Toddler's fractures (TF) are stable tibia fractures in children 1 to 4 years of age. Skin breakdown is a complication associated with casting and splinting and has been a continued issue at our institution. Based on literature review, we implemented a new treatment algorithm for TF. The purpose of this study is to evaluate the outcomes of our protocol with a particular focus on skin breakdown. Our protocol included exclusive utilization of controlled ankle motion (CAM) boots for immobilization, coaching ED and urgent care teams on proper CAM boot application and wear, creation and dissemination of handouts for caregivers, with an emphasis on frequent boot removal and skin checks, and the standardization of clinic scheduling protocols. A retrospective chart review of 429 patients with TF between 2019 and 2023 was performed. This included 358 patients prior to implementation of the new protocol and 71 patients after. Patient demographics, immobilization method, and the degree of skin breakdown was recorded. There was no difference in patient age or sex between the two groups. Significantly larger percentage of patients were treated in CAM boots in the post-protocol group (66/71 (93%)) as compared with the pre-protocol group (116/358 (32.4%), P=0.0001). In the pre-protocol group, 61/358 (17%) had skin breakdown, the majority of whom had been treated in a long leg cast (LLC) (85.2%). In the post-protocol group, 7/71 (9.9%) had skin breakdown. This was not statistically different as compared with the pre-protocol group (P=0.208). However, in the post-protocol group, all incidences of skin breakdown occurred in patients who presented and were treated initially to an outside facility, with breakdown present at the time of initial presentation to our institution. When comparing wounds that developed during treatment at our institution, the post-protocol group had significantly less skin breakdown compared with the pre-protocol group, 0/7 (0%) vs. 27/61 (44.3%), P=0.037. Implementation of the new protocol yielded an average cost savings of $187 per encounter for patients and their families. A care management protocol using CAM boots for immobilization, provided at initial presentation, was successfully implemented at our institution. This protocol yielded decreased skin breakdown rates among internally managed patients and equivalent rates of fracture healing compared with those immobilized via traditional long leg casts. The protocol also reduced overall cost of the episode of care for the patient. Despite these internal improvements, skin breakdown continues to be encountered in patients initially treated at outside facilities unfamiliar with our protocol. Future directions will focus on early clinic follow-up to assess proper fitting of CAM boots, caregiver education, expansion of the protocol to include referral institutions, and further reduction of cost and radiation exposure to patients by eliminating unnecessary follow-up clinic visits and radiographs. III: (retrospective cohort study).

Flow cytometry (FC) is an expensive method that is unaffordable for many patients from underprivileged nations. We aimed to reduce the total budget of the test by optimizing a limited antibody panel, guided by morphological assessment. This retrospective observational study included 395 patients referred for flow cytometry at the Rehman Medical Institute in Peshawar. Bone marrow or peripheral blood samples were immunophenotyped using a limited panel of flow markers after morphological and cytochemical assessments. The samples were stained with fluorochrome-labeled monoclonal antibodies and analyzed using a Cytoflex flow cytometer. Data were analyzed using R and R studio by calculating frequency and percentage for descriptive statistics while results are presented in graphs, tables, and charts. Out of 395 cases, an acute leukemia panel was requested for 225 (56.9%) cases, a lymphoproliferative panel for 80 (20.3%) cases, an absolute CD4 count for 80 (20.3%) cases, and proximal nocturnal hemoglobinuria (PNH) clone screening for 10 (2.5%) cases. Of the 225 acute leukemia cases, 160 (71.1%) were newly diagnosed and 65 (28.9%) were follow-up cases. In the follow-up cases, 21 (32.3%) were in remission, 13 (19.3%) were not in remission, and 31 (48.4%) were in relapse. 98% of cases of acute leukemia and lymphoproliferative disorders and 100% of cases of PNH and absolute CD4 count were conclusively diagnosed using our limited flow panels. Our panel achieved 74-82% average cost reductions and 61-68% reductions in turnaround time (TAT) compared with established reference laboratories in Pakistan. Optimizing a minimal antibody panel in resource-limited settings enhances flow cytometry-based diagnosis, reduces patient financial burden, enables timely and accurate results, and guides treatment decisions to improve patient outcomes.

Abstract Since 2018, the fall armyworm, Spodoptera frugiperda (J.E. Smith) (Lepidoptera: Noctuidae) has posed a significant threat to maize production in Thailand, prompting the government to recommend the use of natural enemy insects (NE) for biological control. However, previous studies on NE propagation costs, which are vital for widespread adoption, have often relied on single-scale estimates and have lacked comprehensive cost classifications. This study estimated the propagation costs of four NE species used to control S. frugiperda in Thailand— Trichogramma pretiosum (Riley) (Hymenoptera: Trichogrammatidae), Eocanthecona furcellata (Wolff) (Hemiptera: Pentatomidae), Sycanus versicolor (Dohrn) (Hemiptera: Reduviidae), and Proreus simulans (Stål) (Dermaptera: Chelisochidae)—based on rearing costs incurred at a government research institute. A small-scale production cost model was developed by considering factors such as the populations of NE, hosts, and prey, and the associated input quantities and costs. The model accounts for economies of scale and estimates both the current and potential costs at the maximum scale manageable by a single worker. At this optimal scale, the average costs were 15 USD/ha for T. pretiosum , 57 USD/ha for E. furcellata , 276 USD/ha for S. versicolor , and 237 USD/ha for P. simulans . Per-hectare costs decline with larger production scales, highlighting the importance of labor-saving innovation. Economic simulations suggest that small-scale T. pretiosum production could be profitable if maize producers accept slightly higher costs than those of conventional pesticides and if adequate distribution networks are in place.

This paper addresses the operational planning problem of redistributing empty load carriers (ELCs) across multiple production sites of an automobile manufacturer during the ramp-up of a new vehicle model. With the increasing prevalence of platform and modular production concepts, identical component groups are produced and consumed in parallel at several sites, creating significant challenges for ELC allocation. To analyse this problem, we formulate a discrete-time, finite-horizon stochastic inventory model with discounted costs. We show analytically that, for each production site, there exists a cost-optimal policy for repositioning ELCs. Based on operational data from a major German car manufacturer, we evaluate alternative ramp-up strategies across vehicle plants. The results demonstrate that overlap-free ramp-ups can reduce costs by up to two orders of magnitude relative to fully synchronised ramp-ups without offsets. Compared to the company’s existing ELC control system, our approach achieves average cost savings of 33% and substantially lowers cost variance. These findings highlight not only the cost-efficiency of the proposed model but also its robustness, providing stable solutions that can be effectively applied across diverse operational scenarios.

Background: The aim of the S.A.P.O.R.E. (Sustainable And Pocket friendly Options for nutritious and Responsible Eating) initiative was to offer students attending the University of Brescia a teaching kitchen programme to develop cooking and food skills (CS and FS) and promote healthy food choices. Methods: The course was structured in four weekly lessons, and both before and after, participants were asked to anonymously complete validated questionnaires to assess CS and FS, adherence to the Mediterranean Diet (MD) and dietary fibre intake. Levels of competence and satisfaction were assessed at the end of the course. Results: Twenty-eight students completed the course. Mean CS and FS scores significantly increased, from 56.1 ± 19.8 to 68.0 ± 16.5 (score range 0–98, p < 0.001) and from 92.7 ± 22.4 to 104.3 ± 21.0 (score range 0–133; p = 0.012), respectively. The MediLite score significantly increased from 9.43 ± 2.77 to 10.9 ± 2.06 (p = 0.006). The mean daily dietary fibre intake increased slightly from 17.8 ± 8.4 to 19.2 ± 7.1 g. More than 70% of participants correctly answered the questionnaire about acquired competence. The average cost for a single meal was EUR 1.50 ± 0.60, and the mean level of students’ satisfaction was 4.4 out of 5. Conclusions: This initiative was significantly associated with improvement in CS, FS and adherence to MD, but not in fibre intake.

Antimicrobial resistance (AMR) is one of the greatest threats to public health, and forecasts for 2050 are even worse. In response, the European Commission (EC) is proposing the Transferable Exclusivity Extension Voucher (TEEV), which aims to encourage the development of innovative antimicrobials. It consists of extending data exclusivity for a medicine selected by the beneficiary company or another company to which the voucher can be sold (i.e. not necessarily the antimicrobial). One requirement for obtaining it is to declare any public contributions received for the antimicrobial R&D. Based on a review of the literature and interviews with five AMR experts, a theoretical and real view of how the TEEV works and its estimated costs is presented, in addition to the impact that the requirement for transparency in R&D costs would have. On the one hand, the results show that a (well-designed) TEEV, coordinated by the EC, offers significant public health benefits compared with the cost of inaction and provides predictability for investors, although, by its nature, it delays the entry of generics/biosimilars and does not provide an access scheme to new antimicrobials. Recent assessments estimate the total healthcare cost at €162 million per voucher and the average cost for each Member State at €6 million. On the other hand, transparency of R&D costs could enable policymakers to design policies focused on public health needs and better design the optimal mix of (push and pull) incentives for new antimicrobials, but they run the risk of threatening trade secrets, discouraging private investment and promoting the application of cost-plus pricing regulations. In conclusion, the TEEV could be a great incentive to combat AMR inaction, but it has not yet been implemented and needs to be complemented by other push and pull incentives. Furthermore, more information is needed on the impact of R&D costs transparency in the context of antimicrobials.

This article proposes a modified method for calculating specific energy intensity and constructs a panel cost model to analyze the impact of energy costs on the cost of milk and meat. The modification was implemented to assess the impact of direct and indirect energy costs on the cost of livestock production. The data source used was reports from 26 agricultural enterprises of various types in southern Russia for the pe-riod 2022–2024, as well as tariff and agricultural statistics data. The relevance of this issue is that farms annually consume 930–1,540 kWh per head of cattle. Pig farming requires 28.7–48.7 kWh to raise one animal from birth to fattening, depending on the housing system. In cow-calf systems, total energy consumption varies from 3,000 to 12,600 megajoules per head of cattle per year, with indirect energy costs for feed ac-counting for the largest portion. Energy costs affect production through direct operat-ing costs (heating, ventilation, lighting, equipment) and indirectly, through feed costs. Methods include elimination, numerical modeling, scenario analysis, and calculation of energy costs in physical units. A methodology for accounting for indirect energy costs is proposed. A factor model has been built that allows for a quantitative assess-ment of the impact of energy prices on production costs, highlighting differences by farm type. Practically significant results of a scenario analysis have been obtained for energy cost increases (10%, 20%, 50%), highlighting differences by enterprise type. The methodology for accounting for indirect energy costs (feed production, transport) has been refined. A model has been built that allows for studying energy price increase scenarios and assessing differences by farm type. A positive and statis-tically significant relationship has been established between the specific energy cost and production costs; With a 10% increase in energy prices, the average cost of live-stock production increases by 1.26%, while with a 20% increase in energy prices, the increase is 2.63%. We summarized various energy costs in standard physical units (J, kWh). We developed a methodology for accounting for direct and indirect energy costs at the enterprise level. The research results can serve as the basis for proposals for energy conservation and support measures for livestock production to improve its sustainability.

BackgroundAccording to CDC, vancomycin should be a key-target for ASP; and high negative-predictive-value of nasal MRSA PCR screening (nMP) for pneumonia has been shown.MethodsInformatics-based ASP interventions were implemented at a tertiary-care-center serving the tristate area in Upper Midwest as current state/ Fishbone analyses showed that vancomycin-use for pneumonia is high and nMP are not being done as not easy to remember/order. SMART aim was to reduce vancomycin-use by 20% for pneumonia by 3/15/25. Automated Default nMP order was incorporated in Pneumonia order-set in EMR (Epic) while ordering vancomycin for Hospital Acquired pneumonia/Ventilator associated pneumonia on 10/7/24 and for Severe Community Acquired pneumonia meeting criteria for vancomycin on 11/4/24.Vancomycin-use during pre-intervention-period(P1: 4/1/24-9/30/24) was compared with intervention-period(P2: 10/15/24-3/15/2025).ResultsOutcome measures (vancomycin duration; cost) showed a significant decline on XmR SPC charts (Figures 1 and 2). Average vancomycin use decreased by 49.5% (from 72.2 DOT/1000 patient days in P1 to 36.3 DOT/1000 patient days in P2, p< 0.01). Average Vancomycin drug inventory cost decreased by 50% (from 1089.5 USD/1000 patient days in P1 to 546.3 USD/1000 patient days in P2; p< 0.05). All Process measures showed a significant, sustained change: proportion of nMP ordering increased to 100% in P2 (p< 0.0001); proportion of negative PCR results leading to discontinuation of vancomycin increased by 84% (p< 0.01) and time to discontinuation of vancomycin declined by >50% (p< 0.05); balancing measures [readmissions and total time from order to PCR results] remained unchanged.ConclusionInformatics-based ASP interventions were highly transformative leading to a significant decline in total vancomycin utilization, considerable healthcare-cost savings and significant increase in nMP screening among patients hospitalized with pneumonia; and should be considered for implementation on a wider scale.DisclosuresAll Authors: No reported disclosures

BackgroundInappropriate antibiotic use, driven by self-medication and community-level misconceptions remains as a major contribution to antimicrobial resistance in India. This study assesses the impact of pharmacist-led, community-based education in the reduction of self-medication practices and antibiotic expectations in rural South India.Cost-Saving OutcomesSelf Medication RatesMethodsWe conducted a controlled pre-post study between July to December 2024 in two demographically similar rural villages of Tamil Nadu, India. The intervention village was provided with a multi-modal educational program, involving weekly awareness sessions, illustrated handouts and social media campaigns. The social media campaign aimed local community groups to promote the importance of proper health-seeking behaviours and to reduce self-medication. The control village received standard care. The primary outcomes included changes in self-medication behaviour and antibiotic expectations, measured using pre- and post-intervention knowledge, attitudes and practices (KAP) surveys as well as self-medication rates from local pharmacy data.KAP Score Improvement ComparisonResultsA total of 827 participants (412 in the intervention and 415 in the control village) completed both the pre and post-surveys. In the intervention village, self-medication practice was significantly reduced by 63.6% (from 44.5% to 16.2%, p < 0.001), while the control village showed no significant change. Antibiotic expectation during fever episodes dropped from 62% to 24% in the intervention village (p < 0.001). Mean knowledge scores increased by 41% in the intervention group (p < 0.001). Post-campaign, 88% of participants in the intervention village recognized pharmacists as a trusted health resource. Analysis of pharmacy records showed a 67–72% reduction in average treatment costs for common self-treated conditions.ConclusionThe study highlights the significant contributions pharmacists can make in promoting antimicrobial stewardship and reducing AMR at the grassroots level. This intervention model, which uses digital and social media platforms, could be applied in other rural areas & communities which could make people understand the importance of AMR.DisclosuresAll Authors: No reported disclosures

BackgroundSolid organ transplant recipients (SOTR) are at high risk for severe COVID-19 infections due to immunosuppression and variable response to immunization. The recommended oral antiviral, paxlovid has significant drug-drug interactions with medications that prevent graft rejection. As an alternative, three-day intravenous (IV) remdesivir is efficacious in the outpatient setting. MedStar Georgetown Infectious Disease (ID) Division and Transplant Institute collaborated with an infusion company to administer remdesivir at home for SOTR to reduce hospitalization while avoiding severe COVID infection, drug interactions, and exposure of vulnerable patients in infusion centers. Here, we describe the feasibility, outcomes, and cost savings of short course remdesivir home infusions for SOTR with COVID-19.MethodsWe conducted a single center retrospective chart review study at MedStar Georgetown University Hospital of SOTR diagnosed with COVID-19 and referred to receive home IV remdesivir December 1, 2022 to May 6, 2024. Patients were evaluated by ID physicians, then started on a three-day course of remdesivir as an outpatient. Analyses included descriptive statistics of study participants’ demographics and outcomes. Costs of average hospital length of stay in Washington DC were compared to those of home infusion administration.ResultsThe study included 144 SOT patients: 50% liver, 50.7% kidney, 3.5% pancreas, and 2.5% small bowel. The average age was 55 years old, with an average duration of COVID symptoms of 2.5 days prior to presentation. 2.78% of patients were hospitalized within 30 days of evaluation, and 0.69% patient died. The average cost of administration for 3 days was $4279, comparable to one day of hospitalization in DC ($4068), saving an estimated $855,900.ConclusionPatients receiving home infusion remdesivir had low hospitalization and mortality rates, suggesting reduced risk of disease progression. This program likely saved $855,900 by avoiding hospitalization. Limitations include an inability to compare actual costs and outcomes to a relevant inpatient population. Home infusion of remdesivir is a safe delivery method and may reduce overall cost of healthcare.DisclosuresRebecca Nirmal Kumar, MD, AstraZeneca: Advisor/Consultant|AstraZeneca: Grant/Research Support|Pfizer: Grant/Research Support Rohit Satoskar, MD, Madrigal: Honoraria

Exoskeletons have exhibited increasingly diverse designs and broader applications in rehabilitation and medical fields. To achieve optimal assistance performance, it is essential that the assistive force be synchronized with human biomechanics. However, current soft exoskeletons still face challenges in achieving natural gait synchronization and providing stable, comfortable assistance. This study proposes a biomimetic assistance method for a hip soft exoskeleton that better matches natural human gait. It explores how integrating a dual‑pretension mechanism with biomechanics‑based force modeling can enhance assistive performance, improve user comfort, and reduce metabolic energy consumption during walking. By mimicking the muscle force characteristics of hip joint extension and flexion, two sets of assistive torque curves were developed to correspond with human biomechanical motion. Additionally, to compensate for the hysteresis inherent in the exoskeleton system, a pre‑tension force was applied before and after the assistive curves to improve response time. To enhance the accuracy of gait cycle prediction and achieve better synchronization with natural gait patterns, a Gaussian-weighted moving average algorithm was employed to adaptively assign higher weights to recent gait data, thereby improving the responsiveness and adaptability of the exoskeleton. In the experiments, six subjects participated, and their net metabolic rates were compared under assisted and unassisted conditions. The results showed that the subjects' average metabolic cost decreased by 16.4% at a walking speed of 3 km/h and by 14.1% on a 4° slope. Compared with previous approaches, the proposed algorithm achieved more accurate gait‑phase adaptation and reduced metabolic expenditure, highlighting its potential for human-exoskeleton co‑adaptation.

The deregulation of the Nigerian power sector and the subsequent 2024 Multi-Year Tariff Order (MYTO) issued by NERC have precipitated a financial crisis for public institutions, as illustrated by the reclassification of government hospitals in Anambra State into “Band A” feeders, which triggered a tariff surge from ~₦68/kWh to ~₦217/kWh and effectively disregarded the social service nature of healthcare. This study assesses the financial and operational impact of these high electricity tariffs on government hospitals in Anambra State, specifically NAUTH and COOUTH, and validates the observed patterns against national trends. Adopting a mixed-methods research design, the study combines a descriptive cross-sectional survey of 12 key administrative informants with a retrospective cost analysis of energy bills from 2023 to 2024, complemented by a comparative digital verification using internet archives to benchmark local findings against reported energy crises in other tertiary institutions such as UCH Ibadan and LUTH. The findings establish a 230.8% increase in grid energy costs after April 2024; despite the “Band A” service promise, the hospitals still rely on diesel generators for 4–6 hours daily at an average cost of ₦1,400 per liter, resulting in energy expenditures consuming 40–60% of hospital overheads. Internet-based comparative analysis confirms that this represents a systemic national crisis, as peer institutions face the risk of disconnection due to similar debt profiles. The study concludes that the current commercial tariff model is unsustainable for public health parastatals and underscores the need for urgent regulatory and infrastructural responses. It recommends immediate intervention by the Anambra State Electricity Regulatory Commission (ASERC) to implement a subsidized “Social Health Tariff,” alongside a strategic migration to embedded solar-hybrid mini-grids to safeguard energy security and ensure the financial viability of affordable healthcare delivery.

This study aims to analyze the profitability and feasibility of sheep farming using intensive and semi-intensive rearing sistems in Suka Raya Village, Pancur Batu Sub-district. The research employed a survey method with purposive sampling, involving 16 farmers (8 intensive and 8 semi-intensive), each rearing more than 15 sheep and operating for at least 3 years. Data were collected through questionnaire interviews and field observations, then analyzed descriptively to calculate production costs, revenue, income, R/C ratio, and Break Even Point (BEP). Results showed that the average total production cost for the intensive sistem was Rp 52,429,313, higher than the semi-intensive sistem at Rp 39,664,375. The average revenue for the intensive sistem was Rp 69,150,000, while the semi-intensive sistem was Rp 63,712,500. The average income for intensive farmers was Rp 16,720,688, compared to Rp 24,048,125 for semi-intensive farmers. The average R/C ratio for the intensive sistem was 1 (near break-even), while the semi-intensive sistem was 2 (more efficient and profitable). BEP analysis indicated higher sales for the intensive sistem (Rp 844,022/sheep/period) compared to the semi-intensive sistem (Rp 691,052/sheep/period), with a larger production BEP for the intensive sistem (44 sheep) than the semi-intensive sistem (33 sheep). The semi-intensive sistem is recommended for farmers with limited capital and small to medium-scale operations due to lower costs and higher profit margins, while the intensive sistem is more suitable for large-scale operations with adequate capital, feed management, and health care.

In recent years, the production and sales volume of EVs (EVs) in China have increased rapidly, but the origin of their international competitiveness is not clear, and there is a great debate. Firstly, this paper constructs a theoretical model of oligopoly competition in an open economy, and reveals the internal mechanism of market scale, subsidy policy, technological innovation and other factors affecting the international competitiveness of export products. Then, based on the reality of subsidies, sales and exports of EVs in China from 2018 to 2024, a data model was constructed to empirically test the theoretical analysis conclusions. The empirical results show that although government subsidies have promoted the development of China's electric vehicle industry in the initial stage, the domestic market size is the root cause of China's international competitiveness of EVs. Further mechanism analysis shows that economies of scale and technological innovation are two important ways for domestic market size to enhance the international competitiveness of China's EVs. Therefore, relying on the huge domestic market scale, promoting the reduction of the average cost and technological innovation of China's electric vehicle enterprises is the fundamental way to enhance the international competitiveness of China's EVs. This paper provides theoretical and empirical basis for how to enhance the international competitiveness of China's EVs.

We aimed to evaluate the cost-effectiveness of blood-based biomarker (BBM) testing vs amyloid positron emission tomography (PET) in patients with signs and symptoms of cognitive decline in a neurologist/specialist care setting. We constructed a decision-tree model to compare diagnostic outcomes and costs of two testing strategies: BBM testing with confirmatory PET scan vs PET scan alone. Their cost-effectiveness was evaluated from a payer perspective with test performance taken from a clinical study and costs including testing/imaging and physician fees. When access to PET scans is unlimited, BBM triage testing would identify 98.2 % of PET+ patients with a lower average cost per diagnosis compared with PET scan alone ($8868 vs 10,345 per PET+ diagnosis). In terms of incremental cost-effectiveness, BBM triage testing would save $93,984 for each loss of PET+ diagnosis (9.1 times the average cost per PET+ diagnosis by PET scan). Under limited capacity of PET scans, more test-positive patients could be identified using BBM testing than PET scan alone. When access to PET scans is limited to 50 % of the patients, BBM testing would identify 90.6 % more test-positive patients (at 93 % sensitivity) at an incremental cost-effectiveness ratio of $3484 per gain of positive diagnosis, lower than the average cost of a PET+ diagnosis by PET scan ($10,938). BBM testing, compared with PET scan alone, is more efficient in the utilization of available amyloid PET scans and is cost-effective for assessment of Alzheimer's disease pathology in patients with signs and symptoms of cognitive decline.

Predictive modelling and optimization of electrocoagulation for nitrate removal using deep learning: Toward intelligent and sustainable water treatment.

Impact of child maltreatment on the costs of health service use and productivity loss: Findings from the Australian child maltreatment study.

Average incremental cost pricing in electricity auctions

Anabolic androgenic steroid (AAS) use is associated with various health risks, yet its impact on healthcare expenditures remains insufficiently explored. This nationwide register-based study examined direct healthcare costs among 1183 males sanctioned for AAS use in Denmark between 2006 and 2017, compared with 59 150 age- and sex-matched controls from the general population. Healthcare costs were calculated across primary care, hospital services, and prescription drugs, with up to 10 years of follow-up. AAS users had significantly higher total healthcare costs, with a mean excess of 3299 euros (EUR) per person (95% CI: 1857-4742; p < 0.0001) over the follow-up period, corresponding to approximately EUR 537 per AAS user per year. This represents a 45% increase over controls, whose average total costs were EUR 7393 per person. The cost difference was primarily driven by hospital care but was also evident in primary care and prescription medication use. Cumulative cost differences increased steadily over time and remained consistent across most diagnostic categories. AAS users were relatively young and otherwise expected to have low healthcare use, suggesting a notable health burden in this group. These findings add real-world evidence on the healthcare implications of AAS use and highlight a sustained cost difference between AAS users and controls over a prolonged period. Continued follow-up may be necessary to fully capture long-term costs, particularly as some complications may appear years after use.

The impact of COBIT implementation on IT operational efficiency, using a mixed- method approach that focuses on quantitative analysis. A total of 387 valid respondents were obtained through stratified random sampling targeting IT professionals from various industry sectors. This study measured improvements in cost reduction, service response time improvement, and security incident reduction. The results indicate that COBIT implementation significantly correlates with an average operational cost reduction of 28.5%, a 34.2% improvement in service response time, and a 41.7% decrease in security incidents. Organizations with a higher COBIT maturity level (Level 4-5) showed better performance compared to Level 2-3. The DSS domain had the highest impact on efficiency (r = 0.847). The developed predictive model explains 74.3% of the variance in operational efficiency. This research offer practical insights for organizations aiming to enhance IT performance through structured governance. The study provides actionable recommendations, including prioritizing DSS processes, conducting maturity assessments, and adopting phased implementation strategies to optimize COBIT adoption.