Greater Resource Use Research Articles

Organization of frame-monolithic works by various methods, determining the dynamics of investment

Construction is a complex system whose parameter values are constantly changing over time and depend on a huge number of factors. Successful completion of a construction project is to achieve the set goals: completion of construction on time, completion of planned workloads, optimal resource allocation, achievement of quality construction products. One of the most important technical and economic indicators of organizational and technological design is the duration of construction. Without its definition, it is impossible to correctly determine the cost of construction, to generate cash flow for the investment period of a construction project, to evaluate its effectiveness.The work is devoted to the organization of frame monolithic works of complexes by different methods, to determine the difference in cost, duration and dynamics of investments, which should be taken into account to the investor. Consideration was given to the construction of a monolithic frame of the house with the use of construction machines and mechanisms.- streaming method, and streaming optimized to eliminate downtime by adjusting construction time;- the parallel method with the greater use of resources;- the method is combined (parallel-sequential);is a sequential method.Functions defined:- cost dependence on the time of general complex construction;- the cost dependence of the time of individual work in the flow with downtime.One of the main tasks was to determine the optimal durationworks for the investor, because the type of organization affects the following indicators:- duration;- cost;- dynamics of investments.Housing is one of the most important areas that determine the economic stability and economic growth of the country, requiring significant and long-term financial investment. That is why the organization of effective management of innovative investment activity in housing construction is a task of particular importance.However, the development of the housing market is hampered by the following factors: inefficient ways of managing construction projects, low level of mobility of economic flows in construction, lack of qualified specialists and participants in the investment construction process. Therefore, the development and implementation of effective ways of managing investment is an important task today.

As tecnologias digitais no processo de ensino e aprendizagem de línguas estrangeiras – estudo de caso de escola da Rede Federal de Ensino – CE/Brasil - em contexto anterior ao da pandemia de covid-19

Este artigo aborda alguns aspectos gerais das tecnologias da informação e comunicação (TICs) no ensino de língua estrangeira, mais precisamente, o seu uso como estratégia do processo de ensino e aprendizagem no ensino de inglês e espanhol, no âmbito de dois campi de uma escola pública da Rede Federal de ensino do estado do Ceará – Brasil, antes da Pandemia de Covid19 e da instauração do ensino remoto na referida instituição. Incluiu-se na análise se o uso de TICs é considerado pelos docentes como importante contributo no processo de ensino e aprendizagem de línguas estrangeiras, bem como a identificação das ferramentas tecnológicas utilizadas na prática docente. Buscou-se reconhecer também os possíveis entraves para um maior emprego desses recursos nas práticas educacionais. Evidenciou-se que, embora os docentes apontem como relevante a inserção das TICs em sua prática de ensino para uma aprendizagem mais significativa, tal uso revela-se aquém face à evolução tecnológica diária em que todos estão imersos. A maior parte dos docentes diz fazer uso de novas tecnologias com pouca regularidade em sala de aula. Justificaram esse uso com os seguintes fatores: precariedade da infraestrutura física da instituição, que não apresenta um bom acesso à Internet; problemas socioeconômicos, pois alguns alunos não dispõem de Internet em suas residências; falta de formação docente, que impossibilita uma exploração de uma maior diversidade desses recursos; sobrecarga de trabalho do professor, que, muitas vezes, não se vê motivado, nem com tempo para incorporar à sua prática as TICs.

Response of Conservation Agriculture on System Productivity and Carbon Sequestration in Rice-Based Cropping Systems

Low crop yields due to constant monocropping systems and deteriorating soil health in a smallholder farmers’ field of Indo-Gangetic plains of India have led to a quest for sustainable production practices with greater resource use efficiencies. The aim of the study was to elucidate the short term effects of conservation agricultural systems on productivity, soil health and carbon sequestration rate of soils in three different diversified cropping systems. The treatments consisted of two different tillage systems (conventional and reduced tillage), two mulch levels (no and straw mulch) and two levels of fertility (100 and 75% RDF) were compared in three rice-based cropping systems (rice-wheat; rice-vegetable pea-greengram; and rice-potato-maize sequences) for two years on an experimental field (clay loam) located at Norman E Borlaug Crop Research Center, Pantnagar, India. The resource conservation technologies (RCT) i.e. reduced tillage, mulch, and 100% RDF had recorded 2.5 and 3.0% higher system productivity and relative production efficiency in rice-vegetablepea-greengram and rice-potato-maize sequences, respectively in two consecutive years. Conservation tillage had sequestered three times higher carbon than conventional tillage while mulching acted four times higher than non-mulched condition in agricultural soils. Even though cropping system not significant significantly influenced on carbon sequestration, rice-vegetablepea-greengram sequence had recorded higher carbon sequestration rate and higher soil organic carbon stock noted in surface plough sole layer than any other cropping systems. Therefore, our results suggested that Indo-Gangetic farmers should consider adopting resource conservation practices together in indogangetic area because of benefits to soil health, carbon sequestration and system productivity.

Intercropping of small millets for agricultural sustainability in drylands : A review

The scope for enhancement of productivity under irrigated conditions is limited because of over-exploitation of available resources, but there is ample opportunity for boosting yield in drylands by adopting suitable crops and cropping systems. The agricultural sustainability in drylands is comparatively hard to achieve due to different constraints like poor soil fertility, lack of irrigation facilities and moisture stress, small holdings and less investment in agriculture. Choice of ecologically sound crops as millets and adoption of intercropping systems are two of suitable options for maximization of productivity in drylands. Millets are ancient nutri-cereals which can play a crucial role in food as well as nutritional security of the country and can assure agricultural sustainability in drylands under intercropping system. The combination of cereal and legume in intercropping is mostly preferred by the farmers in subsistence farming targeting livelihood security. Experiments carried out on intercropping of some small millets in India and abroad clearly indicated numerous benefits like enhancement of crops productivity, greater resource use efficiency, check in run-off of water and soil conservation in erosion prone areas, prevention of loss of soil nutrients, improvement of soil health, insurance against crop failure under aberrant weather conditions, higher monetary return and benefit-cost ratio. But the performance of all small millets is not tested under intercropping under different regions. There is still insufficiency in research on small millets based intercropping system which can create further scope for agricultural sustainability of drylands.

Hospitalización domiciliaria en un área rural, ¿una alternativa a la hospitalización tradicional?

Introducción: El servicio de hospitalización domiciliaria en el área rural es un servicio poco conocido en el resto del ámbito sanitario. Al mismo tiempo existe poca literatura al respecto por lo que con este estudio queremos estudiar las características clínicas, la estancia media y la tasa de reingresos de los pacientes que ingresan en hospitalización domiciliaria en comparación a los pacientes que ingresan en planta de medicina interna pertenecientes a un hospital comarcal de un área rural (Hospital de TresMares).Método: Estudio descriptivo comparativo retrospectivo que incluye un total de 200 pacientes (100 ingresados en hospitalización domiciliaria y 100 ingresados en planta) del hospital de TresMaresResultados: La complejidad de los pacientes que ingresan en planta es superior a los que ingresan en hospitalización domiciliaria requiriendo al mismo tiempo de mayor uso de recursos. La eficacia, entendida como tasa de reingreso, en hospitalización a domicilio es similar a la de los pacientes de la planta. Se demuestra que la hospitalización domiciliaria puede ser una alternativa a la hospitalización tradicional en un área rural.Conclusiones: Se demuestra que la hospitalización domiciliaria puede ser una alternativa a la hospitalización tradicional en un área rural.

Risk factors, resource use, and cost of postoperative low cardiac output syndrome

ObjectiveLow cardiac output syndrome complicates recovery after cardiac surgery. We examined the incidence and risk factors for low cardiac output syndrome and its association with postoperative mortality, morbidity, resource use, and cost. MethodsThis cross-sectional retrospective observational study examined patients having cardiac surgery captured in the Premier Healthcare Database. Low cardiac output syndrome was defined as the requirement for postoperative mechanical circulatory support and/or hemodynamic instability requiring prolonged inotropic support. Incidence, risk factors, and association of low cardiac output syndrome with postoperative outcomes, including mortality, hospital and intensive care unit length of stay, hospital readmission, and cost at 30 days, 90 days, and 6 months, were examined. ResultsAmong 59,810 patients from 164 hospitals having cardiac surgery between July 1, 2012, and June 30, 2014, low cardiac output syndrome developed in 6067 (10.1%) patients. Patients presenting in cardiogenic shock or systolic (± diastolic) heart failure were at greatest risk. Risk-adjusted in-hospital mortality was 12-fold greater with low cardiac output syndrome (odds ratio, 12.0; 95% confidence interval, 10.6-13.5). Risk-adjusted hospital costs (2019$; median [Q1, Q3]) were $64,041 [21,439] in patients who developed low cardiac output syndrome versus $48,086 [16,098] without; P < .001. Increased costs were driven by longer risk-adjusted hospital stay (10.1 [4.5] vs 8.5 [3.8] days); P < .001, intensive care unit (5.5 [2.5] vs 3.3 [1.5] days; P < .001) stay, and all-cause 30-day adjusted hospital readmission rates (mean [SD] 16.6 [8.2]% vs 13.9 [7.2]%; P < .001). ConclusionsCardiac surgical patients who develop postoperative low cardiac output syndrome suffer greater mortality and have greater resource use, health care costs, and all-cause readmission, which informs perioperative decision making, and impacts hospital performance metrics and federal priority to reduce health care costs.

Foundation Species Loss Affects Leaf Breakdown and Aquatic Invertebrate Resource Use in Black Ash Wetlands

The invasion by emerald ash borer (Agrilus planipennis) of extensive black ash wetlands in the upper Great Lakes region of North America is expected to alter plant community structure and composition and, therefore, abiotic factors like temperature and hydrology. We conducted two experiments to examine how changes in leaf litter could alter ecosystem function via 1) changes in litter breakdown and 2) aquatic invertebrate feeding. For the first experiment, we placed litter bags containing black ash (Fraxinus nigra), swamp white oak (Quercus bicolor), and lake sedge (Carex lacustris), in either control or clear-cut black ash plots. We found that black ash litter broke down 2-3 times faster than other species and broke down faster in control plots than in clear-cuts. There was no effect of clear cutting on swamp white oak or lake sedge breakdown rates. For the second experiment, we fed shredding caddisfly larvae (Limnephilus indivisus) one of six species: black ash, swamp white oak, lake sedge, balsam poplar (Populus balsamifera), American elm (Ulmus americana), or speckled alder (Alnus incana) for 14 days. Caddisflies had the highest survival and greater resource use when given black ash or speckled alder, which are abundant in black ash wetlands. These results suggest that loss of black ash will alter ecosystem processes via changes in the physical environment, changes in leaf litter properties, and changes in shredder processing rates of leaf litter.

PDG18 DIFFERENCES IN RESOURCE UTILIZATION AND COSTS BETWEEN NARCOTIC USERS AND NON-NARCOTIC USERS FROM THE 2017 MEDICAL EXPENDITURE PANEL SURVEY

The opioid epidemic in the United States (US) has claimed over 47,000 lives in 2017. However, there is a dearth of literature on the economic impact that opioid-users place on the healthcare system. We sought to investigate the impact of opioid (narcotic) users compared to non-narcotic users on healthcare resources and expenditures using the 2017 Medical Expenditure Panel Survey (MEPS). We used the full consolidated household and prescription files from the 2017 MEPS and their associated survey weights. Narcotic users were defined as responders who reported being prescribed any opioid prescription in 2017. We evaluated the total, prescription, outpatient, inpatient, and emergency department expenditures including the number of outpatient, inpatient, and emergency department visits. Generalized linear models using gamma family and log link were constructed to estimate the marginal effects adjusted for age, race, ethnicity, marital status, region, and poverty status between narcotic and non-narcotic users. There was a weighted total of 235,845,150 adult respondents eligible for analysis; 5.2% of the total population reported having at least one narcotic prescribed. Narcotic users were older (56 versus 47 years, P<0.001), mostly White (83% versus 77%, P<0.001), and mostly non-Hispanic (91% versus 83%, P<0.001). The marginal effects in total expenditures ($11,321; 95%CI: $8,948-$13,694), prescription expenditures ($2,037; 95%CI: $1,477-$2,598), outpatient expenditures ($1,105; 95%CI: $744-$1,466), emergency department expenditures ($413; 95%CI: $285-$540), and inpatient expenditures ($4,742; 95%CI: $2,952-$6,531) were greater in the narcotic group compared to the non-narcotic group. Narcotic users also had higher resource uses in terms of prescriptions (+13.9; 95%CI: 12.0-15.9), outpatient visits (+7.6; 95%CI: 6.5-8.7), emergency department visits (+0.4; 95%CI: 0.3-0.4), and inpatient nights (+0.9; 95%CI: 0.6-1.3). Narcotic users had greater resource use and expenditures compared to non-narcotic users. Understanding the economic impact of narcotic users may influence policies on additional care such as psychosocial services and post-overdose care.

Hospital Stays and Medical Expenses Increase Nationwide Among Patients With Septic Arthritis of the Shoulder Who Inject Drugs.

The authors determined the proportion of patients nationwide with septic arthritis of the shoulder who inject drugs, evaluated differences in hospitalization outcomes and charges between patients with and without injection drug use (IDU), and quantified demographic trends among patients with IDU from 2000 to 2013. Nationally representative data of patients with a principal discharge diagnosis of shoulder septic arthritis were obtained from the Nationwide Inpatient Sample 2000-2013. Using published algorithms, the authors classified septic arthritis of the shoulder as related or unrelated to IDU. They compared length of stay, leaving against medical advice, number of procedures, and mortality rates between the 2 groups, using regression models to control for age, sex, and race. Fifteen percent (95% confidence interval [CI], 13.6%-16.5%) of septic arthritis cases were associated with IDU. From 2000 to 2013, shoulder septic arthritis associated with IDU increased 4-fold. After controlling for age, sex, and race, individuals who inject drugs stayed in the hospital for 3.7 more days (95% CI, 2.4-5.0), incurred an average of $13,250 more charges for medical care (95% CI, $2635-$23,866), and were 5.54 times more likely (95% CI, 3.22-9.55) to leave against medical advice than those without IDU. From 2000 to 2013, there was an increase in the proportion of patients with IDU-related septic arthritis of the shoulder between 35 and 54 years old and 55 and 64 years old, and an increase in the proportion who were white. Injection drug use-related shoulder septic arthritis is linked to suboptimal inpatient outcomes and greater resource use. [Orthopedics. 2020;43(4):e270-e277.].

An analytical intelligence model for the management of resources for the treatment of high-cost diseases: the case of HIV in Mexico

In the health sector, it is very important to have adequate control over the allocation of resources; this becomes much more relevant in the case of high-cost diseases, HIV is one example of this. The use of analytical intelligence allows the transformation of raw data into meaningful and useful information to make decisions. To support the management of resources in the health sector an analytical intelligence model based on survival analysis of patients under antiretroviral treatment in the Ministry of Health of Mexico is proposed. A survival model was carried out using a cohort of people with HIV under antiretroviral treatment attended by the Ministry of Health for the period 2007–2015. Sociodemographic variables, viral load, dates of treatment initiation and death were used. Kaplan–Meier method and the logarithmic rank test, as well as the Cox proportional-hazard model, were used. The proposed model can serve as a strategic information management tool for decision-making about the care and financing of high-cost diseases in the health sector. The results show that the probability of survival in people with HIV is higher for currently preferred treatments for treatment initiation and recently incorporated. Increasing the level of CD4 for the start of treatment generates greater probabilities of survival for patients. It is necessary to comprehensively evaluate the prescription and initiation of treatment policies according to CD4 levels to guarantee the financial sustainability of antiretroviral treatment in the Ministry of Health since these measures imply greater use of resources. It would be helpful to implement this type of analytical intelligence model for the monitoring and management of resources in the health sector.

Association of long-term care needs, approaching death and age with medical and long-term care expenditures in the last year of life: An analysis of insurance claims data.

This study aimed to examine whether long-term care needs, approaching death and age were associated with the use of medical and long-term care resources (care/service use and expenditures) in the last year of life among older Japanese individuals. Using data on insurance claims and death certificates, we described the use of medical and long-term care resources in the last year of life by residents of Soma City in Japan aged ≥65 years who died between September 2006 and October 2009. Using a generalized estimating equation, we examined whether long-term care needs, approaching death and age were associated with resource use during each 3-month period in the last year of life. Resource use in medical and long-term care among 882 non-survivors and 8504 survivors were analyzed. Analyses for the non-survivors showed statistically significant associations between: (i) severe long-term care needs and greater service use in outpatient care, higher expenditures for outpatient care and higher expenditures for in-home/facility services; (ii) approaching death and greater use in both inpatient care and facility services; and (iii) being aged 65-74 years and greater service use in outpatient/in-hospital care and in-home/facility services, higher expenditures in outpatient/inpatient care, and lower expenditures for in-home/facility services. The present study showed that severe long-term care needs and approaching death, rather than advancing age, were significantly and independently associated with greater use of resources in both medical and long-term care services. Geriatr Gerontol Int 2020; 20: 277-284.

Ecophysiological traits of invasive alien Acacia cyclops compared to co‐occuring native species in Strandveld vegetation of the Cape Floristic Region

AbstractTree invasions of Mediterranean‐climate ecosystems pose a significant threat to both biodiversity and functioning, by excluding native species, altering soil nutrient status and depleting water resources. In order to attain greater relative biomass associated with successful invasion in these characteristically resource‐poor environments, invasive species must have novel traits that enable better acquisition (e.g. deep roots) or exploitation of different resources (e.g. N2 fixation) and/or more efficient use of available resources than native species. We compared the ecophysiological and morphological traits of three abundant native species to those of the invasive Australian tree species, Acacia cyclops. This species is widely invasive in the Mediterranean‐climate coastal vegetation of South Africa that includes the Strandveld vegetation type. A. cyclops had 30–50% greater foliar N concentrations (P &lt; 0.001) in comparison with the native species and lower foliar δ15N values that may indicate N2 fixation. Additionally, A. cyclops maintained higher photosynthetic rates over the dry summer season (ca. 15 μmol m−2 s−1) than the native species. These higher photosynthetic rates may result from sustained access to water due to deeper rooting abilities as indicated by the more negative δD values (P &lt; 0.001) of A. cyclops (−43‰) in comparison with the some native species (−29 to −37‰). Acacia cyclops did not, however, exhibit greater water use efficiencies or photosynthetic nitrogen use efficiencies (P &gt; 0.05) compared to native species. Invasiveness of A. cyclops into this resource‐limited Mediterranean‐climate ecosystem appears to be supported by greater resource acquisition, possibly partially through N2 fixation and greater rooting depth, rather than greater resource use efficiency or conservation.

Patients with History of Intravenous Drug Use (IDU) with Septic Arthritis of the Foot and Ankle Have Suboptimal Hospitalization Outcomes Compared to Patients Without IDU

Category:InfectionIntroduction/Purpose:Although intravenous drug use (IDU) is a known risk factor for septic arthritis of the foot and ankle (F&A), little is known about its influence on hospitalization outcomes. This study evaluated differences in demographic characteristics and hospitalization outcomes of septic arthritis of the F&A according to IDU status.Methods:Using the Nationwide Inpatient Sample for the years 2000 to 2013, we identified all patients aged 15-64 with a principal discharge diagnosis of septic arthritis of the F&A. Applying previously published algorithms, septic arthritis of the F&A was classified as related or unrelated to IDU. We assessed differences in demographic characteristics and in-hospital outcomes including length of hospital stay (LOS), leaving against medical advice (AMA), hospital charges, and presence or absence of surgical intervention.Results:Of the 14,198 hospitalizations, 11% were associated with IDU. Patients with IDU were more likely to be younger, black, and have Medicaid or no insurance coverage. Patients with IDU were more likely to leave AMA (9.7% vs 1.4%, p<0.001), have longer LOS (9.2 vs 6.8 days, p<0.001), and incur increased hospital charges ($58,628 vs $38,876, p=0.005). In addition, patients with IDU were significantly less likely to receive an arthroscopy (1.5% vs 6.5%, p<0.001) or arthrotomy (2.2% vs 11.0%, p<0.001) of the foot.Conclusion:IDU-related septic arthritis of the foot and ankle is associated with suboptimal hospitalization outcomes and greater resource use. Given the disparity in outcomes, there is potential to improve outcomes of septic arthritis of the foot and ankle in patients with IDU via enhanced physician communication skills among disenfranchised patient populations and proactively addressing substance abuse issues early during hospital admission.

Readmission Rates and Their Impact on Hospital Financial Performance: A Study of Washington Hospitals

This longitudinal study examines whether readmission rates, made transparent through Hospital Compare, affect hospital financial performance by examining 98 hospitals in the State of Washington from 2012 to 2014. Readmission rates for acute myocardial infarction (AMI), pneumonia (PN), and heart failure (HF) were examined against operating revenues per patient, operating expenses per patient, and operating margin. Using hospital-level fixed effects regression on 276 hospital year observations, the analysis indicated that a reduction in AMI readmission rates is related with increased operating revenues as expenses associated with costly treatments related with unnecessary readmissions are avoided. Additionally, reducing readmission rates is related with an increase in operating expenses. As a net effect, increased PN readmission rates may show marginal increase in operating margin because of the higher operating revenues due to readmissions. However, as readmissions continue to happen, a gradual increase in expenses due to greater use of resources may lead to decreased profitability.

Helping the Planet with Healthy Eating Habits

Abstract A growing number of people are paying more attention to the concept of environmental sustainability, implementing sustainable eating practices to minimize the waste of resources, and the production of waste products related to the food production process. The careful application of sustainable eating practices makes it possible to help the environment, public health, and society by increasing the availability of food and farmland to feed every inhabitant on Earth. Individuals impact the environment through their eating because of three factors: food, energy used in the home, and transport. The most powerful of these factors is food. Animal food production involves a greater use of resources (raw materials, land, water, energy) and produces more pollutants (chemical residues from agriculture, greenhouse gases, manure) than plant-based food. Thus, a lifestyle based on eating plant foods is not only beneficial for the environment, but also protective of a consumer’s health. Alternative practices, such as using renewable energy sources or alternative fuels, however desirable they may be in combination with limiting the consumption of animal foods, are more difficult to implement across society. To change one’s eating habits is, on the other hand, a simple, fast, and inexpensive approach.

Opioid Use and Potency Are Associated With Clinical Features, Quality of Life, and Use of Resources in Patients With Gastroparesis

Many patients with gastroparesis are prescribed opioids for pain control, but indications for opioid prescriptions and the relationship of opioid use to gastroparesis manifestations are undefined. We characterized associations of use of potent vs weaker opioids and presentations of diabetic and idiopathic gastroparesis. We collected data on symptoms, gastric emptying, quality of life, and health care resource use from 583 patients with gastroparesis (>10% 4-h scintigraphic retention) from theNational Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Consortium, from January 2007 through November 2016. Patients completed medical questionnaires that included questions about opioid use. The opioid(s) were categorized for potency relative to oral morphine. Symptom severities were quantified by Patient Assessment of Upper Gastrointestinal Disorders Symptoms questionnaires. Subgroup analyses compared patients on potent vs weaker opioids and opioid effects in diabetic vs idiopathic etiologies. Forty-one percent of patients were taking opioids; 82% of these took potent agents (morphine, hydrocodone, oxycodone, methadone, hydromorphone, buprenorphine, or fentanyl). Abdominal pain was the reason for prescription for 61% of patients taking opioids. Mean scores for gastroparesis, nausea/vomiting, bloating/distention, abdominal pain, and constipation scores were higher in opioid users (P ≤ .05). Opioid use was associated with greater levels of gastric retention, worse quality of life, increased hospitalization, andincreased use of antiemetic and pain modulator medications compared with nonusers (P ≤ .03). Use of potent opioids was associated with worse gastroparesis, nausea/vomiting, upper abdominal pain, and quality-of-life scores, and more hospitalizations compared with weaker opioids (tapentadol, tramadol, codeine, or propoxyphene) (P ≤ .05). Opioid use was associated with larger increases in gastric retention in patients with idiopathic vs diabetic gastroparesis (P= .008). Opioid use is prevalent among patients with diabetic or idiopathic gastroparesis, and is associated with worse symptoms, delays in gastric emptying, and lower quality of life, as well as greater use of resources. Potent opioids are associated with larger effects than weaker agents. These findings form a basis for studies to characterize adverse outcomes of opioid use in patients with gastroparesis and to help identify those who might benefit from interventions to prevent opioid overuse.

Obesity in total laparoscopic hysterectomy for early stage endometrial cancer: health gain and inpatient resource use.

To explore relationships between BMI (morbid/severe obesity; BMI ≥ 35 kg/m2 vs. non morbid/severe obesity; BMI < 35 kg/m2), postoperative health gain and hospital resource use for women who receive a Total Laparoscopic Hysterectomy (TLH) for early stage endometrial cancer. Secondary analysis of RCT data (LACE Study; Total Abdominal Hysterectomy vs. TLH). 20 tertiary gynaecological cancer centres in Australia, New Zealand and Hong Kong. About 404 women who received TLH to treat early stage endometrial cancer. For women with BMI < 35 vs. BMI ≥ 35 kg/m2, we compared (i) postoperative health gain, using utility scores derived from responses to the EQ-5D-3L health-related quality of life instrument, and (ii) inpatient hospital resource use, using adverse events, surgery duration and postoperative length of stay as indicators, to 6 months post-surgery. Health gain, resource use. Mean postoperative health gain was 0.07 units, and did not vary by BMI. Women with a BMI ≥ 35 had an increased rate of severe postoperative AEs (BMI ≥ 35 RR = 1.95, P = 0.02), and the surgery took on average 9.6 min longer (BMI < 35 kg/m2 122.5 min 95% CI 117.4-127.8; BMI ≥ 35 kg/m2 132.1 min 95% CI 126.3-138.2; P = 0.02). While postoperative health gain for women with BMI ≥ 35 was similar to that of women with lower BMI, the gain was achieved at the expense of greater resource use. Further work could definitively quantify the excess cost of TLH for obese patients with endometrial cancer, and investigate the potential for non-surgical treatment options, at least for those women at high risk of postoperative AEs.

Association of Intraoperative Findings With Outcomes and Resource Use in Children With Complicated Appendicitis

The influence of disease severity on outcomes and use of health care resources in children with complicated appendicitis is poorly characterized. Adjustment for variation in disease severity may have implications for ensuring fair reimbursement and comparative performance reporting among hospitals. To examine the association of intraoperative findings as a measure of disease severity with complication rates and resource use in children with complicated appendicitis. This retrospective cohort study used clinical data from the American College of Surgeons National Surgical Quality Improvement Program pediatric appendectomy pilot database (NSQIP-P database) and cost data from the Pediatric Health Information System database. Twenty-two children's hospitals participated in the NSQIP Pediatric Appendectomy Collaborative Pilot Project. Patients aged 3 to 18 years with complicated appendicitis who underwent an appendectomy from January 1, 2013, through December 31, 2014, were included in the study. Appendicitis was categorized in the NSQIP-P database as complicated if any of the following 4 intraoperative findings occurred in the operative report: visible hole, fibropurulent exudate in more than 2 quadrants, abscess, or extraluminal fecalith. Data were analyzed from January 1, 2013, through December 31, 2014. Thirty-day postoperative adverse event rate, revisit rate, hospital cost, and length of stay. Multivariable regression was used to estimate event rates and outcomes for all observed combinations of intraoperative findings, with adjusting for patient characteristics and clustering within hospitals. A total of 1333 patients (58.7% boys; median age, 10 years; interquartile range, 7-12 years) were included; multiple intraoperative findings of complicated appendicitis were reported in 589 (44.2%). Compared with single findings, the presence of multiple findings was associated with higher rates of surgical site infection (odds ratio, 1.40; 95% CI, 0.95-2.06; P = .09), higher revisit rates (odds ratio, 1.60; 95% CI, 1.15-2.21; P = .005), longer length of stay (rate ratio, 1.45; 95% CI, 1.36-1.55; P < .001), and higher hospital cost (rate ratio, 1.35; 95% CI, 1.19-1.53; P < .001). Significant differences were found among different combinations of intraoperative findings for all outcomes, including a 3.6-fold difference in rates of surgical site infection (range, 7.5% for fecalith alone to 27.2% for all 4 findings; P = .002), a 2.6-fold difference in revisit rates (range, 8.9% for exudate alone to 22.9% for all 4 findings; P = .001), a 2.2-fold difference in length of stay (range, 4.0 days for exudate alone to 8.9 days for all 4 findings; P < .001), and a 2.4-fold difference in mean cumulative cost (range, $13 296 for exudate alone to $32 282 for all 4 findings; P < .001). More severe presentations of complicated appendicitis are associated with worse outcomes and greater resource use. Severity adjustment may be needed to ensure fair reimbursement and comparative performance reporting, particularly at hospitals treating underserved populations where more severe presentations are common.

Nurse-led versus doctor-led care for bronchiectasis.

Specialist nursing roles to manage stable disease populations are being used to meet the needs of both patients and health services. With increasing cost pressures on health departments, alternative models such as nurse-led care are gaining momentum as a substitute for traditional doctor-led care. This review evaluates the safety, effectiveness, and health outcomes of nurses practising in autonomous roles while using advanced practice skills, within the context of bronchiectasis management in subacute, ambulatory, and/or community care. To compare the effectiveness of nurse-led care versus doctor-led care in the management of stable bronchiectasis. We searched the Cochrane Airways Group Specialised Register and bibliographies of selected papers in addition to grey literature such as electronic clinical trials registries. Searches were current as of March 2018. Randomised controlled trials were eligible for inclusion in the review. Two reviewers extracted and entered data from included studies. Primary outcomes were numbers of exacerbations requiring treatment with antibiotics, hospital admissions, and emergency department attendances. We included one United Kingdom (UK) study in the review. In this randomised controlled trial, a total of 80 participants, with a mean age of 58 years, were treated for 12 months by a specialist nurse or doctor, then were crossed over to the other clinician for the next 12 months. Two participants died during the study period. Six participants failed to cross over to nurse-led care because of unstable bronchiectasis. Overall, the level of study completion was high.Data show no difference in the numbers of exacerbations requiring treatment with antibiotics (rate ratio 1.09, 95% confidence interval (CI) 0.91 to 1.30, 80 participants, moderate-certainty evidence). Investigators reported more hospital admissions in the nurse-led care group (rate ratio 1.52, 95% CI 1.04 to 2.23, 80 participants, moderate-certainty evidence) and did not report emergency department attendance.For secondary outcomes, participants in the nurse-led care group used more healthcare resources during the first year of the trial. Increased admissions and greater use of resources made treatment costs for nurse-led groups' higher. Total costs for both years of the study were £8,464 and £5,228 for nurse-led care compared with doctor-led care. However, by the second year, treatment costs were almost equitable between the two groups, which may reflect the nurses' learning of how to better treat people with bronchiectasis. No statistically significant changes were observed in quality of life, exercise capacity, mortality, or lung function. Wide confidence intervals led to uncertainty regarding these results. Adverse events were not an outcome for this review. This update of the review shows that only one trial met review criteria. Review authors were unable to demonstrate effectiveness of nurse-led care compared with doctor-led care on the basis of findings of a single study. The included study reported no significant differences, but limited evidence means that differences in clinical outcomes between nurse-led care and usual care within the setting of a specialist clinic remain unclear. Further research is required to determine whether nurse-led care is cost-effective, if guidelines and protocols for bronchiectasis management are followed does this increases costs and how effective nurse-led management of bronchiectasis is in other clinical settings such as inpatient and outreach.

Robotic platform for gastric bypass is associated with more resource utilization: an analysis of MBSAQIP dataset

BackgroundThe current literature comparing robot-assisted Roux-en-Y gastric bypass (RA-RYGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) is limited to single center retrospective series. ObjectivesThis study aims to compare perioperative outcomes of patients who underwent RA-RYGB with those who underwent LRYGB. SettingNational database. MethodsData on patients who underwent RA-RYGB and LRYGB were extracted from the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use file. A 1:8 propensity score matching (RA-RYGB:LRYGB) was performed, and the 30-day outcomes of the propensity-matched cohorts were compared. ResultsIn total, 36,158 patients met inclusion criteria, including 2660 RA-RYGB (7.4%) cases, which were propensity matched (1:8) with 21,280 LRYGB cases having similar preoperative characteristics. RA-RYGB was associated with longer median operative time (136 versus 107 min; P<.001) and a higher 30-day readmission rate (7.3% versus 6.2%; P = .03). There were no statistical differences between the RA-RYGB and LRYGB cohorts with respect to all-cause morbidity (10.6% versus 10.7%; P = .8), serious morbidity (1.2% versus 1.7%; P = .07), mortality (0.1% versus .2%; P = .2), unplanned intensive care unit admission (1.1% versus 1.3%; P = .3), reoperation (2.4% versus 2.4%; P = .97), or reintervention (3.0% versus 2.5%; P = .2) within 30 days after surgery. ConclusionBased on available national data, RA-RYGB appears safe compared with a conventional laparoscopic approach for gastric bypass. However, RA-RYGB was associated with longer operative time and higher readmission rate, indicating greater resource use. Further studies are needed to better delineate the role of robotic platforms in bariatric surgery.