Cost-Effectiveness in Perioperative Care: Application of Markov Modeling to Pathways of Perioperative Care.

OBJECTIVES: This study aimed to evaluate the application of cost-effectiveness modeling to redesign of perioperative care pathways, from a hospital perspective. METHODS: A Markov cost-effectiveness model of patient transition between care locations, each with different characteristics and cost, was developed. Inputs were derived from clinical trials piloting a preoperative call center and a postoperative medium-acuity care unit. The effect chosen was days at home (DAH) after surgery, reflecting quality of in-hospital care, acknowledged financially by fundholders, and relevant to consumers. Cost was from the hospital's perspective. A model cycle time of 4 hours for 30 days reflected relevant timelines and costs. RESULTS: A Markov model was successfully created, accounting for the care locations in the 2 pathways as model states and accounting for consequences and costs. Cost-effectiveness analysis allowed the calculation of an incremental cost-effectiveness ratio comparing these pathways, providing a mean incremental cost-effectiveness ratio of -$427 per additional DAH, where incremental costs and DAH were -$644 and +1.51, respectively. Probabilistic sensitivity analysis suggested the new pathway had a 61% probability of reduced costs and a 74% probability of increased DAH and a 58% probability this pathway was dominant. Tornado analysis revealed the major contributor to increased costs as intensive care unit stay and the major contributor to decreased costs as ward stay. For the new pathway, the probability of transfer from ward to home and the probability of staying at home had the greatest impact on DAH. CONCLUSIONS: These data suggest Markov modeling may be a useful tool for the cost-effectiveness analysis of initiatives in perioperative care.

Efficacy of a multidisciplinary care protocol for the treatment of operated hip fracture patients.

To assess the effects of a multidisciplinary care protocol on cost, length of hospital stay (LOS), and mortality in hip-fracture-operated patients over 65 years. Prospective cohort study between 2011 and 2017. The unexposed group comprised patients who did not receive care according to the multidisciplinary protocol, while the exposed group did. Variables analyzed were demographics, medical comorbidities, treatment, blood parameters, surgical delay, LOS, re-admissions, mortality, and a composite outcome considering in-hospital mortality and/or LOS > 10 days. We performed a Poisson regression and cost analysis. The cohort included 681 patients: 310 unexposed and 371, exposed. The exposed group showed a shorter surgical delay (3.0 vs. 3.6 days; p < 0.001), and a higher proportion received surgery within 48 h (46.1% vs. 34.2%, p = 0.002). They also showed lower rates of 30-day readmission (9.4% vs. 15.8%, p = 0.012), 30-day mortality (4.9% vs. 9.4%, p = 0.021), in-hospital mortality (3.5% vs. 7.7%; p = 0.015), and LOS (8.4 vs. 9.1 days, p < 0.001). Multivariable analysis showed a protective effect of the protocol on the composite outcome (risk ratio 0.62, 95% CI 0.48-0.80, p < 0.001). Hospital costs were reduced by EUR 112,153.3. A multidisciplinary shared care protocol was associated with a reduction in the LOS, surgical delay, 30-day readmissions, and in-hospital and 30-day mortality, in hip-fracture-operated patients.

Dissecting the Perioperative Care Bundle.

Enhanced recovery after surgery (ERAS) protocols are comprehensive perioperative care pathways designed to mitigate the physiologic stressors associated with surgery and, in turn, improve clinical outcomes and lead to health care cost savings. Although individual components may differ, ERAS protocols are typically organized as multimodal care "bundles" that, when followed closely and in their entirety, are meant to generate amplified cumulative benefits. This manuscript examines some of the critical components, describes some areas where the science is weak (but dogma may be strong), and provides some of the evidence or lack thereof behind components of a standard ERAS protocol.

ACERTO Project - 15 years changing perioperative care in Brazil.

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

A comparative cost analysis of transanal and laparoscopic total mesorectal excision for rectal cancer.

Despite proven clinical benefits in the short term, technical difficulties limit utilization of laparoscopy in rectal cancer surgery (RCS). Transanal Total Mesorectal Excision (taTME) overcomes many technical limitations of laparoscopic RCS. However, the costs of this procedure have not been addressed yet. Our goal was to perform a comparative cost analysis of taTME and laparoscopic TME (lapTME). Consecutive patients undergoing curative TME between 1 February 2014 and 31 October 2018 were selected from a prospectively maintained database and stratified, according to the type of procedure, into taTME and lapTME groups. Patient demographics, tumour characteristics, operative parameters, and short-term outcomes were analyzed. The main outcome measure was intraoperative costs of the two procedures. Secondary outcomes were short-term outcome and the utilization of hospital resources to manage the postoperative course. Hundred and fifty-two patients with rectal cancer (66 lapTME, 86 taTME) were included in the study. Surgical supplies required for taTME procedure exceeded the cost of lapTME of 754,54 €. The duration of surgery was not significantly different between the two approaches (266 ± 92.85 vs 271 ± 83.63, p = 0.50). Short-term outcomes were comparable including postoperative complication rate (17 vs 20%, p = 0.68), reintervention rate, and length of stay. There was no difference in hospital resources utilization to manage postoperative course including blood test, diagnostics, consultations, and medications. TaTME has higher intraoperative costs in terms of supplies with respect to lapTME. Short-term outcomes and hospital resources to manage postoperative course are comparable.

Acerto Project - 15 years changing perioperative care in Brazil / Projeto Acerto - 15 anos modificando cuidados perioperatórios no Brasil

ABSTRACT The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

RESUMO O projeto ACERTO é um protocolo multimodal de cuidados perioperatórios. Implementado em 2005, o projeto, nos últimos 15 anos, tem disseminado a ideia de moderno protocolo de cuidados perioperatórios baseados em evidência e com atuação interprofissional. Dezenas de estudos publicados com o uso do protocolo têm mostrado benefícios como redução do tempo de internação, complicações pós-operatórias e custos hospitalares. Disseminado pelo Brasil, o projeto tem apoio do Colégio Brasileiro de Cirurgiões e da Sociedade Brasileira de Nutrição Parenteral e Enteral, entre outros. Este artigo compila publicações dos autores que compõem o grupo de pesquisa do CNPq "Acerto em Nutrição e Cirurgia", cita a experiência de outros autores nacionais em diversas especialidades cirúrgica e finalmente, delineia a evolução do projeto ACERTO ao longo da linha do tempo.

Laparoscopic advanced intraoperative restaging for radiographic non-metastasis pancreatic cancer: Protocol for a single-center, cross-sectional and follow-up study.

BACKGROUND: Although surgical resection holds promise for curing pancreatic cancer, <20% of patients are suitable; however, early postoperative recurrence is common. Currently, radiographic examination is the primary method to determine whether pancreatic cancer has metastasized and to inform clinical staging before surgery. However, the method has a limited detection rate for micro-metastasis within the abdominal cavity; therefore, patients with advanced pancreatic cancer and existing micro-metastasis may receive unnecessary surgical treatment, delaying the timing of adjuvant chemotherapy and resulting in poor prognosis. Laparoscopic staging might be used as a supplement to detect micro-metastasis in patients with pancreatic cancer; however, there is no consistent standard to guide the use of this procedure. Therefore, it is necessary to conduct a trial to further explore the consistency and short-term and long-term efficacy of an intraoperative staging strategy for patients with radiographic non-metastasis. METHODS/DESIGN: This is a single-center cross-sectional and follow-up study. Patients diagnosed with pancreatic cancer without metastasis by radiographic examination and histopathological biopsy, who received intraoperative restaging, will be enrolled. The total sample size required for the trial is approximately 125 patients from May 2020 to December 2022. First, radiographic examination staging will be used. Then, laparoscopic exploration will be performed for patients without definite metastatic lesions. Data collection will include preoperative blood examination, radiographic examination, surgical information, and postoperative recovery. The patients will undergo follow-up every 3 months after surgery until death. The primary endpoint is the metastasis-positive rate via laparoscopic exploration. The secondary endpoints are the consistency, sensitivity, and specificity of the intraoperative restaging strategy and radiographic examination, the incidence of postoperative complications within 30 days, the 6-month relapse-free survival rate, and perioperative indicators (total cost, hospital stay, length of surgery, and intraoperative blood loss). DISCUSSION: We are conducting the trial to explore the metastasis-positive rate of intraoperative restaging strategy for diagnosing pancreatic cancer micro-metastasis. This new intraoperative restaging strategy would help pancreatic cancer patients with potential micro-metastasis avoid receiving unnecessary resection, allow systemic treatment as early as possible, and improve the prognosis of patients.

Impact of perioperative hemodynamic optimization therapies in surgical patients: economic study and meta-analysis.

BACKGROUND: Several studies suggest that hemodynamic optimization therapies can reduce complications, the length of hospital stay and costs. However, Brazilian data are scarce. Therefore, the objective of this analysis was to evaluate whether the improvement demonstrated by hemodynamic optimization therapy in surgical patients could result in lower costs from the perspective of the Brazilian public unified health system. METHODS: A meta-analysis was performed comparing surgical patients who underwent hemodynamic optimization therapy (intervention) with patients who underwent standard therapy (control) in terms of complications and hospital costs. The cost-effectiveness analysis evaluated the clinical and financial benefits of hemodynamic optimization protocols for surgical patients. The analysis considered the clinical outcomes of randomized studies published in the last 20 years that involved surgeries and hemodynamic optimization therapy. Indirect costs (equipment depreciation, estate and management activities) were not included in the analysis. RESULTS: A total of 21 clinical trials with a total of 4872 surgical patients were selected. Comparison of the intervention and control groups showed lower rates of infectious (RR = 0.66; 95% CI = 0.58-0.74), renal (RR = 0.68; 95% CI = 0.54-0.87), and cardiovascular (RR = 0.87; 95% CI = 0.76-0.99) complications and a nonstatistically significant lower rate of respiratory complications (RR = 0.82; 95% CI = 0.67-1.02). There was no difference in mortality (RR = 1.02; 95% CI = 0.80-1.3) between groups. In the analysis of total costs, the intervention group showed a cost reduction of R$396,024.83-BRL ($90,161.38-USD) for every 1000 patients treated compared to the control group. The patients in the intervention group showed greater effectiveness, with 1.0 fewer days in the intensive care unit and hospital. In addition, there were 333 fewer patients with complications, with a consequent reduction of R$1,630,341.47-BRL ($371,173.27-USD) for every 1000 patients treated. CONCLUSIONS: Hemodynamic optimization therapy is cost-effective and would increase the efficiency of and decrease the burden of the Brazilian public health system.

Assessing the Feasibility of an Alternative Payment Model for Mohs Micrographic Surgery at an Academic Center.

BACKGROUND: Mohs micrographic surgery (MMS) is a cost-effective treatment for nonmelanoma skin cancer that bundles costs for surgical excision, tissue processing, and histopathological interpretation. A comprehensive MMS bundle would include all aspects of an episode of care (EOC), including costs of reconstruction, preoperative, and postoperative care. OBJECTIVE: To assess the feasibility of an alternative payment model for MMS and reconstruction. METHODS: Retrospective chart review and payment analysis for 848 consecutive patients with 1,056 tumors treated with MMS. Average Medicare payment of an EOC was compared with bundles based on specific repair types. RESULTS: The bundle for a flap/graft repair averaged $1,028.08 (confidence interval [CI] 95% $951.37-1,104.79), whereas the bundle for a linear closure (LC) averaged $585.07 (CI 95% $558.75-611.38). The average bundle including all repairs was $730.05 (CI 95% $692.31-767.79), which was statistically significant from both the flap/graft and LC bundles. CONCLUSION: Bundling surgical repairs with MMS based on an average payment does not represent the heterogeneity of the care provided and results in either underpayment or overpayment for a substantial portion of cases. Consequently, EOC payments bundling MMS and surgical repairs would inaccurately reimburse physicians for work completed. Current payment methodology allows for accurate payment for this already cost-effective therapy.

Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study.

BACKGROUND: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. METHODS: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. RESULTS: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. CONCLUSIONS: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.

Perioperative inhaled corticosteroids treatment is associated with decreased length-of-stay and direct medical costs in high-respiratory-risk surgeries.

Aims: To examine the impact of perioperative inhaled corticosteroids (ICS) on length-of-stay (LOS) and costs among patients receiving high-respiratory-risk surgeries.Methods: Adult patients who underwent high-respiratory-risk surgeries in 2015 were identified in the Tianjin Urban Employee Basic Medical Insurance database. Patients were grouped into ICS or non-ICS cohorts according to whether they received ICS during the perioperative period of the index hospitalization. Propensity Score Matching was performed to create matched pairs between two cohorts. The impact of perioperative ICS on LOS and direct medical costs was estimated by negative binomial model and generalized liner model.Results: Eight hundred and twenty-one hospital stays with high-respiratory-risk were selected in the ICS cohort and another 821 stays in the non-ICS cohort were matched. The mean LOS was 13.0 (±0.3) days in the ICS cohort, which was significantly lower than the matched non-ICS cohort. Patients with thorax and ear-nose-throat surgeries had a significant decrease in LOS in the ICS cohort compared to the non-ICS cohort, with a mean decrease of 5.5 and 1.1 days, respectively. In adjusted analyses, perioperative ICS treatment was associated with shorter LOS, lower total, and respiratory-related costs (reductions of 10.1%, 7%, and 5.3%, respectively) after controlling for demographic, clinical, and hospital characteristics.Limitations: Some respiratory risk factors such as living behavior and environment were unable to be captured and respiratory-related costs might be underestimated, limited by claim data. Lastly, caution should be taken when generalizing the results to other populations, as only patients with moderate-to-severe surgeries on the thorax and above were selected in this study.Conclusions: Perioperative ICS treatment was associated with decreased LOS and lower costs for patients undergoing high-respiratory-risk surgeries in China.

The financial impact of an enhanced recovery after surgery (ERAS) protocol in an academic gynecologic oncology practice.

OBJECTIVE: To determine the financial impact of an enhanced recovery after surgery (ERAS) protocol in gynecologic oncology patients. METHODS: This study identified gynecologic oncology patients who were placed on the ERAS protocol after elective laparotomy from 10/2016-6/2017. A control group was identified from the year prior to ERAS implementation. Financial experts assisted in procuring data for these patient encounters, including payer status, direct and indirect costs, contribution margin, and length of stay (LOS). SPSS Statistics v. 24 was used for statistical analysis. RESULTS: 376 patients met criteria for inclusion: 179 in the ERAS group and 197 in the control group. Patient demographics were similar between the two cohorts. Payer status across the groups was not statistically significant in patients with private insurance (control 43.7% vs. ERAS 41.3%), Medicare (38.1% vs. 31.8%), or self-pay patients (12.2% vs. 15.1%). There was a significantly higher number of Medicaid patients in the ERAS group (6.1% vs. 11.7%; p = 0.05). Hospital direct costs ($5596 vs. 5346) and indirect costs ($5182 vs. $4954) per encounter were similar between groups. However, overall contribution margin per encounter decreased in the ERAS group ($11,619 vs. $8528; p = 0.01). LOS was significantly lower in the ERAS group (4.1 vs. 2.9 days; p = 0.04). CONCLUSIONS: Implementation of the ERAS protocol in gynecologic oncology patients does not lead to increased costs for the patient or hospital system. The decreased contribution margin is likely due to a reduction in per diem payments caused by the reduction in LOS. On a per-patient-day basis, contribution margin was the same for both groups ($2877 vs $2857). The reduction in LOS also created capacity for additional cases, the financial impact of which was not evaluated.

Using Time-Driven Activity-Based Costing to Demonstrate Value in Perioperative Care: Recommendations and Review from the Society for Perioperative Assessment and Quality Improvement (SPAQI).

A shift in healthcare payment models from volume toward value-based incentives will require deliberate input into systems development from both perioperative clinicians and administrators to ensure appropriate recognition of the value of all services provided-particularly ones that are not reimbursable in current fee-for-service payment models. Time-driven activity-based costing (TDABC) methodology identifies cost drivers and reduces inaccurate costing based on siloed budgets. Inaccurate costing also results from the fact that current costing methods use charges and there has been tremendous cost shifting throughout health care. High cost, high variability processes can be identified for process improvement. As payment models inevitably evolve towards value-based metrics, it will be critical to knowledgably participate in the coordination of these changes. This document provides 8 practical Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI) aimed at outlining the principles of TDABC, creating process maps for patient workflows, understanding payment structures, establishing physician alignment across service lines to create integrated practice units to facilitate development of evidence-based pathways for specific patient risk groups, establishing consistent care delivery, minimizing variability between physicians and departments, utilizing data analytics and information technology tools to track progress and obtain actionable data, and using TDABC to create costing transparency.

Toward Value Based Health Care in pituitary surgery: application of a comprehensive outcome set in perioperative care.

OBJECTIVE: Although widely advocated, applying Value Based Health Care (VBHC) in clinical practice is challenging. This study describes VBHC-based perioperative outcomes for patients with pituitary tumors up to 6 months postoperatively. METHODS: A total of 103 adult patients undergoing surgery were prospectively followed. Outcomes categorized according to the framework of VHBC included survival, degree of resection, endocrine remission, visual outcome (including self-perceived functioning), recovery of pituitary function, disease burden and health-related quality of life (HRQoL) at 6 months (Tier 1); time to recovery of disease burden, HRQoL, visual function (Tier 2); permanent hypopituitarism and accompanying hormone replacement (Tier 3). Generalized estimating equations (GEEs) analysis was performed to describe outcomes over time. RESULTS: Regarding Tier 1, there was no mortality, 72 patients (70%) had a complete resection, 31 of 45 patients (69%) with functioning tumors were in remission, 7 (12%, with preoperative deficits) had recovery of pituitary function and 45 of 47 (96%) had visual improvement. Disease burden and HRQoL improved in 36-45% at 6 months; however, there were significant differences between tumor types. Regarding Tier 2: disease burden, HRQoL and visual functioning improved within 6 weeks after surgery; however, recovery varied widely among tumor types (fastest in prolactinoma and non-functioning adenoma patients). Regarding Tier 3, 52 patients (50%) had persisting (tumor and treatment-induced) hypopituitarism. CONCLUSIONS: Though challenging, outcomes of a surgical intervention for patients with pituitary tumors can be reflected through a VBHC-based comprehensive outcome set that can distinguish outcomes among different patient groups with respect to tumor type.

Enhanced Perioperative Care for Major Spine Surgery.

STUDY DESIGN: The enhanced perioperative care (EPOC) program is an institutional quality improvement initiative. We used a historically controlled study design to evaluate patients who underwent major spine surgery before and after the implementation of the EPOC program. OBJECTIVE: To determine whether multidisciplinary EPOC program was associated with an improvement in clinical and financial outcomes for elective adult major spine surgery patients. SUMMARY OF BACKGROUND DATA: The enhanced recovery after surgery (ERAS) programs successfully implemented in hip and knee replacement surgeries, and improved clinical outcomes and patient satisfaction. METHODS: We compared 183 subjects in traditional care (TRDC) group to 267 intervention period (EPOC) in a single academic quaternary spine surgery referral center. One hundred eight subjects in no pathway (NOPW) care group was also examined to exclude if the observed changes between the EPOC and TRDC groups might be due to concurrent changes in practice or population over the same time period. Our primary outcome variables were hospital and intensive care unit lengths of stay and the secondary outcomes were postoperative complications, 30-day hospital readmission and cost. RESULTS: In this highly complex patient population, we observed a reduction in mean hospital length of stay (HLOS) between TRDC versus EPOC groups (8.2 vs. 6.1 d, standard deviation [SD] = 6.3 vs. 3.6, P < 0.001) and intensive care unit length of stay (ILOS) (3.1 vs. 1.9 d, SD = 4.7 vs. 1.4, P = 0.01). The number (rate) of postoperative intensive care unit (ICU) admissions was higher for the TRDC n = 109 (60%) than the EPOC n = 129 (48%) (P = 0.02). There was no difference in postoperative complications and 30-day hospital readmissions. The EPOC spine program was associated with significant average cost reduction-$62,429 to $53,355 (P < 0.00). CONCLUSION: The EPOC program has made a clinically relevant contribution to institutional efforts to improve patient outcomes and value. We observed a reduction in HLOS, ILOS, costs, and variability. LEVEL OF EVIDENCE: 3.

Cost-analysis of Enhanced Recovery After Surgery (ERAS) program in gynecologic surgery.

OBJECTIVES: Enhanced recovery after surgery (ERAS) programs has shown clinical benefits in gynecologic surgery. The aim of the present study was to compare costs before and after implementation of an ERAS program for gynecologic surgery. METHODS: Retrospective study comparing perioperative costs between consecutive patient groups undergoing gynecologic surgery (benign, staging or debulking) (I, 2012-13) prior, (II) immediately after, and (III, 2014-16) the three years after ERAS implementation. Preoperative, intraoperative, and postoperative real costs were collected for each patient via hospital administration. A bootstrap independent t-test was used for comparison. RESULTS: Demographics and preoperative characteristics were similar between group I (n = 42), II (n = 51), and III (ERAS I; n = 122, II; n = 134, III; n = 90). Average ERAS-specific costs were $687 per patient. Total mean individual costs per patient were $13'329 (95% confidence interval (CI): 11'301-15'213) and $17'710 (95% CI: 14'452-21'605) in the ERAS and pre-ERAS groups respectively, resulting in net savings of $4'381 (95% CI: 549-8'752, p = 0.043) in favour of ERAS group. Cost savings were explained by lower pre- and postoperative costs (difference: $5'011 95% CI: 1'587-8'998, p = 0.019). Total costs continued to decrease by $2'520 (mean: $15'190, 95% CI: 13'791-16'631) in year 1, by $3'077 (mean: $14'633, 95% CI: 13'378-16'250) and $5'070 (mean: $12'640, 95% CI: 11'460-14'015) (p = 0.03) respectively, in year 2 and 3 after implementation. CONCLUSION: Based on real costs and including specific costs due to ERAS implementation, ERAS program in gynecologic surgery induced significant decrease of overall costs by $4'381 per patient. Total costs continued to decrease in the three years after implementation.