Modelling cost-effectiveness of replacement strategies for ambulance services in the Ministry of Health Malaysia.

BACKGROUND: Emergency Medical Service (EMS) is a very crucial aspect of the healthcare system in providing urgent management and transportation of patients during emergencies. The sustainability of the services is however greatly impacted by the quality and age of ambulances. While this has led to numerous replacement policy recommendations, the implementations are often limited due to a lack of evidence and financial constraints. This study thus aims to develop a cost-effectiveness model and testing the model by evaluating the cost-effectiveness of 10-year and 15-year compulsory ambulance replacement strategies in public healthcare for the Malaysian Ministry of Health (MOH). METHODS: A Markov model was developed to estimate the cost and outcomes ambulance replacement strategies over a period of 20 years. The model was tested using two alternative strategies of 10-year and 15-year. Model inputs were derived from published literature and local study. Model development and economic analysis were accomplished using Microsoft Excel 2016. The outcomes generated were costs per year, the number of missed trips and the number of lives saved, in addition to the Incremental Cost-Effectiveness Ratio (ICER). One-Way Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were conducted to identify the key drivers and to assess the robustness of the model. RESULTS: Findings showed that the most expensive strategy, which is the implementation of 10 years replacement strategy was more cost-effective than 15 years ambulance replacement strategy, with an ICER of MYR 11,276.61 per life saved. While an additional MYR 13.0 million would be incurred by switching from a 15- to 10-year replacement strategy, this would result in 1,157 deaths averted or additional live saved per year. Sensitivity analysis showed that the utilization of ambulances and the mortality rate of cases unattended by ambulances were the key drivers for the cost-effectiveness of the replacement strategies. CONCLUSIONS: The cost-effectiveness model developed suggests that an ambulance replacement strategy of every 10 years should be considered by the MOH in planning sustainable EMS. While this model may have its own limitation and may require some modifications to suit the local context, it can be used as a guide for future economic evaluations of ambulance replacement strategies and further exploration of alternative solutions.

Production of Rigid Polyurethane Foams Using Polyol from Liquefied Oil Palm Biomass: Variation of Isocyanate Indexes.

Development of polyurethane foam (PUF) containing bio-based components is a complex process that requires extensive studies. This work reports on the production of rigid PUFs from polyol obtained via liquefaction of oil palm empty fruit bunch (EFB) biomass with different isocyanate (NCO) indexes. The effect of the NCO index on the physical, chemical and compressive properties of the liquefied EFB-based PUF (EFBPUF) was evaluated. The EFBPUFs showed a unique set of properties at each NCO index. Foaming properties had affected the apparent density and cellular morphology of the EFBPUFs. Increasing NCO index had increased the crosslink density and dimensional stability of the EFBPUFs via formation of isocyanurates, which had also increased their thermal stability. Combination of both foaming properties and crosslink density of the EFBPUFs had influenced their respective compressive properties. The EFBPUF produced at the NCO index of 120 showed the optimum compressive strength and released the least toxic hydrogen cyanide (HCN) gas under thermal degradation. The normalized compressive strength of the EFBPUF at the NCO index of 120 is also comparable with the strength of the PUF produced using petrochemical polyol.