Screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus in intensive care units : cost effectiveness evaluation

Objective: To assess the cost-effectiveness of screening, isolation and decolonisation strategies in the control of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs). Design: Economic evaluation. Setting: England and Wales. Population: ICU patients. Main outcome measures: Infections, deaths, costs, quality adjusted life years (QALYs), incremental cost-effectiveness ratios for alternative strategies, net monetary benefits (NMBs). Results: All strategies using isolation but not decolonisation improved health outcomes but increased costs. When MRSA prevalence on admission to the ICU was 5% and the willingness to pay per QALY gained was between £20,000 and £30,000, the best such strategy was to isolate only those patients at high risk of carrying MRSA (either pre-emptively or following identification by admission and weekly MRSA screening using chromogenic agar). Universal admission and weekly screening using polymerase chain reaction (PCR)-based MRSA detection coupled with isolation was unlikely to be cost-effective unless prevalence was high (10% colonised with MRSA on admission to the ICU). All decolonisation strategies improved health outcomes and reduced costs. While universal decolonisation (regardless of MRSA status) was the most cost-effective in the short-term, strategies using screening to target MRSA carriers may be preferred due to reduced risk of selecting for resistance. Amongst such targeted strategies, universal admission and weekly PCR screening coupled with decolonisation with nasal mupirocin was the most cost-effective. This finding was robust to ICU size, MRSA admission prevalence, the proportion of patients classified as high-risk, and the precise value of willingness to pay for health benefits. Conclusions: MRSA control strategies that use decolonisation are likely to be cost-saving in an ICU setting provided resistance is lacking, and combining universal PCR-based screening with decolonisation is likely to represent good value for money if untargeted decolonisation is considered unacceptable. In ICUs where decolonisation is not implemented there is insufficient evidence to support universal MRSA screening outside high prevalence settings.

Comparing the cost-effectiveness of MRSA control strategies between ICU and non-ICU settings

Introduction / objectives Many strategies are used to control MRSA in hospitals. Only a few have been assessed in clinical trials and it is not obvious how findings should be generalised between settings. Uncertainty remains about which strategies represent the most appropriate use of scarce resources. We assess the cost-effectiveness of alternative MRSA screening and infection control strategies in England and Wales and discuss international relevance. Methods Models of MRSA transmission in ICUs and general medical (GM) wards were developed and used to evaluate different screening methods combined with decolonisation or isolation. Strategies were compared in terms of costs and health benefits (quality adjusted life years, QALYs). Different prevalences, proportions of high risk patients and ward sizes were investigated, and probabilistic sensitivity analyses (PSA) conducted. Results Decolonisation strategies were cost-saving in ICUs at a 5% admission prevalence, with admission and weekly PCR screening the most cost-effective (£3,929/QALY). In ICUs, screening and isolation reduced infection rates by ~10%. With admission prevalence ≤5%, targeting screening and isolation to high risk patients was optimal. In GM wards decolonisation and isolation strategies, though able to reduce MRSA infection rates up to ~50%, were not cost-effective. Conclusion The largest reductions in MRSA infection were achieved by screening and decolonisation strategies, and were cost-effective in ICU settings. In comparison, there is limited potential for screening and control strategies to be cost-effective in GM wards due to lower infection and mortality rates.

System identification, estimation and control for a cost effective open-source quadcopter

This paper describes system identification, estimation and control of translational motion and heading angle for a cost effective open-source quadcopter — the MikroKopter. The dynamics of its built-in sensors, roll and pitch attitude controller, and system latencies are determined and used to design a computationally inexpensive multi-rate velocity estimator that fuses data from the built-in inertial sensors and a low-rate onboard laser range finder. Control is performed using a nested loop structure that is also computationally inexpensive and incorporates different sensors. Experimental results for the estimator and closed-loop positioning are presented and compared with ground truth from a motion capture system.

Cost-effectiveness of hospital infection control interventions in resource-limited settings

The aim of this project was to evaluate the cost-effectiveness of hand hygiene interventions in resource-limited hospital settings. Using data from north-east Thailand, the research found that such interventions are likely to be very cost-effective in intensive care unit settings as a result of reduced incidence of methicillin-resistant Staphylococcus aureus bloodstream infection alone. This study also found evidence showing that the World Health Organization's (WHO) multimodal intervention is effective and when adding either goal-setting, reward incentives, or accountability strategies to the WHO intervention, compliance could be further improved.

Impact of control strategies on bellyache bush (Jatropha gossypiifolia L.) mortality, seedling recruitment, population dynamics, pasture yield and cost analysis

Bellyache bush (Jatropha gossypiifolia L.) is an invasive weed that has the potential to greatly reduce biodiversity and pasture productivity in northern Australia’s rangelands. This paper reports an approach to develop best practice options for controlling medium to dense infestations of bellyache bush using combinations of control methods. The efficacy of five single treatments including foliar spraying, slashing, stick raking, burning and do nothing (control) were compared against 15 combinations of these treatments over 4 successive years. Treatments were evaluated using several attributes, including plant mortality, changes in population demographics, seedling recruitment, pasture yield and cost of treatment. Foliar spraying once each year for 4 years proved the most cost-effective control strategy, with no bellyache bush plants recorded at the end of the study. Single applications of slashing, stick raking and to a lesser extent burning, when followed up with foliar spraying also led to significantly reduced densities of bellyache bush and changed the population from a growing one to a declining one. Total experimental cost estimates over 4 successive years for treatments where burning, stick raking, foliar spraying, and slashing were followed with foliar spraying were AU$408, AU$584, AU$802 and AU$789 ha–1, respectively. Maximum pasture yield of 5.4 t ha–1 occurred with repeated foliar spraying. This study recommends that treatment combinations using either foliar spraying alone or as a follow up with slashing, stick raking or burning are best practice options following consideration of the level of control, changes in pasture yield and cost effectiveness.

Optimal control of a stochastic hybrid system with discounted cost

We address the optimal control problem of a very general stochastic hybrid system with both autonomous and impulsive jumps. The planning horizon is infinite and we use the discounted-cost criterion for performance evaluation. Under certain assumptions, we show the existence of an optimal control. We then derive the quasivariational inequalities satisfied by the value function and establish well-posedness. Finally, we prove the usual verification theorem of dynamic programming.

Risk-sensitive optimal control for Markov decision processes with monotone cost

The existence of an optimal feedback law is established for the risk-sensitive optimal control problem with denumerable state space. The main assumptions imposed are irreducibility and a near monotonicity condition on the one-step cost function. A solution can be found constructively using either value iteration or policy iteration under suitable conditions on initial feedback law.

Reinforcement learning with average cost for adaptive control of traffic lights at intersections

We propose for the first time two reinforcement learning algorithms with function approximation for average cost adaptive control of traffic lights. One of these algorithms is a version of Q-learning with function approximation while the other is a policy gradient actor-critic algorithm that incorporates multi-timescale stochastic approximation. We show performance comparisons on various network settings of these algorithms with a range of fixed timing algorithms, as well as a Q-learning algorithm with full state representation that we also implement. We observe that whereas (as expected) on a two-junction corridor, the full state representation algorithm shows the best results, this algorithm is not implementable on larger road networks. The algorithm PG-AC-TLC that we propose is seen to show the best overall performance.

Speed control of brushed DC motor for low cost electric cars

As petrol prices are going up in developing countries in upcoming decades low cost electric cars will become more and more popular in developing world. One of the main deciding factors for success of electric cars specially in developing world in upcoming decades will be its cost. This paper shows a cost effective method to control the speed of low cost brushed D.C. motor by combining a IC 555 Timer with a High Boost Converter. The main purpose of using High Boost Converter since electric cars needs high voltage and current which a High Boost Converter can provide even with low battery supply.

The cost of quinine Cinchona pubescens control on Santa Cruz Island, Galapagos

We analyse the cost of controlling the invasive quinine tree Cinchona pubescens Vahl in the highlands of Santa Cruz Island, Galapagos. Control costs in ten 400 m2 plots formed the basis for estimating the cost of control over the whole island. In the plots, densities were 2100–24,000 stems/ha (stems >150 cm tall) and 55,000–138,000 stems/ha (all size classes combined). Control involved uprooting small plants, and applying of a mix of metsulfuron methyl and picloram to cut stumps or to machete cuts in the bark of larger trees. These methods are presently used by Galapagos National Park field crews to control quinine. Costs (in man hours, herbicide and US$) were related to stem density; the density of stems summed across four height classes was a better predictor of costs than density of any one size class. Regressions (on all size classes combined) formed the basis for predictive models of costs. Costs ranged from $14 to $2225 per ha depending on stem density. The amount of herbicide (active ingredient/ha) that must be applied to high density stands of quinine is higher than typical rates of application in an agricultural setting. The cost of treating all existing plants once across quinine’s known range on Santa Cruz Island (c. 11,000 ha) was estimated at c. US$1.65 million. CDF Contribution Number 1013.