Theoretical Cost Savings Research Articles

Using Machine Learning Models to Identify Factors Associated With 30-Day Readmissions After Posterior Cervical Fusions: A Longitudinal Cohort Study.

Readmission rates after posterior cervical fusion (PCF) significantly impact patients and healthcare, with complication rates at 15%-25% and up to 12% 90-day readmission rates. In this study, we aim to test whether machine learning (ML) models that capture interfactorial interactions outperform traditional logistic regression (LR) in identifying readmission-associated factors. The Optum Clinformatics Data Mart database was used to identify patients who underwent PCF between 2004-2017. To determine factors associated with 30-day readmissions, 5 ML models were generated and evaluated, including a multivariate LR (MLR) model. Then, the best-performing model, Gradient Boosting Machine (GBM), was compared to the LACE (Length patient stay in the hospital, Acuity of admission of patient in the hospital, Comorbidity, and Emergency visit) index regarding potential cost savings from algorithm implementation. This study included 4,130 patients, 874 of which were readmitted within 30 days. When analyzed and scaled, we found that patient discharge status, comorbidities, and number of procedure codes were factors that influenced MLR, while patient discharge status, billed admission charge, and length of stay influenced the GBM model. The GBM model significantly outperformed MLR in predicting unplanned readmissions (mean area under the receiver operating characteristic curve, 0.846 vs. 0.829; p < 0.001), while also projecting an average cost savings of 50% more than the LACE index. Five models (GBM, XGBoost [extreme gradient boosting], RF [random forest], LASSO [least absolute shrinkage and selection operator], and MLR) were evaluated, among which, the GBM model exhibited superior predictive performance, robustness, and accuracy. Factors associated with readmissions impact LR and GBM models differently, suggesting that these models can be used complementarily. When analyzing PCF procedures, the GBM model resulted in greater predictive performance and was associated with higher theoretical cost savings for readmissions associated with PCF complications.

Towards a cost-effective framework for estimating soil nitrogen pools using pedotransfer functions and machine learning

Globally, the strategic use of nitrogen (N) is important in optimizing economic returns and reducing soil nitrogen losses to the environment. Incorporating reliable estimates of nitrogen (N) mineralized over a growing season (GSN) into N-fertilizer rate prescriptions is critical, but may often lack a direct measurement. For this purpose, Pedotransfer functions (PTFs) of total nitrogen (TN) – representing the stable pool from which N is mineralized and biological nitrogen availability (BNA) – representing the labile pool of N mineralization were used to estimate GSN. GSN was calculated based on TN and BNA results from a soil health database (SHD), which also includes a suite of related soil health parameters (n = 2222). Using a process of recursive feature elimination (RFE) and cost-benefit feature elimination (CBFE), the best predictors of TN, BNA, and GSN were identified using a suite of machine learners (MLs) and regression analysis. For TN, RFE revealed that BNA, active carbon (AC), sand (Sa), and soil organic matter (OM) were the best predictors yielding a Lin’s concordance correlation coefficient (CCC) of 0.80 and a reduction in theoretical cost of 41 % compared to the control. CBFE resulted in AC, soil respiration (SR), clay, Sa, and OM as the most cost-effective predictors of TN with a CCC of 0.79 and a theoretical cost savings 49 % below the cost of using all appropriate soil health parameters in the SHD. With respect to BNA, the best predictors from RFE were aggregate stability (AS), AC, SR, and TN with a CCC of 0.78 and a theoretical cost reduction of 23 %. CBFE retained AC, SR, S, TN, OM and pH as predictors of BNA with a CCC of 0.78 and reduction of 29 % in theoretical cost. Finally, GSN results from RFE identified AS, AC, SR, OM and pH as the best predictors with a 0.82 CCC and 17 % reduction in theoretical cost. CBFE, on the other hand, identified AC, SR, sand, OM, and pH as the most cost-efficient predictors while maintaining a CCC of 0.82 and theoretical cost reduction of 29 %. Of the MLs used for pattern recognition (i.e., cubist, random forest, support vector machine, and stochastic gradient boosting), cubist model outperformed the others for the majority of iterations of the RFE and CBFE processes. The cost-effective framework, and the N-related PTFs developed in this study will greatly enhance our ability to predict of soil N-pool dynamics and the ability to incorporate GSN estimates into N-fertilizer recommendations for producers worldwide. Improvements in predictive strength could be achieved by incorporating climate and soil management practices into PTF development. Another area for improvement and future study would include addition of spatial and landscape variability related to N-measures via digital soil mapping applications.

Evaluation of potential cost savings through chemotherapy and biotherapy dose-rounding at a pediatric institution.

Rapidly increasing costs of medication acquisition can pose a challenge for health-system pharmacy budgets. The impact of dose-rounding in a pediatric oncology population has not previously been well documented and a retrospective review was undertaken to quantify the potential cost benefits. A retrospective chart review of patients with an oncologic diagnosis was performed for cytotoxic agents, asparaginase products, and biotherapy administered between January 1, 2014, and December 31, 2017. In the analysis, orders that could be rounded down to the nearest vial size by 5 or 10% were included. Medication pricing information was based on wholesale acquisition cost (WAC) and was provided by the Department of Pharmacy. Cost savings per medication were determined by multiplying the WAC of the medication by the number of vials saved. Over a 4-year span, 347 patients were evaluated and 552 out of a possible 3110 orders (17.7%) met criteria for a theoretical cost savings of approximately $1,126,000 (∼$3200 per patient). Rounding down doses by up to 5% resulted in a potential savings of about $529,000. When rounding was extended to 5-10% of the originally ordered dose, an additional $597,000 of approximate cost savings could have been realized. The medications with the largest impact on cost savings were rituximab, pegaspargase, and erwinia asparaginase. For pediatric oncology patients, there exists a unique potential cost savings opportunity if doses are rounded down within 5 or 10% of the originally ordered weight-based or body surface area-calculated dose.

Can machine learning optimize the efficiency of the operating room in the era of COVID-19?

The cancellation of large numbers of surgical procedures because of the coronavirus disease 2019 (COVID-19) pandemic has drastically extended wait lists and negatively affected patient care and experience. As many facilities resume clinical work owing to the currently low burden of disease in our community, we are faced with operative booking protocols and procedures that are not mathematically designed to optimize efficiency. Using a subset of artificial intelligence called "machine learning," we have shown how the use of operating time can be optimized with a custom Python (a high-level programming language) script and an open source machine-learning algorithm, the ORTools software suite from the Google AI division of Alphabet Inc. This allowed the creation of customized models to optimize the efficiency of operating room booking times, which resulted in a reduction in nursing overtime of 21% - a theoretical cost savings of $469 000 over 3 years.

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety.

As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice. A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge. In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient. A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.

Expanding Grids for Efficient Cloud Dynamics Simulations Across Scales

Abstract With large eddy simulations (LES) and/or cloud-resolving models (CRMs), it is now possible to simultaneously simulate shallow and deep convection. However, using traditional methods, the computational expense is typically very large, due to the small grid spacings needed to resolve shallow clouds. Here, the main purpose is to present a method that is computationally less expensive by a factor of roughly 10 to 50. Unlike traditional grid stretching of only the vertical z grid spacing, the present method involves expansion of the grid spacing in all coordinate directions (x,y,z) and time t. A ˝ne grid spacing of O(10)-O(100) m can be used near the surface to resolve boundary layer turbulence, and the grid spacing expands to be O(1000) m at higher altitudes, which reduces computational cost while still resolving deep convection. Example simulations are conducted with a simpli˝ed LES/CRM in 2D to verify the theoretical cost savings.

PRO94 EXPLORING POTENTIAL CLINICAL BENEFITS AND COST SAVINGS FROM IMPLEMENTING A STANDARDIZED DIGITAL REFERRAL PROCESS FOR DIAGNOSIS AND MANAGEMENT OF RARE DISEASES IN SPAIN: A CASE EXAMPLE FOR CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION

People affected by rare diseases often experience delays in diagnosis. In Spain, one patient out of four needs to be referred to a national expert center outside of his home region to obtain an accurate diagnosis. Physical displacement of patients can be time and cost consuming and impose an additional burden on the patient. Based on expert interviews the aim is to identify potential clinical and economic benefits that could result from the implementation of a standardized digital patient referral process between local hospitals and national expert referral centers for patients with suspected chronic thromboembolic pulmonary hypertension (CTEPH). Expert interviews were conducted to explore inefficiencies in the current patient referral process between local hospitals and national expert referral centers. The current patient pathway was compared to a potential alternative patient pathway based on a digital patient referral platform. Potential differences in clinical outcomes were described and theoretical cost savings were estimated from a payer perspective for different referral scenarios depending on distance traveled, transportation, hospitalization, diagnostic procedures realized, and subsidies paid corresponding to official tariffs in 2018. A digital patient referral platform could potentially improve the time to diagnosis and time to treatment decision for patients with CTEPH. Potential cost savings could derive from avoiding transportation, hospitalization, repetition of diagnostic procedures and subsidies paid for accommodation and diets for patients and their accompanying person. In a hypothetical low and high cost scenario, theoretical costs savings could range from 300€ to 4100€ per referral case avoided. The use of a digital patient referral platform could improve efficiency in the diagnosis and management process of rare diseases by potentially reducing time to diagnosis and treatment decision and could lead to overall cost savings for the national health system by avoiding physical patient displacements and replications of diagnostic tests.

Evidence Basis for a Point-of-Care Ultrasound Examination to Refine Referral for Outpatient Echocardiography

Few data exist on the potential utility of a cardiac point-of-care ultrasound (POCUS) examination in the outpatient setting to assist diagnosis of significant cardiac disease. Using a retrospective sequential cohort design, we sought to derive and then validate a POCUS examination for cardiac application and model its potential use for prognostication and cost-effective echo referral. For POCUS examination derivation, we reviewed 233 consecutive outpatient echo studies for 4 specific POCUS "signs" contained therein representing left ventricular systolic dysfunction, left atrial enlargement, inferior vena cava plethora, and lung apical B-lines. The corresponding formal echo reports were then queried for any significant abnormality. The optimal POCUS examination for identifying an abnormal echo was determined. We then reviewed 244 consecutive outpatient echo studies from another institution for associations between the optimal POCUS examination, clinical variables, and referral source with major adverse cardiac events and all-cause mortality in univariate and multivariate models. Assuming a referral model where the absence of POCUS signs or variables would negate initial echo referral, theoretical cost savings were expressed as a percentage in reduction of echo studies. In the derivation cohort, the combination of two signs, denoting left atrial enlargement and inferior vena cava plethora resulted in the highest accuracy of 72% [95% CI: 65%, 78%] in detecting an abnormal echocardiogram. In the validation cohort, mortality at 5.5 years was 14.6% overall, 23% in patients with the left atrial enlargement sign (OR 3.5 [1.6, 7.6]), 25% with inferior vena cava plethora sign (OR 2.2 [0.8, 6.0]), and 8.0% (OR 0.3 [0.2, 0.7]) in those lacking both signs. After adjusting for age, both diabetes (OR 4.8 [2.0, 11.6]), and the left atrial enlargement sign (OR 2.4 [1.1, 5.4]) remained independently associated with mortality (p<0.05). In the referral model, patients younger than 65 years of age without diabetes and without the left atrial enlargement sign would not have received echo referral, resulting in a 33% reduction in total echo cost and would have constituted a low-risk group with a 1.2% 5.5-year mortality. A quick-look sign for left atrial enlargement is associated with 5-year mortality and could function as an easily obtained outpatient POCUS examination to help in identifying patients in need of echo referral.

Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay, Discharge Disposition, and 90-Day Complications

BackgroundStandardized care pathways are evidence-based algorithms for optimizing an episode of care. Despite the theoretical promise of care pathways, there is an inconsistent literature demonstrating improvements in patient care. The authors hypothesized that implementing a care pathway, across 11 hospitals, would decrease hospital length of stay (LOS), decrease postoperative complications at 90 days, and increase discharges to home. MethodsA multidisciplinary team developed an evidence-based care pathway for total hip arthroplasty (THA) perioperative care. All patients receiving THA in 2013 (pre-protocol, historical control), 2014 (transition), and 2015 (full protocol implementation) were included in the analysis. Multivariable regression assessed the relationship of the care pathway to 90-day postoperative complications, LOS, and discharge disposition. Cost savings were estimated using previously published postarthroplasty episode and per diem hospital costs. ResultsA total of 6090 primary THAs were conducted during the study period. After adjusting for the covariates, the full protocol implementation was associated with a decrease in LOS (mean ratio, 0.747; 95% confidence interval [CI; 0.727, 0.767]) and an increase in discharges to home (odds ratio, 2.079; 95% CI [1.762, 2.456]). The full protocol implementation was not associated with a change in 90-day complications (odds ratio, 1.023; 95% CI [0.841, 1.245]). Payer-perspective-calculated theoretical cost savings, including both index admission and postdischarge costs, were $2533 per patient. ConclusionThe THA care pathway implementation was successful in reducing LOS and increasing discharges to home. The care pathway was not associated with a change in 90-day complications; further targeted interventions in this area are needed. Despite care standardization efforts, high-volume hospitals and surgeons had higher performance. Extrapolation of theoretical cost savings indicates that widespread THA care pathway adoption could lead to national healthcare savings of $1.2 billion annually.

PREPARE OLDER PATIENTS FOR CARDIAC SURGERY: DEVELOPMENT AND FEASIBILITY OF A NURSING INTERVENTION

Abstract Background and aim: In older patients undergoing elective cardiac surgery, timely identification and preparation of patients at risk for frequent postoperative hospital complications provides for the opportunity reducing their risk. We developed an evidence based multi component nursing intervention (PREDOCS-Program) to improve patients’ physical and psychosocial condition in order to reduce their risk on postoperative complications and we tested the PREDOCS-program on its feasibility and estimated theoretical cost savings. Method and material: In a team of researchers, experts, cardiac surgeons, cardiac surgery nurses and patients, the first phase of the revised guidelines for developing and evaluating complex interventions of the Medical Research Council (MRC) were followed. Subsequently, in a mixed-methods multicenter study, following the second phase of the MRC guidelines, we tested the feasibility in three hospitals and calculated theoretical cost savings. Results: PREDOCS-program is administered during a consult by the nurse, two to four weeks before the surgery procedure. Twenty one females and 49 males out of the 114 eligible patients completed the intervention. Patients were equally satisfied with the usual care and the PREDOCS-program (satisfaction rates on a scale from 1–10 respectively: 7.5 (95%CI: 6.4–8.7) and 7.6 (6.6–8.6)). The PREDOCS-program will be cost-effective when postoperative complications are prevented in six to sixteen of 1,000 cardiac surgery patients. Conclusion: In creating transparency in the assumed working mechanisms, an extended stepwise multi-method procedure was used to develop the PREDOCS-program, which will be already cost-effective when postoperative complications are prevented in six to sixteen of 1000 cardiac surgery patients.

Increasing Minimally Invasive Hysterectomy: ACanadian Academic Health Centre Experience.

An institution wide strategic plan was established to improve minimally invasive surgery (MIS) across all surgical divisions at The Ottawa Hospital (TOH). The primary objective of this study is to determine the change in MIS hysterectomy rate between 2005 and 2012 at this centre. Secondary objectives include determining the impact on overall length of stay (LOS) in hospital, complications, return to hospital, operating room time, and cost. We performed a retrospective analysis of all hysterectomies for benign disease performed at TOH between 2005 and 2012. Cases were excluded if they were related to pregnancy or classified as "partial hysterectomy." The outcomes and cost of the approaches were compared. A total of 4337 hysterectomy cases were reviewed. The MIS hysterectomy rate increased from 40.1% in 2005 to 74.2% in 2012. There was a decrease in mean LOS from 2.5 to 1.6 days. This translated to a saving of 1898 inpatient bed days. Compared with laparotomy, laparoscopic hysterectomy was associated with a reduced risk of transfusion and a reduced risk of ileus, and vaginal hysterectomy was associated with an increased risk of postoperative abscess. There was no difference in rates of returning to hospital or other complications between women undergoing abdominal hysterectomy and women undergoing MIS hysterectomy (which included both laparoscopic and vaginal approaches). The mean (SD) cost per approach was $7241 ($1985), $4532 ($1718), and $5637 ($1579) for abdominal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy, respectively. The initiatives implemented at TOH in 2007 resulted in a significant increase in the MIS hysterectomy rate, a decrease in mean LOS, and substantial theoretical cost savings for the hospital.

Feasibility of a nursing intervention to prepare frail older patients for cardiac surgery: a mixed-methods study.

Given the growing number of vulnerable, older cardiac surgery patients, the preadmission PREvention Decline in Older Cardiac Surgery patients (PREDOCS) programme was developed to reduce the incidence of postoperative complications. Before the clinical effects of such a complex multicomponent intervention can be evaluated, the feasibility needs to be determined to detect possible problems with the acceptability, compliance and delivery. The purpose of this study was to test the PREDOCS programme on its feasibility and estimate theoretical cost savings. In a mixed-methods multicentre study, the Medical Research Council (MRC) guidelines concerning testing feasibility were followed, and theoretical cost savings were calculated. We used data from interviews and the continuous data registry at three hospitals. The results were reported following the criteria for reporting the feasibility of complex interventions (CReDECI). Twenty-one females and 49 males out of 114 eligible patients completed the intervention and provided full data. Patients were equally satisfied with the usual care and the PREDOCS programme (satisfaction rate respectively standard deviation (SD): 7.5 (95% confidence interval (CI): 6.4-8.7) and 7.6 (6.6-8.6)). The involved nurses were satisfied with the tools for guiding patients to reduce their risk of postoperative complications and considered the PREDOCS programme as complementary to usual care. Integrating PREDOCS into current hospital structures appeared to be difficult. Both patients and nurses indicated that the additional consult was tiresome for the patient. The PREDOCS programme will be cost-effective when postoperative complications are prevented in six to sixteen of 1000 cardiac surgery patients. The PREDOCS programme is acceptable for patients and nurses but should be built into the hospital's cardiac surgery pathway or applied in home care.

Safety, Efficacy, and Cost Savings of Single Parathyroid Hormone Measurement for Risk Stratification after Total Thyroidectomy

The management of hypocalcemia (HC) after total thyroidectomy (TTx) is a challenge as TTx is transitioned into a same-day surgery. Measurement of parathyroid hormone (PTH) level after TTx may allow for prediction of postoperative HC and lead to shorter hospital stays. A prospective database was queried between January 2010 and June 2012 with 95 patients who had undergone TTx identified. Patient demographics; preoperative diagnosis; laboratory values and cost; complications; intravenous calcium supplementation; and length of stay (LOS) were analyzed. A PTH-based algorithm was retrospectively applied and theoretical cost savings were analyzed in terms of laboratory cost, LOS, and total cost. Ninety-five patients underwent TTx: 37 patients (38.9%) had cancer, whereas 27 (28.4%) had Graves' disease and the remaining 31 (32.6%) had a benign multinodular goiter. Postoperative PTH was recorded in 72 patients (74.4%); 46 (63.8%) had PTH greater than 10 pg/mL and 26 (36.9%) had PTH less than 10 pg/mL. Transient HC occurred in 10 patients (38.4%) with PTH less than 10 pg/mL (relative risk, 17.69; P = 0.0001). Patients with PTH less than 10 pg/mL incurred a 14.9 per cent higher hospital cost compared with those with PTH greater than 10 pg/mL. With retrospective implementation of the algorithm, there is a potential 46.4 per cent cost savings for the PTH less than 10 pg/mL group, 67.3 per cent savings for the PTH greater than 10 pg/mL group, and 46.7 per cent savings when taken altogether. Algorithmic risk stratification based on postoperative PTH less than 10 pg/mL serves as both a sensitive (100%) and specific (76.7%) predictor of postoperative HC. Such risk stratification may allow for same-day discharge in a number of patients, and even in patients requiring an overnight stay, result in cost savings as a result of a reduction in laboratory expenditures.

Rational or rationing? Justifying follow-up after management of kidney cancer

You have just finished meeting with your 46-year-old patient, a mother of 3 school-aged children, now 4 weeks after a successful nephrectomy for a T1 N0 M0 conventional cell renal cell carcinoma (RCC). She has done well and after much reassurance you have made arrangements to see her next year for a chest X-ray. Have you caught yourself questioning whether your patient or her family feels this is adequate? You likely have felt obliged to convey to them that this relatively conservative surveillance schedule is based on sound new follow-up guidelines from our national association. On second thought, you think, this was a 6-cm kidney cancer that required significant intervention, so maybe an extra visit and further imaging would be reassuring to all concerned? From a consumer point of view, well-communicated, timely and empathetic postoperative follow-up after cancer surgery surely is an indicator of good quality of care. Several authoritative bodies (and many individual experts) agree with this and have suggested frequent follow-up schedules for several urologic conditions.1,2 Perhaps you will order that computed tomography (CT) for the chest and abdomen for your patient in 9 months despite the suggested guidelines? The CUA guidelines on follow-up after radical or partial nephrectomy attempt to bring “clarity and guidance to the practicing urologist” given that there is no consensus on which investigations should be performed and at what intervals.3 The goals of any postoperative follow-up schedule for neoplastic disease would be to provide patient reassurance, functional review after a surgical procedure (arguably more relevant after the reconstruction with cystectomy or prostatectomy) and early detection of recurrent disease, for which intercession would lead to some clinical benefit. Unfortunately, the current recommendations of follow-up after nephrectomy rely only on observational and case studies to determine the potential benefit of early detection of recurrence.4 Given the lack of any high level of evidence, the CUA guidelines provide a uniquely Canadian perspective, balancing these goals of follow-up with the limited evidence regarding the benefit of frequent imaging, especially in a universal health care system with finite resources. The article by Dion and colleagues clearly demonstrate the direct cost-savings of adherence to the CUA guidelines for follow-up after radical nephrectomy compared to their previous institutional standards.5 The theoretical cost savings after 6 years of surveillance approach 26% (or $46,806) for the 75 patients in their cohort. These authors should be congratulated for their critical review of their practice, including their insights of the subsequent investigations stimulated by false-positive findings common in routine follow-up imaging, which approached 10% of all incurred costs. Most us will identify with those advocating caution regarding the apparent “epidemic” of imaging which lead to the “epidemic of treatments that inevitably follow.”6 The age-adjusted, per capita rate of diagnostic imaging (CT, magnetic resonance imaging and ultrasound) in Ontario has increased 18% per year over the last decade.7 Dion and colleagues only reviewed their direct costs of follow-up; a detailed assessment of indirect and opportunity costs were well beyond their scope and a true cost-efficacy analysis would likely be unfeasible given the assumptions required regarding the clinical benefit of detecting early disease recurrence of RCC (generally level 3 evidence). However, the very tangible cost-savings described in this article, based simply on following thoughtful peer-reviewed guidelines, seem to underscore the imperative of the CUA to continue developing and advocating for sound and reasonable recommendations balancing rational care with careful rationing.

Dose rounding of chemotherapy in colorectal cancer: An analysis of clinician attitudes and the potential impact on treatment costs

The aims of this study were to calculate theoretical cost savings of oxaliplatin dose rounding in colorectal cancer (CRC), and to assess clinician attitudes to chemotherapy dose rounding. Data were obtained from a prospective data repository (BioGrid Australia) from four hospitals regarding the use of oxaliplatin, given at a standard dose of 85 mg/m(2). We examined potential cost savings for patients with a body surface area (BSA) between 1.77 m(2) and 1.94 m(2), resulting in a calculated dose up to 10% above 150 mg (a 100 mg and 50 mg vial). The attitudes of oncologists at these hospitals toward minor dose reductions were assessed. From January 2003 to June 2008, of 676 patients with Stages III or IV CRC, 227 (33.58%) received oxaliplatin. Overall 66 patients (29%) had a calculated BSA between 1.77 m(2) and 1.94 m(2). The potential cost saving for these hospitals in one year, if oxaliplatin doses were rounded down to 150 mg, is $AU51,898. Extrapolated to the Australian population, estimated savings are over $AU2.5 million per year. Three of nine (33.3%) oncologists were comfortable with an initial dose reduction of up to 10% in the adjuvant disease setting, and seven of nine (77.8%) in the setting of metastatic disease. Minor dose reductions for CRC to accommodate vial sizes would lead to significant cost savings. Oncologists are more comfortable with minor dose reductions when treatment is given in a palliative setting.

An assessment of the cost-effectiveness of fast tracking bacteriological specimens for mycobacteria

A virtual model, using six predetermined criteria for fast tracking tuberculosis specimens was devised to improve the cost effectiveness of the MB/BacT system. All specimens received at a central laboratory were audited for the six criteria over a 6-month period. By assuming that only those specimens fulfilling these criteria were fast tracked the theoretical cost savings could be calculated. To prevent possible delay in speciating mycobacteria, the number of criteria were expanded to nine, and a further 6 month audit carried out In the first 6-month period, 728 specimens were tested. Had the initial hypothetical criteria excluded some of the specimens, only 351 specimens would have been tested through the fast-track system at a saving of £942 ($1696), (52%) of the total cost, but five culture results positive for environmental mycobacteria would have been delayed. In a second 6-month survey the criteria were expanded. Using these no positive culture would have been missed but the savings would only have been 26% of the total cost. Introducing exclusion criteria for rapid testing can improve the cost effectiveness of rapid culture methods with no important loss of clinically necessary information.