Cost effectiveness of adding magnetic resonance imaging to the usual management of suspected scaphoid fractures

Objective: To determine the cost effectiveness of a magnetic resonance imaging scan (MRI) within 5 days of injury compared with the usual management of occult scaphoid fracture. Methods: All patients with suspected scaphoid fractures in five hospitals were invited to participate in a randomised controlled trial of usual treatment with or without an MRI scan. Healthcare costs were compared, and a cost effectiveness analysis of the use of MRI in this scenario was performed. Results: Twenty eight of the 37 patients identified were randomised: 17 in the control group, 11 in the MRI group. The groups were similar at baseline and follow up in terms of number of scaphoid fractures, other injuries, pain, and function. Of the patients without fracture, the MRI group had significantly fewer days immobilised: a median of 3.0 (interquartile range 3.0-3.0) v 10.0 (7-12) in the control group (p = 0.006). The MRI group used fewer healthcare units (median 3.0, interquartile range 2.0-4.25) than the control group (5.0, 3.0-6.5) (p = 0.03 for the difference). However, the median cost of health care in the MRI group ($594.35 AUD, $551.35-667.23) was slightly higher than in the control group ($428.15, $124.40-702.65) (p = 0.19 for the difference). The mean incremental cost effectiveness ratio derived from this simulation was that MRI costs $44.37 per day saved from unnecessary immobilisation (95% confidence interval $4.29 to $101.02). An illustrative willingness to pay was calculated using a combination of the trials measure of the subjects' individual productivity losses and the average daily earnings. Conclusions: Use of MRI in the management of occult scaphoid fracture reduces the number of days of unnecessary immobilisation and use of healthcare units. Healthcare costs increased non-significantly in relation to the use of MRI in this setting. However, when productivity losses are considered, MRI may be considered cost effective, depending on the individual case.

Report on a Review of the Iowa Homeland Security and Emergency Management Department, E911 Cost Data for the period July 1, 2012 through June 30, 2014

Report on a Review of the Iowa Homeland Security and Emergency Management Department, E911 Cost Data for the period July 1, 2012 through June 30, 2014

Climate Change and the Cost of Carbon Sequestration: The Case of Forest Management

The Kyoto protocol allows Annex I countries to deduct carbon sequestered by land use, land-use change and forestry from their national carbon emissions. Thornley and Cannell (2000) demonstrated that the objectives of maximizing timber and carbon sequestration are not complementary. Based on this finding, this paper determines the optimal selective management regime taking into account the underlying biophysical and economic processes. The results show that the net benefits of carbon storage only compensate the decrease in net benefits of timber production once the carbon price has exceeded a certain threshold value. The sequestration costs are significantly lower than previous estimates

Cost-efficient virtual machine management : provisioning, admission control, and consolidation

One of the main challenges in Software Engineering is to cope with the transition from an industry based on software as a product to software as a service. The field of Software Engineering should provide the necessary methods and tools to develop and deploy new cost-efficient and scalable digital services. In this thesis, we focus on deployment platforms to ensure cost-efficient scalability of multi-tier web applications and on-demand video transcoding service for different types of load conditions. Infrastructure as a Service (IaaS) clouds provide Virtual Machines (VMs) under the pay-per-use business model. Dynamically provisioning VMs on demand allows service providers to cope with fluctuations on the number of service users. However, VM provisioning must be done carefully, because over-provisioning results in an increased operational cost, while underprovisioning leads to a subpar service. Therefore, our main focus in this thesis is on cost-efficient VM provisioning for multi-tier web applications and on-demand video transcoding. Moreover, to prevent provisioned VMs from becoming overloaded, we augment VM provisioning with an admission control mechanism. Similarly, to ensure efficient use of provisioned VMs, web applications on the under-utilized VMs are consolidated periodically. Thus, the main problem that we address is cost-efficient VM provisioning augmented with server consolidation and admission control on the provisioned VMs. We seek solutions for two types of applications: multi-tier web applications that follow the request-response paradigm and on-demand video transcoding that is based on video streams with soft realtime constraints. Our first contribution is a cost-efficient VM provisioning approach for multi-tier web applications. The proposed approach comprises two subapproaches: a reactive VM provisioning approach called ARVUE and a hybrid reactive-proactive VM provisioning approach called Cost-efficient Resource Allocation for Multiple web applications with Proactive scaling. Our second contribution is a prediction-based VM provisioning approach for on-demand video transcoding in the cloud. Moreover, to prevent virtualized servers from becoming overloaded, the proposed VM provisioning approaches are augmented with admission control approaches. Therefore, our third contribution is a session-based admission control approach for multi-tier web applications called adaptive Admission Control for Virtualized Application Servers. Similarly, the fourth contribution in this thesis is a stream-based admission control and scheduling approach for on-demand video transcoding called Stream-Based Admission Control and Scheduling. Our fifth contribution is a computation and storage trade-o strategy for cost-efficient video transcoding in cloud computing. Finally, the sixth and the last contribution is a web application consolidation approach, which uses Ant Colony System to minimize the under-utilization of the virtualized application servers.

PINCER trial: a cluster randomised trial comparing the effectiveness and cost-effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors in general practice are an important source of potentially preventable morbidity and mortality. Building on previous descriptive, qualitative and pilot work, we sought to investigate the effectiveness, cost-effectiveness and likely generalisability of a complex pharm acist-led IT-based intervention aiming to improve prescribing safety in general practice. Objectives: We sought to: • Test the hypothesis that a pharmacist-led IT-based complex intervention using educational outreach and practical support is more effective than simple feedback in reducing the proportion of patients at risk from errors in prescribing and medicines management in general practice. • Conduct an economic evaluation of the cost per error avoided, from the perspective of the National Health Service (NHS). • Analyse data recorded by pharmacists, summarising the proportions of patients judged to be at clinical risk, the actions recommended by pharmacists, and actions completed in the practices. • Explore the views and experiences of healthcare professionals and NHS managers concerning the intervention; investigate potential explanations for the observed effects, and inform decisions on the future roll-out of the pharmacist-led intervention • Examine secular trends in the outcome measures of interest allowing for informal comparison between trial practices and practices that did not participate in the trial contributing to the QRESEARCH database. Methods Two-arm cluster randomised controlled trial of 72 English general practices with embedded economic analysis and longitudinal descriptive and qualitative analysis. Informal comparison of the trial findings with a national descriptive study investigating secular trends undertaken using data from practices contributing to the QRESEARCH database. The main outcomes of interest were prescribing errors and medication monitoring errors at six- and 12-months following the intervention. Results: Participants in the pharmacist intervention arm practices were significantly less likely to have been prescribed a non-selective NSAID without a proton pump inhibitor (PPI) if they had a history of peptic ulcer (OR 0.58, 95%CI 0.38, 0.89), to have been prescribed a beta-blocker if they had asthma (OR 0.73, 95% CI 0.58, 0.91) or (in those aged 75 years and older) to have been prescribed an ACE inhibitor or diuretic without a measurement of urea and electrolytes in the last 15 months (OR 0.51, 95% CI 0.34, 0.78). The economic analysis suggests that the PINCER pharmacist intervention has 95% probability of being cost effective if the decision-maker’s ceiling willingness to pay reaches £75 (6 months) or £85 (12 months) per error avoided. The intervention addressed an issue that was important to professionals and their teams and was delivered in a way that was acceptable to practices with minimum disruption of normal work processes. Comparison of the trial findings with changes seen in QRESEARCH practices indicated that any reductions achieved in the simple feedback arm were likely, in the main, to have been related to secular trends rather than the intervention. Conclusions Compared with simple feedback, the pharmacist-led intervention resulted in reductions in proportions of patients at risk of prescribing and monitoring errors for the primary outcome measures and the composite secondary outcome measures at six-months and (with the exception of the NSAID/peptic ulcer outcome measure) 12-months post-intervention. The intervention is acceptable to pharmacists and practices, and is likely to be seen as costeffective by decision makers.

Spatial-temporal aspects of cost-benefit analysis for park management: an example from Khao Yai National Park, Thailand

Using a model calibrated to Khao Yai National Park in Thailand, this paper highlights the importance of generating explicitly spatial and temporal data for developing management plans for tropical protected forests. Spatial and temporal cost-benefit analysis should account for the interactions between different land uses – such as the benefits of contiguous areas of preserved land and edge effects – and the realities of villagers living near forests who rely on extracted resources. By taking a temporal perspective, this paper provides a rare empirical assessment of the importance of quasi-option values when determining optimal management plans.

Cost function for sub-agent elements in multi-agent energy management system

Distributed generation plays a key role in reducing CO2 emissions and losses in transmission of power. However, due to the nature of renewable resources, distributed generation requires suitable control strategies to assure reliability and optimality for the grid. Multi-agent systems are perfect candidates for providing distributed control of distributed generation stations as well as providing reliability and flexibility for the grid integration. The proposed multi-agent energy management system consists of single-type agents who control one or more gird entities, which are represented as generic sub-agent elements. The agent applies one control algorithm across all elements and uses a cost function to evaluate the suitability of the element as a supplier. The behavior set by the agent's user defines which parameters of an element have greater weight in the cost function, which allows the user to specify the preference on suppliers dynamically. This study shows the ability of the multi-agent energy management system to select suppliers according to the selection behavior given by the user. The optimality of the supplier for the required demand is ensured by the cost function based on the parameters of the element.

Municipal solid waste management in the Caribbean: a benefit-cost analysis

Includes bibliography

Position paper on the management of patients with obstructive sleep apnea and hypertension: joint recommendations by the European Society of Hypertension, by the European Respiratory Society and by the members of European COST (COoperation in Scientific and Technological research) ACTION B26 on obstructive sleep apnea

This article is aimed at addressing the current state of the art in epidemiology, pathophysiology, diagnostic procedures and treatment options for appropriate management of obstructive sleep apnea (OSA) in cardiovascular (particularly hypertensive) patients, as well as for the management of cardiovascular diseases (particularly arterial hypertension) in OSA patients. The present document is the result of the work done by a panel of experts participating in the European Union COST (COoperation in Scientific and Technological research) ACTION B26 on OSA, with the endorsement of the European Respiratory Society (ERS) and the European Society of Hypertension (ESH). These recommendations are particularly aimed at reminding cardiovascular experts to consider the occurrence of sleep-related breathing disorders in patients with high blood pressure. They are at the same time aimed at reminding respiration experts to consider the occurrence of hypertension in patients with respiratory problems at night.

Total Cost of Services (TCS) von Learning Management-Systemen

Mit dem zunehmenden Einsatz von E-Learning-Plattformen rücken verstärkt Wirtschaftlichkeitsaspekte in den Betrachtungsmittelpunkt, die Methoden zur Ermittlung systembedingter Kosten voraussetzen. Durch die zunehmende Serviceorientierung und Integration von LMS mit bestehenden Komponenten der Anwendungsarchitektur sind hierfür jedoch neue Methoden notwendig, welche die Defizite traditioneller Total Cost of Ownership-Modelle abbauen. Einen Ansatzpunkt hierfür bietet das ITIL-Referenzmodell, das einen Rahmen für taktische und operative IT-Services vorgibt und somit die Grundlage für eine serviceorientierte Gesamtkostenermittlung in Form der Total Cost of Services (TCS) liefert.

The cost effective management of Central Line-Associated Bloodstream Infections (CLABSIs) comparing the central line bundle to antimicrobialcoated central venous catheters: A systematic review

Central Line-Associated Bloodstream Infections (CLABSIs) are one of the most costly and preventable cases of morbidity and mortality among intensive care units (ICUs) in health care today. In 2008, the Centers for Medicare and Medicaid Services Medicare Program, under the Deficit Reduction Act, announced it will no longer reimburse hospitals for such adverse events among those related to CLABSIs. This reveals the financial burden shift onto the hospital rather than the health care payer who can now withhold reimbursements. With this weighing more heavily on hospital management, decision makers will need to find a way to completely prevent cases of CLABSI or simply pay for the financial consequences. ^ To reduce the risk of CLABSIs, several clinical, preventive interventions have been studied and even instituted including the Central Line (CL) Bundle and Antimicrobial Coated Central Venous Catheters (AM-CVCs). I carried out a formal systematic review on the topic to compare the cost-effectiveness of the Central Line (CL) Bundle to the commercially available antimicrobial coated central venous catheters (AM-CVCs) in preventing CLABSIs among critically and chronically ill patients in the U.S. Evidence was assessed for inclusion against predefined criteria. I, myself, conducted the data extraction. Ten studies were included in the review. Efficacy in reducing the mean incidence rate of CLABSI by the CL Bundle and AM-CVC interventions were compared with one another including costs. ^ The AM-CVC impregnated with antibiotics, rifampin-minocycline (AI-RM) is more clinically effective than the CL Bundle in reducing the mean rate of CLABSI per 1,000 catheter days. The lowest mean incidence rate of CLABSI per 1,000 catheter days among the AM-CVC studies was as low as zero in favor of the AI-RM. Moreover, the review revealed that the AI-RM appears to be more cost-effective than the CL Bundle. Results showed the adjusted incremental cost of the CL Bundle per ICU patient requiring a CVC to be approximately $196 while the AI-RM at only an additional cost of $48 per ICU patient requiring a CVC. ^ Limited data regarding the cost of the CL Bundle made it difficult to make a true comparison to the direct cost of the AM-CVCs. However, using the result I did have from this review, I concluded that the AM-CVCs do appear to be more cost-effective in decreasing the mean rate of CLABSI while also minimizing incremental costs per CVC than the CL Bundle. This review calls for further research addressing the cost of the CL Bundle and compliance and more effective study designs such as randomized control trials comparing the efficacy and cost of the CL Bundle to the AM-CVCs. Barriers that may face health care managers when implementing the CL Bundle or AM-CVCs include additional costs associated with the intervention, educational training and ongoing reinforcement as well as creating a new culture of understanding.^

A Cost-Benefit analysis model for technical debt management considering uncertainty and time

In the last few years, technical debt has been used as a useful means for making the intrinsic cost of the internal software quality weaknesses visible. This visibility is made possible by quantifying this cost. Specifically, technical debt is expressed in terms of two main concepts: principal and interest. The principal is the cost of eliminating or reducing the impact of a, so called, technical debt item in a software system; whereas the interest is the recurring cost, over a time period, of not eliminating a technical debt item. Previous works about technical debt are mainly focused on estimating principal and interest, and on performing a cost-benefit analysis. This cost-benefit analysis allows one to determine if to remove technical debt is profitable and to prioritize which items incurring in technical debt should be fixed first. Nevertheless, for these previous works technical debt is flat along the time. However the introduction of new factors to estimate technical debt may produce non flat models that allow us to produce more accurate predictions. These factors should be used to estimate principal and interest, and to perform cost-benefit analysis related to technical debt. In this paper, we take a step forward introducing the uncertainty about the interest, and the time frame factors so that it becomes possible to depict a number of possible future scenarios. Estimations obtained without considering the possible evolution of the interest over time may be less accurate as they consider simplistic scenarios without changes.