Cost-saving Effect Research Articles

244. The Double-Edged Sword of Cost Effectiveness in Evaluating Antimicrobial Stewardship Interventions

BackgroundThe multiple classical benefits of reducing antimicrobial consumption extend beyond the impact on rates of antimicrobial resistance and infections to include a cost-saving effect of 100,000$-300,000$ per intervention as estimated by the CDC. However, the recent introduction of novel antimicrobial molecules with a high price tag and the fall in the prices of older agents presents a substantial challenge in maintaining cost-effectiveness.MethodsWe retrieved from the antimicrobial stewardship program(ASP) database the consumption of the Gram-negative broad-spectrum antibacterial agents (GNBS): imipenem, meropenem, ertapenem, piperacillin-tazobactam, amikacin, colistin, ceftazidime, ceftolozane-tazobactam and cefepime from January 2015-August 2019 at Saint George Hospital(SGH), a 333-bed tertiary care center in Lebanon. The yearly cost of all antibacterials consumed during this period were obtained from SGH billing records. GNBS consumption was calculated as Daily Defined Doses (DDD)/1000 Patient Days(PD) per WHO guidelines.ResultsThe carbapenem consumption significantly dropped from a peak of 205 DDD/1000PD in 2015 to 33 DDD/1000PD in 2019. This drop was not accompanied by an increase in the consumption of other GNBS. The total use of GNBS dropped by 54% from 288 DDD/1000PD in 2015 to 132 DDD/1000PD by August 2019. Currently, SGH serves a yearly average of 82,000 patient-days. Hence, this reduction in total GNBS consumption corresponds to 12,792 fewer daily defined doses of antimicrobial therapy per year.The average annual cost of all antibacterials at SGH is 1,100,000 $ (U.S. Dollars), ranging from 955679 $ to 1340109 $ for the period 2015–2019. (Table 1)Consumption of Gram-negative Broad-Spectrum Antimicrobial Agents and Cost of Antibiotics at Saint George Hospital, Lebanon ConclusionThe striking decrease in GNBS consumption, namely carbapenems, was not mirrored with a reduction of total antibacterial cost. Although novel antimicrobials carry great potential, they come at a significant increase in overall cost. Modeling ASP interventions solely around cost-effectiveness will limit the better placement of these new agents in institutional therapeutic guidelines. Strict continuous analysis of consumption, antimicrobial resistance, and cost within an ASP provides a proactive and vigilant approach to navigate through the complexity of difficult to treat bacterial infections.Disclosures All Authors: No reported disclosures

Measuring the effectiveness of the Chinese Certified Emission Reduction scheme in mitigating CO2 emissions: A system dynamics approach

As an emerging carbon offset mechanism, the Chinese Certified Emission Reduction (CCER) scheme can theoretically supplement the emissions trading scheme (ETS) to alleviate global warming. However, due to poor data availability and short implementation time, little effort has been made to understand the mechanism and driving factors of the CCER scheme. To fill these gaps, this paper establishes a system dynamics model with feedbacks to analyze the coupling effects of the ETS and the CCER scheme. Three scenarios, including a baseline scenario (BAU scenario), a single trading market scenario (i.e., ETS market only), and a double trading market scenario (i.e., both the ETS market and the CCER market), are considered. The simulation results reveal that compared with the BAU scenario, both the single trading market scenario and the double trading market scenario can accelerate the mitigation of CO2 emissions, reduce abatement costs, and transform the energy structure. Interestingly, in the double trading market scenario, although CO2 emissions are slightly higher and the renewable energy proportion is slightly lower than that in the single trading market scenario, the additional cost-saving effect of the double trading market scenario over time increases significantly. Besides, to fulfill the Intended National Determined Contributions (INDCs) as closely as possible, governments need to set a rational offset rate of CCER quotas and to stabilize the carbon quota trading price. These findings enrich the relevant knowledge in the field of climate change by providing implications for the design of novel carbon offset instruments.

Health insurance as a state institution: The effect of single-payer insurance on expenditures in OECD countries.

A growing literature in comparative political economy and health economics has argued several cost-saving effects of a single-payer healthcare system. Despite this growing evidence, there has been no large-scale empirical examination of whether such an effect exists cross-nationally over time. This paper serves as the first attempt to find and calculate the extent to which healthcare spending is affected by the utilization of a single-payer scheme. I introduce an original dataset for OECD countries that measures when and where systems that qualify as single-payer exist, and employ it to test whether significant differences exist in health expenditures. Results demonstrate a significant difference between single- and multi-payer system expenditures. I estimate the utilization of a single-payer system is associated with decreased expenditure equal to 0.750 percentage-points of a nation's GDP. This would equate to the United States saving well over $1.5 trillion over ten years.

Does disease management for diabetic nephropathy reduce medical expenditure? Evidence from a three-period difference-in-differences analysis

BackgroundTo discriminatively evaluate the cost-saving effects of a disease management program for diabetic nephropathy patients through care process rectification and, subsequently, improved health outcomes.MethodsThis study links public medical insurance claims data to the health records of a disease management program for diabetic nephropathy patients. To account for selection bias caused by the non-randomized allocation of the disease management program for diabetes patients, we adopted a fixed-effect model of panel data analysis. To discriminatively evaluate the cost-saving effects of the disease management program for diabetic nephropathy patients through care process rectification and, subsequently, improved health outcomes, we expanded the difference-in-differences analysis from the traditional two-period model to a three-period model, comprising the before-intervention, during-intervention, and after-intervention periods. Data were extracted from municipal public insurers in Kure, Japan.ResultsThe cost-reduction effect in terms of treatment costs from the before-intervention period to the during-intervention period (the rectification effect) was 4.02%, and the cost-saving effect from the during-intervention period to the after-intervention period (the health improvement effect) was 2.95%.ConclusionsA disease management program for diabetes patients organized by local public insurers in Japan reduced costs both by amending treatment processes and by subsequently improving the prognosis of the disease.

Cost-effectiveness of stereotactic vacuum-assisted biopsy for nonpalpable breast lesions

PurposeTo examine the potential cost-savings of stereotactic vacuum-assisted biopsy (SVAB) over open surgical biopsy (OSB) in diagnosis of nonpalpable lesions on mammography and to estimate the cost-saving effect on lesions at different levels of malignant probability. MethodsThis retrospective study was approved by our Institutional Review Board. We retrospectively reviewed 276 (33.8 %) SVAB and 541 (66.2 %) OSB medical records at a medical center. Direct costs included patients’ self-paid and national health insurance claim charges. Indirect costs were calculated using sick days, average salary, and age-adjusted employment rate. One-way and two-way sensitivity analyses were conducted. Lesion classification was determined by the assessment categories of Breast Imaging Reporting and Data System (BI-RADS), 4th or 5th editions. ResultsSVAB decreased the direct cost by $90.3 (10.1 %) per diagnosis. The indirect cost was decreased by $560.2 (96.0 %). Overall, SVAB saved 43.9 % of resource utilization for each biopsy. Taking the cost of the subsequent malignant surgery into account, from the healthcare providers’ perspective, SVAB was cost-effective if a lesion had less than 19 % likelihood of malignancy. From the societal perspective, SVAB reduced productivity loss for all the lesions. Based on the positive predictive value of the BI-RADS categories, SVAB was more suitable for the lesions of category 4A and category 3, resulting in greater savings in both medical and societal resources. ConclusionsSVAB is a cost-effective diagnostic option for nonpalpable breast lesions. The cost-saving effect is greater for the lesions of category 4A and category 3.

Does the Combination of the Cognitive Interventions Improve the Function of Daily Living and Save the Long-Term Care Cost? A Pilot Study of Effectiveness and Cost Saving Analysis of "Learning Therapy" for People with Dementia.

Although the effects of various types of cognitive interventions have been evaluated, effectiveness and cost-saving effect of the combination of the different cognitive interventions is unknown. This study aimed to evaluate the feasibility of conducting a definitive trial to assess the effectiveness of combined cognitive intervention. A matched controlled trial of learning therapy (LT), a combination of cognitive training and stimulation, was conducted. The samples were recruited from the nursing homes. Inclusion criteria were as follows: age 65 years or older, clinical diagnosis of dementia, level of activities of daily living at II or above, Mini-Mental State Examination score between 10 and 26, receiving long-term-care services without history of LT, and provision of written consent. The primary outcomes were safety, validity of eligibility, retention rate, and effect on the functions of daily living represented by Criterion Time for Certification of Needed Long-Term-Care (CT for CNLTC) at 12 months. Cost-benefit analysis was also conducted to assess the cost saving effect of LT. No serious adverse events were detected. The exclusion rate at the screening phase was 5% and the retention rate was 77% at 12 months. LT demonstrated statistically significant improvement in CT for CNLTC at 12 months (Δ=18.8, almost equivalent to "one" degree of the care needed level) and saved the long-term-care cost by JPY 200,000 (USD 1,618). LT is effective for improving care recipients' level of care needed and has a cost saving effect. A randomized controlled trial is required to verify these findings. This study was approved by the ethics committee at Keio University School of Medicine (ID: 20150061). This trial was registered at University hospital Medical Information Network Clinical Trial Registry (UMIN-CTR ID: UMIN000018223).

Does Import Trade Liberalization Affect Firms’ Output Volatility?

Since its accession to the WTO, China has actively promoted trade liberalization. It is undeniable that trade liberalization has brought excellent products, production technologies and solutions from all over the world. However, it is also important to note that with the deepening of trade liberalization reforms, a large number of high-quality foreign products flood into the domestic market, making the production and sales activities of domestic firms inevitably affected by the impact of import factors, which has a profound impact on the stability of firms’ output growth path（i.e. output volatility）.This paper uses China’s accession to the WTO as the research background, using Chinese micro data to test the relationship between trade liberalization and output volatility. First, we use the residual regression method to calculate the annual fluctuation index and window fluctuation index of the output growth rate of manufacturing enterprises in China from 1998 to 2013. Second, we combine the product tariff data of WITS products and the input-output table to calculate the import trade liberalization index of China’s manufacturing industry. Finally, we use multiple econometric analysis methods（including: fixed effect/difference-in-differences/panel IV）to systematically evaluate the causal relationship between trade liberalization and output volatility, and then demonstrate the mechanism.Input-trade liberalization has a significant stabilizing effect on the output volatility of Chinese manufacturing enterprises. For every 0.01 unit of absolute change in input-import tariff, the volatility of enterprise sales will decrease by 0.785%, and the volatility of total output will decrease by 0.896%. In terms of the impact mechanism, due to cost-saving effect and factor market diversification effect, input-trade liberalization can effectively improve firms’ intermediate input cost and intermediate input source, and thereby smooth the output volatility. On the other hand, output-trade liberalization has not significantly affected the output volatility. This may be because of the influence of China’s unique large economy, such as large market size or export expansion; the competitive effect of trade liberalization has been gradually weakened, so it does not show a significant effect.The main contributions of this paper are: First, it helps us understand the relationship between import trade and output volatility at a micro level. Second, based on the existing research, we can have a more comprehensive understanding of the effect of trade liberalization on the performance of firm behavior. Third, trade liberalization is divided into two levels: output-trade liberalization and input-trade liberalization, so as to better identify how import trade liberalization affects firms’ output volatility.

Higher Density Development for Lower Cost Housing? Understanding the Multifamily Housing Market and the Role of Density in Multifamily Home Prices

This study documents the development and the characteristics of multifamily homes in the Portland metropolitan area and evaluate the roles of density and density-related factors in determining multifamily home prices. The study finds that medium-density multifamily homes sell at lower prices than other housing types in dollar per unit and dollar per square foot. The cost-saving effect of higher density development is weak or even negative, and dwelling size is the primary determinant of multifamily home prices. The effects of neighborhood density on home prices depend on housing types. Investors own almost a half of nonapartment multifamily homes and buy homes at lower prices.

Impact of catheter ablation therapy for atrial fibrillation on healthcare expenditures in a middle European cohort.

Atrial fibrillation (AF) is the most prevalent arrhythmia in western countries. It is associated with increased mortality and morbidity and responsible for hospitalization rates of 10-40% per patient per year. Studies from the UK and the USA have shown that AF is responsible for ∼1% of the total healthcare expenditures in these countries. The only potentially curative treatment is pulmonary vein isolation (PVI). Published health economic data on the impact of PVI mainly consist of simulations of expenditures with assumed efficacy taken from ablation studies. Real expenditure data are missing as well as pre-ablation period data and long-term data. We analyse true healthcare expenditures based on inpatient and outpatient data from the Upper Austrian Health Insurance Fund social security system of patients undergoing PVI during 2005 to 2015. We identified 1135 patients undergoing PVI with 268 having multiple procedures. Days of hospitalization and days of sick leave started to rise in the year before ablation. PVI was able to lower both parameters to the level of 1 year before ablation. Comparing four quarters before and after a single-index ablation, a highly significant reduction in inpatient healthcare expenditures was documented. There was a significant, but numerically small increase in outpatient expenditures, resulting in a significant reduction in overall healthcare expenditures. Analysing a cohort of the Upper Austrian Health Insurance Fund undergoing PVI, we found significant cost-saving effects on post-interventional healthcare expenditures and a reduction in days of sick leave.

Can a semi-quantitative method replace the current quantitative method for the annual screening of microalbuminuria in patients with diabetes? Diagnostic accuracy and cost-saving analysis considering the potential health burden.

ObjectivesDiabetes is a global epidemic, and the high cost of annually and quantitatively measuring urine albumin excretion using the turbidimetric immunoassay is challenging. We aimed to determine whether a semi-quantitative urinary albumin-creatinine ratio test could be used as a screening tool for microalbuminuria in diabetic patients.MethodsWe assessed the diagnostic accuracy of the semi-quantitative method. The costs of false results in the semi-quantitative method were calculated based on the annual probability of disease progression analyzed through a systematic literature review and meta-analysis. The pooled long-term cost-saving effect of the semi-quantitative method compared with the quantitative test was assessed using a Markov model simulating a long-term clinical setting. Diagnostic accuracy and the cost-saving effect were also validated in an independent external cohort.ResultsCompared with the quantitative test, the semi-quantitative method had sensitivities of 93.5% and 81.3% and specificities of 61.4% and 63.1% in the overall sample of diabetic patients (n = 1,881) and in diabetic patients with eGFR ≥60 ml/min/1.73 m2 and a negative dipstick test (n = 1,110), respectively. After adjusting for direct and indirect medical costs, including the risk of disease progression, which was adjusted by the meta-analyzed hazard ratio for clinical outcomes, it was determined that using the semi-quantitative method could save 439.4 USD per person for 10 years. Even after adjusting the result to the external validation cohort, 339.6 USD could be saved for one diabetic patient for 10 years.ConclusionsThe semi-quantitative method could be an appropriate screening tool for albuminuria in diabetic patients. Moreover, it can minimize the testing time and inconvenience and significantly reduce national health costs.

Employee Acceptance of Use: A Precondition for Enhancing Therapy Effectiveness, Patient Safety, and Economic Efficiency.

Introduction: From the workplace engineering sciences, it is evident that work efficiency, measured by the criteria efficiency and effectiveness of therapy, economy and patient safety, is determined mainly by staff acceptance of new technology and reengineered workflows. Accordingly, the aim of this study was to ascertain and assess differences in terms of the acceptance of alternative types of prosthesis instrument configurations, oriented around the research question: “Which product features and process effects determine a high level of employee acceptance of use?”Materials and Methods: This study is designed as a before-and-after comparison, based on the usability engineering approach. In the first study phase, 46 employees participating in the process of providing instruments for a total knee arthroplasty (TKA) procedure were asked to examine the current working situation, using a standard instrumentation set, in terms of instrument handling, work burden, proneness to errors, patient risks, process efficiency, and effectiveness. In the second study phase, 20 weeks after having implemented a size-specific instrumentation set, the same 46 individuals were surveyed on the identical questions. Additionally, in both study phases the time needed to perform the sub-processes related to instrumentation logistics inside the operating room (OR) was measured, in order to identify process efficiency and cost-saving effects.Results: By using standard sets only 30% perceived a need for improvement. After 20 weeks, only 8% of the employees were satisfied with the previous equipment and 69% regarded the standard set as being relatively error-prone, endangering patient safety. In addition, 85% regarded the effectiveness of the standard process as limited. Finally, 75% considered the effectiveness of the reengineered process to be significantly higher, and 69% drew attention to the reduction of handling disadvantages. Furthermore, the time needed for instrumentation logistics inside the OR estimated at about 13 min less when using size-specific sets. This effect on process efficiency cost savings or the generation of additional revenue by performing additional procedures. Based on these findings, an ergonomic decision-making model has been developed.Conclusion: Innovative medical products such as size-specific instrumentation sets contribute to lower procedure costs and improved process efficiency in the operating room (OR). However, employee motivation to use a new technology as part of an optimized workflow organization, is crucial to achieving an enhanced level of effectiveness, efficiency and patient safety. Hence, it is advisable to enhance change-management efforts in order to reduce resistance to change and ensure the new technology is successful.

Trends of Hospital Palliative Care Utilization and Its Associated Factors Among Patients With Systemic Lupus Erythematosus in the United States From 2005 to 2014.

To investigate trends and associated factors of utilization of hospital palliative care among patients with systemic lupus erythematosus (SLE) and analyze its impact on length of hospital stay, hospital charges, and in-hospital mortality. Using the 2005-2014 National Inpatient Sample in the United States, the compound annual growth rate was used to investigate the temporal trend of utilization of hospital palliative care. Multivariate multilevel logistic regression analyses were performed to analyze the association with patient-related factors, hospital factors, length of stay, in-hospital mortality, and hospital charges. The overall proportion of utilization of hospital palliative care for the patient with SLE was 0.6% over 10 years. It increased approximately 12-fold from 0.1% (2005) to 1.17% (2014). Hospital palliative care services were offered more frequently to older patients, patients with high severity illnesses, and in urban teaching hospitals or large size hospitals. Patients younger than 40 years, the lowest household income group, or Medicare beneficiaries less likely received palliative care during hospitalization. Hospital palliative care services were associated with increased length of stay (β = 1.407, P < .0001) and in-hospital mortality (odds ratio, 48.18; 95% confidence interval, 41.59-55.82), and reduced hospital charge (β = -0.075, P = .009). Hospital palliative care service for patients with SLE gradually increased during the past decade in US hospitals. However, this showed disparities in access and was associated with longer hospital length of stay and higher in-hospital mortality. Nevertheless, hospital palliative care services yielded a cost-saving effect.

P.674 Initiation of three-monthly palmitate paliperidone long-acting formulation in French clinical practice: results from the OPTIMUS study

Schizophrenia entails a considerable humanistic and economic burden. Improved treatment continuity to antipsychotic therapy is paramount to reduce the risk of relapse. The novel three-monthly paliperidone palmitate treatment (PP3M) offers the longest dosing interval currently available in France. This study assesses its cost-effectiveness, versus the currently available one-monthly long-acting treatment (PP1M) in French schizophrenic patients.A Markov model with monthly cycles was developed and adapted. It encompassed [a] administration of PP3M or PP1M in first-line, [b] a period where the patient does not receive any active treatment, and [c] a follow-up treatment line consisting of a treatment mix reflecting French clinical practice. Relapse rates in first-line were based on a pivotal non-inferiority head-to-head trial, and treatment discontinuation rates were based on French real-world data. Accounting for differences in drug exposure, time-dependent monthly relapse rates were applied following discontinuation to first line. The impact of a less frequent injection schedule for PP3M in QoL was accounted for through the application of a utility differential. The collective perspective was adopted throughout a 5-year time horizon. Four percent discount rates were applied on costs and outcomes.PP3M was dominant when compared to PP1M, featuring an incremental QALY of 0.123 and a cost saving effect (−669 €) resulting from reduced therapy costs (drug acquisition, administration and monitoring) and relapse-related costs. Sensitivity analysis supported the robustness of the results.With slightly better QALY outcomes and a cost-saving effect when compared to PP1M, introducing PP3M is an improvement to the current treatment in France.

P5245Cost-saving diagnosis approach by artificial intelligence tool in patients with suspected coronary artery disease. The co-operative ARTICA registry database

Abstract Background Although coronary tomographic angiography (CTA) has shown promise as a “gatekeeper” to invasive coronary angiography (ICA) in longitudinal cohort studies, it remains unknown whether the strategy of direct initial performance of CTA is cost-effective when compared with selected exercise treadmill testing (ETT) +/− functional cardiac imaging strategies in patients with suspected coronary artery disease (CAD). An innovative artificial intelligence (AI) Decision Support System (DSS) ESC guidelines based has been used at point of care for evaluating subjects with stable chest pain (SCP). Purpose The objective was to verify the cost-saving effect of the robotic AI DSS vs direct CTA by human standard care (SD) for diagnosing CAD in subjects presenting with SCP. Methods From October 2016 over three hospitals, 1017 subjects, 620 males, age 62±11 years, with clinically SCP being referred for CTA by SD received also a same day pre-scan AI DSS administration. All patients did not demonstrate significant CAD at CTA. CTA/ICA, or exercise treadmill test (ETT)/ stress echocardiography (SE), gated myocardial perfusion scintigraphy (gMPS) or Follow up/No tests (FNT) strategies by AI DSS were analyzed and compared to direct CTA SD. Pre-test likelihood (pt-lk) of CAD consider clinical risk factors into the model. Sensitivity and specificity of non-invasive diagnostic tests within our model were based upon a bivariate analysis of data from published multicenter trials. Costs of procedures were calculated by the sum of technical and professional components. Probabilistic sensitivity analysis was conducted to assess the impact of uncertainty in model parameters. Results The direct approach used performing direct CTA strategy by SD in all subjects costed 406.800 €. Costs of each procedure and distribution of AI DSS outputs are shown in the Table. Across the range of pt-lk of CAD, total costs of AI DSS strategy resulted 146.030€ with −65% vs SD approach. AI DSS tests distribution and costs pt-lk (pt/%) FNT (0€) ETT (90€) SE (350€) Stress gated MPS (750€) CCTA (400€) ICA (3.000€) High (29/2.8) 0 0 1 2 0 26 Int (371/36.5) 259 5 51 48 7 1 Low (612/60.7) 595 2 2 0 13 0 Total costs (€) 0 630 18,900.00 37,500.00 8,000.00 81,000.00 Conclusion These results from ARTICA registry seem to demonstrate that AI DSS is extremely cost-saving in subjects with stable chest pain across the whole range of pt-lk of CAD.

The clinical and economic impact of three-monthly long-acting formulation of paliperidone palmitate versus the one-monthly formulation in the treatment of schizophrenia in France: A cost-utility study

ObjectivesSchizophrenia entails a considerable humanistic and economic burden. Improved treatment continuity to antipsychotic therapy is paramount to reduce the risk of relapse. The novel three-monthly paliperidone palmitate treatment (PP3M) offers the longest dosing interval currently available in France. This study assesses its cost-effectiveness, versus the currently available one-monthly long-acting treatment (PP1M) in French schizophrenic patients. MethodsA Markov model with monthly cycles was developed and adapted. It encompassed [a] administration of PP3M or PP1M in first-line, [b] a period where the patient does not receive any active treatment, and [c] a follow-up treatment line consisting of a treatment mix reflecting French clinical practice. Relapse rates in first-line were based on a pivotal non-inferiority head-to-head trial, and treatment discontinuation rates were based on French real-world data. Accounting for differences in drug exposure, time-dependent monthly relapse rates were applied following discontinuation to first line. The impact of a less frequent injection schedule for PP3M in QoL was accounted for through the application of a utility differential. The collective perspective was adopted throughout a 5-year time horizon. Four percent discount rates were applied on costs and outcomes. ResultsPP3M was dominant when compared to PP1M, featuring an incremental QALY of 0.123 and a cost saving effect (−669€) resulting from reduced therapy costs (drug acquisition, administration and monitoring) and relapse-related costs. Sensitivity analysis supported the robustness of the results. ConclusionWith slightly better QALY outcomes and a cost-saving effect when compared to PP1M, introducing PP3M is an improvement to the current treatment in France.

Distributed ledger technology in supply chains: a transaction cost perspective

With the emergence of distributed ledger technology (DLT), numerous practitioners and researchers have proclaimed its beneficial impact on supply chain transactions in the future. However, the vast majority of DLT initiatives are discontinued after a short period. With the full potential of DLT laying far down the road, especially managers in supply chain management (SCM) seek for short-term cost-saving effects of DLT in order to achieve long-term benefits of DLT in the future. However, the extant research has bypassed grounding long-term as well as short-term effects of DLT on supply chain transaction with empirical data. We address this shortcoming, following an abductive research approach and combining empirical data from a multiple case study design with the corresponding literature. Our study reveals that the effects of DLT on supply chain transactions are two-sided. We found six effects of DLT solutions that have a cost-reducing or cost avoidance impact on supply chain transactions. In addition, we found two effects that change the power distribution between buyers and suppliers in transactions and a single effect that reduces the dependency of supply chain transactions on third parties. While cost-reducing and avoidance as well as dependency-reducing effects are positive effects, the change in power distribution might come with disadvantages. With these findings, the paper provides the first empirical evidence of the impact of DLT on supply chain transactions, which will enable managers to improve their assessment of DLT usage in supply chains.

Cost analysis of day care centres in Norway.

BackgroundDay care services aim to offer meaningful activities and a safe environment for the attendees and a respite for family caregivers while being cost effective. This study compares the use of formal and informal care in users and non-users of day care centres designed for persons with dementia.MethodUsers of day care designed for dementia (DC group) and non-users (NDC group) were followed over a period of 24 months or until nursing home admission (NHA) respectively death. Demographic and clinical characteristics were collected at baseline and after 12 and 24 months. The use of care was recorded by Resource Utilization in Dementia (RUD).ResultsA total of 257 persons with dementia participated in the study, 181 in the DC group and 76 in the NDC group. Users of day care centres cause higher costs due to the expenses for day care, while neither the use of home nursing, secondary care, informal care nor the time until NHA did show any differences between users and non-users. The overall costs were higher in the DC group at baseline and after 12 months, but this difference was no longer present at the end of the two-year study period.ConclusionOur results indicate no potential cost-saving effect of day care designed for people with dementia, as the use of day care did neither result in a reduced use of care nor in a delay of NHA. Future research should balance the non-monetary benefits of day care against its costs for a full cost-effectiveness analysis, most favourable in a RCT-design.

Robust empty container repositioning considering foldable containers

Because of the extreme imbalance in intercontinental trade, the repositioning of empty containers creates a significant problem for shipping companies. There are many efforts to reduce the cost of repositioning empty containers, one of which is a foldable container. This paper proposes a robust formulation for the empty container repositioning problem considering foldable containers under demand uncertainty. The robust formulation can be used as a tractable approximation of a multistage stochastic programming formulation which is computationally intractable. Moreover, the robust formulation requires only limited information about the distribution of demand to replicate real-world situations. Computational results show that the proposed formulation performs well in terms of operating costs and there exists a significant cost-saving effect when foldable containers are used in maritime transportation.

Optimizing compliance with surgical antimicrobial prophylaxis guidelines in patients undergoing gastrointestinal surgery at a referral teaching hospital in southern Iran: clinical and economic impact.

BackgroundAntibiotic prophylaxis is one of the major approaches to prevent surgical site infection. Despite the availability of international guidelines on it, the practice of antibiotic prophylaxis is still far from optimal. This study aimed to assess the impact of guideline implementation on the rational use of prophylactic antibiotics and its cost-saving effect in gastrointestinal surgery by clinical pharmacist intervention.MethodsA pre and post intervention study was carried out between October 2017 and June 2018 on patients who underwent gastrointestinal surgery in a major referral teaching hospital in Shiraz, southern Iran. The intervention phase consisted of revising the institutional guidelines for surgical antimicrobial prophylaxis, assigning a clinical pharmacist to the surgical department, and arranging several meetings with the surgical department regarding the appropriate utilization of antibiotics. Differences in antibiotic utilization in patients before and after the intervention phase were compared. Exposures were surgical antimicrobial prophylaxis timing and agents, and main outcomes were incidence of surgical site infection and length of hospital stay.ResultsA total of 430 patients were included in the post intervention phase, while 445 patients were included in the baseline evaluation. Promoting appropriate antibiotic use in the post intervention group had the potential to decrease medication costs by reducing unnecessary prescriptions and duration of antibiotic usage (P<0.001). In the pre intervention group, the mean cost of antibiotic prescriptions was 11.5 times that of the post intervention group. Mean hospitalization in the pre intervention group was greater than the post intervention group (P<0.001). Furthermore, our data revealed that the rate of postsurgery infection in the post intervention group was 3.03%, while this rate was 6.76% in the preintervention group (P=0.01).ConclusionThis study provides evidence that adherence to surgical antimicrobial prophylaxis guidelines increased the rational use of prophylactic antibiotics, with substantial cost savings in patients who underwent surgery.

Design of counter oxidation vs. CO2 electroreduction for efficient formate production on a tin cathode

Aiming to decrease power consumption during CO2 electro-conversion, SO32− oxidation was employed as a counter reaction vs. CO2 electroreduction for formate production on a Tin cathode. The FE and EE for formate at cathodic potential −1.80 vs. SCE/V in 5h continuous electrolysis were 69.87% and 27.57%, which were increased by ratios of 44.75% and 48.31%, respectively, compared with those in the absence of SO32−, together with obvious decrease of the power consumption from 9.04 to 4.81 kWh/kg formate. The electrochemical properties of anolytes show such performance enhancement originated from lower anodic oxidation potential, larger effective area for oxidation and faster oxidation kinetics associated with the conversion of SO32− to SO42−, which reduce the anodic potential and retard side reaction of HER. The effect of SO32− oxidation works on reducing cell voltage and increasing effect current density, which illustrated by morphology changes of cathodes and variations of electrolytes during CO2 reduction. The productive and economical conversion of CO2 to formate at galvanostatic mode verifies the cost-saving effect of SO32− anolyte to the whole cell and provides lab-scale instances for scale-up implementation. This study puts forward another insight for cost-effective CO2 electroreduction, which are of great value in enhancing balance between energy input and output during CO2 utilization, thus having implication in enriching strategy within electroreduction field.