Increased Cost Savings Research Articles

Space heating demand response potential of retrofitted residential apartment blocks

In future and smarter energy systems, time varying energy prices enable indirect demand response (DR) to assist the electricity supply system to meet demand. This simulation-based study investigates how economic model predictive control (E-MPC) schemes for space heating operation can utilize the thermal mass in an existing multi-story apartment block and eight retrofit scenarios to provide DR. The performance of the E-MPC scheme was evaluated in terms of its ability to enable end-user cost savings, reduce CO2 emissions and to perform load shift of the heating demand compared to a conventional PI controller. Two E-MPC approaches were considered: centralized E-MPC where inter-zonal effects were considered and decentralized E-MPC that neglected heat transfer between adjacent apartments. The E-MPC schemes led to increasing cost savings (up to approx. 6%) and reduced CO2 emissions (up to approx. 3%) as a function of increasing energy efficiency of the retrofit scenarios. The absolute amount of shifted power from peak load periods was rather consistent (approx. 2 kWh/m2 heated net area) across all retrofit scenarios compared to the existing building. The centralized E-MPC scheme led to marginally better results than the decentralized E-MPC. The added complexity involved in establishing a centralized E-MPC compared to a decentralized E-MPC may therefore not be worth the effort.

Inpatients' Preferences, Beliefs, and Stated Willingness to Pay for Complementary and Alternative Medicine Treatments.

Research demonstrates the benefits of complementary and alternative medicine (CAM) in myriad environments. Yet, the majority of CAM services are offered in outpatient settings. Incorporating CAM into hospital settings may lead to increased patient comfort, well-being, and overall satisfaction with hospital admissions. Few studies have examined CAM services among inpatients. Therefore, this study assessed inpatients' preferences and beliefs regarding CAM, as well as their stated willingness to pay for these services. Adult patients (n = 100), ranging in age from 19-95 years (M = 53 years; SD = 19.2 years), were recruited during their hospitalization in the University of California, San Diego, Healthcare System. The inpatients completed a brief individual interview to gather their perspectives on common CAM services, including acupuncture, aromatherapy, art therapy, guided imagery, healthy food, humor therapy, massage therapy, music therapy, pet therapy, Reiki, and stress management. Inpatients were asked which CAM therapies they perceived as being potentially the most helpful, their willingness to pay for those therapies, and their perceived beliefs regarding the use of those therapies. Inpatients most commonly perceived healthy food (85%), massage therapy (82%), and humor therapy (70%) to be the most helpful, and were most willing to pay for healthy food (71%), massage therapy (70%), and stress management (48%). Inpatients most commonly believed CAM treatments would provide relaxation (88%), increase well-being (86%), and increase their overall satisfaction with the hospitalization (85%). This study suggests that CAM services may be a beneficial addition to hospitals, as demonstrated by inpatients' interest and stated willingness to pay for these services. These findings may help organizational leaders when making choices regarding the development of CAM services within hospitals, particularly since a significant percentage of inpatients reported that CAM services would increase their overall satisfaction with the hospitalization. These results merit further attention given the need to increase cost savings while enhancing the overall patient experience in today's medical marketplace.

Identifying the Barriers for Development of Inland Waterway Transport: a Case Study

Inland waterway transport represent environmentally friendly transport mode accompanied with other potential benefits, such as increased transport safety and increased cost savings. In order to encourage further development of inland waterway transport in this paper focus is set on the identification of the barriers that limit and prevent development of inland waterway transport. More specifically, emphasis is placed on the barriers that are preventing the cargo shifting from land to waterway transport system. Research conducted in case of Republic of Serbia investigates several barriers which are classified in four main categories: goods, logistics, infrastructure, framework conditions. Framework conditions barriers are further subdivided and classified in four subcategories: political/legal, environment, economy, technology. Results indicate that the most significant negative influence on the further development of the inland waterway transport in Serbia comes from the political/legal barriers. This result implies that the government need to pay more attention to development of inland waterway transport, as well as to make more effort to enhance the cooperation with stakeholders.

The short-term and long-term cost-effectiveness of a pedometer-based intervention in primary care: a within trial analysis and beyond-trial modelling

BackgroundThere is little evidence of the cost-effectiveness of pedometer-based interventions. We examined the short-term and long-term cost-effectiveness of a pedometer-based walking intervention in inactive adults. MethodsData were collected as part of a three-arm cluster-randomised trial conducted (2012–14) in seven primary care practices in London to assess the effectiveness of pedometer-based walking interventions (PACE-UP trial). Eligible participants were inactive adults aged 45–75 years, without contraindications to increasing moderate-to-vigorous physical activity. 11 015 people were mailed an invitation. 6399 were non-responders, and 548 individuals who self-reported as being active were excluded. 1023 people were randomised to usual care (control, n=338), postal pedometer (339), and nurse-supported pedometer interventions (346). 956 participants (93%) provided outcome data. Intervention groups received pedometers, 12 week walking programmes, and diaries to record physical activity. The nurse group was also offered three physical activity consultations. A within trial cost-effectiveness analysis was done at 1 year. Additionally, a Markov model, using routine data obtained via reviews of epidemiological and economic literature, was used to extend trial results to a life-time horizon. Cost per change in physical activity (step count, and moderate-to-vigorous physical activity in ≥10 minute bouts) and quality-adjusted life-years (QALYs) for interventions were assessed. Costs (in 2013 prices) are presented from a health-care provider's perspective and uncertainty as a cost-effectiveness acceptability curve. Ethics approval was provided by London Research Ethics Committee (Hampstead). PACE-UP is registered with Current Controlled Trials, ISRCTN98538934. FindingsIn the short term, incremental cost per step and cost per min in a 10 min or more bout of moderate-to-vigorous physical activity were £0·19 and £3·61, respectively, for nurse-support. The postal group took a greater number of steps and cost less. In the long term, the postal group dominated both control and nurse groups in that QALY gains (759, 95% CI 400 to 1247) added to increased cost savings (−£11 million, 95% CI −12 to −10), resulting in an incremental net monetary benefit of £26 million (based on a hypothetical cohort of 100 000 people). The postal group had a 50% chance of being cost-effective in terms of QALYs at 1 year and, at a £20 000 per QALY threshold, robustly dominated both nurse and control groups in the long term. InterpretationA pedometer-based intervention delivered by post, compared with current practice, would deliver cost savings in the short term and the most quality of life benefits in the long term. FundingThe PACE-UP trial was funded by the National Institute for Health Research Health Technology Assessment Programme (project number HTA 10/32/02 ISRCTN42122561).

Photography-based Method for Measuring Wrist Range of Motion

Hypothesis: We hypothesized that at-home photography-based wrist range of motion (WROM) measurements would be as reliable as traditional physician-performed goniometry. Methods: Sixty-nine postoperative patients who had wrist surgery greater than 3 months prior were enrolled in this study according to an approved institutional review board protocol. Active and passive wrist flexion/extension and radial/ulnar deviation were recorded by 1 of 2 attending surgeons with a 1° resolution goniometer at the last postoperative office visit. Patients were then provided an illustrated instruction sheet detailing how to take digital photographs at home in 6 wrist positions (active and passive flexion/extension and radial/ulnar deviation). Photographs were reviewed by both attending surgeons in a randomized, blinded fashion on 2 separate occasions greater than 2 weeks apart using the same goniometer. Reliability analysis was performed using the intraclass correlation coefficient (ICC) to assess agreement between clinical and photography-based goniometry, as well as intraobserver and interobserver agreement. Results: Out of 69 enrolled patients, 30 patients sent digital images (43% response rate). Of the 180 digital photographs taken by patients at home, only 9 (5%) were missing or deemed inadequate for WROM measurements. Agreement between clinical and photography-based measurements was “almost perfect” for passive wrist flexion/extension (ICC > .80, P < .01) and “substantial” for active wrist flexion/extension and radial/ulnar deviation (.60 < ICC = .80, P < .01). Interobserver and intraobserver agreement for the 2 attending surgeons for all 6 photography-based measurements was “almost perfect” (ICC > .80, P < .01). Conclusion: This study validates a photography-based goniometry protocol allowing accurate and reliable range of motion (ROM) measurements without direct physician contact. Passive ROM was more accurately measured from photographs than active ROM. This study builds on previous photography-based goniometry literature by validating a protocol in which patients take their own photographs. Patient-performed photography-based goniometry represents an alternative to traditional clinical goniometry with the potential to enable longer term patient follow-up, overcome travel or distance impediments to office visits, improve patient convenience, and increase cost savings.

Pharmacy-Driven Dexmedetomidine Stewardship and Appropriate Use Guidelines in a Community Hospital Setting.

Dexmedetomidine is a widely utilized agent in the intensive care unit (ICU) because it does not suppress respiratory drive and may be associated with less delirium than midazolam or propofol. Cost of dexmedetomidine therapy and debate as to the proper duration of use has brought its use to the forefront of discussion. To validate the efficacy and cost savings associated with pharmacy-driven dexmedetomidine appropriate use guidelines and stewardship in mechanically ventilated patients. This was a retrospective cohort study of adult patients who received dexmedetomidine for ICU sedation while on mechanical ventilation at a 433-bed not-for-profit community hospital. Included patients were divided into pre-enactment (PRE) and postenactment (POST) of dexmedetomidine guideline groups. A total of 100 patients (50 PRE and 50 POST) were included in the analysis. A significant difference in duration of mechanical ventilation (11.1 vs 6.2 days, P = 0.006) and incidence of reintubation (36% vs 18% of patients, P = 0.043) was seen in the POST group. Aggregate use of dexmedetomidine 200-µg vials (37.1 vs 18.4 vials, P = 0.010) and infusion days (5.4 vs 2.5 days, P = 0.006) were significantly lower in the POST group. Dexmedetomidine acquisition cost savings were calculated at $374 456.15 in the POST group. There was no difference between the PRE and POST groups with regard to ICU length of stay, expected mortality, and observed mortality. Pharmacy-driven dexmedetomidine appropriate use guidelines decreased the use of dexmedetomidine and increased cost savings at a community hospital without adversely affecting clinical outcomes.

A Predictive Model to Estimate Cost Savings of a Novel Diagnostic Blood Panel for Diagnosis of Diarrhea-predominant Irritable Bowel Syndrome

PurposeA high incidence of irritable bowel syndrome (IBS) is associated with significant medical costs. Diarrhea-predominant IBS (IBS-D) is diagnosed on the basis of clinical presentation and diagnostic test results and procedures that exclude other conditions. This study was conducted to estimate the potential cost savings of a novel IBS diagnostic blood panel that tests for the presence of antibodies to cytolethal distending toxin B and anti-vinculin associated with IBS-D. MethodsA cost-minimization (CM) decision tree model was used to compare the costs of a novel IBS diagnostic blood panel pathway versus an exclusionary diagnostic pathway (ie, standard of care). The probability that patients proceed to treatment was modeled as a function of sensitivity, specificity, and likelihood ratios of the individual biomarker tests. One-way sensitivity analyses were performed for key variables, and a break-even analysis was performed for the pretest probability of IBS-D. Budget impact analysis of the CM model was extrapolated to a health plan with 1 million covered lives. FindingsThe CM model (base-case) predicted $509 cost savings for the novel IBS diagnostic blood panel versus the exclusionary diagnostic pathway because of the avoidance of downstream testing (eg, colonoscopy, computed tomography scans). Sensitivity analysis indicated that an increase in both positive likelihood ratios modestly increased cost savings. Break-even analysis estimated that the pretest probability of disease would be 0.451 to attain cost neutrality. The budget impact analysis predicted a cost savings of $3,634,006 ($0.30 per member per month). ImplicationsThe novel IBS diagnostic blood panel may yield significant cost savings by allowing patients to proceed to treatment earlier, thereby avoiding unnecessary testing.

Cost profiles and budget impact of rechargeable versus non-rechargeable sacral neuromodulation devices in the treatment of overactive bladder syndrome.

Sacral neuromodulation (SNM) is a guideline-recommended third-line treatment option for managing overactive bladder. Current SNM devices are not rechargeable, and require neurostimulator replacement every 3-6 years. Our study objective was to assess potential cost effects to payers of adopting a rechargeable SNM neurostimulator device. We constructed a cost-consequence model to estimate the costs of long-term SNM-treatment with a rechargeable versus non-rechargeable device. Costs were considered from the payer perspective at 2015 reimbursement levels. Adverse events, therapy discontinuation, and programming rates were based on the latest published data. Neurostimulator longevity was assumed to be 4.4 and 10.0 years for non-rechargeable and rechargeable devices, respectively. A 15-year horizon was modeled, with costs discounted at 3% per year. Total budget impact to the United States healthcare system was estimated based on the computed per-patient cost findings. Over the 15-year horizon, per-patient cost of treatment with a non-rechargeable device was $64,111 versus $36,990 with a rechargeable device, resulting in estimated payer cost savings of $27,121. These cost savings were found to be robust across a wide range of scenarios. Longer analysis horizon, younger patient age, and longer rechargeable neurostimulator lifetime were associated with increased cost savings. Over a 15-year horizon, adoption of a rechargeable device strategy was projected to save the United States healthcare system up to $12 billion. At current reimbursement rates, our analysis suggests that rechargeable neurostimulator SNM technology for managing overactive bladder syndrome may deliver significant cost savings to payers over the course of treatment. Neurourol. Urodynam. 36:727-733, 2017. © 2016 Wiley Periodicals, Inc.

Improvements in a program to convert i.v. to oral medications at an academic medical center.

Results of a study to implement targeted interventions to increase the number of documented i.v.-to-oral conversions and to increase cost savings from these documented conversions are reported. A before-and-after analysis of i.v.-to-oral conversions at an academic medical center following the addition of targeted interventions to an existing pharmacist-initiated conversion program was conducted. Targeted interventions included staff training on i.v.-to-oral conversions, implementation of a new documentation system, and feedback to the staff. Major outcomes studied included the total number of i.v.-to-oral conversions documented per month and the cost savings generated by these conversions. The mean ± S.D. number of i.v.-to-oral conversions documented per month significantly increased after the implementation of targeted interventions (25 ± 9 before and 57 ± 6 after implementation, p < 0.0001). There was a nonsignificant increase in cost savings generated per month after implementation of the interventions. The most commonly converted medication was pantoprazole. Conversions of levetiracetam generated the highest cost savings. Addition of several targeted interventions to an existing pharmacist-initiated i.v.-to-oral conversion program led to a significant increase in the total number of documented conversions.

E-governance in India: Impact and challenges

ICT medium has espoused confidence on the future of governance in India. E-governance facilitates efficient welfarism targeting. It eliminates scope of corruption and makes service delivery effective and accessible, thereby increasing cost savings. E-governance acts as a transparent interface between government and individual, individual and business, and business and government. This paper analyses the positive impacts of the ICT medium has on India and the challenges it entails.

Protein adducts from carbamazepine-10,11-epoxide, the major metabolite of the antiepileptic drug carbamazepine: possible biomarkers of toxicity

A high incidence of irritable bowel syndrome (IBS) is associated with significant medical costs. Diarrhea-predominant IBS (IBS-D) is diagnosed on the basis of clinical presentation and diagnostic test results and procedures that exclude other conditions. This study was conducted to estimate the potential cost savings of a novel IBS diagnostic blood panel that tests for the presence of antibodies to cytolethal distending toxin B and anti-vinculin associated with IBS-D.A cost-minimization (CM) decision tree model was used to compare the costs of a novel IBS diagnostic blood panel pathway versus an exclusionary diagnostic pathway (ie, standard of care). The probability that patients proceed to treatment was modeled as a function of sensitivity, specificity, and likelihood ratios of the individual biomarker tests. One-way sensitivity analyses were performed for key variables, and a break-even analysis was performed for the pretest probability of IBS-D. Budget impact analysis of the CM model was extrapolated to a health plan with 1 million covered lives.The CM model (base-case) predicted $509 cost savings for the novel IBS diagnostic blood panel versus the exclusionary diagnostic pathway because of the avoidance of downstream testing (eg, colonoscopy, computed tomography scans). Sensitivity analysis indicated that an increase in both positive likelihood ratios modestly increased cost savings. Break-even analysis estimated that the pretest probability of disease would be 0.451 to attain cost neutrality. The budget impact analysis predicted a cost savings of $3,634,006 ($0.30 per member per month).The novel IBS diagnostic blood panel may yield significant cost savings by allowing patients to proceed to treatment earlier, thereby avoiding unnecessary testing.

A matter of balance: older adults taking control of falls by building confidence.

A matter of balance: older adults taking control of falls by building confidence.

The economic impact of improving phosphate binder therapy adherence and attainment of guideline phosphorus goals in hemodialysis patients: a Medicare cost-offset model.

Hyperphosphatemia (serum phosphorus>5.5mg/dL) in hemodialysis patients is a key factor in mineral and bone disorders and is associated with increased hospitalization and mortality risks. Treatment with oral phosphate binders offers limited benefit in achieving target serum phosphorus concentrations due to high daily pill burden (7-10 pills/day) and associated poor medication adherence. The economic value of improving phosphate binder adherence and increasing percent time in range (PTR) for target phosphorus concentrations has not been previously assessed in dialysis patients. The current retrospective analysis was conducted to summarize health care cost savings to United States (US) payers associated with improved phosphate binder adherence and increased PTR for target phosphorus concentrations in adult end-stage renal disease (ESRD) patients receiving hemodialysis therapy. Phosphate binder adherence and PTR were derived from hemodialysis patients who were treated at a large dialysis organization between January 2007 and December 2011. Cost model inputs were derived from US Renal Data System data between July 2007 and December 2009. A cost-offset model was constructed to estimate monthly and annual incremental health care costs (total Medicare; inpatient, outpatient, and Medicare Part B) associated with different levels of phosphate binder adherence and PTR. Model inputs included number of ESRD patients, population adherence to phosphate binders, PTR associated with adherence to phosphate binders, and per-patient per-month cost associated with PTR. A base case model estimated monthly and annual costs of phosphate binder therapy in the population using estimated model inputs. The estimated adherence rate was used to determine number of patients in compliant and noncompliant groups. Monthly costs were calculated as the sum of per-patient per-month cost times the number of patients in adherent and nonadherent groups. Annual costs were monthly costs times 12 and assumed the same level of adherence, PTR, and per-patient per-month costs over time. To study the impact of improving phosphate binder adherence and PTR on cost outcomes, we hypothetically and simultaneously increased both base phosphate binders adherence and PTR for adherent patients (adherence/PTR: 10/20%, 20/40%, 30/60%). Monthly and annual costs were derived for each scenario and compared against the results of the base case model. One-way sensitivity analysis was performed to test model robustness. The base case model estimated total Medicare and inpatient costs of $5,152,342 and $1,435,644, respectively (N=1,000). When base case model costs were compared to results of each extended model scenario, overall Medicare cost savings (range 0.3-1.9%) and inpatient cost savings (range 1.2-5.7%) were observed. The one-way sensitivity analysis indicated that results were sensitive to PTR for adherent and nonadherent patients and the factor used to increase adherence rate and PTR associated with adherence in the hypothetical scenarios. However, cost savings in overall Medicare costs and inpatient costs were still noted. Increasing phosphate binder adherence and improving phosphorus control were associated with increased cost savings in total Medicare costs and inpatient costs.

Beam Search Combined With MAX-MIN Ant Systems and Benchmarking Data Tests for Weighted Vehicle Routing Problem

In real-world cargo transportation, there are charges associated with both the traveling distance and the loading quantity. Cargo trucks must comply with a mandatory lower carbon emissions policy: the emissions of large-volume cargo truck/containers depend greatly on the cargo loading and the traveling distance. To address this issue, instead of assuming a constant vehicle loading from one customer to another, a variable vehicle loading should be used in optimizing the vehicle routine, which is known as a weighted vehicle routing problem (WVRP) model. The WVRP is an NP-hard problem; thus, the purpose of this paper is to develop a BEAM-MMAS algorithm that combines a MAX-MIN ant system with beam search to show that the WVRP is more effective than the VRP and to determine the types of VRP instances for which the WVRP has more cost-savings than the VRP. To this end, computational experiments are carried out on benchmark problems of the capacitated VRP for seven types of distributions, and the effectiveness of the BEAM-MMAS algorithm is compared with that of general ACO and MMAS algorithms for large-size benchmarking instances. The benchmarking tests show that lower operation costs are produced using the WVRP than using the optimal or best known paths of the CVRP and that the WVRP can increase cost savings for the instances with a dispersed customer distribution and a large weight.

Antimicrobial stewardship in a community hospital: attacking the more difficult problems.

Antibiotic stewardship has been proposed as an important way to reduce or prevent antibiotic resistance. In 2001, a community hospital implemented an antimicrobial management program. It was successful in reducing antimicrobial utilization and expenditure. In 2011, with the implementation of a data-mining tool, the program was expanded and its focus transitioned from control of antimicrobial use to guiding judicious antimicrobial prescribing. To test the hypothesis that adding a data-mining tool to an existing antimicrobial stewardship program will further increase appropriate use of antimicrobials. Interventional study with historical comparison. Rules and alerts were built into the data-mining tool to aid in identifying inappropriate antibiotic utilization. Decentralized pharmacists acted on alerts for intravenous (IV) to oral conversion, perioperative antibiotic duration, and restricted antimicrobials. An Infectious Diseases (ID) Pharmacist and ID Physician/Hospital Epidemiologist focused on all other identified alert types such as antibiotic de-escalation, bug-drug mismatch, and double coverage. Electronic chart notes and phone calls to physicians were utilized to make recommendations. During 2012, 2,003 antimicrobial interventions were made with a 90% acceptance rate. Targeted broad-spectrum antimicrobial use decreased by 15% in 2012 compared to 2010, which represented cost savings of $1,621,730. There were no statistically significant changes in antimicrobial resistance, and no adverse patient outcomes were noted. The addition of a data-mining tool to an antimicrobial stewardship program can further decrease inappropriate use of antimicrobials, provide a greater reduction in overall antimicrobial use, and provide increased cost savings without negatively affecting patient outcomes.

New-Generation Drillpipes Enhance Extended-Reach Drilling in South China Sea

This article, written by JPT Technology Editor Chris Carpenter, contains highlights of paper IPTC 16798, ’New Generation of Aluminum Drillpipes Enhanced ERD Performances in the Huizhou Field, South China Sea,’ by W. Scaruffi, E. Cristofanelli, S. Yu, and A. Trocchia, Eni China, and C. Molaschi and A. Merlo, Eni, prepared for the 2013 International Petroleum Technology Conference, Beijing, 26-28 March. The paper has not been peer reviewed. Copyright 2013 International Petroleum Technology Conference. Reproduced by permission. This paper presents the results of a performance-improvement effort in extended-reach drilling (ERD) in three campaigns in the Huizhou HZ 25-4 oil field in the South China Sea. The new methodological approach and the deployment of new-generation aluminum drillpipes (ADPs) have resulted in a reduction of drilling risk and increased cost savings. Introduction ERD allows the reduction of the number of drilling sites, including offshore platforms, artificial islands, or other structures, and allows better control of total field-development costs. In addition, ERD technology makes it possible to reach reservoirs located at a considerable distance offshore, reducing the environmental impact of a wellsite. ERD operations are gaining momentum in the industry because they allow reserves exploitation previously considered too expensive when using conventional drilling methods. In addition, ERD techniques increase singlewell production by enlarging the drainage area. Because of their lighter weight when compared with steel drillpipes (SDPs), the use of ADP is a key solution for drilling extended- reach wells for the following reasons: A reduction in operating costs of approximately 10–20% (including savings in rig-capacity upgrade costs, transportation and energy costs, time-hosting costs, and tool-joint/casing-wear costs). An increase in the horizontal deviation of wells of approximately 10–30% (reduced torque-and-drag effect, less pressure drop, higher buckling resistance). Heightened reserves and production growth. A reduction in operative risk. Comparison of ADPs and SDPs Eni E&amp;P first considered ADPs in July 2003, during the proposal and approval of a research-and-development project.

A supplementary home dose of oral ondansetron given in anticipation of recurrent emesis in paediatric acute gastroenteritis

Ondansetron is a useful adjunct for the treatment of acute gastroenteritis in the paediatric ED. The use of ondansetron is associated with many benefits including decreased emesis, decreased need for intravenous fluids, decreased rate of admission, decreased length of stay, decreased revisit rates and increased cost savings (15–18). There may be value in giving patients a second as-needed home dose of ondansetron as part of ED discharge planning, with the appropriate patient education, in anticipation of recurrent emesis. This practice may further reduce ED revisit rates and also prevent morbidity and hospitalization associated with severe dehydration for patients who do eventually return to the ED, especially those in rural communities where timely treatment and access to an ED is difficult. The decision to dispense ondansetron should be made clinically by the ED physician for patients who have failed ORT whose symptoms are predominantly emesis as opposed to diarrhea, and when the discharging physician is reasonably certain of a diagnosis of acute gastroenteritis and not something more sinister. There is currently no consensus on the role of ED-provided ondansetron for out-of-hospital use for paediatric patients with acute gastroenteritis. Future studies are needed to determine the potential impact on morbidity and the health care economy.

Elimination of pneumothorax and hemothorax during placement of implantable venous access ports using ultrasound and fluoroscopic guidance

Implantable venous access ports are essential for patients requiring chronic venous access. Ultrasound guided catheter placement has been recognized as a valuable adjunct for reducing complications during placement of access ports in the radiology and critical care medicine literature. We reviewed the medical records of patients undergoing insertion of implantable venous access ports from June 2006 through June 2009. All procedures were performed using ultrasound guidance with the internal jugular vein as the access site. There were 500 implantable venous access ports placed and included for review. There were no post-procedure pneumothoraces or hemothoraces. Carotid puncture was documented in 4 (0.8%)cases. Routine use of ultrasound guidance during placement of implantable venous access ports has eliminated the complications of pneumothorax and hemothorax during placement of internal jugular venous access ports on our vascular surgery service. Elimination of these complications and decreased use of chest x-rays should also provide increased cost savings for this procedure.

Medicare Part D Research Highlights and Policy Updates, 2013: Impact and Insights

BackgroundSince its implementation in 2006, Medicare Part D has evolved from a program that offered basic access to covered drugs for beneficiaries to one that has the potential to affect patient outcomes. ObjectivesThe purpose of this article was to highlight key research findings on Medicare Part D published in 2012 and major public policy initiatives for Part D for 2013. MethodsPubMed/MEDLINE was searched for research studies on Part D published in 2012 in biomedical/scientific, peer-reviewed, English-language journals. For policy updates, sources included the Federal Register, the 2013 Final Call Letter, guidance from the Centers for Medicare and Medicaid Services, and 2012 publications on Part D policy identified in PubMed. ResultsPart D has been associated with higher medication use and lower out-of-pocket (OOP) costs of many long-term medications; however, differences within subgroups of beneficiaries have been observed. Studies on health outcomes have been inconclusive. Part D policy changes in 2013 have addressed problems with the benefit, namely coverage of benzodiazepines and barbiturates; reducing coinsurance in the coverage gap; reducing fraud, waste, and abuse; medication therapy management program standardization; and an expanded appeals process. ConclusionsResearch continues to suggest that Part D is effective in increasing medication utilization and lowering OOP costs. Further work is needed to clarify the effects of Part D on nondrug health care service utilization and health outcomes. Policy changes for 2013 addressed specific improvements in the Medicare Part D benefit while potentially generating cost-savings for Medicare and Medicaid. Future challenges include alleviating access burden to medications during the phase-out of the coverage gap, minimizing disparities among Part D beneficiaries, and coordinating the Part D benefit with Medicare parts A and B via Medicare Accountable Care Organizations. A more integrated and coordinated Medicare benefit among all of its components would benefit overall health outcomes and increase cost-savings.

Intérêt d’un programme préopératoire simplifié de rééducation à domicile sur la durée de séjour des patients opérés d’une prothèse totale de genou

In patients with severe knee osteoarthritis (OA), total knee arthroplasty (TKA) is performed for both symptom relief and to achieve better function in daily life. Implementation of efficient TKA rehabilitation programs with shorter length of stay (LOS) and reduced medical expenditures is an important issue in clinical practice. However, the effectiveness of preoperative rehabilitation programs is still under debate. Most preoperative rehabilitation programs last many weeks and may be more expensive than TKA. The purpose of this study was to investigate the effects of a simplified, easy-to-learn, and less time-consuming preoperative rehabilitation education program on TKA patients. In this randomzied controlled study, we allocated all the patients into study and control group according to chart number. The study group, which comprised 126 patients, participated in a 40-min preoperative home rehabilitation education program 4 weeks prior to TKA. One hundred and seventeen patients in the control group did not participate in this preoperative program. The study group required a shorter hospital LOS (mean, 7.12 days; P = 0.027) and had less hospitalization-related medical expenditures (mean, 123726 New Taiwan dollars [NTD], equivalent to 4266.4 United States dollars [USD] or 3022.1 [Euros]), ( P = 0.001) than the control group. However, the study group showed no significant improvement in function when compared to the control group. Our study demonstrates that a simplified preoperative rehabilitation program can reduce LOS and increase cost savings. This program was recommended as a routine protocol for OA patients before admission for TKA. Level II. Prospective randomized study.