Clinical and Cost-Effectiveness of Procalcitonin Test for Prodromal Meningococcal Disease-A Meta-Analysis

BACKGROUND: Despite vaccines and improved medical intensive care, clinicians must continue to be vigilant of possible Meningococcal Disease in children. The objective was to establish if the procalcitonin test was a cost-effective adjunct for prodromal Meningococcal Disease in children presenting at emergency department with fever without source.

METHODS AND FINDINGS: Data to evaluate procalcitonin, C-reactive protein and white cell count tests as indicators of Meningococcal Disease were collected from six independent studies identified through a systematic literature search, applying PRISMA guidelines. The data included 881 children with fever without source in developed countries.The optimal cut-off value for the procalcitonin, C-reactive protein and white cell count tests, each as an indicator of Meningococcal Disease, was determined. Summary Receiver Operator Curve analysis determined the overall diagnostic performance of each test with 95% confidence intervals. A decision analytic model was designed to reflect realistic clinical pathways for a child presenting with fever without source by comparing two diagnostic strategies: standard testing using combined C-reactive protein and white cell count tests compared to standard testing plus procalcitonin test. The costs of each of the four diagnosis groups (true positive, false negative, true negative and false positive) were assessed from a National Health Service payer perspective. The procalcitonin test was more accurate (sensitivity=0.89, 95%CI=0.76-0.96; specificity=0.74, 95%CI=0.4-0.92) for early Meningococcal Disease compared to standard testing alone (sensitivity=0.47, 95%CI=0.32-0.62; specificity=0.8, 95% CI=0.64-0.9). Decision analytic model outcomes indicated that the incremental cost effectiveness ratio for the base case was £-8,137.25 (US $ -13,371.94) per correctly treated patient.

CONCLUSIONS: Procalcitonin plus standard recommended tests, improved the discriminatory ability for fatal Meningococcal Disease and was more cost-effective; it was also a superior biomarker in infants. Further research is recommended for point-of-care procalcitonin testing and Markov modelling to incorporate cost per QALY with a life-time model.

The cost of treating severe refractory asthma in the UK: an economic analysis from the British Thoracic Society Difficult Asthma Registry

Severe refractory asthma poses a substantial burden in terms of healthcare costs but relatively little is known about the factors which drive these costs. This study uses data from the British Thoracic Society Difficult Asthma Registry (n=596) to estimate direct healthcare treatment costs from an National Health Service perspective and examines factors that explain variations in costs. Annual mean treatment costs among severe refractory asthma patients were £2912 (SD £2212) to £4217 (SD £2449). Significant predictors of costs were FEV1% predicted, location of care, maintenance oral corticosteroid treatment and body mass index. Treating individuals with severe refractory asthma presents a substantial cost to the health service.

Numerical Method for Cost-Weight Optimisation of Stringer-Skin Panels

The need to integrate cost into the early product definition process as an engineering parameter is addressed. The application studied is a fuselage panel that is typical for commercial transport regional jets. Consequently, a semi-empirical numerical analysis using reference data was coupled to model the structural integrity of thin-walled structures with regard to material failure and buckling: skin, stringer, flexural, and interrivet. The optimization process focuses on direct operating cost (DOC) as a function of acquisition cost and fuel burn. It was found that the ratio of acquisition cost to fuel burn was typically 4:3 and that there was a 10% improvement in the DOC for the minimal DOC condition over the minimal weight condition because of the manufacturing cost saving from having a reduced number of larger-area stringers and a slightly thicker skin than that preferred by the minimal weight condition. Also note that the minimal manufacturing cost condition was slightly better than the minimal weight condition, which highlights the key finding: The traditional minimal weight condition is a dated and suboptimal approach to airframe structural design.

Cost Estimation of Machined Parts within an Aerospace Supply Chain

A generic, hierarchical, and multifidelity unit cost of acquisition estimating methodology for outside production machined parts is presented. The originality of the work lies with the method’s inherent capability of being able to generate multilevel and multifidelity cost relations for large volumes of parts utilizing process, supply chain costing data, and varying degrees of part design definition information. Estimates can be generated throughout the life cycle of a part using different grades of the combined information available. Considering design development for a given part, additional design definition may be used as it becomes available within the developed method to improve the quality of the resulting estimate. Via a process of analogous classification, parts are classified into groups of increasing similarity using design-based descriptors. A parametric estimating method is then applied to each subgroup of the machined part commodity in the direction of improved classification and using which, a relationship which links design variables to manufacturing cycle time may be generated. A rate cost reflective of the supply chain is then applied to the cycle time estimate for a given part to arrive at an estimate of make cost which is then totalled with the material and treatments cost components respectively to give an overall estimate of unit acquisition cost. Both the rate charge applied and the treatments cost calculated for a given procured part is derived via the use of ratio analysis.

Review of Aerospace Engineering Cost Modelling: The Genetic Causal Approach

The primary intention of this paper is to review the current state of the art in engineering cost modelling as applied to aerospace. This is a topic of current interest and in addressing the literature, the presented work also sets out some of the recognised definitions of cost that relate to the engineering domain. The paper does not attempt to address the higher-level financial sector but rather focuses on the costing issues directly relevant to the engineering process, primarily those of design and manufacture. This is of more contemporary interest as there is now a shift towards the analysis of the influence of cost, as defined in more engineering related terms; in an attempt to link into integrated product and process development (IPPD) within a concurrent engineering environment. Consequently, the cost definitions are reviewed in the context of the nature of cost as applicable to the engineering process stages: from bidding through to design, to manufacture, to procurement and ultimately, to operation. The linkage and integration of design and manufacture is addressed in some detail. This leads naturally to the concept of engineers influencing and controlling cost within their own domain rather than trusting this to financers who have little control over the cause of cost. In terms of influence, the engineer creates the potential for cost and in a concurrent environment this requires models that integrate cost into the decision making process.

Aircraft Cost Modelling using the Genetic Causal Technique within a Systems Engineering Approach

The paper is primarily concerned with the modelling of aircraft manufacturing cost. The aim is to establish an integrated life cycle balanced design process through a systems engineering approach to interdisciplinary analysis and control. The cost modelling is achieved using the genetic causal approach that enforces product family categorisation and the subsequent generation of causal relationships between deterministic cost components and their design source. This utilises causal parametric cost drivers and the definition of the physical architecture from the Work Breakdown Structure (WBS) to identify product families. The paper presents applications to the overall aircraft design with a particular focus on the fuselage as a subsystem of the aircraft, including fuselage panels and localised detail, as well as engine nacelles. The higher level application to aircraft requirements and functional analysis is investigated and verified relative to life cycle design issues for the relationship between acquisition cost and Direct Operational Cost (DOC), for a range of both metal and composite subsystems. Maintenance is considered in some detail as an important contributor to DOC and life cycle cost. The lower level application to aircraft physical architecture is investigated and verified for the WBS of an engine nacelle, including a sequential build stage investigation of the materials, fabrication and assembly costs. The studies are then extended by investigating the acquisition cost of aircraft fuselages, including the recurring unit cost and the non-recurring design cost of the airframe sub-system. The systems costing methodology is facilitated by the genetic causal cost modeling technique as the latter is highly generic, interdisciplinary, flexible, multilevel and recursive in nature, and can be applied at the various analysis levels required of systems engineering. Therefore, the main contribution of paper is a methodology for applying systems engineering costing, supported by the genetic causal cost modeling approach, whether at a requirements, functional or physical level.

The Cost of Sustainability Capital and the Creation of Sustainable Value by Companies

We develop and apply a valuation methodology to calculate the cost of sustainability capital, and, eventually, sustainable value creation of companies. Sustainable development posits that decisions must take into account all forms of capital rather than just economic capital. We develop a methodology that allows calculation of the costs that are associated with the use of different forms of capital. Our methodology borrows the idea from financial economics that the return on capital has to cover the cost of capital. Capital costs are determined as opportunity costs, that is, the forgone returns that would have been created by alternative investments. We apply and extend the logic of opportunity costs to the valuation not only of economic capital but also of other forms of capital. This allows (a) integrated analysis of use of different forms of capital based on a value-based aggregation of different forms of capital, (b) determination of the opportunity cost of a bundle of different forms of capital used in a company, called cost of sustainability capital, (c) calculation of sustainability efficiency of companies, and (d) calculation of sustainable value creation, that is, the value above the cost of sustainability capital. By expanding the well-established logic of the valuation of economic capital in financial markets to cover other forms of capital, we provide a methodology that allows determination of the most efficient allocation of sustainability capital for sustainable value creation in companies. We demonstrate the practicability of the methodology by the valuation of the sustainability performance of British Petroleum (BP).

A generic tool for cost estimating in aircraft design

A methodology to estimate the cost implications of design decisions by integrating cost as a design parameter at an early design stage is presented. The model is developed on a hierarchical basis, the manufacturing cost of aircraft fuselage panels being analysed in this paper. The manufacturing cost modelling is original and relies on a genetic-causal method where the drivers of each element of cost are identified relative to the process capability. The cost model is then extended to life cycle costing by computing the Direct Operating Cost as a function of acquisition cost and fuel burn, and coupled with a semi-empirical numerical analysis using Engineering Sciences Data Unit reference data to model the structural integrity of the fuselage shell with regard to material failure and various modes of buckling. The main finding of the paper is that the traditional minimum weight condition is a dated and sub-optimal approach to airframe structural design.

Uncertainty and Sensitivity Analysis in Aircraft Operating Costs in Structural Design Optimization

The paper focuses on the development of an aircraft design optimization methodology that models uncertainty and sensitivity analysis in the tradeoff between manufacturing cost, structural requirements, andaircraft direct operating cost.Specifically,ratherthanonlylooking atmanufacturingcost, direct operatingcost is also consideredintermsof the impact of weight on fuel burn, in addition to the acquisition cost to be borne by the operator. Ultimately, there is a tradeoff between driving design according to minimal weight and driving it according to reduced manufacturing cost. Theanalysis of cost is facilitated withagenetic-causal cost-modeling methodology,andthe structural analysis is driven by numerical expressions of appropriate failure modes that use ESDU International reference data. However, a key contribution of the paper is to investigate the modeling of uncertainty and to perform a sensitivity analysis to investigate the robustness of the optimization methodology. Stochastic distributions are used to characterize manufacturing cost distributions, andMonteCarlo analysis is performed in modeling the impact of uncertainty on the cost modeling. The results are then used in a sensitivity analysis that incorporates the optimization methodology. In addition to investigating manufacturing cost variance, the sensitivity of the optimization to fuel burn cost and structural loading are also investigated. It is found that the consideration of manufacturing cost does make an impact and results in a different optimal design configuration from that delivered by the minimal-weight method. However, it was shown that at lower applied loads there is a threshold fuel burn cost at which the optimization process needs to reduce weight, and this threshold decreases with increasing load. The new optimal solution results in lower direct operating cost with a predicted savings of 640=m2 of fuselage skin over the life, relating to a rough order-of-magnitude direct operating cost savings of $500,000 for the fuselage alone of a small regional jet. Moreover, it was found through the uncertainty analysis that the principle was not sensitive to cost variance, although the margins do change.

Irish Credit Unions: Investigating performance determinants and the opportunity cost of regulatory compliance

The study investigates how producer-specific environmental factors influence the performance of Irish credit unions. The empirical analysis uses a two-stage approach. The first stage measures efficiency by a data envelopment analysis (DEA) estimator, which explicitly incorporates the production of undesirable outputs such as bad loans in the modelling, and the second stage uses truncated regression to infer how various factors influence the (bias-corrected) estimated efficiency. A key finding of the analysis is that 68% of Irish credit unions do not incur an extra opportunity cost in meeting regulatory guidance on bad debt.