Total Management Cost Research Articles

Wind-Hydro Combined Bidding Approach for Congestion Management Under Secured Bilateral Transactions in Hybrid Power System

After restructuring of power system, independent system operator is facing a big challenge to manage operations on transmission networks due to growing renewables share and involvement of large market players in power system operation. Among all renewables, wind power has the most stochastic nature and faces penalties due to mismatch in its initial power committed and final power delivered. Also, wind power plants are generally located at remote areas and need longer transmission lines for power delivery. This leads to congestion of transmission lines and poses a threat to security and safety of power system. To manage congestion on transmission lines, this paper proposes a novel rescheduling based combined bidding approach for wind integrated hybrid (pool + bilateral) power system. Congestion management problem has been formulated as mixed integer non-linear programming problem incorporating proposed combined bidding approach with an objective to reduce total congestion management cost through rescheduling of wind and hydro units on the basis of their combined up and down generation cost bids. The hydro units that have lowest operating cost and fast turn-on time have been used in coordination with wind units to alleviate congestion cost. Secured bilateral transactions have been confirmed while implementing the combined bidding approach for congestion management. Performance of proposed strategy has been analyzed by demonstrating it on modified IEEE-24 bus RTS system.

Moderate separation of household kitchen waste towards global optimization of municipal solid waste management

The sorting treatment of food waste is gradually considered as an available strategy to improve the sustainability of municipal solid waste (MSW) management, but the separation of household kitchen waste (HKW), the main component of food waste, is controversial because of its disperse sources and possible social cost. Social life cycle assessment is applied in this study to integrate environmental, economic, and social analyses, including the time investment of households, aiming to assess the influence of HKW separation comprehensively. The results show HKW separation at different separation rates improve the environmental performance of MSW treatment. When HKW separation rate increases by every 20 percentages, the net carbon emission reduces 5–7%, the acidic gas emission reduces by 3.1–3.5%, and the cumulative energy demand decreases by approximately 2.1–2.2%, owing to the higher heat value of incineration feedstock and more yield of energy products. HKW separation increases the energy consumption of waste collection and transportation system, but its contribution to the overall energy consumption is very limited. The whole MSW management system also has better economic performance along with more HKW separation and more energy output. In contrary, a huge amount of time cost of households increases the total social cost of MSW management, making HWK separation not an attractive option. From the point of view of residents, the external cost, including environmental cost and household time cost, should not exceed zero to ensure residents obtain some benefits from HKW separation, implying that HKW separation rate of 20% is acceptable. HKW water content and proportion in MSW are the two sensitive factors influencing the comprehensive performance of MSW management. Source HKW draining to water content 60% and source reduction by 30% can decrease the total social cost by 124–215% and 66–73%, respectively. The two effective measures are easy and convenient for residents to carry out with significant improvement of social sustainability of MSW management. Based on the effects on social cost, the priority of HKW management strategies should be given to source draining and then source reduction, followed by source separation from MSW at 20%.

The burden of bites and stings management: Experience of an academic hospital in the Kingdom of Saudi Arabia

PurposeThe main aim of this study is to estimate the economic burden and prevalence of bites and stings injuries in Saudi Arabia. MethodsA retrospective, cross-sectional study was conducted at King Saud University Medical City (KSUMC) for all bites and stings cases presented to the Emergency Department (ED) between the period June 2015 and May 2019. ResultsA total of 1328 bites and stings cases were treated in the ED at KSUMC. There were 886 insect bites and stings cases, 376 animal bites, 22 human bites, 34 scorpion stings, and ten snakebites. Most cases were reported in April - June. Females account for 62% of the reported cases, and the mean age was 24 years old. The total management cost of bite and sting cases during the study period was 3.4 million Saudi Riyal (SR). The spending cost of the management of animal bites was the highest as it cost 1,681,920.76 SR, followed by insect's management costing 1,228,623.68 SR. ConclusionBites and stings have a considerable health care burden on our society. Although the vast majority of the cases were not associated with a severe life-threatening condition, many were visit ED and associated with high medical costs. Increased awareness of the hazards of animal-related injuries, especially during spring and summer, where most cases take place may lower its incidence and decrease EDs visits.

The Application Effect of Regional Family Doctor Contract Service Based on Internet Platform in the Management of Hypertensive Patients in Primary Hospital

Objective: To analyze the application effect of regional family doctor contract service based on Internet platform in the management of hypertension patients in community hospitals. Methods: Since June 2017, the Yetang Health Center has established a model of family doctors contracted chronic disease management based on the Internet platform under the guidance of the General Medical Department of the First People’s Hospital of Changshu City. The Internet platform for patient management was developed, and a regional data sharing center for hypertensive patients was established. The combination with the family doctor contract model enabled the effective management of hypertensive patients. In the 12 months before the model was implemented, 525 patients with hypertension were selected, and 2173 patients with hypertension after 12 months of implementation were included in the control group and the observation group. The differences in treatment compliance, selfmanagement rate and other indicators between the two groups were compared to analyze the application effect of the model. Results: Compliance, compliance rate, self-management rate and awareness rate of hypertensionrelated knowledge in the observation group were higher than those in the control group, and the difference was statistically significant (P < 0.05). The total management cost, unit management cost and standard management cost of hypertension patients in the observation group were lower than those in the control group. The satisfaction rate of hypertension management in the observation group was 96.87% (2105/2173), which was higher than 63.05% (331/525) in the control group (P < 0.05). The awareness rate of diagnostic criteria, risk factors, hazards and treatment methods of hypertension in the observation group was higher than that in the control group, and the difference was statistically significant (P < 0.05). Conclusion: The regional family doctor contract service based on Internet platform can significantly improve the effectiveness and efficiency of community hospital management of hypertension patients, and it is also an effective way to reduce management costs and ensure patient satisfaction, which is worth further optimization and promotion.

Dual-Plane Gluteal Myocutaneous Flap for Reconstruction of Ischial Tuberosity Pressure Wounds.

Ischial tuberosity pressure wounds are the most common type of pressure wound and contribute to a large percentage of the total cost of surgical and nonsurgical management of pressure wounds. Gluteal myocutaneous and fascocutaneous flaps are well-documented methods of coverage for ischial pressure wounds. This study aimed to describe results using a novel dual-plane gluteal myocutaneous flap technique for reconstruction of ischial tuberosity pressure wounds. A retrospective chart review was performed of all patients who underwent dual-plane gluteus maximus myocutaneous flap reconstruction for ischial tuberosity pressure wounds performed by a single surgeon from 2012 to 2018. Patient demographic, clinical, and operative characteristics were reviewed. Outcomes were assessed by analyzing complication rates including recurrence, need for revision surgery, dehiscence, necrosis, wound infection, seroma, and hematoma. Eight dual-plane gluteus maximus myocutaneous flaps were performed for reconstruction of ischial tuberosity pressure wounds in 7 male patients with a mean age of 49.1 ± 14.9 years (mean ± SD) and mean body mass index of 26.7 ± 6.4 kg/m. All patients were nonambulatory secondary to spinal cord injury or congenital neurological disease. Two patients (28.6%) were diabetic, and 1 patient (14.3%) was an active smoker. The mean defect size after debridement of ischial pressure wounds was 60.7 ± 29.4 cm. After a mean follow-up of 16.4 months, partial wound dehiscence occurred in 1 patient (14.3%) and was managed with local wound care only. Infection and recurrence occurred in another patient (14.3%) and required revision surgery. The dual-plane gluteal myocutaneous flap is an effective method for reconstruction of ischial tuberosity pressure wounds. Partially elevating the cutaneous layer off the gluteus maximus muscle allows for greater mobility and rotation of the muscle flap into the ischial pressure wound defect and closure of the flap and donor site with the cutaneous layer.

Recent Technologies in Construction; A Novel Search for Total Cost Management of Construction Projects.

There is a continuous rise in the implementation of information-driven technology in construction, especially for effective control and management of construction resources. However, the enormous opportunities that these technologies provide have not been adequately utilized for construction cost management. There are so many innovations in the current IR 4.0 era, where digitization and connected systems are the trend of activities in engineering and other allied industries. These innovations are being adopted in the construction industry, to enhance the efficiency of construction processes. The areas of the current trend include Internet of things [IoT], Augmented and Virtual Reality [AR and VR], 5D-BIM, Autonomous Equipment, Artificial Intelligence and Machine Learning, and Predictive Analytics. This paper explores the applications and benefits of these areas of new technological trends in construction project management with emphasis laid in cost management of construction projects. Eighty-one[81] recent publications in journal articles, textbooks, web pages and conference proceedings published between 2008 and 2019 were reviewed in order to articulate and reveal areas of application of the technologies in project cost management and control. The paper exposes areas of application of the current ICT trends which construction managers and project cost managers should harness.

Antimicrobial Sensitivity Pattern of Pseudomonas Aeruginosa Isolated from a Tertiary Care Hospital

Introduction: Pseudomonas aeruginosa (P. aeruginosa) is one of the major cause of nosocomial infection. Multi-drug-resistant P. aeruginosa (MDR PA) are increasingly encountered in clinical samples .Therefore, this study was undertaken to know the sensitivity pattern of P. aeruginosa and to detect MDR PA from clinical samples.
 Methods: This was a laboratory based retrospective-cross sectional study conducted at Department of Microbiology at a tertiary care referral centre in Kathmandu, Nepal from December 2018 to December 2019. Total of 200 isolates of P. aeruginosa were isolated from clinical samples. Non repetitive sample per patient was included in the study. Samples were processed according to standard methodology and antimicrobial sensitivity testing (AMST) was carried out by Modified Kirby Bauer disk diffusion test as per Clinical Laboratory Standard Institute guideline. MDR was defined as strains resistant to one or more agent of ≥ 3 groups of antimicrobial categories.
 Results: Highest number of P. aeruginosa were isolated from sputum (93), followed by wound swab (35), and pus (29). AMST revealed the most sensitive drug to be Amikacin (91.51%) followed by Meropenem (78.5%) and Piperacillin/Tazobactam (77.50%). Out of 200 isolates, 69 (34.5%) were MDRPA.
 Conclusions: The information regarding sensitivity pattern of P. aeruginosa will help clinicians to choose most effective antimicrobials for the treatment of patients thus saving the time duration and total cost of patient management and also it will play a key role in setting antimicrobial stewardship policy.

Constrained optimization model of the volume of initial rainwater storage tank based on ANN and PSO.

Rainfall runoff pollution is one of the main causes of water quality deterioration in urban water system. Setting up initial rainwater storage tank could be one of the rapid and effective methods to control runoff pollution. In order to speed up the water environment management processes, the Chinese government has adopted the Public-Private-Partnership (PPP) mode in the water environment treatment to deal with the shortage of funds. Ensuring water quality and controlling water environment management cost are key to PPP projects. Therefore, factors such as pollutant accumulation characteristics of the catchment, land space availability, sewage treatment plants capacity, and river water management cost should be considered during the design of the initial rainwater storage tank on the premise of ensuring water quality. The empirical design method can hardly meet these requirements simultaneously. Under the background of PPP water environment treatment project, a constrained economic optimization model of the initial rainwater storage tank was presented in this paper. The relationship between the total cost of the water environment management and the interception rate of the initial rainwater storage tanks was established by means of Artificial Neural Network (ANN), while the penalty function was used to transform the constrained optimization problem into an unconstrained optimization problem. The interception rate of the initial rainwater storage tanks was then optimized by means of Particle Swarm Optimization (PSO), and the designed volume of the storage tanks was calculated according to the relationship between the interception rate of the storage tank and the cumulative runoff of the related catchment. Finally, a case study of a PPP demonstration project in a plain city in China was conducted. The results demonstrated that compared with the specification method, the total volume of the initial rainwater storage tank increased by 38.7%, the interception rate increased by 68.4%, and the total cost of river water treatment decreased by 5.7% under the constraints of land space availability and sewage treatment capacity. In addition, the optimized method proposed in this paper could reflect the pollutant accumulation characteristics of the catchment. It not only reduce the total cost of the water environment management but also effectively reduce the impact of non-point source pollution on urban water system, and could be more widely used in other areas and PPP projects.

OPTIMIZED ROUTING OF TRUCKS FOR INSTITUTIONAL SOLID WASTE COLLECTION IN KUMASI, GHANA

Solid waste collection constitutes 60-80% of the total solid waste management cost. Reduction of solid waste collection cost can be achieved through route optimization in a geographic information system (GIS) environment. The purpose of this study was to generate optimized routes for solid waste collection on Kwame Nkrumah University of Science and Technology campus in Kumasi, Ghana. The study modelled the existing routes for a complete collection cycle using travel time criteria and generated optimized routes for same using an ArcGIS software. Validation of the optimized outcome (travel distance and travel time) was done by subjecting the solid waste collection trucks to the optimized routes. The results from the study showed significant reduction in total travel time from 1,000.75 mins to 855.70 mins for existing and optimized routes respectively, translating into saving of 14.5%. Total travel distance significantly reduced from 367.30 km to 334.20 km for existing and optimized routes respectively, representing saving of 9.0%. Significant savings in travel time and travel distance have implications on reduction of fuel and maintenance cost of institutional solid waste collection trucks. The results indicate that the application of GIS-based route optimization in solid waste collection can provide significant improvement in reduction of operating cost.

RETRACTED: Integrated maintenance/spare parts management for manufacturing system according to variable production rate impacting the system degradation

This study develops an analytical model in order to determine an optimal integrated maintenance plan and spare parts management. We consider a manufacturing system, producing only one type of product, over a finite planning horizon H equal to the sum of all production periods and the production quantity of each period is known. This system is subject to a continuously increasing degradation rate. That is why a preventive maintenance strategy is adopted in order to face the increasing failure rate. We noted that contrarily to the majority of studies in literature, we take into account the impact of the production rate variation on the manufacturing system degradation and consequently on the adopted optimal maintenance strategy. In addition, the real need of spare parts relative to the scheduled maintenance actions is taken into account. In fact, the purpose of our study consists at determining the optimal preventive maintenance frequency and the optimal quantity of spare parts to order by minimizing a total cost, including maintenance and spare parts management. Numerical examples are presented along with a sensitivity study in order to prove the use of the developed model for deriving the optimal integrated strategy for any instance of the problem.

Monthly direct and indirect costs of management of CKD 3 - 5 non-dialysis patients in an out-of-pocket expenditure system: The Case of Yaoundé.

Chronic kidney disease (CKD) affects ~10% of the world population. In most developing nations, the costs for the treatment of CKD are met by patients. Data on the economic burden of early stages of CKD are scarce; few studies have evaluated the cost of management of CKD stages 3-5 in non-dialysis (ND) patients in an out-of-pocket expenditure system. This study estimated the direct, indirect, and global economic cost of management of CKD stages 3-5 ND patients in Yaoundé, Cameroon. It was 1-month retrospective cost analysis. Sampling was consecutive and exhaustive of CKD 3-5 ND patients. We evaluated direct medical, direct non-medical, and indirect costs. 69 patients were included in the study, and the mean age was 55 years. The median monthly salary of the population was USD 162. Only 1.4% of patients had 100% health insurance coverage. The total cost of management was ~USD 163. Direct medical, direct non-medical, and indirect costs accounted for 86.4%, 7.1%, and 6.3%, respectively. That global cost was prohibitive to Cameroonians and was tantamount to 2.7 times the minimal wage in Cameroon.

A simulation-optimization approach to determine optimal order-up-to level for inventory system with long lead time

This paper proposes a simulation-optimisation technique to determine an optimal order-up-to level for a single product in a periodic review inventory system. A vital aspect of the problem is that the replenishment lead time is much longer than the review period. Customer demands are stochastic, discrete, and intermittent, and the lead times are stochastic and discrete. With these demand and lead time characteristics, an empirical distribution is used to fit the distribution of demand during the lead time. A simulation-optimisation approach is developed with the objective to minimise the total annual inventory management cost, which consists of the holding cost and backlog cost, while maintaining an acceptable service level. Real data from a warehouse of an international trading company are used to test the performance of the proposed method. Results from a computational test show the method effectiveness.

The Economic Burden of Short-Term Adverse Events Associated with the CHOP Chemotherapy Regimen in Patients with Lymphoproliferative Disorders in the United States: A Comprehensive Literature Review

Objectives: CHOP (vincristine, cyclophosphamide, prednisone, doxorubicin) is a treatment option for post-transplant lymphoproliferative disorder (PTLD) following solid organ transplant, an aggressive and potentially fatal disease. The most common and impactful CHOP-related adverse events (AEs) are febrile neutropenia (FN), chemotherapy-induced (CI) peripheral neuropathy (PN), infection, CI-anemia (A), and CI-nausea and vomiting (NV). These CHOP-related AEs have a large humanistic burdensignificant impact to quality of life (QoL) of patients, especially shortly after treatment. The evidence for a positive QoL benefit associated with some AE treatments (e.g., erythropoietin stimulating agents [ESA], granulocyte colony stimulating factors) is inconsistent and many patients likely remain with QoL deficits even after treatment. The impact of these short-term CHOP-related AEs is likely to be accompanied by an increase in healthcare resource utilization and costs. The objective of this study was to explore the economic burden of short-term CHOP-associated AEs in PTLD patients. Since PTLD is a rare disease with limited available data, we expanded our search to include all patients with lymphoproliferative disorders (LPD). Methods: Short-term (within several months after treatment) AEs associated with CHOP with an incidence of >4% in patients with LPDs were determined and sourced from the published literature and cancer websites. A comprehensive literature search was conducted using PubMed and EMBASE to identify economic burden studies published from 2010 to 2018 of the AEs associated with CHOP and its components in the United States (US). Studies incorporating rituximab alongside CHOP (CHOP + R) were also included as this is a valid treatment option for PTLD patients. Economic burden was defined as the management costs and resource utilization associated with treating CHOP-emergent adverse events. The conduct of this comprehensive literature review was guided by the PRISMA protocol wherein the research question (using the PICOS format), search strategy, target short-term AEs, and inclusion and exclusion criteria were pre-specified in detail. Results: Overall, 3,946 non-duplicate citations were screened, 39 studies were included for abstraction and no studies included patients with PTLD. Studies were methodologically heterogenous, with approximately half (56%) based on some form of retrospective analysis or prospective observational study. FN was the AE most commonly encountered, followed by CIA, infection, CI-nausea and vomiting, and CIPN. FN was an important driver of hospitalization (proportion of FN patients with hospitalization was up to 83.2%) and extended length of stay (LOS) was substantial for several AEs (LOS range in days: infection, 8.4-23.6; FN, 7.9-19.7). Mean LOS was longer in FN patients with multiple hospitalizations as well as in FN patients with comorbidities. Rates of transfusion in CI-anemia patients varied dramatically, from 10.8% to 47.4%. Transfusion rates were attenuated by ESA use in LPD patients, although a significant proportion of anemic cancer patients receiving ESAs still required transfusions. Total management costs were highly variable, ranging from nominal for events such as CIPN to over $197,000 in hospitalization costs per infection discharge per patients complicated with clostridium difficile. One recent study showed the inpatient costs attributable to FN were $33,006 per patient per episode. Studies identified CINV as a top reason for unplanned service use, but no studies were identified assessing its economic impact in LPD patients. Outpatient care costs for each AE varied but tended to have a low to moderate economic impact. The costs attributable to several AEs (FN, infection) were highest in the first cycle of chemotherapy. Conclusions: Several common short-term AEs due to CHOP in the LPD population were associated with substantial healthcare resource utilization and costs that were primarily driven by increased hospitalization and length of inpatient stays. Costs for FN and infections associated with CHOP ranged from $33,000 to over $197,000, demonstrating the high economic burden to the US healthcare system. No PTLD-specific studies were found, highlighting the absence of published data addressing the economic burden associated with chemotherapy in PTLD patients and the need for effective and tolerable therapies. Disclosures Watson: Atara Biotherapeutics: Employment, Equity Ownership. Barlev:Atara Biotherapeutics: Employment, Equity Ownership. Worrall:Atara Biotherapeutics, Inc: Consultancy. Duff:Atara Biotherapeutics, Inc: Consultancy. Beckerman:Atara Biotherapeutics, Inc: Consultancy.

Cost-effectiveness of Stapedectomy vs Hearing Aids in the Treatment of Otosclerosis

Otosclerosis can be managed through surgical treatment, such as stapedectomy, or through hearing amplification with hearing aids. To our knowledge, there has been no cost-effectiveness analysis of these 2 treatment methods. To determine the cost-effectiveness of stapedectomy vs hearing aid use for the treatment of otosclerosis. In this cost-effectiveness analysis, a decision tree was built to model the treatment choices for otosclerosis. The tree was run as a Markov model of a case patient aged 30 years. The model spanned the patient's lifetime to determine total costs of management of otosclerosis with stapedectomy or hearing aids. Cost-effectiveness was measured using an incremental cost-effectiveness ratio, with a willingness to pay of $50 000 per quality-adjusted life-year (QALY) considered cost-effective. One-way sensitivity analyses were performed for all variables. A 2-way sensitivity analysis was performed for the cost of stapedectomy vs the cost of hearing aids. Probabilistic sensitivity analysis was performed to determine the likelihood that stapedectomy would be cost-effective across a range of model inputs. Stapedectomy vs hearing aid use. The primary objective of this study was to determine the cost-effectiveness of stapedectomy vs hearing aids in the treatment of otosclerosis. The secondary objectives were to determine which factors are associated with the cost-effectiveness of the interventions. Stapedectomy had an estimated lifetime cost of $19 417.95, while hearing aids had an average lifetime cost of $16 439.94. Stapedectomy also had a benefit of 16.58 QALYs, and hearing aids had a benefit of 15.82 QALYs. Stapedectomy increases lifetime costs by $2978.01, with a benefit of 0.76 QALYs compared with hearing aids. The incremental cost-effectiveness ratio for stapedectomy is $3918.43 per QALY. The model was sensitive to the cost of stapedectomy and the cost of stapedectomy revision surgery. Probabilistic sensitivity analysis showed that stapedectomy was cost-effective compared with hearing aids 99.98% of the time. Stapedectomy appears to be a cost-effective option for treating otosclerosis compared with hearing aid use, from the patient perspective.

PCN237 IMPACT OF ORAL TARGETED THERAPY ON THE ECONOMIC BURDEN OF CLL IN CANADA

Although oral targeted therapy (OTT) for chronic lymphocytic leukemia (CLL) represents an improved therapeutic strategy, this approach is accompanied by a major challenge related to the economic burden on the healthcare system. The objective of this study was to estimate future direct costs, as well as the prevalence, of CLL in the era of OTT in Canada. The economic burden of OTT compared to chemoimmunotherapy (CIT) for treating patients with CLL was assessed from 2011 to 2025. For the OTT scenario, CIT was considered the standard of care before 2015, while OTT was considered for CLL patients with either unmutated immunoglobulin heavy-chain variable (IGHV) or del(17p)/TP53 mutations starting in 2015 and, from 2020 onwards, for all first-line treatments except for patients with mutated IGHV. A Markov model was developed including four health states: watchful-waiting, first-line treatment, relapse and death. Costs of therapy, follow-up/monitoring and adverse event were included. Key clinical parameters were extracted from pivotal clinical trials. As incidence rates and rate of survival are increasing, the prevalence of CLL in Canada is projected to increase from 8,301 in 2011 to 14,654 by 2025 (177% increase). Correspondingly, the total annual costs of CLL management will increase from $60.8 million to $957.5 million from 2011 to 2025, respectively (15.7-fold increase). With the implementation of OTT as a first-line treatment option, the per patient lifetime cost of CLL, for treated and untreated, is projected to increase from $4,036 to $43,309 (10.7-fold increase). While OTT enhances survival for CLL patients, it is nonetheless associated with an important economic burden due to the projected vast increase in costs from 2011 to 2025. Changes in clinical strategies, such as implementation of a fixed OTT treatment duration or discontinuation and retreatment based on depth of response, would help alleviate financial burden.

The Annual Direct and Indirect Health Care Costs for Patients with Chronic Pruritus and their Determining Factors

The Annual Direct and Indirect Health Care Costs for Patients with Chronic Pruritus and their Determining Factors

Optimization of a large industrial wastewater treatment plant using a modeling approach: A case study

The objective of this paper is to find the optimum solid retention time (SRT) of a wastewater treatment plant (WWTP), which minimizes operating costs, using a modeling approach with WEST software by MIKE DHI®. For the determination of the kinetic and stoichiometric parameters (used for the correct calibration of the model implemented), respirometric and kinetic batch tests were carried out. Each Oxidation ditch was modeled by a sequence of four aerated activated sludge units (ASUs) and four anoxic ASUs with recirculation. The model is able to simulate the separation efficiency of the secondary settler, which is generally quite low: in fact, the industrial origin of the wastewater induces the formation of small flocs, the dimensions of which can be further reduced by the presence of surface aerators. The nitrification/denitrification process is also accurately predicted. Using data obtained from the model, mass balances at the steady state for COD and N were made and compared to the ones obtained using measured data. After calibration and validation of the model, steady-state simulations were carried out by increasing and decreasing the SRT of the system under two different operational conditions used by the managing company and by evaluating the costs related to the water treatment line and the sludge treatment line for each scenario. It is interesting to note how the total costs are lower in summer than in winter (7.2 €cent/m3 in summer and 8.7 €cent/m3 in winter, in scenario 0). In general, the increase in the SRT led to a decrease in the total management costs. In fact, differences between scenario 0 and the scenario with the lowest total treatment costs (corresponding to an SRT of 11.4 d in winter and 10.0 d in summer) could give rise to total savings of about 44·000€/year in summer and 93·000€/year in winter.

Cost-effectiveness of Operative Versus Non-operative Management of Acute Achilles Tendon Ruptures

BackgroundThe management of acute Achilles tendon ruptures is controversial, and most injuries are treated with surgery in the USA. The cost utility of operative versus non-operative treatment of acute Achilles tendon injury is unclear.Questions/PurposesThe purpose of this study was to compare the cost-effectiveness of operative versus functional non-operative treatment of acute Achilles tendon ruptures.MethodsA Markov cost-utility analysis was conducted from the societal perspective using a 2-year time horizon. Hospital costs were derived from New York State billing data, and physician and rehabilitation costs were derived from the Medicare physician fee schedule. Indirect costs of missed work were calculated using estimates from the US Bureau of Labor Statistics. Rates of re-rupture, major and minor complications, and the associated costs were obtained from the literature. Effectiveness was expressed in quality-adjusted life years (QALYs). For the base-case analysis, operative and non-operative patients were assumed to have the same utilities (quality of life) following surgery. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of model assumptions.ResultsIn the base-case model, non-operative management of acute Achilles tendon ruptures dominated operative management, resulting in both lower costs and greater QALY gains. The differences in costs and effectiveness were relatively small. The benefit of non-operative treatment was 1.69 QALYs, and the benefit of operative treatment was 1.67 QALYs. Similarly, the total cost of operative and non-operative management was $13,936 versus $13,413, respectively. In sensitivity analyses, surgical costs and days of missed work were important drivers of cost-effectiveness. If hospitalization costs dropped below $2621 (compared with $3145) or the hourly wage rose above $29 (compared with $24), then operative treatment became a cost-effective strategy at the willingness-to-pay threshold of $50,000/QALY. The model results were also highly sensitive to the relative utilities for operative versus non-operative treatment. If non-operative utilities decreased relative to operative utilities by just 2%, then operative management became the dominant treatment strategy.ConclusionFor acute Achilles tendon ruptures, non-operative treatment provided greater benefits and lower costs than operative management in the base case; however, surgical costs and the economic impact associated with return to work are important determinants of the preferred cost-effective strategy.

Economic impact of the 31-gene expression profile test in the Medicare-eligible population with cutaneous melanoma.

6630 Background: Sentinel lymph node biopsy (SLNB) is recommended as a staging procedure for patients with cutaneous melanoma (CM), but SLNB is associated with additional surgical risks and costs. The SLN positivity rate is approximately 12-16% overall and varies by age. Older patients have lower SLN positivity rates despite a higher metastatic rate. A 31-gene expression profile (31-GEP) test classifies 5-year metastatic risk (Classes 1A [lowest risk], 1B, 2A, and 2B [highest risk]), including SLN metastasis. As previously demonstrated using a large multicenter database, patients with Class 1A, T1-T2 (≤2.0 mm thickness) CM have an overall SLN positivity likelihood < 5%, below the NCCN guideline threshold for SLNB. The aim of this study was to determine the relative cost impact of patient management via traditional care versus using the 31-GEP test to guide SLNB and surveillance plans for 16,572 patients ≥65 years (Medicare-eligible) with T1-T2 CM who are SLNB-eligible. Methods: Decision tree models were used to compare management strategies (surveillance, SLNB) according to traditional care based on SLNB staging and with 31-GEP test utilization. Models used T category from AJCC TNM staging guidelines and SEER data for incidence estimations. Model outcomes included total Medicare costs of melanoma treatment and patient management. Cost impact of the 31-GEP test was calculated based on the difference in Medicare costs between the traditional care and 31-GEP test paradigms. Results: Under the paradigm in which the 31-GEP guided SLNB and surveillance in patients ≥65 years with T1-T2 CM who are eligible for SLNB, 11,157 fewer SLNBs would be performed per year, a 67% reduction in SLNB procedures in this population. This would result in a net annual cost savings of $68M, a 31% reduction in total costs. Use of the 31-GEP testing to guide surveillance in patients ≥65 with T3-T4 melanoma, in addition to T1-T2 melanoma, were also analyzed and also demonstrated a reduction in costs. Conclusions: Results from this study suggest that using the 31-GEP test to guide SLNB and surveillance offers substantial cost savings compared to traditional care for Medicare-eligible patients.

A health economic evaluation of using N-terminal pro brain natriuretic peptide for the management of acute heart failure: A pilot study in an Indonesian tertiary referral hospital

Heart failure represents a major health problem and economic burden also in development countries such as Indonesia. Based on current guidelines, the use of natriuretic peptides can improve diagnosis, risk stratification, and decrease in hospital length of stay. However, mostly due to the related high costs, many Indonesian physicians currently do not routinely use these biomarkers in their daily clinical practice. By comparing the results of guidance with N-terminal pro brain natriuretic peptide (NT-proBNP) and without NT-proBNP, this pilot study was aimed to determine the clinical effectiveness and costs of using natriuretic peptides in the management of acute heart failure (AHF) patients admitted at National Cardiovascular Center Harapan Kita Hospital, a tertiary referral hospital in Jakarta, Indonesia. This was a health economic evaluation using a single-blind, randomized controlled trial. AHF patients adjudicated following European Society of Cardiology guidelines were randomly assigned to the 2 groups: NT-proBNP group (group A) and control group (group B). In the group A, NT-proBNP level was obtained at admission and pre-discharge, with the target of achieving a decrease of ≥30%. Randomised patients were followed up to 90 days post-discharge to assess short-term outcomes and costs. In total, one hundred and twelve patients were enrolled, of whom 56 were randomized in group A and 56 patients in group B. Compared to Group B, in Group A the total costs of patients management resulted to be significantly higher (P<0.05), while no significant difference between the 2 groups was observed for inhospital length of stay, total mortality rate, rehospitalization, and emergency department visits within 90 days post-discharge. In this pilot study for the management of AHF at an Indonesian National Cardiovascular Center, the routine use of NT-proBNP compared to the non use, at hospital admission and discharge resulted into a significant increase of medical cost without any evident favourable impact on patients outcomes. Larger study in greater Asia Pacific populations should be performed to confirm these preliminary results.