Cost-reducing Strategies Research Articles

Cost-Related Medication Behaviors for Patients With and Without Systemic Autoimmune Rheumatic Diseases.

Medication nonadherence challenges the management of systemic autoimmune rheumatic diseases (SARDs). We investigated cost-related medication behaviors among patients with SARDs, and compared them to those of patients without SARDs, in a large diverse cohort across the United States. As part of the All of Us (version 7), a nationwide diverse adult cohort with linked electronic health records begun in 2017, participants completed questionnaires concerning cost-related medication behaviors. Chi-square tests compared responses between patients with SARDs, by disease and medication type, and to those without SARDs. Logistic regression analyses were used to calculate odds ratios (95% confidence intervals [CIs]). We analyzed data from 3,997 patients with SARDs and 73,990 participants without SARDs. After adjustment, patients with versus without SARDs had 1.56 times increased odds of reporting unaffordability of prescription medicines (95% CI 1.43-1.70), 1.43 times increased odds of cost-related medication nonadherence (95% CI 1.31-1.56), and 1.23 times increased odds of using cost-reducing strategies (95% CI 1.14-1.32). Patients with SARDs who reported unaffordability were 16.5% less likely to receive a disease-modifying drug (95% CI 0.70-0.99) but 18.1% more likely to receive glucocorticoids (95% CI 0.99-1.42). In addition, unaffordability of prescription medicines was likely to have 1.27 times increased odds of one to two emergency room visits per year (95% CI 1.03-1.57) and 1.38-fold increased odds of three or more emergency room visits per year (95% CI 0.96-1.99). In this large diverse cohort, patients with versus without SARDs had more self-reported cost-related medication behaviors, and those who reported medication unaffordability received fewer disease-modifying drugs and had more emergency room visits.

Lightning Network Economics: Topology

By design, the Bitcoin protocol has a low throughput. The Lightning Network (LN) is a layer-two solution built to increase throughput by cryptographically securing commitments to transactions and only occasionally converting cumulative balances into on-chain transactions. LN channels enable payments between nodes connected by a path of channels. The payment flow through a channel determines its cost. Different channel topologies can support the same underlying flows but impose different costs. This paper obtains necessary conditions for cost-minimizing topologies by identifying local cost-reducing strategies. The first local strategy entails repositioning of channels. The second entails adding hubs to handle the flows of groups of nodes. The paper also evaluates the efficiency of a global configuration, obtaining bounds on the minimum cost topology and showing the unusual circumstances in which the cost minimal structure is a hub that connects to all other nodes. This paper was accepted by Joshua Gans, business strategy. Funding: This work was partially supported by Science Foundation Ireland [Grants 16/IA/4443, 16/SPP/3347], Columbia-International Business Machines Center for Blockchain and Data Transparency, Chaire Fintech at University Paris Dauphine-Paris Sciences et Lettres, Algorand Foundation, and Simons Institute.

Incidence and prevalence of idiopathic inflammatory myopathies in Thailand from the Ministry of Public Health data analysis

The epidemiology of idiopathic inflammatory myopathies (IIMs) varies by country. Investigating the epidemiological profile among Thai IIMs could help to inform public health policy, potentially leading to cost-reducing strategies. We aimed to assess the prevalence and incidence of IIM in the Thai population between 2017 and 2020. A descriptive epidemiological study was conducted on patients 18 or older, using data from the Information and Communication Technology Center, Ministry of Public Health, with a primary diagnosis of dermatopolymyositis, as indicated by the ICD-10 codes M33. The prevalence and incidence of IIMs were analyzed with their 95% confidence intervals (CIs) and then categorized by sex and region. In 2017, the IIM cases numbered 9,074 among 65,204,797 Thais, resulting in a prevalence of 13.9 per 100,000 population (95% CI 13.6–14.2). IIMs were slightly more prevalent among women than men (16.8 vs 10.9 per 100,000). Between 2018 and 2020, the incidence of IIMs slightly declined from 5.09 (95% CI 4.92–5.27) in 2017 and 4.92 (95% CI 4.76–5.10) in 2019 to 4.43 (95% CI 4.27–4.60) per 100,000 person-years in 2020. The peak age group was 50–69 years. Between 2018 and 2020, the majority of cases occurred in southern Thailand, with incidence rates of 7.60, 8.34, and 8.74 per 100,000 person-years. IIMs are uncommon among Thais, with a peak incidence in individuals between 60 and 69, especially in southern Thailand. The incidence of IIMs decreased between 2019 and 2020, most likely due to the COVID-19 pandemic, which reduced reports and investigations.

Exploring the impact of the national tender system on the use of costly drugs treating rheumatoid arthritis patients in ten rheumatology centers in Norway (2010–2019)

BackgroundBiologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) are highly effective in treating rheumatoid arthritis (RA), albeit high drug cost has restricted their use in many countries. As a countermeasure, Norway implemented pharmaceutical tendering as a cost-reducing strategy. The aim of this study was to assess the annual proportion of different b/tsDMARDs registered to treat RA patients under the influence of a Norwegian pharmaceutical tendering between 2010 and 2019.MethodThe data is collected from ten Norwegian outpatient centers. The included patients are categorized as naïve, non-naïve, and current b/tsDMARD users. 13 individual b/tsDMARDs are assessed and compared with the tender rankings from each year. Overview of subcutaneous (sc) with per oral vs. intravenous (iv) and biosimilars vs. non-biosimilar are also described.ResultThe tender-winning b/tsDMARD was the most or second most used drug in nine out of ten years for naïve users, seven for non-naïve users, and twice for current users. The average sum of the highest and second highest proportion among naïve, non-naïve, and current b/tsDMARD users were 75%, 53%, and 50% during the ten years, respectively. The tender-winning drug was iv in eight out of ten years. However, the average total proportion of sc and per oral b/tsDMARDs was about 70% for naïve b/tsDMARD users, 50% for non-naïve b/tsDMARD users, and 60% for current b/tsDMARD users. The main contributors to sc and per oral b/tsDMARD were etanercept (reference and biosimilar) and certolizumab pegol. The main contributors to iv b/tsDMARD were rituximab reference and infliximab biosimilar. Despite low-ranking offers, rituximab reference (offered as a second-line drug) often achieved a high proportion among non-naïve and current b/tsDMARD users. After the introduction of biosimilars, their average proportion was about 40%, 40%, and 20% for naïve, non-naïve, and current b/tsDMARD users, respectively.ConclusionBased on observed data, a higher tender rank was associated with a higher proportion among naïve and non-naïve b/tsDMARD users. However, in most cases, sc b/tsDMARDs achieved a higher proportion with lower tender ranks than iv b/tsDMARDs with higher tender ranks.

Abstract 56: Integrated Breast and Cervical Cancer Prevention: What is the Cost of Cost Reduction?

Abstract Purpose: coupling of breast and cervical cancer prevention has been proposed as a possible low hanging fruit to accelerate simultaneous reduction in burden of both cancers in low resource settings but unfortunately the evidence on effectiveness of such strategy is limited. We have therefore documented and compared the implementation processes of 2 intervention programs in low resource settings with the aim of catalyzing further research into the effectiveness of coupling prevention of breast and cervical cancer in low resource settings. Methods: Action research model was adopted in the implementation of coupling of breast cancer prevention strategies onto cervical cancer screening programs that End Cervical Cancer Nigeria Initiative (ECCNI) is involved in. This study compared the implementation processes and outcomes of leveraging two cervical cancer screening programs to prevent breast cancer in Kebbi State of Nigeria. Budget impact of the programs was projected and compared. Results: Two thousand four hundred and sixty-six (2,466) women were screened for cervical cancer across 10healthcare facilities under the WHO/CHAI/MCF supported pilot HPV screening in Kebbi State while the number of women who had clinical breast examination could not be ascertained. At the police cottage hospital, 125 women were screened for cervical cancer using VIA and 131 women had clinical breast examination within the reporting period. The estimated financial cost of implementation (excluding economic cost) per center was $4,550 for cervical cancer screening and $1,850 for clinical breast examination-based prevention program. The implementation cost for the integrated breast and cervical cancer screening at the police cottage hospital was $4,550, implying that no additional funding is required to leverage clinical breast examination on budgeted cervical cancer screening at the primary healthcare level. Conclusion: Integrated breast and cervical cancer prevention is a confirmed cost reducing strategy but further research is needed to determine cost effectiveness of the strategy. Citation Format: Ishak Lawal, Zainab Shinkafi-Bagudu, Nuhu Koko, Jamilu Mohammad, Abdullahi Bala Rano, Kabir Aliyu Suleiman. Integrated Breast and Cervical Cancer Prevention: What is the Cost of Cost Reduction? [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 56.

Patient-reported outcomes among people living with HIV on single- versus multi-tablet regimens: Data from a real-life setting.

BackgroundThe use of single-tablet regimens (STRs) in HIV treatment is ubiquitous. However, reintroducing the (generic) components as multi-tablet regimens (MTRs) could be an interesting cost-reducing strategy. It is essential to involve patient-reported outcome measures (PROs) to examine the effects of such an approach. Hence, this study compared PROs of people living with HIV taking an STR versus a MTR in a real world setting.Materials and methodsThis longitudinal study included 188 people living with HIV. 132 remained on a MTR and 56 switched to an STR. At baseline, months 1-3-6-12-18 and 24, participants filled in questionnaires on health-related quality of life (HRQoL), depressive symptoms, HIV symptoms, neurocognitive complaints (NCC), treatment satisfaction and adherence. Generalized linear mixed models and generalized estimation equations mixed models were built.ResultsClinical parameters and PROs of the two groups were comparable at baseline. Neurocognitive complaints and treatment satisfaction did differ over time among the groups. In the STR-group, the odds of having NCC increased monthly by 4,1% as compared to the MTR-group (p = 0.035). Moreover, people taking an STR were more satisfied with their treatment after 6 months: the median change score was high: 24 (IQR 7,5–29). Further, treatment satisfaction showed a contrary evolution in the groups: the estimated state score of the STR-group increased by 3,3 while it decreased by 0,2 in the MTR-group (p = 0.003). No differences over time between the groups were observed with regard to HRQoL, HIV symptoms, depressive symptoms and adherence.ConclusionsNeurocognitive complaints were more frequently reported among people on an STR versus MTR. This finding contrasts with the higher treatment satisfaction in the STR-group over time. The long-term effects of both PROs should guide the decision-making on STRs vs. (generic) MTRs.

Cost-reducing strategy or emission-reducing strategy? The choice of low-carbon decisions under price threshold subsidy

Different from the traditional subsidy scheme previously studied, we explore the incentive of price threshold subsidy scheme (PTS) for the sustainable operation of automobile enterprises. A product differential model on gasoline vehicles (GVs) and battery energy vehicles (BEVs) is analyzed within a PTS mechanism. We examine and compare the economic and environmental effectiveness of two low-carbon strategies: BEV cost reduction (BCR) strategy and GV emission reduction (GER) strategy. The results indicate that the PTS forces the manufacturer to deploy three different pricing decisions based on BEV production costs. Raising the price threshold is a positive sign for the manufacturer. However, when the government implements the PTS policy mainly to increase BEV sales, blindly raising the price threshold under the medium-cost case will be counterproductive. Besides, the active BCR strategy can bring significant economic and environmental benefits compared to the strategy without cost investment. We unexpectedly find that high consumer environmental concerns trigger BCR strategy to generate greater cost advantages. But the BCR strategy is not always the optimal choice. When the initial carbon emissions of GV are low and the emission reduction efficiency is high enough, the GER strategy is more effective than the BCR strategy in terms of profit and total carbon emissions. And this advantage expands with the increase in BEV cost and emission-reducing subsidy.

Cost-Related Nonadherence to Medications Among US Adults With Chronic Liver Diseases

ObjectiveTo estimate the prevalence, risk factors, and consequences of cost-related medication nonadherence (CRN) in individuals with chronic liver diseases (CLDs) in the United States. Patients and MethodsUsing the National Health Interview Survey from January 1, 2014, to December 31, 2018, we identified individuals with CLDs. Using complex weighted survey analysis, we obtained national estimates and risk factors for CRN and its association with cost-reducing behaviors and measures of financial toxicity. We evaluated the association of CRN with unplanned health care use, adjusting for age, sex, race/ethnicity, insurance, income, education, and comorbid conditions. ResultsOf 3237 respondents (representing 4.6 million) US adults with CLDs, 813 (representing 1.2 million adults, or 25%; 95% CI, 23% to 27%) reported CRN, of whom 68% (n=554/813) reported maladaptive cost-reducing behaviors. Younger age, female sex, low income, and multimorbidity were associated with a higher prevalence of CRN. Compared with patients without CRN, patients experiencing CRN had 5.1 times higher odds of financial hardship from medical bills (adjusted odds ratio [aOR], 5.05; 95% CI, 3.73 to 6.83) and 2.9 times higher odds of food insecurity (aOR, 2.85; 95% CI, 2.02 to 4.01). The CRN was also associated with 1.5 times higher odds of emergency department visits (aOR, 1.46; 95% CI, 1.11 to 1.94). ConclusionWe observed a high prevalence of CRN and associated consequences such as high financial distress, financial hardship from medical bills, food insecurity, engagement in maladaptive cost-reducing strategies, increased health care use, and work absenteeism among patients with CLD. These financial determinants of health have important implications in the context of value-based care.

Delirium and Associated Length of Stay and Costs in Critically Ill Patients.

Purpose Delirium frequently affects critically ill patients in the intensive care unit (ICU). The purpose of this study is to evaluate the impact of delirium on ICU and hospital length of stay (LOS) and perform a cost analysis. Materials and Methods Prospective studies and randomized controlled trials of patients in the ICU with delirium published between January 1, 2015, and December 31, 2020, were evaluated. Outcome variables including ICU and hospital LOS were obtained, and ICU and hospital costs were derived from the respective LOS. Results Forty-one studies met inclusion criteria. The mean difference of ICU LOS between patients with and without delirium was significant at 4.77 days (p < 0.001); for hospital LOS, this was significant at 6.67 days (p < 0.001). Cost data were extractable for 27 studies in which both ICU and hospital LOS were available. The mean difference of ICU costs between patients with and without delirium was significant at $3,921 (p < 0.001); for hospital costs, the mean difference was $5,936 (p < 0.001). Conclusion ICU and hospital LOS and associated costs were significantly higher for patients with delirium, compared to those without delirium. Further research is necessary to elucidate other determinants of increased costs and cost-reducing strategies for critically ill patients with delirium. This can provide insight into the required resources for the prevention of delirium, which may contribute to decreasing healthcare expenditure while optimizing the quality of care.

Strategies to mitigate economic hardship among family dairy farms of Central Mexico

AbstractThe economic hardship of dairy producers has worsened in the last decade because of increasing costs of production. A field survey with 51 dairy farmers was conducted to explore strategies to mitigate economic hardship. Factor and cluster analyses were conducted to characterize the farmers and their farms. Differences among groups regarding changes adopted to increase incomes, to reduce costs, and to pay bills were tested using Fisher’s exact test. Four factors explained 76.2% of the cumulative variance and four groups were identified: “stagnant farms” were in group 1, with the lowest daily income over concentrate feed cost (DIOCFC) and the least number of changes, “effectively management farms” were in group 2, with the highest DIOCFC and the highest number of income-increasing changes, the “cost reducing farms” were in group 3, with the smallest in size with a focus on cutting cost, and the “mixed strategy farms” were in group 4, with the largest herd size. Most prevalent income-increasing strategies included attempts to improve cow nutritional balance and milk composition, whereas the most prevalent cost-reducing strategies included reductions in input purchases of inputs (concentrates and fertilizers) and selected household expenses. Selling cows was a common strategy to generate cash in acute hardship situations. In conclusion, responses to economic hardship varied substantially among groups of farms, cost-reducing strategies were linked to lower cow productivity and lower technological levels, but income-increasing strategies were linked to higher cow productivity and higher DIOCFC. Our findings may contribute to the design of extension initiatives to promote useful strategies to help mitigate economic hardship on dairy farms.

Cost-effectiveness of teduglutide in pediatric patients with short bowel syndrome: Markov modeling using traditional cost-effectiveness criteria

Teduglutide use in pediatric patients with short bowel syndrome can aid in the achievement of enteral autonomy, but with a price of >$400,000 per y. The current study evaluated the cost-effectiveness of using teduglutide in conjunction with offering intestinal transplantation in US pediatric patients with short bowel syndrome. A Markov model was used to evaluate the costs (in US dollars) and effectiveness [in quality-adjusted life years (QALYs)] of using teduglutide compared with offering intestinal transplantation. Parameters were estimated from published data where available. The primary effect modeled was the probability of weaning from parenteral nutrition while on teduglutide. Sensitivity analyses were performed on all model parameters. Compared with offering only intestinal transplantation, adding teduglutide cost ${\$}$124,353/QALY gained. Reducing the cost of the medication by 16% allowed the cost to reach the typical benchmark of ${\$}$100,000/QALY gained. Probabilistic sensitivity analysis favored transplantation without offering teduglutide in 68% of iterations at a ${\$}$100,000/QALY threshold. Never using teduglutide created an opportunity cost of over ${\$}$100,000 per patient. At its current price, teduglutide does not provide a cost-effective addition to transplantation in the treatment of pediatric short bowel syndrome. Further work should look to identify cost-reducing strategies, including alternative dosing regimens.

National Estimates of Financial Hardship From Medical Bills and Cost-related Medication Nonadherence in Patients With Inflammatory Bowel Diseases in the United States

Inflammatory bowel diseases (IBDs) are associated with substantial health care needs. We estimated the national burden and patterns of financial toxicity and its association with unplanned health care utilization in adults with IBD in the United States. Using the National Health Interview survey (2015), we identified individuals with self-reported IBD and assessed national estimates of financial toxicity across domains of financial hardship due to medical bills, cost-related medication nonadherence (CRN) and adoption of cost-reducing strategies, personal and health-related financial distress (worry about expenses), and health care affordability. We also evaluated the association of financial toxicity with emergency department (ED) utilization. Of the estimated 3.1 million adults with IBD in the United States, 23% reported financial hardships due to medical bills, 16% of patients reported CRN, and 31% reported cost-reducing behaviors. Approximately 62% of patients reported personal and/or health-related financial distress, and 10% of patients deemed health care unaffordable. Prevalence of financial toxicity was substantial even in participants with higher education, with private insurance, and belonging to middle/high-income families, highlighting underinsurance. Inflammatory bowel disease was associated with 1.6 to 2.6 times higher odds of financial toxicity across domains compared with patients without IBD. Presence of any marker of financial toxicity was associated with higher ED utilization. One in 4 adults with IBD experiences financial hardship due to medical bills, and 1 in 6 adults reports cost-related medication nonadherence. These financial determinates of health-especially underinsurance-have important implications in the context of value-based care.

Microalgae production cost in aquaculture hatcheries

Microalgae are a crucial part in many aquaculture feed applications processes, mainly in hatcheries. Many aquaculture hatcheries maintain a small scale microalgae production facility in-house for the production of live feed. Microalgae are usually grown in non-automated bubble-column systems at unknown production costs. Other reactor systems or scenarios utilizing artificial light or sunlight and at different scales could result in a more cost efficient production processes. To determine the cost-price and cost-distribution of microalgae production facilities in Dutch aquaculture industry and identify the most efficient cost reducing strategies a techno-economic analysis for small scale microalgae production facilities (25-1500 m2) was developed. Commercially available reactors commonly used in aquaculture were compared; tubular photobioreactors (TPBR) and bubble-columns (BC) in two placement possibilities; using artificial light in an indoor facility (AL) and utilizing sunlight in a greenhouse (GH) under Dutch climate conditions. Data from commercial microalgae facilities in the Netherlands are used to model reference scenarios describing the cost price of microalgae production with state of the art technology in aquaculture for a biomass production capacity of 125 kg year−1. The reference cost price for algae biomass (on the basis of dry matter) is calculated at €290,- kg−1 and € 329 kg−1 for tubular reactors under artificial light and a greenhouse, respectively and €587,- kg−1 and €573 kg−1 for bubble-columns under artificial light and a greenhouse, respectively. The addition of more artificial light will significantly reduce production costs (by 33%) in all small-scale systems modelled. Biomass yield on light (Yx,ph) showed the largest effect on cost price when not considering a different scale of the production process. Process parameters like temperature control should be aimed at optimizing Yx,ph rather than other forms of cost reduction. The scale of a microalgae production facility has a very large impact on the cost price. With state of the art technologies a cost price reduction of 92% could be achieved by changing the scale from 25m2 to 1500m2, resulting in a cost price of €43,- kg−1, producing 3992 kg year−1 for tubular reactors in a greenhouse. The presented techno-economic model gives valuable insights in the cost price distribution of microalgae production in aquaculture. This allows to focus research efforts towards the most promising cost reduction methods and to optimize existing production facilities in aquaculture companies to achieve economically sustainable microalgae production for live feed in hatcheries.

Key drivers of financial performance of insurers in the Affordable Care Act market exchange.

While most publicly-traded insurers have experienced losses and exited the Affordable Care Act individual insurance market exchange, insurers specializing in Medicaid managed care have been profitable in this market. Accessing individual market data, this study compares the financial performance of 20 state insurers owned by two publicly-traded companies that historically focused on insuring Medicaid members compared to 40 insurers owned by other publicly-traded companies. Medicaid-focused insurers incurred a significantly lower medical loss ratio of 83.3% compared to the medical loss ratio of 93.7% of other publicly-traded insurers, and they earned a significantly higher profit margin of 4.6% compared to the operating loss of 6.5% incurred by other publicly-traded insurers. This superior financial performance of Medicaid-focused insurers could be due to one or a combination of: their care management experience with the Medicaid population, other cost reducing strategies such as provider contracting, or the enrollment of a healthier than average population.

A review and future directions on enhancing sustainability benefits across food-energy-water systems: the potential role of biochar-derived products

The future of food-energy-water resources is an ever-increasing global concern due to a growing standard of living and population. This study presents opportunities for sustainable growth based on the previous research and developments across food-energy-water systems through biomassbased products (bioproducts), such as biochar, an emerging by-product of biofuel production. Bioproducts are in a nascent stage, but are growing steadily with improvements in production technologies and other cost-reducing strategies. Perspectives on solutions and opportunities that can promote the socio-economic resilience and ecological integrity of regional food-energy-water resources are identified through narrative and systematic literature reviews. These solutions are examined within the context of the environmental and economic parameters that influence stakeholders’ decisions concerning the adoption and use of technological solutions. Biochar has shown to be one of these products with the ability to improve productivity, particularly, in organic farming through increased water-nutrient holding capacity, organic-matter efficiency, and carbon sequestration. Additionally, biochar sorption abilities and textural features have shown to be a special solution for removing a large range of contaminants (e.g., metals and toluene) from water. However, biomass collection, transportation, and conversion costs have been identified as major challenges to produce market-responsive bioproducts. It is concluded that the recent interest in food-energy-water systems has led to research opportunities in bioproducts that can, in turn, bridge the gaps and provide groundbreaking developments for future research and growth. It is also concluded that there is an essential need for solutions-oriented projects across the food-energy-water nexus at both domestic and global level.

In silico REPOSITIONING OF NEW DRUGS AGAINST Schistosoma mansoni

Schistosomiasis is a neglected tropical disease caused by parasites of the genus Schistosoma. In Brazil only Schistosoma mansoni causes this disease. The World Health Organization estimated in 2012 approximately 249 million people at risk of acquiring this disease around the world. The main strategy to control this disease is praziquantel treatment of individuals living in endemic areas. The drug praziquantel is used on a large scale in the treatment of schistosomiasis and currently there are reported cases of resistance, indicating the need to discover new drugs. In silico drug repositioning is a time and cost reducing strategy in the search for anti-Schistosoma agents. This work used bioinformatic tools to identify potential schistosomicidal drugs. A list was compiled of S. mansoni potential targets that are part of essential processes in the database TDR and the targets that are part of the tegument were obtained in the scientific literature. The file with S. mansoni targets contained 1,376 targets, and of these only 61 targets associated with 399 drugs had homology with drug targets. After removal of duplicate drugs, drugs found in previous studies and after the analysis of the conservation of the binding site, only 28 S. mansoni targets associated with 102 drugs had 60% or more of the active site conserved. Some of the drugs had activity and are interesting to validate this study such as: artemether, lumefantrine, meloxicam. Among the drugs found 18 drugs were selected to be tested in prospective experimental assays according to the following criteria: low toxicity in vivo, off-patent status, and logP &lt;5.0.

Competing analyses and differential cost in the production of non-subject relative clauses

The computational cost of restrictive non-subject relative clauses (RCs) in different processing conditions is discussed in relation to competing analyses of RCs. An elicited production experiment is reported in which adult speakers of Brazilian Portuguese (BP) were asked to continue a preamble in such a way that a right-branching restrictive RC would enable a particular referent to be identified. Two processing conditions were contrasted: fully planned (FPlan), in which the speaker could plan the RC as the sentence production started; and partially planned (PPlan), in which production started before it was clear that a restrictive RC was the only option to encode the reference unambiguously. It was anticipated that the number of standard RCs would be lower in the PPlan condition, with an increase in the non-standard alternatives. This prediction is verified, with chopping standing as a cost reducing strategy in the production of indirect object RCs. It is argued that, for the standard strategy, RCs as complements (as conceived of in most raising analyses) suit an online model of RC computation in the fully planned condition; however, the possibility of RCs as adjuncts, as proposed by most head external and matching analyses, is required for the incremental computation of a restrictive RC in the partially planned condition.

Denitrification of Nitric Oxide Using Hollow Fiber Membrane Bioreactor; Effect of Nitrate and Nitric Oxide Loadings on the Reactor Performance and Microbiology

Nitric oxide (NO) removal from a gas stream containing ~500 ppm NO was studied in a hollow fiber membrane (HFM) bioreactor. Compared to other biological NO removal methods the HFM bioreactor achieved NO removal rates that were as good if not better, of up to 92% NO removal, under comparable loadings and reactor size. Results showed that a wastewater stream containing organic carbon can be used as the electron donor to reduce the NO. Hence, combining biological NO treatment with treatment of a wastewater containing organic carbon has may be an effective overall cost-reducing strategy. The effect of different nitrate (NO 3 − ) concentrations on the NO reduction rate was also evaluated, and results showed that NO 3 − does enhance the NO removal rate. The reactor’s performance was studied under six different NO:NO 3 − loading regimes and the NO removal rate as well as the microbial denitrifier community in the reactor was tracked. Specifically, the relevant genes responsible for each denitrification step were tracked during each different NO:NO 3 − loading regime to the reactor. Results showed that the denitrifying microbial community adjust rapidly to changes in the different N loadings, but overall the performance of the reactor is robust and can withstand such variability in terms of NO, NO 3 − and organic carbon removal.

Coopetition in regional clusters: Keep calm and expect unexpected changes

This study focuses on changes over time in inter-firm cooperation of an export-oriented regional cluster within a Latin American emerging economy. The study was conducted in the Chilean salmon industry. A longitudinal study, collecting primary data from managers, was conducted over ten years. Unexpectedly, findings revealed that as the cluster matured, firm's members tended towards more individual behaviour than strategic inter-firm cooperation though, they continued to cooperate in more basic cost-reducing strategies. This result extends the industry cluster literature and provides insights into the cooperative and competitive changes that take place over time.

Discussing Health Care Expenses in the Oncology Clinic: Analysis of Cost Conversations in Outpatient Encounters

ASCO identified oncologist-patient conversations about cancer costs as an important component of high-quality care. However, limited data exist characterizing the content of these conversations. We sought to provide novel insight into oncologist-patient cost conversations by determining the content of cost conversations in breast cancer clinic visits. We performed content analysis of transcribed dialogue from 677 outpatient appointments for breast cancer management. Encounters featured 677 patients with breast cancer visiting 56 oncologists nationwide from 2010 to 2013. Cost conversations were identified in 22% of visits (95% CI, 19 to 25) and had a median duration of 33 seconds (interquartile range, 19 to 62). Fifty-nine percent of cost conversations were initiated by oncologists (95% CI, 51 to 67), who most commonly brought up costs for antineoplastic agents. By contrast, patients most frequently brought up costs for diagnostic tests. Thirty-eight percent of cost conversations mentioned cost-reducing strategies (95% CI, 30 to 46), which most commonly sought to lower patient costs for endocrine therapies and symptom-alleviating treatments. The three most commonly discussed cost-reducing strategies were: switching to a lower-cost therapy/diagnostic, changing logistics of the intervention, and facilitating copay assistance. We identified cost conversations in approximately one in five breast cancer visits. Cost conversations were mostly oncologist initiated, lasted < 1 minute, and dealt with a wide range of health care expenses. Cost-reducing strategies were mentioned in more than one third of cost conversations and often involved switching antineoplastic agents for lower-cost alternatives or altering logistics of diagnostic tests.