Relative Cost Reduction Research Articles

The Value of Reducing Inconclusive and False-Positive Newborn Screening Results for Congenital Hypothyroidism, Congenital Adrenal Hyperplasia and Maple Syrup Urine Disease in The Netherlands.

Inconclusive and false-positive newborn screening (NBS) results can cause parental stress and increase healthcare expenditures. These results can be reduced by improving NBS algorithms. This was recently done for Congenital Hypothyroidism (CH), Congenital Adrenal Hyperplasia (CAH) and Maple Syrup Urine Disease (MSUD) in the Dutch NBS program. The current study estimates the financial consequences of these improved algorithms related to the reduction in inconclusive results and false-positives. For each improved algorithm, the care pathway of an inconclusive/false-positive result was analyzed. The costs associated with the improvements, based on the change in inconclusive results/false-positives, were assessed to estimate the cost reduction per year. The improvements resulted in a reduction of inconclusive results and/or false-positives, without increasing false-negatives. For CH, false positives decreased by 26 per year with a related cost reduction of EUR 31,156. For CAH, 95 second heel punctures and seven false-positives per year were avoided, leading to a related cost reduction of EUR 7340. For MSUD, five false-positives per year were avoided with a related cost reduction of EUR 11,336. The improved screening algorithms led to a cost reduction of EUR 49,832 annually. Together with the known negative psychosocial effects associated with an inconclusive or false-positive NBS result, these results highlight the importance of improving NBS algorithms.

Inpatient Infliximab Biosimilar Cost-Savings: Cost Analysis of Inpatient Treatment with Originator Infliximab (Remicade™) versus Biosimilar Infliximab (Renflexis™) for Acute Severe Ulcerative Colitis

Introduction: Infliximab (IFX) is a standard, inpatient salvage therapy for the treatment of refractory acute severe ulcerative colitis (ASUC). Remicade™ is the originator IFX. Its biosimilar Renflexis™ offers a reduced cost structure. We performed a cost-minimization analysis to compare costs with Remicade™ and Renflexis™ for the inpatient treatment of ASUC. Methods: Retrospective clinical and financial data were obtained from 34 inpatients with refractory ASUC who received Renflexis™ (n = 17) or Remicade™ (n = 17) between 2019 and 2021. Clinical data included admission and discharge laboratory values. Financial data included a decision support drug cost (DSDC), constituting the total cost associated with inpatient IFX administration, and total inpatient cost of care. The following equation generated a ratio (rDSDC) representing the percentage of drug cost (or DSDC) of the total inpatient cost of care, after controlling for IFX dose and length of stay: [DSDC of IFX/Number of Units of IFX] ÷ [Total Inpatient Cost of Care/Length of Stay in Days]. Median and non-parametric Wilcoxon ranked sum test were used for analyzing patient demographics, clinical, and financial data. Results: No differences were found in baseline or discharge clinical parameters. The median unadjusted ratio of DSDC to total inpatient cost of care was 0.387 versus 0.241 in the Remicade™ versus Renflexis™ groups (p = 0.0025), respectively, representing an absolute difference of ∼14%. Median adjusted rDSDC were 0.04 versus 0.024 in the Remicade™ versus Renflexis™ groups, respectively, representing a relative cost reduction of ∼40% (p = 0.0001). Discussion: The unadjusted absolute cost reduction and adjusted relative cost reduction were, respectively, 14% and 40% in the Renflexis™ group as compared to Remicade™, when treating inpatient ASUC. Our calculation included median DSDC as a percentage of the total inpatient cost of care, controlling for IFX dose and length of stay. This reduced cost structure promotes use of Renflexis™ for ASUC inpatients and may reduce costs systemically.

A Cost-Effectiveness Analysis of Wittmann Patch-Assisted Abdominal Closure Compared to Planned Ventral Hernia in Management of the Open Abdomen.

Inability to achieve primary fascial closure after damage control laparotomy is a frequently encountered problem by acute care and trauma surgeons. This study aims to compare the cost-effectiveness of Wittmann patch-assisted closure to the planned ventral hernia closure. A literature review was performed to determine the probabilities and outcomes for Wittmann patch-assisted primary closure and planned ventral hernia closure techniques. Average utility scores were obtained by a patient-administered survey for the following: rate of successful surgeries (uncomplicated abdominal wall closure), surgical site infection, wound dehiscence, abdominal hernia and enterocutaneous fistula. A visual analogue scale (VAS) was utilized to assess the survey responses and then converted to quality-adjusted life years (QALYs). Total cost for each strategy was calculated using Medicare billing codes. A decision tree was generated with rollback and incremental cost-utility ratio (ICUR) analyses. Sensitivity analyses were performed to account for uncertainty. Wittmann patch-assisted closure was associated with higher clinical effectiveness of 19.43 QALYs compared to planned ventral hernia repair (19.38), with a relative cost reduction of US$7777. Rollback analysis supported Wittmann patch-assisted closure as the more cost-effective strategy. The resulting negative ICUR of -156,679.77 favored Wittmann patch-assisted closure. Monte Carlo analysis demonstrated a confidence of 96.8% that Wittmann patch-assisted closure was cost-effective. This study demonstrates using the Wittmann patch-assisted closure strategy as a more cost-efficient management of the open abdomen compared to the planned ventral hernia approach.

Released heat of hydrating particle fractions of Portland cement

Portland cement had belonged to the most used binder world-wide. Besides long tradition of its production, its specific technical properties are highly different in comparison with previous decades. Currently produced Portland cement exhibits similar mechanical properties, however the process of its hydration had slightly different character, inducing new challenges and technical difficulties during its use. The particle size distribution of currently produced cement is highly different in comparison with previous decades, because of optimized grinding process motivated by the reduction of related costs. Hence, the fines create the dominant part of current Portland cement. Present work follows previous research focused on the crack-resistant cement and confirmed direct influence of the fast kinetics of cement hydration on crack induction on drying. This paper deals with an experimental study focused on the hydration heat of selected particle fractions of Portland cement.

Operational envelope for planning cold flow production

The paper presents a method to determine an operational envelope for the cold flow technology with respect to producing gas–oil ratio (GOR) and water cut (WC). The cold flow technology is a flow assurance method that enables cold production flow in thermal equilibrium with the seabed temperature. Cold flow converts hydrate and wax into dry, non-plugging microparticles inside a subsea cold flow unit downstream the wellhead. The small particles travel along with the liquid in the form of a slurry to the receiving host. The operational envelope shows that if the production flow reaches certain combinations of GOR and Wc, the hydrate volume fraction in liquid and consequently the slurry’s effective viscosity could be too high for pipe transportation. This paper also investigates the case when the slurry is transported with remaining water, where there might be some emulsion phenomena. Results show that this could reduce the operational region of the cold flow envelope, particularly for GOR–Wc values around the inversion point volume fraction. Therefore, water–slurry emulsification should also be taken into consideration when considering the operational envelope. If the hydrate–oil mixture is found to be too viscous to transport it can be resolved by, for example, removing water from the production flow upstream the cold flow unit. GOR–WC profiles from a real field case are over-imposed on the operational envelope to see the development during the field lifetime. Tieback costs for the cold flow technology are found to be 20–30% less than conventional methods for a 100 km tieback. The relative cost reduction increases with increasing tieback distance.

A hybrid Finite Volume-Smoothed Particle Hydrodynamics approach for shock capturing applications

A hybrid Finite Volume Method (FVM)-Smoothed Particle Hydrodynamics (SPH) approach for shock capturing in compressible fluids is presented. The Python framework Pyro2 is employed to simulate a coarse FVM mesh, while the Python framework PySPH is utilized to model the fluid in regions with high gradients through SPH particles. New FVM-SPH coupling approaches are explored, including online SPH particle injection and deletion around time persistent SPH regions around shocks. The SPH simulation is coupled to the FVM simulation through boundary particles surrounding the active SPH regions, with FVM values interpolated to SPH boundary particles at each timestep. Values in active SPH regions are similarly interpolated to the overlying FVM mesh at each timestep. The performance of the hybrid FVM-SPH scheme in comparison to the individual FVM and SPH methods on two-dimensional test problems is assessed. Our results indicate that the hybrid approach offers higher computational efficiency than SPH while preserving its accuracy, although it remains slower than the FVM. This hybrid SPH algorithm may enable future compressible fluid simulations with more extensive capabilities than grid-based methods alone, offering potential applications in modeling fluid–structure interaction and solid deformation and fracturing in blast simulations. Further research will focus on applying the hybrid method to three-dimensional blast problems, where the relative computational cost reduction is expected to be more significant.

Development of HOIS guidance for ultrasonic NDT for non-intrusive inspection at elevated temperatures

The non-intrusive inspection (NII) of pressure vessels using external in-service ultrasonic NDT has multiple advantages compared to internal visual inspection, including the significant reduction of down-time related costs and safety benefits from avoiding manentry into vessels. The HOIS joint industry project, with support from the Net Zero Technology Centre (NZTC), has recently been focussing on NII of components with operating temperatures of up to 250°C (typical of upstream applications). These inspections are challenging because they require probes to be in contact with the hot surface much longer than for spot thickness measurements. The aim of the work has been to develop recommendations for in-service inspection of components at relatively high operating temperatures, thereby extending the benefits of the NII process, including avoiding or deferring internal visual inspection, to a wider range of vessels. Experimental trials have been performed on test components at up to ~250°C, with an emphasis on scanning ultrasonic systems used for corrosion mapping and weld inspection using TOFD and angled-beam phased-array (PA). The most successful trials gave corrosion mapping and TOFD weld examination results that had similar differences from benchmark values to those achieved in earlier ambient temperature trials. For angled-beam PA, it was found that some trials appeared to have issues with accurate correction of the data for the effects of the elevated component temperature on both the refracted beam angle and signal arrival times. Other trials were more successful in this respect. The lessons learned from trials on both ex-service and manufactured samples are leading to the development of specific guidance for NII at elevated temperatures. The paper highlights the technical challenges associated with ultrasonic scanning systems at elevated temperatures, share the lessons learned from the experimental trials and summarise the guidance developed.

An integrated analysis of COVID-19 impacts on energy and environment: Lessons learnt

Carbon neutrality, sustainable development and reducing our impact on the environment is the top priority in future measures. The COVID-19 pandemic brought challenges to every sector at a global scale but can provide valuable insight to reach these goals. The main objective of this work is to provide an integrated analysis of the impact of the COVID-19 pandemic, focused on energy and its related aspects, i.e., environment and costs. Mainland Portugal was used as a case study and two years were analysed, one pre pandemic (2019) and another post pandemic (2020). In 2020, the majority of sectors - Transport, Services, Industry and Agriculture & Fisheries – show a reduction of energy consumption, atmospheric emissions, carbon footprint and related monetary and social costs. In contrast, the Domestic sector presents an overall increase, with maximums of 25.4% in electricity consumption (during Spring), 0.72% in the PM10 (particulate matter) and NOx (nitrogen dioxides) emissions (in Summer), and 2.9% in carbon footprint (in Spring). The integrated analysis proposed in this work was crucial to identify the paths to a post pandemic world focused on the different aspects of sustainability – new concepts of mobility and workplace, as well as increased investment in energy performance and renewable energy sources. This study showed that changing our energy consumption patterns could significantly affect future greenhouse gas emissions, and contribute to the sustainable growth of the economy, while maintaining good progress towards climate-neutral goals.

Power-assisted Liposuction for Lymphedema: A Cost-utility Analysis.

Extremity volumes from all patients who underwent debulking surgery of the upper extremity at two institutions between December 2017 and January 2020 with at least 12 months follow-up were included. Procedural costs were calculated using Medicare reimbursement data. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years. A decision tree was generated, and incremental cost-utility ratios were calculated. Sensitivity analyses were performed to evaluate our findings. Debulking surgery is associated with a higher clinical effectiveness (quality-adjusted life year) of 27.05 compared to conservative management (23.34), with a relative cost reduction of $74,487. Rollback analysis favored debulking surgery as the cost-effective option compared to conservative management. The resulting negative incremental cost-utility ratio of -20,115.07 favored debulking surgery and indicated a dominant strategy. Our study supports the use of debulking surgery for the treatment of chronic lymphedema of the upper extremity.

Development of a cost-effective diagnostic algorithm incorporating transcription factor immunohistochemistry in the evaluation of pituitary tumours

PurposeTo determine the utility of the 2022 WHO Classification of pituitary tumours in routine clinical practice and to develop an optimal diagnostic algorithm for evaluation of tumour type in a real-world setting.MethodsRetrospective evaluation of pituitary tumour immunohistochemistry (IHC), operatively managed at St Vincent’s Hospital Sydney, between 2019 and 2021. Routine IHC comprised evaluation of transcription factors [steroidogenic factor 1 (SF1), T-box transcription factor 19 (TPIT) and pituitary-specific positive transcription factor (PIT1)] and anterior pituitary hormones. Three tiered algorithms were tested, in which hormone IHC was performed selectively based on the initial transcription factor results. These were applied retrospectively and compared with current practice ‘gold standard’ comprising all transcription factor and hormone IHC. Diagnostic accuracy and cost were evaluated for each.ResultsThere were 113 tumours included in the analysis. All three algorithms resulted in 100% concordance with the ‘gold standard’ in the characterisation of tumour lineage. While all three were associated with relative cost reduction, Algorithm #3, which omitted hormone IHC in the setting of positive SF1 or TPIT and performed IHC for growth hormone, prolactin and thyroid stimulating hormone only in the setting of PIT1 positivity, was the most cost-efficient. Additionally, there were 12/113 tumours with no distinct cell lineage.ConclusionA diagnostic algorithm omitting hormone IHC except in cases of PIT1 positivity is an accurate and cost-effective approach to diagnose the type of pituitary tumour. A significant subgroup of pituitary tumours with no distinct cell lineage, frequently plurihormonal, remains difficult to classify with the new WHO criteria and requires further evaluation.

Potential Cost Savings Associated with a Multiuse Preoperative and Preinjection Eyedrop Protocol

To calculate the cost savings associated with a multiuse preoperative and preinjection eyedrop protocol. Economic analysis. Adults undergoing ophthalmic surgical procedures requiring preoperative dilation and intravitreal injections. Economic modeling with scenario analysis was used to derive the value for cost savings secondary to a protocol in which perioperative mydriatic eyedrop bottles are used across multiple patients versus the current protocol in which drop bottles are wasted after single-patient use. Similar analyses were performed for a multiuse povidone-iodine protocol for intravitreal injections. Sensitivity analyses were used to test baseline model assumptions with varying degrees of waste and patient volume. The multiuse mydriatic protocol allowed for a 97.1% reduction in the number of eyedrop bottles required for the single-use protocol (1037 bottles vs. 35 850 bottles). This led to an estimated 5-year cost savings of approximately $240 000 (nominal) per institution (performing an average of 1434 cases/year) in the base case. This savings varied minimally in sensitivity analyses accounting for practical limitations (loss, expiration, or contamination) of multiuse containers, with savings of 97.54% to 95.00% for excess supply ranges from 0% to 100% in the multiuse protocol. Likewise, the cost savings varied minimally in sensitivity analyses for eyedrop sizes, with savings of 99.23% to 96.69% for mydriatic eyedrop sizes of 15 μl per drop to 65 μl per drop, respectively, in the multiuse protocol. Over a 5-year period, for povidone-iodine drops before performing intravitreal injection, the multiuse protocol required 153 bottles compared with 41 954 bottles (99.6% reduction) for the current single-use protocol, resulting in a nominal cost savings of $41 801, which varied minimally in sensitivity analyses. Multiuse perioperative mydriatic eyedrops are a viable option for cost and environmental waste reduction for ophthalmologic procedures and surgeries requiring dilation. Likewise, multiuse povidone-iodine may allow for large relative cost reduction for in-office procedures. The total potential savings over 5 years was estimated at more than $280 000 before adjusting for inflation.

The Renewable Hydrogen–Methane (RHYME) Transportation Fuel: A Practical First Step in the Realization of the Hydrogen Economy

The permanent introduction of green hydrogen into the energy economy would require that a discriminating selection be made of its use in the sectors where its value is optimal in terms of relative cost and life cycle reduction in carbon dioxide emissions. Consequently, hydrogen can be used as an energy storage medium when intermittent wind and solar power exceed certain penetration in the grid, likely above 40%, and in road transportation right away, to begin displacing gasoline and diesel fuels. To this end, the proposed approach is to utilize current technologies represented by PHEV in light-duty and HEV in heavy-duty vehicles, where a high-performance internal combustion engine is used with a fuel comprised of 15–20% green hydrogen and 85–89% green methane depending on vehicle type. This fuel, designated as RHYME, takes advantage of the best attributes of hydrogen and methane, results in lower life cycle carbon dioxide emissions than BEVs or FCEVs and offers a cost-effective and pragmatic approach, both locally as well as globally, in establishing hydrogen as part of the energy economy over the next ten to thirty years.

A Cost-Utility Analysis Comparing Immediate Oncoplastic Surgery with Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients.

Oncoplastic reduction mammoplasty for smoking breast cancer patients committed to smoking cessation may be performed immediately (increasing smoking-related risk) or in a delayed fashion (increasing radiation-related risk). Our aim was to examine the cost utility of immediate versus delayed oncoplastic reconstruction when operating on a smoking patient with breast cancer and macromastia with a long-term commitment to smoking cessation. A literature review determined the probabilities and outcomes for the treatment of unilateral breast cancer with immediate or delayed oncoplastic surgery. Reported utility scores were used to estimate quality-adjusted life-years (QALYs) for varying health states. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy, and an incremental cost-utility ratio (ICUR) was calculated. Sensitivity analyses were performed to validate the robustness of the results. Immediate oncoplastic surgery is associated with a higher clinical effectiveness (QALY) of 33.3 compared with delayed oncoplastic surgery (33.26), with a higher increment of clinical effectiveness of 0.07 and relative cost reduction of $3458.11. This resulted in a negative ICUR of -50,194, which favored immediate reconstruction, indicating a dominant strategy. In one-way sensitivity analyses, delayed reconstruction was the more cost-effective strategy if the probability of successful immediate reconstruction falls below 29% or its cost exceeds $29,611. Monte-Carlo analysis showed a confidence of 99% that immediate oncoplastic surgery is more cost effective. Despite the risk of postoperative complications associated with smoking, immediate oncoplastic surgery is more cost effective compared with delayed oncoplastic surgery in which reconstructive surgery would occur after radiation.

A Cost–Utility Analysis Comparing Immediate Oncoplastic Surgery to Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients

PURPOSE: Oncoplastic surgery allows for lower positive margin rates and improved aesthetic outcomes compared with traditional breast conservation surgery.1 A Level 2 volume displacement oncoplastic surgery (LVOS) (also known as an oncoplastic reduction) allows for a large partial mastectomy through a reduction mammoplasty incision and is ideal for breast cancer patients with macromastia. Typically, a concurrent ipsilateral reduction mammoplasty is also performed.2,3 However, if the patient is a smoker, the decision to perform a concurrent reconstruction is challenging. It can be argued that in order to allow sufficient time for the patient to stop smoking, reconstruction should be delayed until after adjuvant radiation. However, radiation can also cause poor wound healing and can increase the risk of a wound-related complication. LVOS with immediate and delayed reconstruction are associated with different clinical outcomes and costs. Our aim was to examine the cost–utility of immediate versus delayed reconstruction in LVOS when operating on a smoking patient with macromastia and a long-term commitment to smoking cessation. METHODS: A literature review was performed to determine the probabilities and outcomes related to the treatment of unilateral breast cancer with immediate or delayed reconstruction with LVOS.1–3 Reported utility scores were used to estimate the quality adjusted life years associated with a successful procedure as well as postoperative complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost–utility ratio was calculated. Single variable and probabilistic sensitivity analyses were performed to validate the robustness of the results. RESULTS: Immediate LVOS is associated with a higher clinical effectiveness (quality adjusted life years) of 33.3 compared with delayed (33.26), with a higher increment of clinical effectiveness of 0.07 and relative cost reduction of $3458.11. This resulted in a negative incremental cost–utility ratio of −50,194, which was in favor of immediate reconstruction, indicating a dominant strategy. In 1-way sensitivity analyses, delayed reconstruction was the more cost-effective strategy if the probability of successful immediate reconstruction falls below 29% or its cost exceeds $29,611. Monte Carlo analysis showed a confidence of 99% that immediate oncoplastic surgery costs less and is the more effective strategy. CONCLUSIONS: Despite the known risk of postoperative complications associated with smoking, immediate LVOS is more cost-effective compared with delayed LVOS. The risks of postoperative complications are higher when operating on a radiated breast in the delayed setting, thus favoring immediate LVOS. REFERENCES: 1. Munhoz AM, Aldrighi CM, Montag E, et al. Outcome analysis of immediate and delayed conservative breast surgery reconstruction with mastopexy and reduction mammaplasty techniques. Ann Plast Surg. 2011;67:220–225. 2. Asban A, Homsy C, Chen C, et al. A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with single stage implant reconstruction in the treatment of breast cancer. Breast. 2018;41:159–164. 3. Chatterjee A, Offodile II AC, Asban A, et al. A cost-utility analysis comparing oncoplastic breast surgery to standard lumpectomy in large breasted women. Adv Breast Cancer Res. 2018;7:187–200.

Cost Reduction in Pressurized Irrigation Networks under a Rotation Schedule

Rotation scheduling implies a reduction in pipe flows and, consequently, in network cost. This kind of scheduling is considered rigid, but the recent development of new technologies, such as Supervisory Control And Data Acquisition systems (SCADA), has allowed high-frequency irrigation (1 day or less), making it an interesting option when either designing or managing an irrigation network. In this paper, simple formulas and relevant variables are presented to easily assess the relative flow reduction in networks under a rotation schedule. The flow reduction depends on the number of outlets supplied and the probability of these being opened. The presented equations were applied to different networks, and the results obtained were accurate, with an average error of only 5%. It was observed that the ratio between relative cost reduction and the relative flow reduction had a mean value of 0.50. This ratio might be used to roughly estimate the cost reduction from the calculated relative flow reduction. The flexibility of the networks under a rotation schedule was improved by adding just one outlet flow rate to those used to size the pipes.

Methodology for calculating diesel SCR systems

Selective catalytic reduction systems are widely applied as a NOX emission control technology in modern onand off highway diesel engines. Considering the stringent limits of emission standards, they should ensure high rates of conversion efficiency. To achieve that at the design stage numerical modelling is used to optimize physical and chemical processes. New mathematical models and methods that can provide the reduction of calculation time and related costs keeping the acceptable level of prediction accuracy are desired. In this study a methodology for calculating SCR systems based on the use both of CFD models and simplified catalyst models are presented. The capabilities of the suggested numerical approach were demonstrated during the simulations of a SCR system where the influence of UWS injection angle on NOX reduction efficiency was investigated.

Melatonin in neuropaediatric MRI: a retrospective study of efficacy in a general hospital setting.

Melatonin may offer a safe and cheap alternative to general anaesthesia and sedatives in neuropaediatric MRI. The purpose of our study was to evaluate its efficacy during a daily scanning programme and to assess its financial benefit. Neuro-MRI scans, performed in a general hospital setting after administration of melatonin in 64 children aged 10 months-5 years, were retrospectively reassessed by an experienced paediatric neuroradiologist, rating them as diagnostically contributing or as failed. The financial benefit was calculated. 49/64 scans (77%) were diagnostically contributing, in 11 (22%) no movement artefact was seen in any sequence; 15/64 scans failed (23%), in 3/15 because of serious movement artefacts, in 12/15 the scan was not started. Repeat scans under general anaesthesia were performed in 17 cases (27%): in the 15 failed cases and in 2 cases initially assessed as failed, but were considered diagnostically contributing in the present study. The financial benefit at the time the scans were made was approximately 13,360 Euro. In this retrospective study, the use of melatonin in neuropaediatric MRI, made during a daily scanning programme with a remote waiting room, was associated with a high success rate in infants and young children. A minority of scans had no movement artefacts, indicating most children were not asleep. The sleep-inducing effect of melatonin could therefore not be proven, but the high success rate may be attributed to the sedative and/or anxiolytic effect of melatonin. Only a minority of scans had to be repeated under general anesthesia, leading to a reduction of scan related costs.

776 Accelerated Infliximab Infusion Protocol for Inflammatory Bowel Disease: A Safety and Cost-Effectiveness Study in an Asian Tertiary Center

INTRODUCTION: The recommended infusion time for infliximab for inflammatory bowel disease (IBD) is 2 hours or more. Time spent on receiving infliximab infusions in the hospital disrupts school and work activities. Significant nursing time is also spent which increases healthcare costs. Shortening infliximab infusion to over 1 hour has been shown to be safe and has the potential to decrease time spent in hospital. This study aims to determine the safety and effectiveness of this accelerated infliximab infusion protocol in patients with IBD in Southeast Asia. METHODS: We conducted a retrospective study on patients with Crohn's disease (CD) and ulcerative colitis (UC), who received infliximab from September 2018 to May 2019 at Singapore General Hospital. Patients on stable maintenance infliximab were offered the accelerated protocol if they had tolerated ≥4 infliximab infusions without reactions. The need for pre-medications was determined by the prescribing physician. Primary endpoint was infusion-related reaction rate and secondary endpoints were cost and time saved per infusion. RESULTS: A total of 187 infusions were administered to 57 patients (53 CD, 4 UC). The mean age was 52.0 ± 17.0 years and 61.4% of the subjects were male. Out of the 57 patients, 22 of them received the accelerated infusion protocol with a total of 86 1-h infusions. Three reactions (1 immediate, 2 delayed) were observed during the 1-h infusions and were reverted back to the standard 2-h infusion subsequently. However, this was not found to be statistically significant after adjustment for age, sex, administration of pre-medications or types of disease. The median time spent per infusion in the hospital for the accelerated infusion protocol was significantly reduced compared to for the standard infusion (138 ± 26 minutes vs. 216 ± 26 minutes; P < 0.05). This improvement amounts to an estimate of 65 minutes returned to the patient for normal activities outside of the hospital per infusion. There was also a reduction in nursing time and cost (S$ 42.9 per infusion and 46.4% relative cost reduction) to the hospital. CONCLUSION: The accelerated infliximab infusion protocol is safe in our cohort of IBD patients. It also results in a decrease in in-hospital time for patients and improves the efficiency of healthcare delivery.

Effect of Implementation of Standard Clinical Practice Guideline on Management of Gastrointestinal Bleeding Patients in Emergency Department; a Cross-Sectional Study.

Introduction:A clinical practice guideline (CPG) is developed with the aim of improving the quality of health care and reducing unnecessary interventions, hospitalization time, and related costs. Objective:This study attempted to design a standard protocol for gastrointestinal bleeding (GIB) patients.Methods: This was a cross-sectional study conducted during 2013 and 2014 in an educational medical center in Isfahan, Iran. A checklist containing questions about waiting time for the services, hospitalization time, and costs was completed for the GIB patients. After this primary data gathering, a CPG was designed, codified, underwent several revisions, and finally implemented. Thereafter, the checklist was completed by GIB patients and compared with the previous ones.Results:Fifty patients in each of the two phases were included. The mean age and sex of the studied patients were not different.The time from emergency departments (ED) arrival until the first visit (14 ± 9.8 Vs. 19.4 ± 13.4 minutes; p = 0.03), hospitalization (73.7 ± 49.2 Vs. 116.2 ± 7.2 hours; p=0.003) and costs (1.3 ± 0.81 Vs. 3.68 ± 3.51 million rials; p < 0.001) were significantly reduced following the CPG implementation. The time from admission until conducting endoscopy was not different in the two study periods (16.5 ± 7.8 Vs. 23.9 ± 24.5 hours, p = 0.89).Conclusion: The implementation of the CPG for the management of GIB patients in the ED resulted in a reduction in the waiting time for the services and, further, reduction of hospitalization time and related costs.

Evaluating Health Co-Benefits of Climate Change Mitigation in Urban Mobility.

There is growing recognition that implementation of low-carbon policies in urban passenger transport has near-term health co-benefits through increased physical activity and improved air quality. Nevertheless, co-benefits and related cost reductions are often not taken into account in decision processes, likely because they are not easy to capture. In an interdisciplinary multi-model approach we address this gap, investigating the co-benefits resulting from increased physical activity and improved air quality due to climate mitigation policies for three urban areas. Additionally we take a (macro-)economic perspective, since that is the ultimate interest of policy-makers. Methodologically, we link a transport modelling tool, a transport emission model, an emission dispersion model, a health model and a macroeconomic Computable General Equilibrium (CGE) model to analyze three climate change mitigation scenarios. We show that higher levels of physical exercise and reduced exposure to pollutants due to mitigation measures substantially decrease morbidity and mortality. Expenditures are mainly born by the public sector but are mostly offset by the emerging co-benefits. Our macroeconomic results indicate a strong positive welfare effect, yet with slightly negative GDP and employment effects. We conclude that considering economic co-benefits of climate change mitigation policies in urban mobility can be put forward as a forceful argument for policy makers to take action.