Resource utilization and cost analyses of home-based palliative care service provision:The Niagara West End-of-Life Shared-Care Project

Background: Increasing emphasis is being placed on the economics of health care service delivery - including home-based palliative care. Aim: This paper analyzes resource utilization and costs of a shared-care demonstration project in rural Ontario (Canada) from the public health care system's perspective. Design: To provide enhanced end-of-life care, the shared-care approach ensured exchange of expertise and knowledge and coordination of services in line with the understood goals of care. Resource utilization and costs were tracked over the 15 month study period from January 2005 to March 2006. Results: Of the 95 study participants (average age 71 years), 83 had a cancer diagnosis (87%); the non-cancer diagnoses (12 patients, 13%) included mainly advanced heart diseases and COPD. Community Care Access Centre and Enhanced Palliative Care Team-based homemaking and specialized nursing services were the most frequented offerings, followed by equipment/transportation services and palliative care consults for pain and symptom management. Total costs for all patient-related services (in 2007 CAN) were 1,625,658.07 - or 17,112.19 per patient/117.95 per patient day. Conclusion: While higher than expenditures previously reported for a cancer-only population in an urban Ontario setting, the costs were still within the parameters of the US Medicare Hospice Benefits, on a par with the per diem funding assigned for long-term care homes and lower than both average alternate level of care and hospital costs within the Province of Ontario. The study results may assist service planners in the appropriate allocation of resources and service packaging to meet the complex needs of palliative care populations. © 2012 The Author(s).

Road Design for Future Maintenance : Life-cycle Cost Analyses for Road Barriers

The cost of a road construction over its service life is a function of design, quality of construction as well as maintenance strategies and operations. An optimal life-cycle cost for a road requires evaluations of the above mentioned components. Unfortunately, road designers often neglect a very important aspect, namely, the possibility to perform future maintenance activities. Focus is mainly directed towards other aspects such as investment costs, traffic safety, aesthetic appearance, regional development and environmental effects. This doctoral thesis presents the results of a research project aimed to increase consideration of road maintenance aspects in the planning and design process. The following subgoals were established: Identify the obstacles that prevent adequate consideration of future maintenance during the road planning and design process; and Examine optimisation of life-cycle costs as an approach towards increased efficiency during the road planning and design process. The research project started with a literature review aimed at evaluating the extent to which maintenance aspects are considered during road planning and design as an improvement potential for maintenance efficiency. Efforts made by road authorities to increase efficiency, especially maintenance efficiency, were evaluated. The results indicated that all the evaluated efforts had one thing in common, namely ignorance of the interrelationship between geometrical road design and maintenance as an effective tool to increase maintenance efficiency. Focus has mainly been on improving operating practises and maintenance procedures. This fact might also explain why some efforts to increase maintenance efficiency have been less successful. An investigation was conducted to identify the problems and difficulties, which obstruct due consideration of maintainability during the road planning and design process. A method called “Change Analysis” was used to analyse data collected during interviews with experts in road design and maintenance. The study indicated a complex combination of problems which result in inadequate consideration of maintenance aspects when planning and designing roads. The identified problems were classified into six categories: insufficient consulting, insufficient knowledge, regulations and specifications without consideration of maintenance aspects, insufficient planning and design activities, inadequate organisation and demands from other authorities. Several urgent needs for changes to eliminate these problems were identified. One of the problems identified in the above mentioned study as an obstacle for due consideration of maintenance aspects during road design was the absence of a model for calculating life-cycle costs for roads. Because of this lack of knowledge, the research project focused on implementing a new approach for calculating and analysing life-cycle costs for roads with emphasis on the relationship between road design and road maintainability. Road barriers were chosen as an example. The ambition is to develop this approach to cover other road components at a later stage. A study was conducted to quantify repair rates for barriers and associated repair costs as one of the major maintenance costs for road barriers. A method called “Case Study Research Method” was used to analyse the effect of several factors on barrier repairs costs, such as barrier type, road type, posted speed and seasonal effect. The analyses were based on documented data associated with 1625 repairs conducted in four different geographical regions in Sweden during 2006. A model for calculation of average repair costs per vehicle kilometres was created. Significant differences in the barrier repair costs were found between the studied barrier types. In another study, the injuries associated with road barrier collisions and the corresponding influencing factors were analysed. The analyses in this study were based on documented data from actual barrier collisions between 2005 and 2008 in Sweden. The result was used to calculate the cost for injuries associated with barrier collisions as a part of the socio-economic cost for road barriers. The results showed significant differences in the number of injuries associated with collisions with different barrier types. To calculate and analyse life-cycle costs for road barriers a new approach was developed based on a method called “Activity-based Life-cycle Costing”. By modelling uncertainties, the presented approach gives a possibility to identify and analyse factors crucial for optimising life-cycle costs. The study showed a great potential to increase road maintenance efficiency through road design. It also showed that road components with low investment costs might not be the best choice when including maintenance and socio-economic aspects. The difficulties and problems faced during the collection of data for calculating life-cycle costs for road barriers indicated a great need for improving current data collecting and archiving procedures. The research focused on Swedish road planning and design. However, the conclusions can be applied to other Nordic countries, where weather conditions and road design practices are similar. The general methodological approaches used in this research project may be applied also to other studies.

Lifecycle environmental impact and cost analyses of steel bridge piers with seismic risk

Lifecycle approaches have found their wide applications in analyzing, evaluating and assessing technologies and management methods in the infrastructure systems. While environmental problems such as global warming have become a serious issue in the world, researchers and practicing engineers in civil engineering have to pay attention to environmental impacts as well as function, safety, cost and aesthetics in the
whole lifecycle of civil infrastructures. In addition to the normal lifecycle activities accompanied with operation and aging, the effects of natural hazards such as earthquakes with a low occurrence probability but a high
hazard loss require a full consideration in determining both lifecycle cost and lifecycle environmental impact. In this research, an approach is proposed to predetermine the lifecycle environmental impact and costs of bridges from their construction and maintenance as well as the losses and recovery after natural hazards. Based on this research, it becomes possible to quantitatively outline the roles of bridge construction, maintenance and earthquake in both environmental impact and cost in the whole lifetime of a bridge, especially their constituent parts from seismic losses and recoveries.

Statistiques appliquées en chirurgie cardiaque adulte : analyses de survie et applications du “propensity score”

L'objectif principal de ce travail est d’étudier en profondeur certaines techniques biostatistiques avancées en recherche évaluative en chirurgie cardiaque adulte. Les études ont été conçues pour intégrer les concepts d'analyse de survie, analyse de régression avec “propensity score”, et analyse de coûts. Le premier manuscrit évalue la survie après la réparation chirurgicale de la dissection aigüe de l’aorte ascendante. Les analyses statistiques utilisées comprennent : analyses de survie avec régression paramétrique des phases de risque et d'autres méthodes paramétriques (exponentielle, Weibull), semi-paramétriques (Cox) ou non-paramétriques (Kaplan-Meier) ; survie comparée à une cohorte appariée pour l’âge, le sexe et la race utilisant des tables de statistiques de survie gouvernementales ; modèles de régression avec “bootstrapping” et “multinomial logit model”. L'étude a démontrée que la survie s'est améliorée sur 25 ans en lien avec des changements dans les techniques chirurgicales et d’imagerie diagnostique. Le second manuscrit est axé sur les résultats des pontages coronariens isolés chez des patients ayant des antécédents d'intervention coronarienne percutanée. Les analyses statistiques utilisées comprennent : modèles de régression avec “propensity score” ; algorithme complexe d'appariement (1:3) ; analyses statistiques appropriées pour les groupes appariés (différences standardisées, “generalized estimating equations”, modèle de Cox stratifié). L'étude a démontrée que l’intervention coronarienne percutanée subie 14 jours ou plus avant la chirurgie de pontages coronariens n'est pas associée à des résultats négatifs à court ou long terme. Le troisième manuscrit évalue les conséquences financières et les changements démographiques survenant pour un centre hospitalier universitaire suite à la mise en place d'un programme de chirurgie cardiaque satellite. Les analyses statistiques utilisées comprennent : modèles de régression multivariée “two-way” ANOVA (logistique, linéaire ou ordinale) ; “propensity score” ; analyses de coûts avec modèles paramétriques Log-Normal. Des modèles d’analyse de « survie » ont également été explorés, utilisant les «coûts» au lieu du « temps » comme variable dépendante, et ont menés à des conclusions similaires. L'étude a démontrée que, après la mise en place du programme satellite, moins de patients de faible complexité étaient référés de la région du programme satellite au centre hospitalier universitaire, avec une augmentation de la charge de travail infirmier et des coûts.

Evaluation of the performance and cost-effectiveness of pavement sections containing open-graded base courses

Moisture induced distresses have been the prevalent distress type affecting the deterioration of both asphalt and concrete pavement sections. While various surface techniques have been employed over the years to minimize the ingress of moisture into the pavement structural sections, subsurface drainage components like open-graded base courses remain the best alternative in minimizing the time the pavement structural sections are exposed to saturated conditions. This research therefore focuses on assessing the performance and cost-effectiveness of pavement sections containing both treated and untreated open-graded aggregate base materials. Three common roadway aggregates comprising of two virgin aggregates and one recycled aggregate were investigated using four open-ended gradations and two binder types. Laboratory tests were conducted to determine the hydraulic, mechanical and durability characteristics of treated and untreated open-graded mixes made from these three aggregate types. Results of the experimental program show that for the same gradation and mix design types, limestone samples have the greatest drainage capacity, stability to traffic loads and resistance to degradation from environmental conditions like freeze-thaw. However, depending on the gradation and mix design used, all three aggregate types namely limestone, natural gravel and recycled concrete can meet the minimum coefficient of hydraulic conductivity required for good drainage in most pavements. Tests results for both asphalt and cement treated open-graded samples indicate that a percent air void content within the range of 15-25 will produce a treated open-graded base course with sufficient drainage capacity and also long term stability under both traffic and environmental loads. Using the new Mechanistic and Empirical Design Guide software, computer simulations of pavement performance were conducted on pavement sections containing these open-graded base aggregate base materials to determine how the MEPDG predicted pavement performance is sensitive to drainage. Using three truck traffic levels and four climatic regions, results of the computer simulations indicate that the predicted performance was not sensitive to the drainage characteristics of the open-graded base course. Based on the result of the MEPDG predicted pavement performance, the cost-effectiveness of the pavement sections with open-graded base was computed on the assumption that the increase service life experienced by these sections was attributed to the positive effects of subsurface drainage. The two cost analyses used gave two contrasting results with the one indicating that the inclusion of open-graded base courses can lead to substantial savings.

Downtime reduction analysis of the Australia Post flat mail optical character reader

Machine downtime, whether planned or unplanned, is intuitively costly to manufacturing organisations, but is often very difficult to quantify. The available literature showed that costing processes are rarely undertaken within manufacturing organisations. Where cost analyses have been undertaken, they generally have only valued a small proportion of the affected costs, leading to an overly conservative estimate. This thesis aimed to develop a cost of downtime model, with particular emphasis on the application of the model to Australia Post’s Flat Mail Optical Character Reader (FMOCR). The costing analysis determined a cost of downtime of $5,700,000 per annum, or an average cost of $138 per operational hour. The second section of this work focused on the use of the cost of downtime to objectively determine areas of opportunity for cost reduction on the FMOCR. This was the first time within Post that maintenance costs were considered along side of downtime for determining machine performance. Because of this, the results of the analysis revealed areas which have historically not been targeted for cost reduction. Further exploratory work was undertaken on the Flats Lift Module (FLM) and Auto Induction Station (AIS) Deceleration Belts through the comparison of the results against two additional FMOCR analysis programs. This research has demonstrated the development of a methodical and quantifiable cost of downtime for the FMOCR. This has been the first time that Post has endeavoured to examine the cost of downtime. It is also one of the very few methodologies for valuing downtime costs that has been proposed in literature. The work undertaken has also demonstrated how the cost of downtime can be incorporated into machine performance analysis with specific application to identifying high costs modules. The outcome of this report has both been the methodology for costing downtime, as well as a list of areas for cost reduction. In doing so, this thesis has outlined the two key deliverables presented at the outset of the research.

Towards integrated island management: lessons from Lau, Malaita, for the implementation of a national approach to resource management in Solomon Islands: final report

Solomon Islands has recently developed substantial policy aiming to support inshore fisheries management, conservation, climate change adaptation and ecosystem approaches to resource management. A large body of experience in community based approaches to management has developed but “upscaling” and particularly the implementation of nation-wide approaches has received little attention so far. With the emerging challenges posed by climate change and the need for ecosystem wide and integrated approaches attracting serious donor attention, a national debate on the most effective approaches to implementation is urgently needed. This report discusses potential implementation of “a cost-effective and integrated approach to resource management that is consistent with national policy and needs” based on a review of current policy and institutional structures and examination of a recent case study from Lau, Malaita using stakeholder, transaction and financial cost analyses.

Collaboration on procurement of e-content between the National Health Service and higher education in the UK

Urquhart, C. J., Cox, A. M.& Spink, S. (2007). Collaboration on procurement of e-content between the National Health Service and higher education in the UK. Interlending & Document Supply, 35(3), 164-170. Sponsorship: JISC, LKDN

Diferencias en costo efectividad del cuidado paliativo domiciliario frente a la atención convencional hospitalaria para el manejo de enfermedades crónicas en fase terminal

En Colombia la dinámica poblacional ha experimentado cambios a través de los años; lo cual modifica las características epidemiológicas y los perfiles de morbimortalidad de la población, aumentando la incidencia y prevalencia de enfermedades crónicas de difícil pronóstico dentro de la población; siendo estos grupos etarios hacía quienes deben destinarse nuevas modalidades de atención y soporte paliativo. Se realizó una revisión sistemática de diversos artículos, clasificados con niveles de evidencia I y II; cuyas variables de análisis fueron: El lugar de fallecimiento del paciente, alivio de la sintomatología, nivel de satisfacción del paciente y sus cuidadores con los servicios recibidos, número de ingresos hospitalarios independientemente de la causa y días promedio de estancia hospitalaria. El 88% de los pacientes que fueron vinculados a la atención domiciliaria falleció en su hogar; el 68% refirió haber experimentado disminución en la intensidad de al menos 2 síntomas como resultado de la atención en casa. El nivel de satisfacción para el cuidado en casa puntuó 19 puntos porcentuales por encima de la calificación que obtuvo el manejo hospitalario. El 23% de los pacientes tratados en su hogar, requirió al menos una hospitalización durante el manejo; mostrando una disminución en el tiempo de estancia hospitalaria de 3.4 días promedio. El manejo paliativo domiciliario de pacientes crónicos en fase terminal, no sólo es una alternativa en la reducción de costos para el sistema de salud, sino que es un factor protector de tipo emocional que refleja también una importante disminución de los riesgos de la hospitalización.

Sistemas de criação para o Acará-bandeira Pterophyllum scalare

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

An assessment of the economic impact of climate change on the Agriculture, Health and Tourism sectors in Saint Lucia

This report analyses the agriculture, health and tourism sectors in Saint Lucia to assess the potential economic impacts of climate change on the sectors. The fundamental aim of this report is to assist with the development of strategies to deal with the potential impact of climate change in Saint Lucia. It also has the potential to provide essential input for identifying and preparing policies and strategies to help advance the Caribbean subregion closer to solving problems associated with climate change and attaining individual and regional sustainable development goals. Some of the key anticipated impacts of climate change for the Caribbean include elevated air and sea-surface temperatures, sea-level rise, possible changes in extreme events and a reduction in freshwater resources. The economic impact of climate change on the three sectors was estimated for the A2 and B2 IPCC scenarios until 2050. An evaluation of various adaptation strategies for each sector was also undertaken using standard evaluation techniques. The key subsectors in agriculture are expected to have mixed impacts under the A2 and B2 scenarios. Banana, fisheries and root crop outputs are expected to fall with climate change, but tree crop and vegetable production are expected to rise. In aggregate, in every decade up to 2050, these sub-sectors combined are expected to experience a gain under climate change with the highest gains under A2. By 2050, the cumulative gain under A2 is calculated as approximately US$389.35 million and approximately US$310.58 million under B2, which represents 17.93% and 14.30% of the 2008 GDP respectively. This result was unexpected and may well be attributed to the unavailability of annual data that would have informed a more robust assessment. Additionally, costs to the agriculture sector due to tropical cyclones were estimated to be $6.9 million and $6.2 million under the A2 and B2 scenarios, respectively. There are a number of possible adaptation strategies that can be employed by the agriculture sector. The most attractive adaptation options, based on the benefit-cost ratio are: (1) Designing and implementation of holistic water management plans (2) Establishment of systems of food storage and (3) Establishment of early warning systems. Government policy should focus on the development of these adaption options where they are not currently being pursued and strengthen those that have already been initiated, such as the mainstreaming of climate change issues in agricultural policy. The analysis of the health sector placed focus on gastroenteritis, schistosomiasis, ciguatera poisoning, meningococal meningitis, cardiovascular diseases, respiratory diseases and malnutrition. The results obtained for the A2 and B2 scenarios demonstrate the potential for climate change to add a substantial burden to the health system in the future, a factor that will further compound the country’s vulnerability to other anticipated impacts of climate change. Specifically, it was determined that the overall Value of Statistical Lives impacts were higher under the A2 scenario than the B2 scenario. A number of adaptation cost assumptions were employed to determine the damage cost estimates using benefit-cost analysis. The benefit-cost analysis suggests that expenditure on monitoring and information provision would be a highly efficient step in managing climate change and subsequent increases in disease incidence. Various locations in the world have developed forecasting systems for dengue fever and other vector-borne diseases that could be mirrored and implemented. Combining such macro-level policies with inexpensive micro-level behavioural changes may have the potential for pre-empting the re-establishment of dengue fever and other vector-borne epidemic cycles in Saint Lucia. Although temperature has the probability of generating significant excess mortality for cardiovascular and respiratory diseases, the power of temperature to increase mortality largely depends on the education of the population about the harmful effects of increasing temperatures and on the existing incidence of these two diseases. For these diseases it is also suggested that a mix of macro-level efforts and micro-level behavioural changes can be employed to relieve at least part of the threat that climate change poses to human health. The same principle applies for water and food-borne diseases, with the improvement of sanitation infrastructure complementing the strengthening of individual hygiene habits. The results regarding the tourism sector imply that the tourism climatic index was likely to experience a significant downward shift in Saint Lucia under the A2 as well as the B2 scenario, indicative of deterioration in the suitability of the island for tourism. It is estimated that this shift in tourism features could cost Saint Lucia about 5 times the 2009 GDP over a 40-year horizon. In addition to changes in climatic suitability for tourism, climate change is also likely to have important supply-side effects on species, ecosystems and landscapes. Two broad areas are: (1) coral reefs, due to their intimate link to tourism, and, (2) land loss, as most hotels tend to lie along the coastline. The damage related to coral reefs was estimated at US$3.4 billion (3.6 times GDP in 2009) under the A2 scenario and US$1.7 billion (1.6 times GDP in 2009) under the B2 scenario. The damage due to land loss arising from sea level rise was estimated at US$3.5 billion (3.7 times GDP) under the A2 scenario and US$3.2 billion (3.4 times GDP) under the B2 scenario. Given the potential for significant damage to the industry a large number of potential adaptation measures were considered. Out of these a short-list of 9 potential options were selected by applying 10 evaluation criteria. Using benefit-cost analyses 3 options with positive ratios were put forward: (1) increased recommended design speeds for new tourism-related structures; (2) enhanced reef monitoring systems to provide early warning alerts of bleaching events, and, (3) deployment of artificial reefs or other fish-aggregating devices. While these options had positive benefit-cost ratios, other options were also recommended based on their non-tangible benefits. These include the employment of an irrigation network that allows for the recycling of waste water, development of national evacuation and rescue plans, providing retraining for displaced tourism workers and the revision of policies related to financing national tourism offices to accommodate the new climate realities.

Economic evaluation of latent tuberculosis infection screening among health care workers in Houston

Since interferon-gamma release assays (IGRAs) were introduced in the 2000's, tuberculin skin testing (TST) and IGRAs have been used in various latent tuberculosis infection (LTBI) screening settings. IGRAs are laboratory-based tests and are considered not to be affected by previous Bacille de Calmette et Guérin (BCG) vaccination; however, they are more costly when compared directly with TST, which does not require specimen processing in a laboratory. This study aimed to examine TST and two types of IGRAs, QuantiFERON-TB Gold in Tube (QFT-GIT) and T-SPOT. TB (TSPOT), from an economic viewpoint. Firstly, a systematic literature review was conducted to identify cost related analyses of LTBI screening. Secondly, specific cost information detailing each test's items and labor was collected from an LTBI screening program of health care workers in Houston, and the cost of each test was computed. Thirdly, using the computed cost estimate of each test, cost-effectiveness analyses were conducted to compare TST and IGRAs.^ A literature search showed that a limited number of studies have been conducted, but the IGRA's economic advantages were common among studies. Cost analyses showed that IGRAs were much more costly than TST. The results were consistent with previous studies. In cost-effectiveness analyses, where test cost and consequential TB-related cost were considered, IGRAs showed variable advantages over TST depending on the targeted population. When only non BCG-vaccinated people were considered, TST was the least costly option among the three tests. On the other hand, when only BCG-vaccinated people were considered, IGRAs were less costly options. These results were mostly consistent even with varying assumption parameters.^ IGRAs can be more costly than TST, but their economic disadvantages are alleviated when the target population was BCG-vaccinated. Based on current knowledge, IGRAs may be recommended in a population where the BCG history is mixed. Additional studies are needed to better understand IGRA's reliability among low-incidence and low-risk populations in which background TB prevalence is low.^

A Simplified Energy Consumption Model for Fibre-Based Next Generation Access Networks

Presentación realizada en el PhD Seminar del ITS 2011 en Budapest. ICTs (Information and Communication Technologies) currently account for 2% of total carbon emissions. However, although modern standards require strict measures to reduce energy consumption across all industrial and services sectors, the ICT sector also faces an increase in services and bandwidth demand. The deployment of Next Generation Networks (NGN) will be the answer to this new demand; more specifically, Next Generation Access Networks (NGANs) will provide higher bandwidth access to users. Several policy and cost analyses are being carried out to understand the risks and opportunities of new deployments, but the question of what role energy consumption plays in NGANs seems off the table. Thus, this paper proposes a model to analyse the energy consumption of the main fibre-based NGAN architectures: Fibre To The House (FTTH), in both Passive Optical Network (PON) and Point-to-Point (PtP) variations, and FTTx/VDSL. The aim of this analysis is to provide deeper insight on the impact of new deployments on the energy consumption of the ICT sector and the effects of energy consumption on the life-cycle cost of NGANs. The paper also presents an energy consumption comparison of the presented architectures, particularised to the specific geographic and demographic distribution of users of Spain but easily extendable to other countries.