Generate Cost Savings Research Articles

Investment case for primary health care in low- and middle-income countries: A case study of Kenya.

Primary healthcare (PHC) systems attain improved health outcomes and fairness and are affordable. However, the proportion of PHC spending to Total Current Health Expenditure in Kenya reduced from 63.4% in 2016/17 to 53.9% in 2020/21 while external funding reduced from 28.3% (Ksh 69.4 billion) to 23.9% (Ksh 68.2 billion) over the same period. This reduction in PHC spending negatively affects PHC performance and the overall health system goals. We conducted a cost-benefit analysis and computed costs against the economic benefits of a PHC scale-up. Activity-Based Costing (ABC) on the provider perspective was employed to estimate the incremental costs. The OneHealth Tool was used to estimate the health impact of operationalizing PHC over five years. Finally, we quantified Return on Investment (ROI) by estimating monetized DALYs based on a constant value per statistical life year (VSLY) derived from a VSL estimate. The total projected cost of PHC interventions in the Kenya was Ksh 1.65 trillion (USD 15,581.91 billion). Human resource was the main cost driver accounting for 75% of the total cost. PHC investments avert 64,430,316 Disability Adjusted Life-Years (DALYs) and generate cost savings of Ksh. 21.5 trillion (USD 204.4 Billion) over five years. Shifting services from high-level facilities to PHC facilities generates Ksh 198.2 billion (USD 1.9 billion) and yields a benefit-cost ratio of 16:1 in 5 years. Thus, every $1 invested in PHC interventions saves up to $16 in spending on conditions like stunting, NCDs, anaemia, TB, Malaria, and maternal and child health morbidity. Evidence of the economic benefits of continued prioritization of funding for PHC can strengthen the advocacy argument for increased domestic and external financing of PHC in Kenya. A well-resourced and functional PHC system translates to substantial health benefits with positive economic benefits. Therefore, governments and stakeholders should increase investments in PHC to accelerate economic growth.

INTRODUCTION OF A MULTIMODAL PAIN REHABILITATION INTERVENTION IN PRIMARY CARE: A PILOT STUDY.

To evaluate patient-reported outcome measures in patients with chronic musculoskeletal pain 1 year after participation in a case manager-led multimodal rehabilitation intervention in a Finnish primary care centre. Changes in healthcare utilization (HCU) were also explored. A prospective pilot study with 36 participants. The intervention consisted of screening, multidisciplinary team assessment, a rehabilitation plan and case manager follow-up. Data were collected through questionnaires filled in after the team assessment and 1 year later. HCU data 1 year before and 1 year after team assessment were compared. At follow-up, satisfaction with vocational situation, self-reported work ability and health-related quality of life (HRQoL) had improved and pain intensity had diminished significantly for all participants. The participants who reduced their HCU improved their activity level and HRQoL. Early intervention by a psychologist and mental health nurse was distinctive for the participants who reduced HCU at follow-up. The findings demonstrate the importance of early biopsychosocial management of patients with chronic pain in primary care. Identification of psychological risk factors at an early stage may lead to better psychosocial wellbeing, improve coping strategy and reduce HCU. A case manager may free up other resources and thereby contribute to cost savings.

Projecting the potential cost-effectiveness of dapagliflozin for chronic kidney disease in Kuwait

IntroductionIn 2019, the prevalence of dialysis in Kuwait were 465 patient/million population, while the annual mortality rate among dialysis patients reached 12%. To improve resource allocation within the health care system, a cost-effectiveness model was conducted from a societal perspective to assess the cost-effectiveness of the use of dapagliflozin as an add-on-therapy against SoC (ramipril) among CKD patients with or without type-2 diabetes over their lifetime.MethodologyA Markov process model was utilized to assess the cost-effectiveness of dapagliflozin + ramipril versus ramipril alone on a cohort of patients with an eGFR of 25 to 75 mL/min/1.73, with or without type-2 diabetes and a urinary ACR of 200 to 5,000 over their lifetime. The model included nine health states: (i) the six stages of CKD representing stages 1, 2, 3a, 3b, 4 and 5; (ii)ESRD, which represents RRT as dialysis or kidney transplant and (iii) death. Most of the clinical data were captured from the DAPA-CKD study. We assumed that the mortality risk of our study was similar to DAPA-CKD. The utility data were captured from different studies. Direct medical and indirect costs were captured from local data sources. Sensitivity analyses were conducted.ResultsThe difference in QALY between dapagliflozin + ramipril versus ramipril was 0.2. The difference in cost between the two arms was KWD −4,120 (−USD25750). Dapagliflozin + ramipril generate better QALYs and lower costs than ramipril in CKD patients. Dapagliflozin improved the outcomes and generated cost savings in CKD patients.ConclusionAdoption of dapagliflozin + ramipril is considered to be a cost saving option in addition to the improvement in QALYs in CKD patients with or without type-2 diabetes due to its nephroprotective effect, regardless of the aetiology of CKD, which eventually leads to reduction of dialysis and the transplantation cost burden on the Kuwaiti health care system. This study was focussed only on DAPA-CKD cohort.

A Cost-Effectiveness Analysis of Biomarkers for Risk Prediction in Atrial Fibrillation.

Atrial fibrillation (AF) is associated with an increased risk of thromboembolism. This risk is currently assessed with scoring systems based on clinical characteristics. However, these tools have limited prognostic performance. Circulating biomarkers are proposed for improved prediction of major clinical events and individualization of treatments in patients with AF. The aim was to assess the cost-effectiveness of precision medicine (PM), i.e., the use of combined biomarkers and clinical variables, in comparison to standard of care (SOC) for risk stratification in a hypothetical cohort of AF patients at risk of stroke. A Markov cohort model was developed to evaluate the costs and quality-adjusted life-years (QALYs) of PM compared to SOC, over 20 years using a Canadian healthcare system perspective. PM decreased the mean per-patient overall costs by 7% ($94,932 vs $102,057 [Canadian dollars], respectively) and increased the QALYs by 12% (8.77 vs 7.68 QALYs, respectively). The calculated incremental cost-effectiveness ratio was negative, indicating that PM is an economically dominant strategy. These results were robust to one-way and probabilistic sensitivity analyses. PM compared to SOC is economically dominant and is projected to generate cost savings.

Oxidation Kinetics of Ti-6Al-4V Alloys by Conventional and Electron Beam Additive Manufacturing.

New manufacturing processes for metal parts such as additive manufacturing (AM) provide a technological development for the aeronautical and aerospace industries, since these AM processes are a means to reduce the weight of the parts, which generate cost savings. AM techniques such as Laser Powder Bed Fusions (LPBF) and Electron Beam Fusion (EBM), provided an improvement in mechanical properties, corrosion resistance, and thermal stability at temperatures below 400 °C, in comparison to conventional methods. This research aimed to study the oxidation kinetics of Ti-6Al-4V alloys by conventional and Electron Beam Additive Manufacturing. The thermogravimetric analysis was performed at temperatures of 600 °C, 800 °C, and 900 °C, having a heating rate of 25 °C/min and oxidation time of 24 h. The microstructural analysis was carried out by thermogravimetric analysis. Thickness and morphology of oxide layers were analyzed by field emission scanning electron microscope, phase identification (before and after the oxidation process) was realized by X-ray diffraction at room temperature and hardness measurements were made in cross section. Results indicated that the oxidation kinetics of Ti-6Al-4V alloys fabricated by EBM was similar to conventional processing and obeyed a parabolic or quasi-parabolic kinetics. The samples oxidized at 600 °C for 24 h presented the lowest hardness values (from 350 to 470 HV). At oxidation temperatures of 800 and 900 °C, however, highest hardness values (from 870 close to the alpha-case interface up to 300 HV in base metal) were found on the surface and gradually decreased towards the center of the base alloy. This may be explained by different microstructures presented in the manufacturing processes.

Cost-Utility Analysis of a Medication Adherence-Enhancing Educational Intervention for Glaucoma

To evaluate the cost utility of a glaucoma medication-enhancing intervention compared to standard of care over a lifetime from the United States Department of Veterans Affairs (VA) payer perspective. Model-based cost-utility analysis of a glaucoma medication-enhancing intervention from a randomized clinical trial. Veterans with glaucoma, or suspected glaucoma who were prescribed topical glaucoma medications, had their visual field assessed within the last 9 months, and endorsed poor glaucoma medication adherence. Veterans were randomized either to a behavioral intervention to promote adherence or to a standard of care (control) session about general eye health. A decision analytic model was developed to simulate lifelong costs and quality-adjusted life years (QALYs) for an intervention tested in a randomized clinical trial at a single VA eye clinic. Costs included direct medical costs that the VA payer would incur, as informed initially by the clinical trial and then by published estimates. Health-state quality of life was based on published utility values. Scenario analyses included addition of booster interventions, a 3% decline in chance of staying medication adherent annually, and the combination of the two. Analyses were also conducted in the following subgroups: those with companion versus not, and those with once-daily versus more than once-daily dosing frequency. Incremental cost-effectiveness ratio (ICER). Compared to standard of care, the intervention dominated resulting in lower costs ($23 339.28 versus $23 504.02) and higher QALYs (11.62 versus 11.58). Among the 4 subgroups, the intervention dominated for 3 of them. In the fourth subgroup, those with more than once-daily dosing, the ICER was $2625/QALY. Compared to standard of care, an intervention with booster interventions led to an ICER of $3278/QALY. Assuming both a 3% annual loss in chance of continuing to be adherent and addition of booster interventions, the ICER increased to $71 371/QALY. From a VA payer perspective over a lifetime, the glaucoma medication-enhancing behavioral intervention dominated standard of care in terms of generating cost savings and greater QALYs. Proprietary or commercial disclosure may be found after the references.

Collaboration with Clinical Laboratory Positively Impacts Proper Test Utilization and Decreases Diagnostic Errors.

Diagnostic errors in clinical laboratory testing are extremely common and are major roadblocks in providing timely patient care. The purpose of this project was to investigate whether collaboration between the clinical laboratory, a diagnostic management team (DMT), and physicians who are ordering tests for a patient, resulted in improved test utilization by choosing wisely and better patient care in an academic medical center. A retrospective study for a period of 24 months between 2017 and 2019 evaluated whether improvement of test ordering was achieved by timely interventions from the clinical laboratory and the coagulation DMT, resulting in fewer test selection errors. The results showed about 54% improvement in diagnostic errors for coagulation test selection in 634 patients evaluated for bleeding or thrombotic disorders by DMT when compared to previous studies. Furthermore, a total of approximately 2,400 coagulation test orders for patients that were done from July 2017 to July 2018 required intervention in 12% of the cases in the initial six months. When physician education was provided, intervention was needed in only approximately 4% of the cases, an improvement of 67% that was statistically significant at p-value < 0.05. Only 28% of the cases were associated with underutilization or failure to order required initial tests. The generated cost savings from prevention of over and underutilization of laboratory tests was in the order of ~ $16,000. The clinical laboratory and a DMT can function as an effective decision support system in decreasing errors in diagnostic test selection and facilitate knowledge among care providers regarding test results and interpretation, that may help in proper evidence-based guidelines and disease management.

Cost-effectiveness of precision molecular diagnostic tests for stage II colorectal cancer

In colorectal cancer, inappropriate use of adjuvant chemotherapies may lead to significant increases in healthcare costs and harms to patients. Genome-based interventions are being increasingly used in the stratification of patients according to their risk profiles. However, earlier cost-effectiveness analyses of precision molecular diagnostics have indicated a paucity of data on comparative health economic outcomes. Our aim was to compare the cost-effectiveness of marketed genomic tests used in the prognosis of stage II colorectal cancer patients. A Markov model was developed to compare the cost-effectiveness of treatment guided by any one of the following genomic tests: 12-gene assay or the 18-gene expression assay or the 482-gene signature or the Immunoscore assay in a hypothetical cohort of patients (n=1,000) with stage II colorectal cancer. Our study investigated outcomes in three health states: no recurrence, recurrence and death. This study was conducted from a societal perspective, and a 3% discount was applied to the costs and health outcomes. Sensitivity analyses were performed to assess the uncertainty of model parameters on the results. The cost of the Immunoscore assay strategy in stage II colorectal cancer patients was estimated to be US $23,564 with a gain of 3.903 quality-adjusted life years (QALYs) as compared with the 12-gene assay strategy at US $24,545 and 3.903 QALYs; the 18-gene assay strategy at US $28,374 and 3.623 QALYs; and the 482-gene signature treatment strategy at US $33,315 with 3.704 QALYs. Sensitivity analyses indicated that incremental cost-effectiveness ratio (ICER) values were sensitive to costs of genomic tests and adjuvant chemotherapies; and utilities related to patients in the no-recurrence health state. Overall, the Immunoscore assay seems to be a dominant strategy at a threshold willingness-to-pay of $50,000 per QALY, but in the US other tests have been used for longer. Thus, the 12-gene assay may generate cost savings compared to the 18-gene expression assay. The findings of our study may provide useful information to policymakers regarding selection of the most appropriate genomic test, and resource allocation decisions.

Beyond medicines’ barriers: exploring the true cost of multiple myeloma

Aim The goal of this research was to quantify and qualify all the costs associated with multiple myeloma (MM) from a healthcare and societal perspective and to highlight certain costs that are often underestimated. Materials and Methods The study used a mixed methods approach that consisted of three phases: a systemic literature review (SLR), a virtual roundtable discussion based on the results of the SLR, and an online survey. Results In total, 4321 records were identified by literature and snowball searches. After applying the eligibility criteria, 49 articles were included in the narrative summary. As combination treatments have become the mainstay of MM treatment, drug costs have become the most important component of the total healthcare costs. Collected evidence suggests that optimizing treatment pathways, besides prolonging patient survival and maintaining quality of life, has the potential to generate cost savings for all stakeholders (payers and patients). Improved patient access to new therapies that can improve outcomes may reduce the “financial toxicity” of MM by decreasing patients’ and caregivers’ productivity loss due to better prognosis and it also has the potential of reducing patients’ direct health care payments. Limitations Heterogeneity of research objectives of included studies, costing methods, and applied measurement units limited the comparability of cost data between studies. Data for more than half of the world’s population, including China, Russia, the Middle East, and Africa were not investigated. Conclusion While treatment costs are burdensome for healthcare systems, it is only one of several items that make up the True Cost of MM. Understanding these burdens is one way to argue for optimized treatment pathways and improve patient outcomes by tearing down access barriers.

Cost effectiveness of Electronic Gate Keeping (EGK) system on laboratory tests demand at a rural academic hospital in Eastern Cape, South Africa: a cross sectional study

Background: Monitoring laboratory expenditure is crucial to ensure that laboratory services remain sustainable and affordable. In South Africa, the National Department of Health (NDoH) and its partner, the National Health Laboratory Services (NHLS) collaborated to introduce Electronic Gate Keeping (EGK) systems across the country. This study estimated the cost-effectiveness of EGK on laboratory tests requested at a rural academic hospital in the Eastern Cape province of South Africa. Methods: The methodological approach involved the use of a cross-sectional study design. For 24 months (June 2015 to May 2017), data on the number and types of laboratory tests initially requested along with those rejected because there were unnecessary was obtained. Data management and cost effectiveness analysis to estimate cost savings due to EGK on laboratory test demands were carried out using MS Excel and Stata software. There were 28 types of tests requested, of which 22 were chemical tests, two were haematological tests, and four were serological tests. Results: Out of 448 028 tests requested, 17,480 (3.9%) were rejected after being identified as unnecessary through the EGK system. This rejection rate of 3.9% generated cost savings of USD 51,967.07. The top three tests that generated the most savings were the c-reactive protein (USD 6,077.68), free thyroxine (USD 5,199.92) and hepatitis A IgM (USD 3,813.61). Conclusions: The study demonstrates that the introduction of EGK has positive spinoffs; it reduced costs, strengthened the dialogue between clinicians and pathologists allowing a platform for continuous education, teaching and learning.

Development of an End State Vision to Implement Digital Monitoring in Nuclear Plants

Nuclear plant sites collect and store large volumes of data gathered from various equipment and systems. These datasets typically include plant process parameters, maintenance records, technical logs, online monitoring data, and equipment failure data. The collection of such data affords an opportunity to leverage data-driven machine learning (ML) and artificial intelligence (AI) technologies to provide diagnostic and prognostic capabilities within the nuclear power industry, thus reducing operations and maintenance (O&amp;M) costs. In this way, nuclear energy can become more economically competitive with other energy sources, and premature plant closures can be avoided. From a maintenance standpoint, savings can be achieved by leveraging ML and AI technologies to develop data-driven algorithms that better diagnose and predict potential faults within the system. Improved model accuracy can help reduce unnecessary maintenance and foster more efficient planning of future maintenance, thereby lowering the costs associated with parts, labor, and costly planned, forced, or extended outages. From an operations perspective, cost savings can be generated by shifting from routine-based monitoring to online monitoring by taking advantage of advancements in sensors and wireless communication technologies. Advancements in data storage, mapping, management, and analytics would inform the transition from onsite- to cloud-based computing and storage services. Online monitoring would reduce the number of operator manhours required for taking routine measurements, while cloud computing services would generate cost savings by reducing the amount of hardware needing to be purchased and maintained all while scaling to both computational and storage demands. This paper summarizes an end state vision of how to shift from costly, labor-intensive preventative maintenance to cost-effective predictive maintenance.

A Preference Analysis for a Peer-to-Peer (P2P) Electricity Trading Platform in South Korea

The Korean government is committed to advance the country’s energy transition to greener energy by increasing the share of renewable electricity to 20 percent by 2030 and to 30–35 percent by 2040. Achieving these goals will necessitate flexibility in energy markets as well as innovative business models and technological solutions. Peer-to-peer (P2P) electricity trading platforms (ETPs) are rapidly gaining traction, as they enable the integration of distributed energy sources into power systems. This study explores whether South Koreans are willing to participate in a hypothetical P2P ETP, which allows prosumers (who both consume and produce electricity) to trade electricity surpluses with their neighbours or with KEPCO (Korea Electric Power Corporation). We employ a choice experiment (CE) to examine respondent heterogeneous preferences and their willingness to pay (WTP) for a hypothetical P2P ETP in South Korea. Our findings indicate that two-thirds of total respondents in our CE are in favour of a P2P ETP if available. Cost savings and security play an essential role in respondent preferences for a P2P ETP business model. Respondents also prefer to trade renewable electricity with KEPCO rather than with other individuals. Per our statistical estimations, respondent WTP for a P2P ETP was estimated at USD 55.68/per month. Our analysis strongly recommends increasing consumer awareness of P2P ETPs to spur adoption. Energy trading platforms that are anchored in secure block chain technology can generate cost savings as well as support the country’s policy tilt toward green energy.

Impact of health technology assessment implementation with a special focus on middle-income countries

ObjectivesBuilding an efficient health technology assessment (HTA) system requires significant effort and political commitment, in addition to human and financial resources. Expectations of what HTA can offer to middle-income countries (MICs) are continuously rising, which drives health policymakers to raise the question of whether HTA could help secure the financial sustainability needed to implement universal health coverage. In this study, we explored the impact HTA adoption may have on the countries and its impact on health system objectives, as well as transferability of benefits and drawbacks observed in higher-income to middle-income countries. MethodsWe utilized secondary data from a systematic literature review and primary data by disseminating a survey among local stakeholders in three MICs across three continents to capture their perspective on the impact of HTA implementation from a local context. ResultsIt was evident from the results of both the literature review and survey that the positive impacts of HTA implementation outweigh the negative impacts. Most of the reviewed literature discussed the impact of HTA on the intermediate objectives of the health finance policy in relation to the broad health system goals. According to the survey respondents, the most evident benefit of HTA implementation is improving the transparency and accountability of healthcare decisions. ConclusionsOverall, HTA implementation can introduce a myriad of benefits to healthcare systems in MICs as well. Our findings show that while HTA implementation may have the potential to generate cost savings in specific areas, there is no guarantee that HTA can generate savings at the macro level. Public Interest SummaryHealth technologies (medicines, devices, and interventions) are rapidly increasing in complexity and cost. Health Technology Assessment (HTA) guides healthcare decision-makers in choosing the most suitable, effective, affordable, and acceptable health technology to invest limited healthcare resources. However, healthcare decision-makers in middle-income countries (MICS) are still uncertain about whether adopting HTA would help them achieve the financial sustainability needed to achieve universal health coverage. Thereforewe sought to gather evidence on how HTA has affected the health systems of countries that have already adopted it by reviewing published research reports. In addition, healthcare decision-makers from three MICs were questioned about their perception of how HTA implementation will affect their country's health system. Wefound that the positive effects of HTA implementation outweigh the negative ones; specifically, the transparency and accountability of decisions are improved. However, although HTA implementation may generate cost savings in specific areas, it may not significantly contribute to overall financial sustainability.

A Venture Capital Model for Surgical Innovation at Academic Medical Centers

This Viewpoint discusses the feasibility of a model that uses venture capital to seed innovation in academic medical centers and generate cost savings through creative solutions.

Spend less to achieve more: Economic analysis of intermittent versus continuous cetuximab in KRAS wild-type patients with metastatic colorectal cancer

BackgroundIn 2014, the COIN-B clinical trial demonstrated that intermittent cetuximab (IC) was a safe alternative to continuous cetuximab (CC), with less cytotoxic chemotherapy, in first-line treatment for KRAS wild-type metastatic colorectal cancer (mCRC). Cetuximab has been available for this indication in England since 2015, but treatment breaks beyond 6 weeks were prohibited, despite real-world evidence that therapy de-escalation maintains equivalent disease control, but with superior Quality-of-Life (QoL). We performed health economic analyses of IC versus CC and used this evidence to help underpin policy change and guide clinical practice through reduction in unnecessary treatment for mCRC patients. MethodsEmploying cost-minimization analysis, we conducted partitioned survival modelling (PSM) and Markov Chain Monte-Carlo (MCMC) simulation to determine costs and quality-adjusted-life-years for IC versus CC. ResultsIC reduced costs by £ 35,763 (PSM; p < 0.001) or £ 30,189 (MCMC) per patient annually, while preserving treatment efficacy and enhancing QoL. Extrapolating to all mCRC patients eligible for cetuximab therapy would have generated cost savings of ~£ 1.2 billion over this cohort’s lifetime. These data helped underpin a request to NHS England to remove treatment break restrictions in first-line mCRC therapy, which has been adopted as an interim treatment option policy in colorectal cancer during the Covid-19 pandemic. ConclusionsOur results highlight substantial cost savings achievable by treatment de-escalation, while also reinforcing the importance of therapy breaks to potentially increase tumour responsiveness and reduce treatment toxicity. Our study also highlights how health economic evidence can influence health policy, championing reduced treatment intensity approaches without compromising patient outcomes, which is of particular relevance when addressing the reduced capacity and treatment backlogs experienced during the pandemic.

Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective.

Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation with minimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the main concern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patients aged between 4 and 18 years in Colombia. A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a 5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment without FeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-related cases). Univariate 1-way sensitivity analyses were performed. In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and €480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for the routine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis. FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used by decision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries.

Use of Robots in Critical Care: Systematic Review.

BackgroundThe recent focus on the critical setting, especially with the COVID-19 pandemic, has highlighted the need for minimizing contact-based care and increasing robotic use. Robotics is a rising field in the context of health care, and we sought to evaluate the use of robots in critical care settings.ObjectiveAlthough robotic presence is prevalent in the surgical setting, its role in critical care has not been well established. We aimed to examine the uses and limitations of robots for patients who are critically ill.MethodsThis systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, Embase, IEEE Xplore, and ACM Library were searched from their inception to December 23, 2021. Included studies involved patients requiring critical care, both in intensive care units or high-dependency units, or settings that required critical care procedures (eg, intubation and cardiopulmonary resuscitation). Randomized trials and observational studies were included.ResultsA total of 33 studies were included. The greatest application of robots in the intensive care unit was in the field of telepresence, whereby robots proved advantageous in providing a reduced response time, earlier intervention, and lower mortality rates. Challenges of telepresence included regulatory and financial barriers. In therapy and stroke rehabilitation, robots achieved superior clinical outcomes safely. Robotic use in patient evaluation and assessment was mainly through ultrasound evaluation, obtaining satisfactory to superior results with the added benefits of remote assessment, time savings, and increased efficiency. Robots in drug dispensing and delivery increased efficiency and generated cost savings. All the robots had technological limitations and hidden costs.ConclusionsOverall, our results show that robotic use in critical care settings is a beneficial, effective, and well-received intervention that delivers significant benefits to patients, staff, and hospitals. Looking ahead, it is necessary to form strong ethical and legislative frameworks and overcome various regulatory and financial barriers.Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42021234162; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=234162

The impact of optimal parcel locker locations on costs and the environment

PurposeLast-mile delivery is associated with a negative environmental impact and high costs. The purpose of this paper is to develop an approach to designing stationary parcel locker (SPL) networks while minimizing both CO2 equivalent (CO2e) emissions and costs during delivery and pick-up.Design/methodology/approachThis study uses a multinomial logit model to evaluate recipients' willingness to use SPLs based on their availability at home and travel distance. To determine optimal SPL locations, this study formulates a mixed-integer linear programming model.FindingsThe empirical study of different regional clusters reveals that optimal SPL locations can generate cost savings of up to 11.0%. SPLs have a positive impact on total CO2e emission savings in urban areas (i.e. up to 2.5%), but give rise to additional emissions (i.e. 4.6%) in less populated areas due to longer travel distances during the pick-up process.Originality/valueThis paper optimizes SPL locations and the ecological effect of SPLs by minimizing emissions and costs simultaneously. Furthermore, it extends existing discrete choice models by also including recipients' availability at home, increasing the accuracy of recipients' preferences. So far, the effect of SPLs has been studied for metropolitan areas only. A global logistics service provider shared a real dataset which allows us to study seven different regional clusters ranging from rural areas to large cities. Thus, this study contributes to the field of sustainable urban logistics.

Use of provider education, intra-operative decision support, and an email-feedback system in improving compliance with sugammadex dosage guideline and reducing drug expenditures

Study objectiveDue to excessive sugammadex expenditures at our institution, we designed dosing guidelines that utilize adjusted body weight and informatics-based tools aimed at reducing variability in dosing practices. DesignWe retrospectively reviewed rates of high-dose sugammadex administration in three phases: Pre-intervention - May 2018 to November 2018; First intervention - November 2018 to April 2019; and Second intervention - April 2019 to July 2019. SettingAcademic medical center in the United States - Vanderbilt University Medical Center (VUMC) PatientsN/A InterventionsFirst, anesthesia providers were educated on adjusted body weight-based dosing guidelines. Providers also received intraoperative decision support displaying a patient's actual and adjusted body weight along with rates of high-dose (>200 mg) sugammadex administration for each respective provider. Second, we implemented an email-feedback system to remind providers of the new guidelines. MeasurementsWeekly rate of high-dose sugammadex cases. Main resultsDuring the pre-intervention stage, 1556 (12.3%) cases involved high-dose sugammadex. Comparatively, 550 (4.3%) and 187 (3.1%) high-dose sugammadex cases occurred during the first and second intervention stages, respectively. Segmented regression analysis demonstrated a significant rate change of −3.51% (95% CI: −5.64%, −1.38%) in sugammadex dosing practices after provider education and the implementation of digital improvement initiatives but failed to reveal a significant change after implementation of the email-feedback system. Overall, our interventions were associated with $2563.05 in estimated weekly savings of sugammadex expenditures. ConclusionsProvider education and digital quality improvement was associated with reduced rates of high-dose sugammadex administration, generating cost savings at a large academic medical institution.

Biomarkers for assessing acute kidney injury for people who are being considered for admission to critical care: a systematic review and cost-effectiveness analysis.

Acute kidney injury is a serious complication that occurs in the context of an acute critical illness or during a postoperative period. Earlier detection of acute kidney injury may facilitate strategies to preserve renal function, prevent further disease progression and reduce mortality. Acute kidney injury diagnosis relies on a rise in serum creatinine levels and/or fall in urine output; however, creatinine is an imperfect marker of kidney function. There is interest in the performance of novel biomarkers used in conjunction with existing clinical assessment, such as NephroCheck® (Astute Medical, Inc., San Diego, CA, USA), ARCHITECT® urine neutrophil gelatinase-associated lipocalin (NGAL) (Abbott Laboratories, Abbott Park, IL, USA), and urine and plasma BioPorto NGAL (BioPorto Diagnostics A/S, Hellerup, Denmark) immunoassays. If reliable, these biomarkers may enable earlier identification of acute kidney injury and enhance management of those with a modifiable disease course. The objective was to evaluate the role of biomarkers for assessing acute kidney injury in critically ill patients who are considered for admission to critical care. Major electronic databases, conference abstracts and ongoing studies were searched up to June 2019, with no date restrictions. MEDLINE, EMBASE, Health Technology Assessment Database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Web of Science, World Health Organization Global Index Medicus, EU Clinical Trials Register, International Clinical Trials Registry Platform and ClinicalTrials.gov were searched. A systematic review and meta-analysis were conducted to evaluate the performance of novel biomarkers for the detection of acute kidney injury and prediction of other relevant clinical outcomes. Random-effects models were adopted to combine evidence. A decision tree was developed to evaluate costs and quality-adjusted life-years accrued as a result of changes in short-term outcomes (up to 90 days), and a Markov model was used to extrapolate results over a lifetime time horizon. A total of 56 studies (17,967 participants), mainly prospective cohort studies, were selected for inclusion. No studies addressing the clinical impact of the use of biomarkers on patient outcomes, compared with standard care, were identified. The main sources of bias across studies were a lack of information on blinding and the optimal threshold for NGAL. For prediction studies, the reporting of statistical details was limited. Although the meta-analyses results showed the potential ability of these biomarkers to detect and predict acute kidney injury, there were limited data to establish any causal link with longer-term health outcomes and there were considerable clinical differences across studies. Cost-effectiveness results were highly uncertain, largely speculative and should be interpreted with caution in the light of the limited evidence base. To illustrate the current uncertainty, 15 scenario analyses were undertaken. Incremental quality-adjusted life-years were very low across all scenarios, ranging from positive to negative increments. Incremental costs were also small, in general, with some scenarios generating cost savings with tests dominant over standard care (cost savings with quality-adjusted life-year gains). However, other scenarios generated results whereby the candidate tests were more costly with fewer quality-adjusted life-years, and were thus dominated by standard care. Therefore, it was not possible to determine a plausible base-case incremental cost-effectiveness ratio for the tests, compared with standard care. Clinical effectiveness and cost-effectiveness results were hampered by the considerable heterogeneity across identified studies. Economic model predictions should also be interpreted cautiously because of the unknown impact of NGAL-guided treatment, and uncertain causal links between changes in acute kidney injury status and changes in health outcomes. Current evidence is insufficient to make a full appraisal of the role and economic value of these biomarkers and to determine whether or not they provide cost-effective improvements in the clinical outcomes of acute kidney injury patients. Future studies should evaluate the targeted use of biomarkers among specific patient populations and the clinical impact of their routine use on patient outcomes and management. This study is registered as PROSPERO CRD42019147039. This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 7. See the NIHR Journals Library website for further project information.