our needs, which led to the development of a plan to implement an automated transport and sorting system. We systematically analyzed and studied our specimen containers, test submission requirements and temperatures, and the workflow and movement of people, specimens, and information throughout the laboratory. We performed an intricate timing study that identified bottlenecks in our manual handling processes. We also evaluated various automation options.

RESULTS

The automation alternative viewed to best meet our needs was a transport and sorting system from MDS AutoLab. Our comprehensive plan also included a new standardized transport tube; a centralized automated core laboratory for higher volume tests; a new "automation-friendly" software system for order entry, tracking, and process control; a complete reengineering of our order-entry, handling, and tracking processes; and remodeling of our laboratory facility and specimen processing area.

CONCLUSIONS

The scope of this project and its potential impact on overall laboratory operations and performance justified the extensive time we invested (nearly 4 years) in a systematic approach to the evaluation, design, and planning of this project.

Automated transport and sorting system in a large reference laboratory: part 2. Implementation of the system and performance measures over three years

BACKGROUND

Our laboratory implemented a major automation system in November 1998. A related report describes a 4-year process of evaluation and planning leading to system installation. This report describes the implementation and performance results over 3 years since the system was placed into use.

METHODS

Project management software was used to track the project. Turnaround times of our top 500 tests before and after automation were measured. We compared the rate of hiring of employees and the billed unit per employee ratio before and after automation by use of linear regression analysis. Finally, we analyzed the financial contribution of the project through an analysis of return on investment.

RESULTS

Since implementation, the volume of work transported and sorted has grown to >15,000 new tubes and >25,000 total tubes per day. Median turnaround time has decreased by an estimated 7 h, and turnaround time at the 95th percentile has decreased by 12 h. Lost specimens have decreased by 58%. A comparison of pre- and post-implementation hiring rates of employees estimated a savings of 33.6 employees, whereas a similar comparison of ratios of billed units per employee estimated a savings of 49.1 employees. Using the higher figure, we estimated that the $4.02 million cost of the project would be paid off approximately 4.9 years subsequent to placing the system into daily use.

CONCLUSIONS

The overall automation project implemented in our laboratory has contributed considerably to improvement of key performance measures and has met our original project objectives.

[Modularization by the open standard. (I)]

We are proceeding with the project called "Open LA21 Project" in the course of the clinical laboratory automation toward the 21st century. With the modular system that realizes integration, downsizing, a reasonable price, and is the future course in the clinical testing automation system as well, we aim to establish common standards among manufacturers as the only way to create user friendly market environments where the proper competition exists among the manufacturers. The common standards which are in preparation by the participating companies as "Open module system standards" are the standards which are going to be made public. They are intended to guarantee connection, compatibility of the products in conformity with the standards. In this project, we intend to realize the modular system that integrates each field, such as chemistry, hematology, coagulation/fibrinolysis, immunology, urinalysis in an early stage, and contribute positively to restructuring and upgrading the "raison d'etre" of the 21st century clinical testing.

[Developmental frontier of a modular automated system]

The clinical laboratory is faced with increasing problems such as healthcare reform, cost pressure and increased laboratory regulations. Despite these problems, the users have even higher expectations for laboratory services. To resolve these issues, the clinical laboratory must become more efficient by incorporating creative solutions and adapting to changes. One key word is increased automation of laboratory procedures and integration of automated systems. First, automation will reduce the dependence on manual labor. Second, laboratories could perform a larger menu of tests in-house. This not only reduces expense but also reduces the turn around time for testing. To realize cost reduction and reduce turn around time, we propose the Modular system.

[Standardization of operation monitoring and control of the clinical laboratory automation system]

Laboratory automation systems showed up in the 1980s and have been introduced to many clinical laboratories since early 1990s. Meanwhile, it was found that the difference in the specimen tube dimensions, specimen identification formats, specimen carrier transportation equipment architecture, electromechanical interfaces between the analyzers and the automation systems was preventing the systems from being introduced to a wider extent. To standardize the different interfaces and reduce the cost of laboratory automation, NCCLS and JCCLS started establishing standards for laboratory automation in 1996 and 1997 respectively. Operation monitoring and control of the laboratory automation system have been included in their activities, resulting in the publication of an NCCLS proposed standard in 1999.

[Recent trends in the standardization of laboratory automation]

Laboratory automation systems have been introduced to many clinical laboratories since early 1990s. Meanwhile, it was found that the difference in the specimen tube dimensions, specimen identification formats, specimen carrier transportation equipment architecture, electromechanical interfaces between the analyzers and the automation systems was preventing the systems from being introduced to a wider extent. To standardize the different interfaces and reduce the cost necessary for the laboratory automation, NCCLS and JCCLS started establishing standards for the laboratory automation in 1996 and 1997 respectively. NCCLS has published five proposed standards which that are expected to be approved by the end of 2000.

The role of total laboratory automation in a consolidated laboratory network

BACKGROUND

In an effort to reduce overall laboratory costs and improve overall laboratory efficiencies at all of its network hospitals, the North Shore-Long Island Health System recently established a Consolidated Laboratory Network with a Core Laboratory at its center.

METHODS

We established and implemented a centralized Core Laboratory designed around the Roche/Hitachi CLAS Total Laboratory Automation system to perform the general and esoteric laboratory testing throughout the system in a timely and cost-effective fashion. All remaining STAT testing will be performed within the Rapid Response Laboratories (RRLs) at each of the system's hospitals.

RESULTS

Results for this laboratory consolidation and implementation effort demonstrated a decrease in labor costs and improved turnaround time (TAT) at the core laboratory. Anticipated system savings are approximately $2.7 million. TATs averaged 1.3 h within the Core Laboratory and less than 30 min in the RRLs.

CONCLUSIONS

When properly implemented, automation systems can reduce overall laboratory expenses, enhance patient services, and address the overall concerns facing the laboratory today: job satisfaction, decreased length of stay, and safety. The financial savings realized are primarily a result of labor reductions.

Laboratory automation: trajectory, technology, and tactics

Laboratory automation is in its infancy, following a path parallel to the development of laboratory information systems in the late 1970s and early 1980s. Changes on the horizon in healthcare and clinical laboratory service that affect the delivery of laboratory results include the increasing age of the population in North America, the implementation of the Balanced Budget Act (1997), and the creation of disease management companies. Major technology drivers include outcomes optimization and phenotypically targeted drugs. Constant cost pressures in the clinical laboratory have forced diagnostic manufacturers into less than optimal profitability states. Laboratory automation can be a tool for the improvement of laboratory services and may decrease costs. The key to improvement of laboratory services is implementation of the correct automation technology. The design of this technology should be driven by required functionality. Automation design issues should be centered on the understanding of the laboratory and its relationship to healthcare delivery and the business and operational processes in the clinical laboratory. Automation design philosophy has evolved from a hardware-based approach to a software-based approach. Process control software to support repeat testing, reflex testing, and transportation management, and overall computer-integrated manufacturing approaches to laboratory automation implementation are rapidly expanding areas. It is clear that hardware and software are functionally interdependent and that the interface between the laboratory automation system and the laboratory information system is a key component. The cost-effectiveness of automation solutions suggested by vendors, however, has been difficult to evaluate because the number of automation installations are few and the precision with which operational data have been collected to determine payback is suboptimal. The trend in automation has moved from total laboratory automation to a modular approach, from a hardware-driven system to process control, from a one-of-a-kind novelty toward a standardized product, and from an in vitro diagnostics novelty to a marketing tool. Multiple vendors are present in the marketplace, many of whom are in vitro diagnostics manufacturers providing an automation solution coupled with their instruments, whereas others are focused automation companies. Automation technology continues to advance, acceptance continues to climb, and payback and cost justification methods are developing.

In situ detection of a PCR-synthesized human pancentromeric DNA hybridization probe by color pigment immunostaining: application for dicentric assay automation

We report a low cost and efficient method for synthesizing a human pancentromeric DNA probe by the polymerase chain reaction (PRC) and an optimized protocol for in situ detection using color pigment immunostaining. The DNA template used in the PCR was a 2.4 kb insert containing human alphoid repeated sequences of pancentromeric DNA subcloned into pUC9 (Miller et al. 1988) and the primers hybridized to internal sequences of the 172 bp consensus tandem repeat associated with human centromeres. PCR was performed in the presence of biotin-11-dUTP, and the product was used for in situ hybridization to detect the pancentromeric region of human chromosomes in metaphase spreads. Detection of pancentromeric probe was achieved by immunoenzymatic color pigment painting to yield a permanent image detected at high resolution by bright field microscopy. The ability to synthesize the centromeric probe rapidly and to detect it with color pigment immunostaining will lead to enhanced identification and eventually to automation of various chromosome aberration assays.