Downstream Costs Research Articles

Cost Analysis of Avoiding Gastrostomy Tube in Robin Sequence Neonates that Undergo Mandibular Distraction.

To evaluate costs associated with perioperative gastrostomy tube (G-tube) placement for neonates with Robin sequence (PRS) that undergo mandibular distraction osteogenesis (MDO). Retrospective chart review was performed to examine the medical records of neonates with RS who received treatment at our institution between 2012 and 2021. Patients under 6 months of age that underwent MDO for RS were included. Billing records of hospital costs over a 2-year period were analyzed. The study included 26 total patients with 11 in the MDO-only group, 9 in G-tube after MDO group, and 6 in G-tube before MDO group. There was a significant difference (p < 0.001) in total hospital costs between groups with MDO-only group averaging $119,532 (SD 33,503), the G-tube after MDO group averaging $245,315 (SD 102,327), and G-tube before MDO group averaging $252,300 (SD 84,990). Multiple linear regression was performed controlling for genetic syndrome and birth weight, which still showed a statistically significant difference in total cost between the MDO-only group and G-tube after MDO (p = 0.006), and between the MDO-only group and G-tube prior to MDO (p = 0.01). There was a significant difference in costs between all three groups for total inpatient/outpatient costs with MDO-only group averaging $78,502 (SD 30,953), the G-tube after MDO group averaging $176,125 (SD 84,315), and the G-tube prior to MDO group averaging $156,309 (SD 95,746). MDO performed without perioperative G-tube placement may reduce charges by >$100,000. The associated improvement of dysphagia after MDO surgery and potential for avoiding a G-tube has tremendous downstream cost and social benefits for families. NA Laryngoscope, 2024.

Telemetry discontinuation education for Nurse Practitioners decreases hospital costs-A quality-improvement project.

Despite updated American Heart Association guidelines, interventions designed to reduce telemetry misuse are uncommon. There was a systemic failure within the institution to adopt the most recent guidelines, resulting in poor use of resources and downstream costs. Case-control. Pre-post educational intervention, quality-improvement (QI) project in an urban academic cancer institution. Baseline telemetry usage was observed in 2,984 nonintensive inpatients in 21 hospital services over 6 months. Outcome measures were weekly telemetry usage in total minutes and cost savings based on a cost-predicted algorithm. Performance was compared between the intervention group and a control group for 3 months. Measures were compared using QI control charts and inferential statistics. Three high-using telemetry services primarily staffed by certified nurse practitioners (CNPs) were provided with a telemetry education intervention. The intervention consisted of four ten-minute educational sessions over 2 weeks delivered to the highest three telemetry using services. Forty-five providers received the educational intervention (78% CNPs and physician assistants [PAs] and 22% medical doctors [MDs]) and 272 did not (57% CNPs and PAs and 43% MDs). Only the educational intervention group showed measurable decreases shown by shifts in QI control charts. Decreased usage in the intervention group produced greater cost savings per patient when compared with the control group ($71.98 vs. $60.68), resulting in an estimated total annual cost savings of $94,740. Educational interventions for inpatient CNPs that reinforce national policies for telemetry discontinuation improve practice efficiency and potentially decrease health care costs.

Stress CMR Perfusion Imaging in the Medicare-Eligible Population: Insights From the SPINS Study.

Patients aged ≥65 years account for a disproportionately large portion of cardiovascular (CV) events and pose a challenge for noninvasive detection of coronary artery disease. This study sought to determine the prognostic value of stress cardiac magnetic resonance (CMR) in a Medicare-eligible group of patients in a multicenter setting in the United States. From a multicenter U.S. registry, the study identified patients aged≥65 years who were referred for stress CMR for evaluation of myocardial inducible ischemia. The primary outcome was defined as CV death or nonfatal myocardial infarction, whereas the secondary outcome was defined as any primary outcome, hospitalization for unstable angina, hospitalization for congestive heart failure, and unplanned late coronary artery bypass grafting. The associations of CMR findings with CV outcomes adjusted to clinical risk markers and health care cost spending were determined. Among 1,780 patients (aged 73 ± 5.7 years; 46% female), study investigators observed 144 primary eventsand 323 secondary events, over a median follow-up of 4.8 years. The presence of inducible ischemia and late gadolinium enhancement (LGE) was associated with incrementally higher event rates. Patients with neither inducible ischemia nor LGE experienced a<1% annualized rate of primary outcome. In a multivariable model adjusted for CV risk factors, inducible ischemia and LGE maintained an independent association with primary (HR: 2.80 [95%CI: 1.93-4.05]; P< 0.001; and HR: 1.85 [95%CI: 1.21-2.82]; P = 0.004, respectively) and secondary (HR: 2.46 [95%CI: 1.90-3.19]; P< 0.001; and HR: 1.72 [95%CI: 1.30-2.27]; P< 0.001, respectively) outcomes. Rates of revascularization, as well as downstream costs for patients without CMR-detected inducible ischemia, remained low throughout the follow-up period. In a multicenter cohort of Medicare-eligible older patients, stress CMR was effective in providing risk stratification. (Stress CMR Perfusion Imaging in the United States [SPINS] study; NCT03192891).

Health and Economic Outcomes of Pembrolizumab in the Treatment of Metastatic Non-small Cell Lung Cancer (mNSCLC) and Melanoma in Italy.

In Italy, the management of metastatic non-small cell lung cancer and melanoma leads to significant healthcare challenges, necessitating cost-effective treatment strategies and offering valuable insights for healthcare policymakers and stakeholders. This study was designed to assess the costs, quality-adjusted life-years (QALYs) and disability-adjusted life-years (DALYs) associated with the health and economic outcomes of (1) pembrolizumab-combined chemotherapy administered as a first-line treatment for metastatic non-squamous and squamous non-small cell lung cancer (NSCLC) where the tumour presents with a programmed death-ligand 1 expression level <50% and of (2) adjuvant pembrolizumab treatment for stage III melanoma. Three cost-effectiveness models developed by MSD were investigated for each treatment indication. A unique model was built to assess the overall effect of pembrolizumab versus chemotherapy or watchful waiting in patients with lung cancer or melanoma, respectively. Theoretical cohorts of patients with metastatic squamous and non-squamous NSCLC were followed over time using a partitioned survival model with weekly cycles. A weekly cycle Markov model was employed for melanoma. The analysis was conducted from the Italian National Health Service perspective, considering a time horizon of 40 years (lifetime). A single closed cohort of treatable patients was followed over time for each indication (4000, 7000 and 900 for NSCLC squamous, non-squamous and melanoma, respectively). The costs evaluated included those for adverse drug events, non-drug disease management, subsequent treatment and terminal care. Drug acquisition and administration costs were excluded. For each treatment indication assessed, pembrolizumab produced downstream direct cost offsets (- €122,498,568, -€133,369,076 and -€32,993,242 for NSCLC squamous, non-squamous and melanoma indications, respectively), increased quality of life (+2088, +5317 and +2307 QALYs for NSCLC squamous, non-squamous and melanoma indications, respectively) and reduced disability (-2658, -7202 and -3029 DALYs for NSCLC squamous, non-squamous and melanoma indications, respectively). Across indications, the total cost offsets of pembrolizumab were -€288,860,885, with 9712 QALYs gained and 12,889 DALYs avoided. The analysis demonstrated that, compared with chemotherapy, pembrolizumab is more cost effective in Italy as a first-line treatment in patients with metastatic squamous or non-squamous NSCLC and, if compared with watchful waiting, as adjuvant treatment in patients with stage III melanoma. The present analysis suggested that pembrolizumab use could lead to important health benefits for patients while offsetting a portion of cancer care costs.

In Silico Analysis and Development of the Secretory Expression of D-Psicose-3-Epimerase in Escherichia coli.

D-psicose-3-epimerase (DPEase), a key enzyme for D-psicose production, has been successfully expressed in Escherichia coli with high yield. However, intracellular expression results in high downstream processing costs and greater risk of lipopolysaccharide (LPS) contamination during cell disruption. The secretory expression of DPEase could minimize the number of purification steps and prevent LPS contamination, but achieving the secretion expression of DPEase in E. coli is challenging and has not been reported due to certain limitations. This study addresses these challenges by enhancing the secretion of DPEase in E. coli through computational predictions and structural analyses. Signal peptide prediction identified PelB as the most effective signal peptide for DPEase localization and enhanced solubility. Supplementary strategies included the addition of 0.1% (v/v) Triton X-100 to promote protein secretion, resulting in higher extracellular DPEase (0.5 unit/mL). Low-temperature expression (20 °C) mitigated the formation of inclusion bodies, thus enhancing DPEase solubility. Our findings highlight the pivotal role of signal peptide selection in modulating DPEase solubility and activity, offering valuable insights for protein expression and secretion studies, especially for rare sugar production. Ongoing exploration of alternative signal peptides and refinement of secretion strategies promise further enhancement in enzyme secretion efficiency and process safety, paving the way for broader applications in biotechnology.

Opioid-related clinical outcomes and associated healthcare costs following abuse/misuse of oxycodone formulations: A HEOR analysis from real-world data.

The United States (US) opioid epidemic is a continued burden on the healthcare system and on the lives of individuals affected by the consequences of opioid abuse/misuse. The objective of this study was to use real-world data from intentional abuse/misuse exposures managed by US poison centers to compare clinical outcomes and quantify healthcare costs among three study cohorts: -exposures that involved Xtampza ER®, other oxycodone extended-release (ER), and oxycodone immediate-release (IR). A real-world, observational study. Descriptive statistics were used to describe patient and exposure characteristics. Drug utilization-adjusted rates of intentional abuse/misuse and clinical outcomes were used to determine relative risk. Healthcare cost estimates were calculated by extrapolating average charge per opioid-related disorder emergency department (ED) visit and per inpatient stay based upon case disposition rates, adjusted for population and drug utilization. Compared to Xtampza ER, exposures that involved other oxycodone ER were 7.4 times more likely to be intentional abuse/misuse, 25.9 times more likely to result in major effect or death, 9.7 times more likely to require a visit to the ED, and 14.3 times more likely to result in hospital admission. Similar results were found for oxycodone IR when compared to Xtampza ER. This study is the first of its kind to synthesize clinical outcomes with opioid-related healthcare costs, suggesting that even when Xtampza ER is abused/misused, the rates of major effect/death, ED visits, and hospital admissions were significantly lower than those for other oxycodone-containing medications, resulting in relatively low downstream opioid-related healthcare costs.

Jail-Based For-Profit Mental Health Providers and Treatment Engagement After Release.

This study compared mental health treatment engagement among people with serious mental illness after release from jails that had either a for-profit (N=3 jails) or a nonprofit mental health provider (N=7 jails). Across the 10 jails, data were collected in 2019 for 1,238 individuals with serious mental illness. Data included demographic characteristics (age, race-ethnicity, gender, geography, and jail type) and behavioral health variables (previous mental health treatment, psychotropic medication use, substance use, and receipt of jail-based mental health services). Logistic regression was used to predict treatment engagement during the year after release, stratified by type of jail-based mental health provider, in analyses controlled for demographic and behavioral health variables. Almost half (46%, N=573) of the individuals had stayed in jails with a for-profit mental health provider; the other half (54%, N=665) had stayed in jails with a nonprofit provider. In the year after release, 37% (N=458) of all individuals engaged in mental health treatment, and 63% (N=780) did not. Those who had stayed in a jail with a for-profit provider were significantly less likely to engage in mental health treatment during the year after release (AOR=0.59, 95% CI=0.42-0.83, p<0.01), compared with those in jails having a nonprofit provider. Staying in a jail with a for-profit mental health provider was associated with reduced postrelease engagement with community service providers. Less engagement with services during a pivotal time after release may increase behavioral health crises that erode individuals' well-being and may raise downstream costs due to further criminal legal involvement and emergency care use.

Efficient Bio-Oxidation of Cellobiose with Engineered Gluconobacter oxydans to Provide Highly Concentrated Cellobionic Acid

Cellobionic acid (CBA) can be obtained through the oxidation of cellobiose, the monomer of cellulose. CBA serves as a plant-based alternative to its stereoisomer lactobionic acid, which is used in the pharmaceutical, cosmetic, and food industries. Gluconobacter oxydans is a well-established whole-cell biocatalyst with membrane-bound dehydrogenases (mDH) for regio-specific oxidations. As G. oxydans wildtype cells show low cellobiose oxidation activities, the glucose mDH from Pseudomonas taetrolens was overexpressed in G. oxydans BP9, a multi mDH deletion strain. Whole-cell biotransformation studies were performed with resting cells of the engineered G. oxydans in stirred tank bioreactors. Initial biomass specific cellobionate formation rates increased with increasing cellobiose concentrations up to 190 g L−1, and were constant until the solubility limit. The maximal volumetric CBA formation rates and the oxygen uptake rates increased linearly with the concentration of engineered G. oxydans. This enables the estimation of the maximum biocatalyst concentration limited by the maximum oxygen transfer rate of any bioreactor. Thus, 5.2 g L−1 G. oxydans was sufficient to produce 502 g L−1 CBA with &gt;99% yield in a simple aerobic batch process. The highly concentrated CBA will reduce downstream processing costs considerably after cell separation.

Implementation, intervention, and downstream costs for implementation of a multidisciplinary complex pain clinic in the Veterans Health Administration.

To determine the budget impact of implementing multidisciplinary complex pain clinics (MCPCs) for Veterans Health Administration (VA) patients living with complex chronic pain and substance use disorder comorbidities who are on risky opioid regimens. We measured implementation costs for three MCPCs over 2 years using micro-costing methods. Intervention and downstream costs were obtained from the VA Managerial Cost Accounting System from 2 years prior to 2 years after opening of MCPCs. Staff at the three VA sites implementing MCPCs were supported by Implementation Facilitation. The intervention cohort was patients at MCPC sites who received treatment based on their history of chronic pain and risky opioid use. Intervention costs and downstream costs were estimated with a quasi-experimental study design using a propensity score-weighted difference-in-difference approach. The healthcare utilization costs of treated patients were compared with a control group having clinically similar characteristics and undergoing the standard route of care at neighboring VA medical centers. Cancer and hospice patients were excluded. Activity-based costing data acquired from MCPC sites were used to estimate implementation costs. Intervention and downstream costs were extracted from VA administrative data. Average Implementation Facilitation costs ranged from $380 to $640 per month for each site. Upon opening of three MCPCs, average intervention costs per patient were significantly higher than the control group at two intervention sites. Downstream costs were significantly higher at only one of three intervention sites. Site-level differences were due to variation in inpatient costs, with some confounding likely due to the COVID-19 pandemic. This evidence suggests that necessary start-up investments are required to initiate MCPCs, with allocations of funds needed for implementation, intervention, and downstream costs. Incorporating implementation, intervention, and downstream costs in this evaluation provides a thorough budget impact analysis, which decision-makers may use when considering whether to expand effective programming.

The role of race, gender, and poverty on length of pretrial jail stays: A multi‐site analysis

AbstractResearch SummaryThe average length of jail stays is increasing despite national efforts to reduce these populations. The current study examines variations in lengths of stay, differentiating between short and long pretrial stays. Using data from two large jails in metropolitan jurisdictions, we take an intersectional perspective and model potential differences among race, gender, and residing in a high‐poverty area. In both locations, we find that Black men are the most likely to have long lengths of stay, but that length of stay varies depending on the intersection of gender, race, and neighborhood poverty.Policy Implications:The human costs of pretrial detention are paid unequally by different groups of people. Given the downstream costs of pretrial detention, this work suggests that focusing policy efforts on the barriers to release among people of color, particularly Black men, would be fruitful. There is evidence that bail reform can reduce some barriers to release without increases in crime. Further, attending to obstacles to case processing could lead to pretrial system reform. This work also highlights another area of the criminal legal system where Black males, compared to their White counterparts, are disparately affected and denotes the continuing need for intersectional perspectives on reform.

Healthcare resource utilization and economic burden of multiple sclerosis in Chinese patients: results from a real-world survey

Multiple sclerosis (MS) is uncommon in China and the standard of care is underdeveloped, with limited utilization of disease-modifying treatment (DMT). An understanding of real-world disease burden (including direct medical, non-medical, and indirect costs, such as loss of productivity), is currently lacking in this population. To investigate the overall burden of managing patients with MS in China, a cross-sectional survey of physicians and their consulting patients with MS was conducted in 2021. Physicians provided information on healthcare resource utilization (HCRU; consultations, hospitalizations, tests, medication) and associated costs. Patients provided data on changes in their life, productivity, and impairment of daily activities due to MS. Results were stratified by disease severity using generalized linear models, with a p value < 0.05 considered statistically significant. Patients with more severe disease had greater HCRU, including hospitalizations, consultations and tests/scans, and incurred higher direct and indirect costs and productivity loss, compared with those with milder disease. However, the use of DMT was higher in patients with mild disease severity. With the low uptake and limited efficacy of non-DMT drugs, Chinese patients with MS experience a high disease burden and significant unmet needs. Therapeutic interventions could help save downstream costs and lessen societal burden.

The Aspire Social Impact Bond: How social impact bond financing can promote positive social and economic outcomes

AbstractFinancing human service delivery through social impact bonds (SIBs) is the subject of some critical commentary in the academic literature, but this tends to be largely theoretical rather than empirically based. This paper presents empirical evidence of how SIB financing can promote positive social and economic outcomes for governments, not‐for‐profit providers, individual service beneficiaries and society more broadly. The paper presents some of the results of an evaluation of the Aspire SIB, which financed an innovative intensive case management program providing housing and wraparound supports over a 3‐year period for people experiencing chronic homelessness. Aspire participants experienced significantly improved outcomes and decreased service needs, delivering downstream cost savings across several areas of government service delivery. This paper describes how the SIB financing mechanism underpinned the success of Aspire by promoting flexible, collaborative, outcome‐focussed and data‐informed responses to a challenging, multi‐faceted social problem.

Evolution-aided improvement of the acid tolerance of Levilactobacillus brevis and its application in sourdough fermentation

Levilactobacillus brevis is crucial in food fermentation, particularly in sourdough production. However, the cultivation of L. brevis faces a challenge with accumulation of lactic acid, a major inhibitor. We aimed to increase the acid tolerance of L. brevis, an industrial strain for sourdough fermentation. We used the adaptive laboratory evolution (ALE) to obtain lactic acid tolerant strains. The evolved strain’s fermentation and metabolite profiles, alongside sensory evaluation, were compared with the parental strain by using various analytical techniques. The ALE approach increased lactic acid tolerance in the evolved strain showing an increased growth rate by 1.1 and 1.9 times higher than the parental strain at pH 4.1 and 6.5, respectively. Comprehensive analyses demonstrated its potential application in sourdough fermentation, promising reduced downstream costs. The evolved strain, free from genetically modified organisms concerns, has great potential for industrial use by exhibiting enhanced growth in acidic conditions without affecting consumers’ bread preferences.

Carbon‐Efficient CO2 Electrolysis to Ethylene with Nanoporous Hydrophobic Copper

AbstractElectrochemical carbon dioxide (CO2) reduction offers a low‐carbon route to ethylene, when powered from renewable energy. Yet, the best‐performing CO2 electrolysis systems employ neutral or alkaline electrolytes, resulting in low conversion efficiencies, which increases downstream separation costs. High conversion rates can be achieved with acidic electrolytes, albeit at the cost ethylene faradaic efficiency (FE &lt; 45%). As a result, achieving high ethylene selectivity simultaneously with high conversion efficiency is an unmet challenge. Here, a 3D‐nanoporous catalyst is designed to modulate water and CO2 concentration at the catalyst surface, reaching higher ethylene selectivity in a forward‐bias bipolar MEA that recovers unreacted CO2. An ethylene FE of 63% at 150 mA cm−2 is reported, and by optimizing for conversion efficiency, an ethylene FE of 58% along with an overall conversion efficiency of 82% is achieved. Stable performance for &gt; 65 h at industrial current densities combined with a high ethylene concentration in the product stream showcases promising industrial viability.

Does FDG-PET/CT for incidentally found pulmonary lesions lead to a cascade of more incidental findings?

ObjectiveTo determine the frequency, nature, and downstream healthcare costs of new incidental findings that are found on whole-body FDG-PET/CT in patients with a non-FDG-avid pulmonary lesion ≥10 mm that was incidentally found on previous imaging. Materials and methodsThis retrospective study included a consecutive series of patients who underwent whole-body FDG-PET/CT because of an incidentally found pulmonary lesion ≥10 mm. ResultsSeventy patients were included, of whom 23 (32.9 %) had an incidentally found pulmonary lesion that proved to be non-FDG-avid. In 12 of these 23 cases (52.2 %) at least one new incidental finding was discovered on FDG-PET/CT. The total number of new incidental findings was 21, of which 7 turned out to be benign, 1 proved to be malignant (incurable metastasized cancer), and 13 whose nature remained unclear. One patient sustained permanent neurologic impairment of the left leg due to iatrogenic nerve damage during laparotomy for an incidental finding which turned out to be benign. The total costs of all additional investigations due to the detection of new incidental findings amounted to €9903.17, translating to an average of €141.47 per whole-body FDG-PET/CT scan performed for the evaluation of an incidentally found pulmonary lesion. ConclusionIn many patients in whom whole-body FDG-PET/CT was performed to evaluate an incidentally found pulmonary lesion that turned out to be non-FDG-avid and therefore very likely benign, FDG-PET/CT detected new incidental findings in our preliminary study. Whether the detection of these new incidental findings is cost-effective or not, requires further research with larger sample sizes.

Healthcare Resource Utilization and Costs in an At-Risk Population With Diabetic Retinopathy.

Several investigators have suggested the cost-effectiveness of earlier screening, management of risk factors, and early treatment for diabetic retinopathy (DR). We aimed to evaluate the extent of health care utilization and cost of delayed care by insurance type in a vulnerable patient population. A retrospective analysis of patients with DR was conducted using electronic medical record (EMR) data from January 2014 to December 2020 at Denver Health Medical Center, a safety net institution. Patients were classified by disease severity and insurance status. DR-specific costs were assessed via Current Procedural Terminology (CPT) codes over a 24-month follow-up period. Among the 313 patients, a higher proportion of non-English speaking patients were uninsured. Rates of proliferative DR at presentation differed across insurance groups (62% of uninsured, 42% of discount plan, and 33% of Medicare/Medicaid, P = 0.016). There was a significant difference in the total median cost between discount plan patients ($1258, interquartile range [IQR] = $0 - $5901) and both Medicare patients ($751, IQR = $0, $7148, P = 0.037) and Medicaid patients ($593, IQR = $0 - $6299, P = 0.025). There were higher rates of proliferative DR at presentation among the uninsured and discount plan patients and greater total median cost in discount plan patients compared to Medicare or Medicaid. These findings prioritize mitigating gaps in insurance coverage and barriers to preventative care among vulnerable populations. Advanced diabetic disease and increased downstream health care utilization and cost vary across insurance type, suggesting improved access to preventative care is needed in these specific at-risk populations.

Recent innovations in long-term care coverage and financing: a rapid scoping review

ObjectivesTo identify, chart and analyse the literature on recent initiatives to improve long-term care (LTC) coverage, financial protection and financial sustainability for persons aged 60 and older.DesignRapid scoping review.Data sourcesFour...

Societal costs of sepsis in the Netherlands

BackgroundSepsis is a life-threatening syndrome characterized by acute loss of organ function due to infection. Sepsis survivors are at risk for long-term comorbidities, have a reduced Quality of Life (QoL), and are prone to increased long-term mortality. The societal impact of sepsis includes its disease burden and indirect economic costs. However, these societal costs of sepsis are not fully understood. This study assessed sepsis’s disease-related and indirect economic costs in the Netherlands.MethodsSepsis prevalence, incidence, sepsis-related mortality, hospitalizations, life expectancy, QoL population norms, QoL reduction after sepsis, and healthcare use post-sepsis were obtained from previous literature and Statistics Netherlands. We used these data to estimate annual Quality-adjusted Life Years (QALYs), productivity loss, and increase in healthcare use post-sepsis. A sensitivity analysis was performed to analyze the burden and indirect economic costs of sepsis under alternative assumptions, resulting in a baseline, low, and high estimated burden. The results are presented as a baseline (low–high burden) estimate.ResultsThe annual disease burden of sepsis is approximately 57,304 (24,398–96,244; low–high burden) QALYs. Of this, mortality accounts for 26,898 (23,166–31,577) QALYs, QoL decrease post-sepsis accounts for 30,406 (1232–64,667) QALYs. The indirect economic burden, attributed to lost productivity and increased healthcare expenditure, is estimated at €416.1 (147.1–610.7) million utilizing the friction cost approach and €3.1 (0.4–5.7) billion using the human capital method. Cumulatively, the combined disease and indirect economic burdens range from €3.8 billion (friction method) to €6.5 billion (human capital method) annually within the Netherlands.ConclusionsSepsis and its complications pose a substantial disease and indirect economic burden to the Netherlands, with an indirect economic burden due to production loss that is potentially larger than the burden due to coronary heart disease or stroke. Our results emphasize the need for future studies to prevent sepsis, saving downstream costs and decreasing the economic burden.

CO2 conversion to solar fuels and chemicals: Opening the new paths

This future article discusses the new prospects and directions of CO2 conversion via the photo-electro-catalytic (PEC) route. The second (2nd) generation solar fuels and chemicals (SFs) are generated directly in PEC systems via electrons/protons reactions without forming molecular H2 as an intermediate, overcoming the thermodynamics limitations and practical issues encountered for electro-fuels produced by multistep thermocatalytic processes (i.e. CO2 conversion with H2 coming from water electrolysis). A distributed and decentralized production of SFs requires very compact, highly integrated, and intensified technologies. Among the existing reactors of advanced design (based on artificial leaves or photosynthesis), the integrated photovoltaic plus electrocatalytic (PV-EC) device is the only system (demonstrated at large scale) to produce SFs with high solar-to-fuel (STF) efficiency. However, while the literature indicates STF efficiency as the main (and only) measure of process performance, we remark here the need to refer to productivity (in terms of current density) and make tests with reliable flow PEC systems (with electrodes of at least 5–10 cm2) to accelerate the scaling-up process. Using approaches that minimize downstream separation costs is also mandatory. Many limitations exist in PEC systems, but most can be overcome by proper electrode and cell engineering, thus going beyond the properties of the electrocatalysts. As examples of current developments, we present the progress of (i) artificial leaf/tree devices for green H2 distributed production and (ii) a PEC device producing the same chemicals at both cathode and anode parts without downstream operations for green solvent distributed production. Based on these developments, future directions, such as producing fertilizers and food components from the air, are outlined. The aim is to provide new ideas and research directions from a personal perspective.

Long term cost outcomes among commercially insured patients undergoing bariatric surgical procedures.

Bariatric procedures have become safer in recent years, warranting new data on long-term costs. This study examined the impact of bariatric procedures on a person's long-term healthcare costs up to 10years and if it differed by socio-economic status (SES). This retrospective observational study compared the downstream health care cost of patients with obesity who had undergone bariatric surgery (BS) between 2009 and 2018 to a 1:1 matched group of members with obesity but no surgery. 167,764 individuals from administrative claims data with an obesity diagnosis were included; 83,882 in the BS group and 83,882 in the non-surgical group. In follow-up years 2-10, the BS group was associated with lower total medical healthcare cost compared to the non-surgical group (cost ratios ranged 0.85-0.93, p values<0.05). When stratifying the BS group by SES quartiles, there were no significant cost differences by SES (cost ratios ranged from 0.96 to 1.05, most p values>0.05). BS was associated with lower long-term follow-up medical cost and cost savings appeared similar among the SES quartiles in the BS group. The study results may help policy makers and employers in designing benefits and extending coverage for bariatric surgical procedures.