An analysis of protocols and publications suggested that most discontinuations of clinical trials were not based on preplanned interim analyses or stopping rules.

OBJECTIVES To investigate the frequency of interim analyses, stopping rules, and data safety and monitoring boards (DSMBs) in protocols of randomized controlled trials (RCTs); to examine these features across different reasons for trial discontinuation; and to identify discrepancies in reporting between protocols and publications. STUDY DESIGN AND SETTING We used data from a cohort of RCT protocols approved between 2000 and 2003 by six research ethics committees in Switzerland, Germany, and Canada. RESULTS Of 894 RCT protocols, 289 prespecified interim analyses (32.3%), 153 stopping rules (17.1%), and 257 DSMBs (28.7%). Overall, 249 of 894 RCTs (27.9%) were prematurely discontinued; mostly due to reasons such as poor recruitment, administrative reasons, or unexpected harm. Forty-six of 249 RCTs (18.4%) were discontinued due to early benefit or futility; of those, 37 (80.4%) were stopped outside a formal interim analysis or stopping rule. Of 515 published RCTs, there were discrepancies between protocols and publications for interim analyses (21.1%), stopping rules (14.4%), and DSMBs (19.6%). CONCLUSION Two-thirds of RCT protocols did not consider interim analyses, stopping rules, or DSMBs. Most RCTs discontinued for early benefit or futility were stopped without a prespecified mechanism. When assessing trial manuscripts, journals should require access to the protocol.

Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

Uncertainty analysis of cost effectiveness in a tailored intervention to promote screening for colorectal cancer

Background. Screening for colorectal cancer (CRC) is considered cost effective but screening compliance in the US remains low. There have been very few studies on economic analyses of screening promotion strategies for colorectal cancer. The main aim of the current study is to conduct a cost effectiveness analysis (CEA) and examine the uncertainty involved in the results of the CEA of a tailored intervention to promote screening for CRC among patients of a multispeciality clinic in Houston, TX. ^ Methods. The two intervention arms received a PC based tailored program and web based educational information to promote CRC screening. The incremental cost of implementing a tailored PC based program was compared to the website based education and the status quo of no intervention for each unit of effect after 12 months of delivering the intervention. Uncertainty analysis in the point estimates of cost and effect was conducted using nonparametric bootstrapping. ^ Results. The cost of implementing a web based educational intervention was $36.00 per person and the cost of the tailored PC based interactive intervention was $43.00 per person. The additional cost per person screened for the web-based strategy was $2374 and the effect of the tailored intervention was negative. ^

Improving the Quality of Life of spousal caregivers of stroke survivors: A cost effectiveness analysis

Back ground and Purpose. There is a growing consensus among health care researchers that Quality of Life (QoL) is an important outcome and, within the field of family caregiving, cost effectiveness research is needed to determine which programs have the greatest benefit for family members. This study uses a multidimensional approach to measure the cost effectiveness of a multicomponent intervention designed to improve the quality of life of spousal caregivers of stroke survivors. Methods. The CAReS study (Committed to Assisting with Recovery after Stroke) was a 5-year prospective, longitudinal intervention study for 159 stroke survivors and their spousal caregivers upon discharge of the stroke survivor from inpatient rehabilitation to their home. CAReS cost data were analyzed to determine the incremental cost of the intervention per caregiver. The mean values of the quality-of-life predictor variables of the intervention group of caregivers were compared to the mean values of usual care groups found in the literature. Significant differences were then divided into the cost of the intervention per caregiver to calculate the incremental cost effectiveness ratio for each predictor variable. Results. The cost of the intervention per caregiver was approximately $2,500. Statistically significant differences were found between the mean scores for the Perceived Stress and Satisfaction with Life scales. Statistically significant differences were not found between the mean scores for the Self Reported Health Status, Mutuality, and Preparedness scales. Conclusions. This study provides a prototype cost effectiveness analysis on which researchers can build. Using a multidimensional approach to measure QoL, as used in this analysis, incorporates both the subjective and objective components of QoL. Some of the QoL predictor variable scores were significantly different between the intervention and comparison groups, indicating a significant impact of the intervention. The estimated cost of the impact was also examined. In future studies, a scale that takes into account both the dimensions and the weighting each person places on the dimensions of QoL should be used to provide a single QoL score per participant. With participant level cost and outcome data, uncertainty around each cost-effectiveness ratio can be calculated using the bias-corrected percentile bootstrapping method and plotted to calculate the cost-effectiveness acceptability curves.^

Towards data-aware cost-driven adaptation for service orchestrations.

Several activities in service oriented computing, such as automatic composition, monitoring, and adaptation, can benefit from knowing properties of a given service composition before executing them. Among these properties we will focus on those related to execution cost and resource usage, in a wide sense, as they can be linked to QoS characteristics. In order to attain more accuracy, we formulate execution costs / resource usage as functions on input data (or appropriate abstractions thereof) and show how these functions can be used to make better, more informed decisions when performing composition, adaptation, and proactive monitoring. We present an approach to, on one hand, synthesizing these functions in an automatic fashion from the definition of the different orchestrations taking part in a system and, on the other hand, to effectively using them to reduce the overall costs of non-trivial service-based systems featuring sensitivity to data and possibility of failure. We validate our approach by means of simulations of scenarios needing runtime selection of services and adaptation due to service failure. A number of rebinding strategies, including the use of cost functions, are compared.

Termination and cost analysis: Complexity and precision issues

The research in this thesis is related to static cost and termination analysis. Cost analysis aims at estimating the amount of resources that a given program consumes during the execution, and termination analysis aims at proving that the execution of a given program will eventually terminate. These analyses are strongly related, indeed cost analysis techniques heavily rely on techniques developed for termination analysis. Precision, scalability, and applicability are essential in static analysis in general. Precision is related to the quality of the inferred results, scalability to the size of programs that can be analyzed, and applicability to the class of programs that can be handled by the analysis (independently from precision and scalability issues). This thesis addresses these aspects in the context of cost and termination analysis, from both practical and theoretical perspectives. For cost analysis, we concentrate on the problem of solving cost relations (a form of recurrence relations) into closed-form upper and lower bounds, which is the heart of most modern cost analyzers, and also where most of the precision and applicability limitations can be found. We develop tools, and their underlying theoretical foundations, for solving cost relations that overcome the limitations of existing approaches, and demonstrate superiority in both precision and applicability. A unique feature of our techniques is the ability to smoothly handle both lower and upper bounds, by reversing the corresponding notions in the underlying theory. For termination analysis, we study the hardness of the problem of deciding termination for a speci�c form of simple loops that arise in the context of cost analysis. This study gives a better understanding of the (theoretical) limits of scalability and applicability for both termination and cost analysis.

Low-cost retrofitting solutions for RC frames using masonry infill panels

A large number of reinforced concrete (RC) frame structures built in earthquake-prone areas such as Haiti are vulnerable to strong ground motions. Structures in developing countries need low-cost seismic retrofit solutions to reduce their vulnerability. This paper investigates the feasibility of using masonry infill walls to reduce deformations and damage caused by strong ground motions in brittle and weak RC frames designed only for gravity loads. A numerical experiment was conducted in which several idealized prototypes representing RC frame structures of school buildings damaged during the Port-au-Prince earthquake (Haiti, 2010) were strengthened by adding elements representing masonry infill walls arranged in different configurations. Each configuration was characterized by the ratio Rm of the area of walls in the direction of the ground motion (in plan) installed in each story to the total floor area. The numerical representations of these idealized RC frame structures with different values of Rm were (hypothetically) subjected to three major earthquakes with peak ground accelerations of approximately 0.5g. The results of the non-linear dynamic response analyses were summarized in tentative relationships between Rm and four parameters commonly used to characterize the seismic response of structures: interstory drift, Park and Ang indexes of damage, and total amount of energy dissipated by the main frame. It was found that Rm=4% is a reasonable minimum design value for seismic retrofitting purposes in cases in which available resources are not sufficient to afford conventional retrofit measures.

Aprovechamiento térmico de residuos estériles de carbón para generación eléctrica mediante tecnologías de combustión y gasificación eficientes y con mínimo impacto ambiental

La presente tesis doctoral, “Aprovechamiento térmico de residuos estériles de carbón para generación eléctrica mediante tecnologías de combustión y gasificación eficientes y con mínimo impacto ambiental”, desarrolla la valorización energética de los residuos del carbón, estériles de carbón, producidos durante las etapas de extracción y lavado del carbón. El sistema energético se encuentra en una encrucijada, estamos asistiendo a un cambio en el paradigma energético y, en concreto, en el sector de la generación eléctrica. Se precipita un cambio en la generación y el consumo eléctricos. Una mayor concienciación por la salud está forzando la contención y eliminación de agentes contaminantes que se generan por la utilización de combustibles fósiles de la forma en la que se viene haciendo. Aumenta la preocupación por el cambio climático y por contener en 2°C el aumento de la temperatura de la Tierra para final de este siglo, circunstancia que está impulsando el desarrollo e implantación definitiva de tecnología de control y reducción de emisiones CO2. Generar electricidad de una manera sostenible se está convirtiendo en una obligación. Esto se materializa en generar electricidad respetando el medioambiente, de una forma eficiente en la utilización de los recursos naturales y a un coste competitivo, pensando en el desarrollo de la sociedad y en el beneficio de las personas. En la actualidad, el carbón es la principal fuente de energía utilizada para generar electricidad, y su empleo presenta la forma de energía más barata para mejorar el nivel de vida de cualquier grupo y sociedad. Además, se espera que el carbón siga presente en el mix de generación eléctrica, manteniendo una significativa presencia y extrayéndose en elevadas cantidades. Pero la producción de carbón lleva asociada la generación de un residuo, estéril, que se produce durante la extracción y el lavado del mineral de carbón. Durante décadas se ha estudiado la posibilidad de utilizar el estéril y actualmente se utiliza, en un limitado porcentaje, en la construcción de carreteras, terraplenes y rellenos, y en la producción de algunos materiales de construcción. Esta tesis doctoral aborda la valorización energética del estéril, y analiza el potencial aprovechamiento del residuo para generar electricidad, en una instalación que integre tecnología disponible para minimizar el impacto medioambiental. Además, persigue aprovechar el significativo contenido en azufre que presenta el estéril para producir ácido sulfúrico (H2SO4) como subproducto de la instalación, un compuesto químico muy demandado por la industria de los fertilizantes y con multitud de aplicaciones en otros mercados. Se ha realizado el análisis de caracterización del estéril, los parámetros significativos y los valores de referencia para su empleo como combustible, encontrándose que su empleo como combustible para generar electricidad es posible. Aunque en España se lleva extrayendo carbón desde principios del siglo XVIII, se ha evaluado para un período más reciente la disponibilidad del recurso en España y la normativa existente que condiciona su aplicación en el territorio nacional. Para el período evaluado, se ha calculado que podrían estar disponibles más de 68 millones de toneladas de estéril susceptibles de ser valorizados energéticamente. Una vez realizado el análisis de la tecnología disponible y que podría considerarse para emplear el estéril como combustible, se proponen cuatro configuraciones posibles de planta, tres de ellas basadas en un proceso de combustión y una de ellas en un proceso de gasificación. Tras evaluar las cuatro configuraciones por su interés tecnológico, innovador y económico, se desarrolla el análisis conceptual de una de ellas, basada en un proceso de combustión. La instalación propuesta tiene una capacidad de 65 MW y emplea como combustible una mezcla de carbón y estéril en relación 20/80 en peso. La instalación integra tecnología para eliminar en un 99,8% el SO2 presente en el gas de combustión y en más de un 99% las partículas generadas. La instalación incorpora una unidad de producción de H2SO4, capaz de producir 18,5 t/h de producto, y otra unidad de captura para retirar un 60% del CO2 presente en la corriente de gases de combustión, produciendo 48 tCO2/h. La potencia neta de la planta es 49,7 MW. Se ha calculado el coste de inversión de la instalación, y su cálculo resulta en un coste de inversión unitario de 3.685 €/kW. ABSTRACT The present doctoral thesis, “Thermal utilisation of waste coal for electricity generation by deployment of efficient combustion and gasification technologies with minimum environmental impact”, develops an innovative waste-to-energy concept of waste coals produced during coal mining and washing. The energy system is at a dilemma, we are witnessing a shift in the energy paradigm and specifically in the field of electricity generation. A change in the generation and electrical consumption is foreseen. An increased health consciousness is forcing the containment and elimination of pollutants that are generated by the use of fossil fuels in the way that is being done. Increasing concern about climate change and to contain the rise of global temperature by 2°C by the end of this century, is promoting the development and final implementation of technology to control and reduce the CO2 emission. Electricity generation in a sustainable manner is becoming an obligation. This concept materialised in generating electricity while protecting the environment and deployment of natural resources at a competitive cost, considering the development of society and people´s benefit. Currently, coal is the main source of energy employ to generate electricity, and its use represents the most cost competitive form of energy to increase the standard of living of any group or society. Moreover, coal will keep playing a key role in the global electricity generation mix, maintaining a significant presence and being extracting in large amounts. However, coal production implies the production of waste, termed waste coal or culm in Pennsylvania anthracite extraction, produced during coal mining and coal washing activities. During the last decades, the potential use of waste coal has been studied, and currently, in a limited amount, waste coal is used in roads construction, embankments and fillings, and to produce some construction materials. This doctoral thesis evaluates the waste to energy of waste coals and assesses its potential use to generate electricity, implementing available technology to minimise the environment impact. Additionally, it pursues the significant advantage that presents sulphur content in waste coal to produce sulphuric acid (H2SO4) as a byproduct of the waste-to-energy process, a chemical compound highly demanded by the fertiliser industry and many applications in other markets. It analyses the characteristics of waste coal, and assesses the significant parameters and reference values for its use as fuel, being its fuel use for electricity generation very possible. While mining coal is taking place in Spain since the 1700s, it has been evaluated for a more recent period the waste coal available in Spain and the existing legislation that affects its application and deploy to generate electricity in the country. For the evaluation period has been calculated that may be available more than 68 million tons of waste coal that can be waste-toenergy. The potential available technology to deploy waste coal as fuel has been evaluated and assessed. After considering this, the doctoral thesis proposes four innovative alternatives of facility configuration, three of them based on a combustion process and one in a gasification process. After evaluating the four configurations for its technological, innovative and economic interest, the conceptual analysis of one of alternatives, based on a combustion process, takes place. The proposed alternative facility developed has a capacity of 65 MW, using as fuel a mixture of coal and waste coal 80/20 by weight. The facility comprises technology to remove 99.8% SO2 present in the flue gas and more than 99% of the particles. The facility includes a unit capable of producing 18.5 t/h of H2SO4, and another capture facility, removing 60% of CO2 present in the flue gas stream, producing 48 tCO2/h. The net capacity of the power station is 49.7 MW. The facility unitary cost of investment is 3,685 €/kW.

Signaling of need, sibling competition, and the cost of honesty

Young birds and mammals frequently solicit food by means of extravagant and apparently costly begging displays. Much attention has been devoted to the idea that these displays are honest signals of need, and that their apparent cost serves to maintain their honesty. Recent analyses, however, have shown that the cost needed to maintain a fully informative, honest signal may often be so great that both offspring (signaler) and parent (receiver) would do better to refrain from communication. This apparently calls into question the relevance of the costly signaling hypothesis. Here, I show that this argument overlooks the impact of sibling competition. When multiple signalers must compete for the attention of a receiver (as is commonly the case in parent–offspring interactions), I show that (all other things being equal) individual equilibrium signal costs will typically be lower. The greater the number of competitors, the smaller the mean cost, though the maximum level of signal intensity employed by very needy signalers may actually increase with the number of competitors. At the same time, costs become increasingly sensitive to relatedness among signalers as opposed to relatedness between signalers and receivers. As a result of these trends, signaling proves profitable for signalers under a much wider range of conditions when there is competition (though it is still likely to be unprofitable for receivers).

The impact of the internet on the pricing strategies of the European low cost airlines

This study seeks to analyse the price determination of low cost airlines in Europe and the effect that Internet has on this strategy. The outcomes obtained reveal that both users and companies benefit from the use of ICTs in the purchase and sale of airline tickets: the Internet allows consumers to increase their bargaining power comparing different airlines and choosing the most competitive flight, while companies can easily check the behaviour of users to adapt their pricing strategies using internal information. More than 2500 flights of the largest European low cost airlines have been used to carry out the study. The study revealed that the most significant variables for understanding pricing strategies were the number of rivals, the behaviour of the demand and the associated costs. The results indicated that consumers should buy their tickets before 25 days prior to departure.

The Impact of BIM on the Distribution of Cost and Return on Investment in UK Construction Projects

It has been widely documented that when Building Information Modelling (BIM) is used, there is a shift in effort to the design phase. Little investigation into the impact of this shift in effort has been done and how it impacts on costs. It can be difficult to justify the increased expenditure on BIM in a market that is heavily driven by costs. There are currently studies attempting to quantify the return on investment (ROI) for BIM for which these returns can be seen to balance out the shift in efforts and costs to the design phase. The studies however quantify the ROI based on the individual stakeholder’s investment without consideration for the impact that the use of BIM from their project partners may have on their own profitability. In this study, a questionnaire investigated opinions and experience of construction professionals, representing clients, consultants, designers and contractors, to determine fluctuations in costs by their magnitude and when they occur. These factors were examined more closely by interviewing senior members representing each of the stakeholder categories and comparing their experience in using BIM within environments where their project partners were also using BIM and when they were not. This determined the differences in how the use and the investment in BIM impacts on others and how costs are redistributed. This redistribution is not just through time but also between stakeholders and categories of costs. Some of these cost fluctuations and how the cost of BIM is currently financed are also highlighted in several case studies. The results show that the current distribution of costs set for traditional 2D delivery is hindering the potential success of BIM. There is also evidence that stakeholders who don’t use BIM may benefit financially from the BIM use of others and that collaborative BIM is significantly different to the use of ‘lonely’ BIM in terms of benefits and profitability.

Cost-effectiveness of Transcatheter Mitral Valve Leaflet Repair for the Treatment of Mitral Regurgitation in Heart Failure

Contexte: La régurgitation mitrale (RM) est une maladie valvulaire nécessitant une intervention dans les cas les plus grave. Une réparation percutanée de la valve mitrale avec le dispositif MitraClip est un traitement sécuritaire et efficace pour les patients à haut risque chirurgical. Nous voulons évaluer les résultats cliniques et l'impact économique de cette thérapie par rapport à la gestion médicale des patients en insuffisance cardiaque avec insuffisance mitrale symptomatique. Méthodes: L'étude a été composée de deux phases; une étude d'observation de patients souffrant d'insuffisance cardiaque et de régurgitation mitrale traitée avec une thérapie médicale ou le MitraClip, et un modèle économique. Les résultats de l'étude observationnelle ont été utilisés pour estimer les paramètres du modèle de décision, qui a estimé les coûts et les avantages d'une cohorte hypothétique de patients atteints d'insuffisance cardiaque et insuffisance mitrale sévère traitée avec soit un traitement médical standard ou MitraClip. Résultats: La cohorte de patients traités avec le système MitraClip était appariée par score de propension à une population de patients atteints d'insuffisance cardiaque, et leurs résultats ont été comparés. Avec un suivi moyen de 22 mois, la mortalité était de 21% dans la cohorte MitraClip et de 42% dans la cohorte de gestion médicale (p = 0,007). Le modèle de décision a démontré que MitraClip augmente l'espérance de vie de 1,87 à 3,60 années et des années de vie pondérées par la qualité (QALY) de 1,13 à 2,76 ans. Le coût marginal était 52.500 $ dollars canadiens, correspondant à un rapport coût-efficacité différentiel (RCED) de 32,300.00 $ par QALY gagné. Les résultats étaient sensibles à l'avantage de survie. Conclusion: Dans cette cohorte de patients atteints d'insuffisance cardiaque symptomatique et d insuffisance mitrale significative, la thérapie avec le MitraClip est associée à une survie supérieure et est rentable par rapport au traitement médical.

How much does EU citizenship cost? The Maltese citizenship-for-sale affair: A breakthrough for sincere cooperation in citizenship of the union? CEPS Liberty and Security in Europe No. 64, April/2014

How much does European citizenship cost in the EU? This was the question that has raised so much controversy over the Maltese citizenship-for-sale programme. The outright selling of Maltese nationality to rich foreigners led to unprecedented responses by the European Parliament and European Commission. This paper examines the affair and its relevance for current and future configurations of citizenship of the EU. It studies the extent to which member states are still free to lay down the grounds for the acquisition and loss of nationality without any EU supervision and accountability. It provides a comparative overview of member state schemes and the exact price for buying citizenship and a residency permit in the EU. It is argued that the EU’s intervention on the Maltese citizenship-for-sale affair constitutes a legal precedent for assessing the lawfulness of passport-for-sale or golden migration programmes in other EU member states. The affair has also revealed the increasing relevance of a set of European and international legal principles limiting member states’ discretion over citizenship matters and providing a supranational constellation of accountability venues scrutinising the impact of their decisions over citizenship of the Union. The Maltese citizenship-for-sale affair has placed at the forefront the EU general principle of sincere cooperation in nationality matters. Member states’ actions in the citizenship domain cannot negatively affect in substance the concept and freedoms of European citizenship. That notwithstanding, the European institutions’ insistence on the need for Maltese nationality law to require a ‘genuine link’ in the form of an effective residence criteria for any rich applicants to benefit from the fast-track naturalisation poses a fundamental dilemma from the angle of Union citizenship: what is this genuine link really about? And what is precisely ‘habitual’, ‘effective’ or ‘functional’ residence? It is argued that by supporting the ‘real connections’ as the most relevant standard, the European institutions may be paradoxically fuelling nationalistic misuses by member states of the ‘genuine link’ as a way to justify restrictive integration policies on the acquisition of nationality.

Past, present and future safety benefit assessment methods.

Mode of access: Internet.

Is the risk of product market predation a cost of disclosure?

Thesis (Ph.D.)--University of Washington, 2016-06