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Cost Savings Associated With Implementing 4 Total Joint Replacement Electronic Clinical Quality Measures Nationally: 2020-2040.

Digital transformation using widely available electronic data is a key component to improving health outcomes and customer choice and decreasing cost and measurement burden. Despite these benefits, existing information on the potential cost savings from electronic clinical quality measures (eCQMs) is limited. We assessed the costs of implementing 4 eCQMs related to total hip and/or total knee arthroplasty into electronic health record systems across healthcare systems in the United States. We used published literature and technical expert panel consultation to calculate low-, mid-, and high-range hip and knee arthroplasty surgery projections, and used empirical testing, literature, and technical expert panel consultation to develop an economic model to assess projected cost savings of eCQMs when implemented nationally. Low-, mid-, and high-range projected cost savings for year's 2020, 2030, and 2040 were calculated for 4 orthopedic eCQMs. Mid-range projected cost savings for 2020 ranged from $7.9 to $31.9 million per measure per year. A breakeven of between 0.5% and 5.1% of adverse events (measure dependent) must be averted for cost savings to outweigh implementation costs. All measures demonstrated potential cost savings. These findings suggest that eCQMs have the potential to lower healthcare costs and improve patient outcomes without adding to physician documentation burden. The Centers for Medicare and Medicaid Services' investment in eCQMs is an opportunity to reduce adverse outcomes and excess costs in orthopedics.

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Stakeholder collaboration in the forecast-informed reservoir operations (FIRO) pilot project at Lake Mendocino, California

PurposeWater is a critical and contentious resource in California, hence any changes in reservoir management requires coordination among many basin stakeholders. The Forecast-Informed Reservoir Operations (FIRO) pilot project at Lake Mendocino, California explored the viability of using weather forecasts to alter the operations of a United States Army Corps of Engineers (USACE) reservoir. The pilot project demonstrated FIRO's ability to improve water supply reliability, but also revealed the key role of a collaborative Steering Committee. Because Lake Mendocino's Viability Assessment did not explore the features of the Steering Committee, this study aims to examine the relationships and interactions between Steering Committee members that supported FIRO's implementation at Lake Mendocino.Design/methodology/approachThe project identified 17 key project participants who spoke at a FIRO workshop or emerged through chain-referrals. Using semi-structured interviews with these participants, the project examined the dynamics of human interactions that enabled the successful multi-institutional and multi-criteria innovation as analyzed through text-coding.FindingsThe results reveal the importance for FIRO Steering Committee members to understand the limitations and constraints of stakeholder counterparts at other organizations, the importance of building and safeguarding relationships, and the role of trust and belonging between members. The lessons learned suggest several interventions to support successful group collaboration dynamics for future FIRO projects.Originality/valueThis study identifies features of the Steering Committee that contributed to FIRO's success by supporting collaborative negotiations of infrastructure operations within a multi-institutional and multi-criteria context.

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Open Access
Atmospheric aerosol particles before, during, and after a convective dust event on the Jornada experimental range as measured using Raman hyperspectral imaging

AbstractThe effects of winds and local mineralogy on ambient aerosol composition are poorly understood. We measured the Raman spectra (RS) of ambient aerosol particles on the Jornada Experimental Range, a desert location in southern New Mexico, used these RS to group spectra by composition or spectral features, and compared the numbers of RS with the winds and minerology. An aerosol Raman hyperspectral imager was used to collect particles onto a tape and measure a hyperspectral Raman image in 15‐ or 20‐min intervals. Over a 48 h period, 6306 RS were above the thresholds used and were analyzed further. Multiple RS may originate from the same particle. Of these 6306 RS, 2567 were classified as luminescence; 2647 contained the D and G peaks of DG Carbon (DGC, which includes soots, black carbon, and similar materials); 43 exhibited peaks consistent with CH stretching; and 130, 102, and 29 RS were consistent with quartz, carbonates (calcite and dolomite), and potassium feldspar, respectively. A convective dust event was concurrent with an increase in the number of RS of luminescent particles >20X the median; numbers of DGC RS in the interquartile range of DGC for the entire measurement period; RS consistent with quartz, calcite, iron oxides, feldspar, and anatase; and no RS consistent with oxalates or nitrates. This work shows that hyperspectral Raman imaging can help understand the time‐dependent composition of ambient aerosol particles at time resolutions below an hour.

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Quantification of natural gas and other hydrocarbons from production sites in northern West Virginia using tracer flux ratio methodology.

Tracer flux ratio (TFR) methodology performed downwind of 15 active oil and natural gas production sites in Ohio County, West Virginia sought to quantify air pollutant emissions over two weeks in April 2018. In coordination with a production company, sites were randomly selected depending on wind forecasts and nearby road access. Methane (CH4), ethane (C2H6), and tracer gas compounds (acetylene and nitrous oxide) were measured via tunable infrared direct absorption spectroscopy. Ion signals attributed to benzene (C6H6) and other volatile gases (e.g., C7 - C9 aromatics) were measured via proton-transfer reaction time-of-flight mass spectrometry. Short-term whole facility emission rates for 12 sites are reported. Results from TFR were systematically higher than the sum of concurrent on-site full flow sampler measurements, though not all sources were assessed on-site in most cases. In downwind plumes, the mode of the C2H6:CH4 molar ratio distribution for all sites was 0.2, which agreed with spot sample analysis from the site operator. Distribution of C6H6:CH4 ratios was skew but values between 1 and 5 pptv ppbv-1 were common. Additionally, the aromatic profile has been attributed to condensate storage tank emissions. Average ratios of C7 - C9 to C6H6 were similar to other literature values reported for natural gas wells.

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Open Access
System Approach for Characterizing and Evaluating Factors for Occupational Health Impacts Due to Nonfatal Injuries and Illnesses for the Use in Life Cycle Assessment.

Occupational injuries and illnesses are major risk factors for human health impacts worldwide, but they have not been consistently nor comprehensively considered in life cycle impact assessment (LCIA) methods. In this study, we quantified occupational health impacts as disability-adjusted life years (DALYs) for nonfatal injuries and illnesses in all US industries. We further applied an economic input-output model of the US economy to develop a new data set of characterization factors (CFs) that links direct and indirect occupational health impacts to product life cycle final demand. We found that the CF data set varies significantly by industry, ranging from 6.1 to 298 DALYs per billion dollars. About 20% of final demand in the US economic system contributes nearly 50% of the total impacts of occupational health, suggesting occupational health impacts are concentrated in a small portion of industries. To verify the feasibility of the CFs and demonstrate their importance, we included a case of an office chair. The occupational health impacts caused by nonfatal injuries and illnesses during the production of an office chair are of the same order of magnitude as those caused by chemical emissions across the chair's life cycle, with 1.1 × 10-5 and 1.4 × 10-5 DALYs per chair, respectively. Results and data sets derived from this study support the integration of occupational health impacts with LCIA methods.

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Open Access
Diatom-based transfer functions for pH and total phosphorus in Vermont, USA lakes

Abstract At a landscape scale, lakes function as early warning signs of ecological change in response to environmental stressors. Changes to the terrestrial landscape such as alterations in land-use or land-cover alter the quality and quantity of subsidies delivered to downstream lakes, resulting in cascading impacts on aquatic communities and ecosystem function. Together with climate change processes that alter subsidy delivery and processing rates, lakes are inextricably connected to their adjacent landscape, acting as dynamic integrators of auto- and allogenic stressors. These processes are recorded in lake sediments and can be inferred and reconstructed using paleolimnological proxies. Like much of the Northeastern USA, lakes in the state of Vermont are changing rapidly in response to multiple stressors. This includes more than 800 lakes that span gradients of elevation, latitude, trophic status, depth, clarity, and watershed area. Long term monitoring data indicates that oligotrophic lakes are experiencing increases in total phosphorus, and many montane lakes recovering from acidification are now experiencing browning and rapid surface water warming. Understanding these trends at long-term scales requires proxy-based reconstruction of sediment records. Here we describe regional training-sets and transfer functions for TP and pH developed using modern water chemistry and sediment diatom records from 80 and 96 lakes, respectively, spanning chemical, trophic, latitudinal, and elevation gradients. We reconstruct these variables for the period predating the European settlement of the state (~ 1800) using a top-bottom approach for 96 lake cores and present a high-resolution reconstruction of these variables for acid-impaired, mesotrophic Beaver Pond. Based on our findings, we present recommendations and limitations for model application.

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Open Access
Impact of oxygenated fuels on atmospheric emissions in major Colombian cities

The use of oxygenated gasolines has increased in Latin America over the past several years with the goal to reduce oil dependence, improve gasoline combustion and emit fewer pollutants to the atmosphere. Countries such as Brazil, Colombia, Mexico, Argentina, and Peru blend their gasoline with ethanol in different proportions. In Colombia, the regulation establishes a 10% vol of ethanol in gasoline (E10). Ethers are also used to oxygenate gasolines. MTBE (methyl tert-butyl ether) is blended in gasoline primarily in Mexico, Venezuela, and Chile, while ETBE (ethyl tertiary-butyl ether) is used in Argentina. The U.S. EPA Motor Vehicle Emissions Simulator (MOVES) model was adapted to Colombia to evaluate gasoline blends with two renewable oxygenates (ethanol and ETBE) on the emission of criteria pollutants (PM2.5, CO, NOx, SO2), Total Gaseous Hydrocarbons (TGH), Volatile Organic Compounds (VOCs), and toxic compounds. We followed the same approach used to build MOVES-Mexico and assess fuel specifications changes on vehicle emissions.The MOVES-Colombia model finds that E10 increases fuel volatility, VOCs, NOx, PM2.5, and SO2 emissions, and decreases CO relative to the unoxygenated base gasoline (E0). The impact of E10 consumption on air quality is due not only to primary pollutants, but also to the emission of ozone and PM2.5 precursors. Compared to E10 and E0, the ETBE blends reduce fuel volatility and emissions of VOCs, TGH, CO, NOx, PM2.5, and SO2. The introduction of ETBE could help major urban areas to meet air quality standards even with their current vehicle fleets. This work highlights that the effect of new fuel specifications needs to be properly assessed in terms of air quality before they are put in place. The development of modeling tools, such as MOVES-Colombia, facilitates the study of fuel quality and vehicle technology on pollutant emissions.

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Complexities in attributing lead contamination to specific sources in an industrial area of Philadelphia, PA

Globally, lead (Pb) contamination is one of the top ten chemical exposure issues affecting public health. The identification of specific Pb sources provides valuable information to determine assignment of liability for site cleanup, improve sampling plans and develop remedial strategies. This paper examines Pb concentrations and Pb isotopic data from samples collected at and near the site of a Pb paint production facility with a long operating history. Although high soil Pb concentrations were found at the site, Pb concentrations in surrounding neighborhoods did not simply decline with distance from the site. We evaluated soil concentrations and isotopic mixing lines to explore potential sources of Pb pollution. Three-isotope plots showed overlap of site samples and the surrounding neighborhood, consistent with pollution from the facility affecting offsite soils. A major challenge in separation of potential sources, however, is that the isotopic signatures of other potential Pb sources fall within the range of the soil data. The long operational site history, soil disturbances, the presence of nearby smelters, and other local and remote sources affect identification of lead sources. This analysis demonstrates that source attribution can be confounded by incomplete site and material sourcing information. An integrated approach that includes in-depth site characterization and an evaluation of historical activities (e.g., Pb ores used over time, amounts of Pb emitted by all area smelters, land use changes, and soil disturbances) is important for determining source attribution. This analysis provides insight into future site investigations where soil lead contamination has resulted from a long industrial history in an urban setting.

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Open Access