High Procurement Costs Research Articles

Ownership structure and hospital service costs and fees: A decomposition approach

This paper analyzes hospital characteristics that are associated with higher average costs and charges for venipuncture, computed tomography procedures (computerized axial tomography [CAT] scans), and electrocardiograms (EKG). Using data from a Medicare database, our results indicate that higher wages, larger hospital sizes, and greater service quality are associated with higher procedure costs, whereas system membership is generally associated with lower procedure costs. Blinder‐type decompositions, which are the main focus of this study, suggest (a) that venipuncture costs are about 17% to 19% lower at proprietary hospitals than at nonprofit or government hospitals, (b) CAT scan costs are about 6% to 12% lower at nonprofit hospitals than at proprietary and government hospitals, and (c) that EKG costs are about 3% lower at proprietary hospitals than at nonprofit or government hospitals. Lastly, large portions of each of these differences are found to be due to both differences in mean values of the hospitals' characteristics by ownership type and differences in the mechanism by which the hospitals' characteristics are transmitted to procedure costs.

Kinetics, physicochemical properties, and antioxidant activities of Angelica keiskei processed under four drying conditions

The herb Japanese angelica (Angelica keiskei) has been consumed for centuries as a healthy vegetable. The drying kinetics, microstructure, color, and polyphenol components, as well as antioxidant capacity of stems and leaves of A. keiskei were investigated and compared, after undergoing natural drying (ND), convective drying (CD), freeze-drying (FD), and vacuum oven drying (VOD). The freeze-dried products showed the lowest color differences compared with their fresh counterpart, and also provided the highest retention of the main polyphenol components (i.e., quercetin, luteolin, and chlorogenic acid) and antioxidant activity (DPPH and FRAP), followed by ND. The CD and VOD processes at 60 °C in which heat was applied caused the additional loss of color, total phenolic content (TPC), total flavonoid content (TFC), and antioxidant activity. In addition, the leaves exhibited stronger antioxidant activity and contained higher phenolic content than stems; for example, the quercetin content in fresh stems and leaves was 89.82 vs 638.20 mg/kg dry weight, respectively. Our results implied that FD could be a superior drying technique for A. keiskei, however, high cost of FD procedures may limit its application. Natural drying thus could be an alternative method when finance becomes the main concern.

Statistics on the use of cardiac electronic devices and interventional electrophysiological procedures in Africa from 2011 to 2016: report of the Pan African Society of Cardiology (PASCAR) Cardiac Arrhythmias and Pacing Task Forces.

AimsTo provide comprehensive information on the access and use of cardiac implantable electronic devices (CIED) and catheter ablation procedures in Africa.Methods and resultsThe Pan-African Society of Cardiology (PASCAR) collected data on invasive management of cardiac arrhythmias from 2011 to 2016 from 31 African countries. A specific template was completed by physicians, and additional information obtained from industry. Information on health care systems, demographics, economics, procedure rates, and specific training programs was collected. Considerable heterogeneity in the access to arrhythmia care was observed across Africa. Eight of the 31 countries surveyed (26%) did not perform pacemaker implantations. The median pacemaker implantation rate was 2.66 per million population per country (range: 0.14–233 per million population). Implantable cardioverter-defibrillator and cardiac resynchronization therapy were performed in 12/31 (39%) and 15/31 (48%) countries respectively, mostly by visiting teams. Electrophysiological studies, including complex catheter ablations were performed in all countries from Maghreb, but only one sub-Saharan African country (South Africa). Marked variation in cost (up to 1000-fold) was observed across countries with an inverse correlation between implant rates and the procedure fees standardized to the gross domestic product per capita. Lack of economic resources and facilities, high cost of procedures, deficiency of trained physicians, and non-existent fellowship programs were the main drivers of under-utilization of interventional cardiac arrhythmia care.ConclusionThere is limited access to CIED and ablation procedures in Africa. A quarter of countries did not have pacemaker implantation services, and catheter ablations were only available in one country in sub-Saharan Africa.

Global supply chain network design and Asian analysis with material-based carbon emissions and tax

Global warming has become a serious problem. Global supply chain networks in Asia should reduce not only CO2 emissions but also the fixed opening costs for factories/routes as well as the cost of transportation and procurement. Life cycle assessment (LCA) quantitatively estimates and visualizes the CO2 emissions for each part based on their component materials produced on a country by country basis using a life cycle inventory (LCI) database. In general, in order to reduce both of the CO2 emissions and the costs, supply chain planners should make the decision to switch the suppliers of component parts with higher CO2 emissions but lower procurement costs from emerging countries and/or with lower CO2 emissions but higher procurement costs from developed countries. In addition, the European Union (EU) approaches to reducing CO2 emissions through the introduction of emissions tax and trading. This study proposes a design method of an Asian global supply chain network that minimizes the costs under targeted material-based CO2 emissions reduction ratios, and determines the suppliers and factory locations that satisfy demands for low-carbon material supply, through the adoption of the Asian LCI database. Based on this result, a sensitivity analysis is conducted by changing emission prices for reducing the costs and the carbon emissions, and the difference between the supply chain networks comprising of either two and three different Asian countries is compared.

Heart valves from polyester fibers: a preliminary 6-month in vivo study.

Transcatheter aortic valve implantation (TAVI) has become a popular alternative technique to surgical valve replacement for critical patients. Biological valve tissue has been used in TAVI procedures for over a decade, with over 150,000 implantations to date. However, with only 6 years of follow up, little is known about the long-term durability of biological tissue. Moreover, the high cost of tissue harvesting and chemical treatment procedures favor the development of alternative synthetic valve leaflet materials. In that context, textile polyester [polyethylene terephthalate (PET)] could be considered as an interesting candidate to replace the biological valve leaflets in TAVI procedures. However, no result is available in the literature about the behavior of textile once in contact with biological tissue in the valve position. The interaction of synthetic textile material with living tissues should be comparable to biological tissue. The purpose of this preliminary work is to compare the in vivo performances of various woven textile PET valves over a 6-month period in order to identify favorable textile construction features. In vivo results indicate that fibrosis as well as calcium deposit can be limited with an appropriate material design.

How to build a low-cost underwater camera housing for aquatic research

Remote cameras are an increasingly important tool in field-based biological research. Terrestrial researchers can purchase inexpensive off-the-shelf cameras, but aquatic researchers face challenges in adopting similar systems for underwater science. Although technology allows researchers to deploy cameras in any aquatic environment, high procurement costs are often a barrier, particularly for studies that require the collection of lengthy videos. In this note, we provide a detailed guide explaining how to assemble an underwater camera system for less than $425 USD. We focus especially on the construction of the underwater housing, which is typically the most expensive component of an underwater camera system. As described, this system can record 13 h full high-definition videos in depths up to 100 m. It can be constructed and assembled with limited technical background using tools available in most workshops. The guide includes a general overview of the system, a full list of components, detailed instructions on constructing the camera housing, and suggestions on how to mount and use the camera in fieldwork. Our goal for this note is to promote the wider use of remote underwater cameras in aquatic research by making them accessible to those with limited financial means.

Correlates of stone quarry workers' awareness of work-related ocular health hazards and utilization of protective eye devices: Findings in southeastern Nigeria

Objective:To assess the awareness of work-related ocular health hazards and utilization of personal protective eye devices (PPEDs) among stone quarry workers in Abakaliki, southeastern Nigeria.Materials and Methods:In a cross-sectional survey of stone quarry industry workers in Abakiliki, conducted between March and April, 2012, data on participants' socio-demographics, job characteristics, PPED awareness, and utilization were collected. Descriptive and analytical statistics were performed. For intergroup comparisons, P < 0.05 was considered statistically significant.Results:All workers were aware of the need for utilization of eye protective devices; however, 98.7% declined its use for various reasons. About 74.6% attributed nonutilization to nonavailability while 10.4% attributed it to high cost and 10.2% declined its utilization due to discomfort associated with its use.Discussion:Usage of PPEDs was associated with job specification, educational level, duration of work experience, awareness of work hazards, and knowledge about the purpose of PPEDs. Nonusage was associated with unavailability, high cost of procurement, and ocular discomfort from poor fitting and misty/cloudy vision with use. Users were more numerous among blasters and crushers whose jobs were most predisposed to work related accidents and workers with formal education.Conclusions:Findings from the study reveal high level of awareness yet nonutilization of eye protection. Barriers to the utilization of these eye protective devices should be addressed to ensure greater compliance of its use.

SMEs: The Smart Enterprises - Revisited

Small and Medium Enterprises (SMEs) are crucial for the economic growth and stability of any country. By facilitating economic activity and provide employment they play a vital role especially for developing countries for contributing to poverty reduction. SME’s considered as the backbone of Indian economy.The major constraints of SMEs are lack of finance for start-up and working capital, Lack of skilled manpower to manage the production, service and marketing. Lack of Line of credit from the suppliers, inability to use new technology to produce quality products/give service.Most of the banks consider lending to SMEs an unattractive venture due to a range of factors including information asymmetries and consequently high transaction costs, collateral requirement, financial products not meeting SME sector requirements in medium to long term Information asymmetries, due to inefficient legal system and weak governance structures of SMEs, result in higher transaction costs on the supply side. On the demand side we find most of the SMEs tend to shy away from formal modes of financing due to the high cost of credit, lengthy procedures, collateral requirements and lack of awareness about the benefits of corporate governance.External finance cannot be obtained by firms in their start-up phase as their management structures are not transparent and usually have intangible assets. International investors are often reluctant to invest in developing countries because their institutions do not provide an adequate level of security for their investment particularly in terms of enforceability of legal rights and governance framework.MNCs and international investors will be willing to forge partnership with SMEs only when their level of confidence and trust increases regarding transparency and governance of the local partner.Most of the SMEs are family owned enterprises and there is no clarity on the roles resulting in credibility problems and inability to arrive at strategic decisions.Good governance is vital for the development of a healthy and competitive corporate sector. For SMEs, corporate governance is about the respective roles of the shareholders as owners and the managers. It is about establishing rules and procedures to manage and run the enterprise.It has been empirically tested that good governance practices of a company gives a positive signal to investors. With the globalization of markets, international capital flows have become extremely valuable source of external financing.Good corporate governance leads to development of a framework that provides adequate protection to the interests of stakeholders and reinforces the fiduciary responsibilities of those vested with the authority to act on behalf of the stakeholders.This paper would analyze the current status of Indian SMEs and how, the introduction SMART governance frame work can make the SMEs SMART Enterprises.

Robust optimal offering strategy of large consumer using IGDT considering demand response programs

In restructured electricity market, the consumers have various procurement strategies to supply their electricity demand from alternative resources. An approach to cost reduction and risk management for a large consumer is participation in demand response programs (DRP). Due to uncertain nature of pool prices and price fluctuations in pool market, uncertainty modeling is inevitable. For evaluation of different procurement strategies of large consumer, a technique based on information gap decision theory (IGDT) is proposed. This paper develops an energy acquisition model for large consumer with multiple procurement options including distributed generation (DG), bilateral contracts and pool market purchase with participating in DRP. This paper is focused to study the effect of DRP on the procurement strategy problem. Also, the time-of-use (TOU) rates of demand response programs have been modeled and consequently its influence on load profile and procurement strategy has been discussed. The proposed method does not minimize the procurement cost, but allows deriving robust decision with respect to price volatility. The robustness of procurement strategies for high procurement costs is optimized and related procurement strategy is proposed. The proposed method either deals with optimizing the opportunities to take advantage from low procurement costs or low pool prices. Finally, a case study is studied to show the advantages of proposed method.

Sourcing assemble-to-order inventories under supplier risk uncertainty

In this paper, we consider sourcing and inventory spare-parts decisions in an assemble-to-order setting wherein components are subject to defect risk. Sourcing from dual suppliers diversifies the defect risk and reduces the variability of random defects. Upon careful consideration of assemble-to-order (ATO)-type repair and uncertainty of supplier reliability, we found that dual sourcing minimizes spare-part inventory cost by reducing the shortage cost or enabling storage of lesser amounts of the common resource. This paper identifies the conditions under which dual sourcing is better than sourcing from a single supplier in spite of lost pooling effect, higher procurement cost, and failure to achieve higher reliability.

Cost Analysis of Failed Shoulder Stabilization

ABSTRACTBackgroundShoulder instability is a common problem, especially in the young, active population. Revision stabilization has a high rate of recurrent instability, low rates of return to play, and low clinical outcome scores. The challenge for surgeons is identifying the best surgery for each patient. To our knowledge, no studies have been published examining the cost of failed shoulder stabilization.HypothesisThe high cost of index and revision stabilization procedures in a cohort of patients with recurrent shoulder instability can be reduced through judicious preoperative planning and the use of more aggressive surgical techniques during the index operation.MethodsWe retrospectively reviewed the medical records and billing information of 18 consecutive patients treated at our institution for failed shoulder instability repairs during a 36-month period. Using the billing records for each case, a cost analysis was conducted from a societal perspective.ResultsThe actual costs of index stabilization and revision stabilization procedures for our cohort of 18 patients amounted to $1,447,690. The costs of revision surgeries conducted for this cohort by a single surgeon at our institution amounted to $673,248. The hypothetical costs of primary arthroscopic stabilization and open stabilization for a cohort of 18 patients leading to permanent repair was $395,415 and $585,639 respectively. The incremental difference between actual costs and hypothetical costs of primary osteoarticular (OA) allograft stabilization for patients with bony defects is $278,394. For patients with significant bone defects, an open repair with failure rate of 44.9%, or an arthroscopic repair with failure rate of 62.8%, is cost neutral to a primary open repair with OA allograft. In addition, an open repair with failure rate of 13.0%, or an arthroscopic repair with failure rate of 41.3%, is cost neutral to a primary definitive repair.ConclusionFailed shoulder stabilization bears high costs to society, even without considering the psychological costs to patients. We must identify and refine diagnostic and prognostic factors to better determine the appropriate treatment modality for patients with primary shoulder instability.Godin JA, Skendzel JG, Sekiya JK. Cost Analysis of Failed Shoulder Stabilization. The Duke Orthop J 2015;5(1):14-19.

Radiofrequency ablation: an assessment of clinical and cost efficacy.

Varicose veins are common and frequently cause patient distress. In recent years, Radiofrequency ablation (RFA) has emerged as a minimally invasive alternative to traditional open venous ligation surgery. The aim of this study was to directly compare RFA and open saphenofemoral ligation. This was a single-centre retrospective cohort study. Consecutive patients undergoing surgical management over a 2-year period commencing from January 2011 were studied. Radiological success, peri-operative serological testing and hospital length of stay were documented. Procedural cost was calculated. A focused cohort analysis was undertaken to compare the initial 50 RFA procedures performed with the last 50. During the study period, 296 patients underwent surgical intervention. A total of 204 patients underwent RFA. Sixty-six percent of all patients were female. RFA was associated with a reduction in overnight hospital stay (18 vs. 78 %, P = <0.001) when compared with open ligation with a success rate of 98 %. No significant inter-group difference was noted for 30-day readmission (p = 0.203). Focused cohort analysis identified an increase in hospital day case activity (74 vs. 90 %, p = 0.002), which contributed to a reduction in procedural cost (€1,024 vs. €971, p = 0.003) over the study period. Radiofrequency ablation is a viable alternative to open repair offering excellent efficacy. It is however associated with a higher procedural cost than the open surgical option.

The use and correlates of illicit silicone or "fillers" in a population-based sample of transwomen, San Francisco, 2013.

There is a dearth of studies to quantify the use of illicit fillers by transwomen. Case studies of illicit filler injections have pointed to an array of serious health complications, including death. The aims of this study were to determine the population prevalence and identify correlates of filler use among transwomen in San Francisco, CA. An analysis of data collected in 2013 with a population-based sample of 233 transwomen recruited using respondent-driven sampling (RDS). We used RDS weights to conduct bivariate and multivariate analyses of correlates of filler use. Main outcome measures were an RDS-weighted population prevalence of filler use among transwomen and differences in demographic characteristics, transition-related care factors, and self-esteem related to appearance. Weighted filler prevalence among transwomen was 16.7%. Being a transwoman between 30 and 49 years of age, owning/renting or living with a partner/family/friend, having had and planning to have surgery in the future, and having used nonprescribed hormones were all significantly associated with filler use. HIV was not associated with filler use. This study provides the first known estimate to date of the prevalence of filler use in a population-based sample of transwomen in San Francisco. Accessing illicit fillers may be the only choice available for many transwomen to make changes to their appearance due to the high cost of legal surgeries and other cosmetic procedures. An important next step in this research is to determine the overall prevalence and long-term consequences of filler use among transwomen, to explore how the use of fillers is protective to the safety and well-being of transwomen, and to find safe and affordable alternatives to this method that meet important gender-related appearance needs.

MP18-11 PEDIATRIC NEPHROLITHIASIS: PRACTICE PATTERNS AND COST OF SURGICAL MANAGEMENT

INTRODUCTION AND OBJECTIVES: Extracorporeal shockwave lithotripsy (ESWL) previously predominated in the surgical management of pediatric nephrolithiasis. More recently, ureteroscopy (URS) has been increasingly utilized as improvements in endoscopic instrumentation have been made. Additionally, studies have demonstrated that URS has better stone-free rates and acceptable complication rates compared to ESWL. This study examines the cost and pattern of surgical management associated with pediatric stones in two private insurer databases. METHODS: Claims from the Humana and Ingenix administrative databases were queried using appropriate current procedural terminology (CPT) and international classification of disease, 9th Revision (ICD-9) codes between 2004 and 2012. Procedural, associated medication, outpatient, and emergency room (ER) utilization and costs were analyzed. RESULTS: 1100 procedures in 618 pediatric patients were identified (368 primary URS, 250 primary ESWL). The average total cost associated with primary URS and ESWL were $2671 95% CI [$2447,2895] and $3,709 95% CI [$3,342,$4076] respectively. ESWL had a higher procedural cost ($2861) compared with primary URS ($1637), p1⁄42.9x10-17. Secondary procedures were more common in the ESWL (19.2%) than the URS (11.4%) cohort, p1⁄40.01. ER and outpatient costs were significantly more in the primary URS group ($891) compared to the ESWL group ($689), p1⁄40.03. Medication cost were similar between the groups, $159 and $143 for ESWL and URS respectively, p1⁄40.14. Primary ESWL declined over the study period from a high of 57.7% cases in 2004 to 25.6% of primary procedures in 2012. CONCLUSIONS: The surgical management of pediatric nephrolithiasis has changed over the 8 year period of study with URS more frequently utilized. Primary ESWL is associated with higher overall cost due to higher procedural cost and increased secondary procedures, while URS is associated with increased outpatient and ER costs but a lower total cost.

A Comprehensive Framework for Intrinsic OpenStreetMap Quality Analysis

AbstractOpenStreetMap (OSM) is one of the most popular examples of a Volunteered Geographic Information (VGI) project. In the past years it has become a serious alternative source for geodata. Since the quality of OSM data can vary strongly, different aspects have been investigated in several scientific studies. In most cases the data is compared with commercial or administrative datasets which, however, are not always accessible due to the lack of availability, contradictory licensing restrictions or high procurement costs. In this investigation a framework containing more than 25 methods and indicators is presented, allowing OSM quality assessments based solely on the data's history. Without the usage of a reference data set, approximate statements on OSM data quality are possible. For this purpose existing methods are taken up, developed further, and integrated into an extensible open source framework. This enables arbitrarily repeatable intrinsic OSM quality analyses for any part of the world.

Labyrinth of High Parameter Valve Technology Application and Prospects in the Power Plant

In order to solve the domestic sub and super-critical unit import the high cost of procurement of high parameters of valves and valve operation in the common issues such as defects, and introduces the new valve of the Sino-ROK cooperative project--the labyrinth of high parameter control valve. First elaborates its structure characteristics, the core technology and application, and introduces concrete application for the settlement of condensate water pump recirculation valve defect. And we can see the labyrinth of high parameter control valve important role and development prospects in the future power plant.

TCT-392 Drug-coated balloon angioplasty for de-novo lesions in coronary bifurcations

Treatment of coronary bifurcation lesions represents a challenging area in interventional cardiology. When compared with nonbifurcation interventions, bifurcation interventions have a lower rate of procedural success, higher procedural costs, longer hospitalization, and a higher rate of clinical and

SMEs -The Smart Enterprises

Small and Medium Enterprises (SMEs) are crucial for the economic growth and stability of any country and play a vital role especially for developing countries as they facilitate economic activity and provide employment thus contributing to poverty reduction. In the Indian context they can be considered as the backbone of national economy. The major constraints of SMEs are finance for initial capital and working capital, Line of credit from the suppliers, new technology to produce quality products/ give service, ability to hire qualified and professional staff for production, service and marketing. Majority of the banks consider lending to SMEs an unattractive venture due to a range of factors including information asymmetries and consequently high transaction costs, collateral requirement, financial products not meeting SME sector requirements in medium to long term Information asymmetries, due to inefficient legal system and weak governance structures of SMEs, result in higher transaction costs on the supply side. On the demand side we find most of the SMEs tend to shy away from formal modes of financing due to the high cost of credit, lengthy procedures, collateral requirements and lack of awareness about the benefits of corporate governance. External finance cannot be obtained by firms in their start-up phase as their management structures are not transparent and usually have intangible assets. International investors are often reluctant to invest in developing countries because their institutions do not provide an adequate level of security for their investment particularly in terms of enforceability of legal rights and governance framework. MNCs and international investors will be willing to forge partnership with SMEs only when their level confidence and trust increases regarding transparency and governance of the local partner. Another problem for most of the SMEs being family owned enterprises is that there is no clarity on the roles resulting in credibility problems and inability to arrive at strategic decisions. Good governance is vital for the development of a healthy and competitive corporate sector. For SMEs, corporate governance is about the respective roles of the shareholders as owners and the managers. It is about establishing rules and procedures to manage and run the enterprise. It has been empirically tested that good governance practices of a company gives a positive signal to investors. With the globalization of markets, international capital flows have become extremely valuable source of external financing. Good corporate governance leads to development of a framework that provides adequate protection to the interests of stakeholders and reinforces the fiduciary responsibilities of those vested with the authority to act on behalf of the stakeholders. This paper would analyze the current status of Indian SMEs and how, the introduction SMART governance frame work can make the SMEs SMART Enterprises.

Pricing and Replenishment of Competing Perishable Product Variants under Dynamic Demand Substitution

I consider pricing and ordering decisions faced by a retailer selling a perishable product with a two‐period shelf life over an infinite horizon. In the first period, the product is “new”; in the next, it becomes “old.” The new product is perceived by customers to have a higher quality than the old product. Every period, the retailer makes three decisions: prices for the new and old products and how much new product to order. I first show, with some simple cases, that demand uncertainty can make the sale of the old product profitable. I then consider a more realistic case with dynamic demand substitution among customers. I recognize that the retailer's decisions may be constant or may vary across different periods, under different contexts. For instance, varying the price of the new product can sometimes be difficult due to the negative impact it generates among customers. I find that (i) the benefit obtained from selling the old product with constant decisions is much higher than the benefit from allowing all the decisions to vary; (ii) the former benefit increases with a higher procurement cost, a higher quality of the new product, and higher demand volatility; however, the latter benefit is non‐monotone in these parameters; (iii) most of the latter benefit can be obtained by just changing the order quantity; and (iv) as the inventory of the old product increases, when all the decisions vary, the optimal price of the new product may increase or decrease.

English

Introduction Ultrasound guidance for cannulation of the internal jugular vein has been shown to improve success and complication rates in comparison with the landmark techniques. The aim of this study is to verify if ultrasound is also cost-effective. Materials and Methods A systematic review of the literature in PubMed, Medline, and Google was performed between years 1966 and 2010. A decision tree model was built with failure and complication rates from the studies selected. A costeffectiveness analysis and sensitivity analysis were performed with this model. Randomised controlled trials on adult patients, with real-time B-mode ultrasound guidance, comparison between ultrasonography and landmark methods and reported outcomes (early complications, failures, time to successful cannulation) were included. Exclusion criteria were: enrolment of paediatric patients, ultrasound before puncture, Doppler ultrasound guidance, no clear description of outcomes, and no prospective clinical trial. Results About 8 randomised controlled trials were selected. The ultrasound guidance significantly reduces the occurrence of arterial puncture (risk ratio, risk ratio 0.21, 95% CI 0.13–0.33), pneumothorax complications (risk ratio 0.15, 95% CI 0.03–0.88), and cannulation failures (R 0.12, 95% CI 0.04-0.39). It proves to have € 1,225 additional cost every 1,000 procedures. The major determinants of ultrasound costs are the purchase cost of the ultrasound unit and the machine uses per week. Conclusion Although the ultrasound approach introduces a clinically relevant improvement of success and complication rates, it does not appear to be cost-effective. Introduction Central venous catheters (CVCs) are essential for the clinical management of many patients both in the acute care setting and in the chronic, longterm care. Studies have reported an associated complication rate >15% for central venous cannulations1,2. Up to recent years, the internal jugular vein (IJV) has gained the greatest popularity among the different central cannulation routes due to its consistent anatomical position, large diameter, and low likelihood of catheter obstruction or misplacement3. This route, however, is not devoid of early mechanical complications like arterial puncture and pneumothorax. Two meta-analyses have shown that ultrasound-guided CVC placement is associated with a significant improvement of early complication rates, length of execution, and firstpass success rate when compared with the landmark (LM) technique4,5. However, in a survey by the Society of Cardiovascular Anaesthesiologists only 15% of responders stated to routinely use ultrasound (US) for CVC placement6. A presumed higher procedural cost was among the most common objections for not utilizing this approach. According to many providers, the initial financial investments for equipment and operators’ training, and fixed costs for maintenance and additional supplies (e.g. sterile sheaths), may not be outweighed by the better clinical performances of US guidance. Calvert and coworkers have performed a decision analysis showing that B-mode US guidance for CVC placement is significantly cost-effective when compared with the traditional LM technique7,8. Their decision model considered a 12% incidence of arterial puncture and a 9% failure for internal jugular vein cannulations with the LM technique. Although the analysis used conservative assumptions against the US approach (such as no pneumothorax complications, expert operators, allowance of only one failed attempt), these complication rates are higher than data published in the studies on CVC placement with the LM approach9,10. The aim of this study is to perform a systematic review of the existing literature and to update the economic evaluation of cost-effectiveness of real-time B-mode US guidance compared with the LM technique for IJV cannulation. Materials and Methods Selection of studies A search in PubMed, Medline, and Google was carried out with the following headings: central venous catheter, internal jugular vein, and ultrasound. Articles were limited to those in English. The time period was between 1966 and December 2010. Inclusion criteria were: * Corresponding author Email: riccardo.moretti77@gmail.com 1 Teaching Hospital of Val Vibrata, Department of Anesthesia and Critical Care, Sant’Omero (Teramo) Italy 2 Department of Cost Analysis and Control, HBG, Rome, Italy