Standardization of laparoscopic trays using an inventory optimization model to produce immediate cost savings and efficiency gains.

Perioperative services comprise a large portion of hospital budgets; the procurement and processing of surgical inventories can be an area for optimization in operational inefficiency. Surgical instrument trays can be customized as procedure-specific or standardized as trays that can be used in numerous procedure types. We conducted an interventional study to determine the cost savings from standardizing laparoscopic surgery instrument trays. A single-period inventory optimization model was used to determine the configuration of a standardized laparoscopic (SL) tray and its minimal stock quantity (MSQ). Utilization of instruments on the general surgery, gynecology, and gynecological oncology trays was recorded, and daily demand for trays (mean, SD) was assessed using daily operating room (OR) case lists. Pre- and post-intervention costs were evaluated by reviewing procurement data and quantifying medical device reprocessing (MDR) and OR processes. The SL tray was trialled in the OR to test clinical safety and user satisfaction. Prior to standardization, the customized trays had a total inventory size of 391 instruments (mean instruments per tray: 17, range: 12-22). Daily demand was an MSQ of 23 trays. This corresponded to a procurement cost of $322,160 and reprocessing cost of $41,725. The SL tray (mean instruments per tray: 15, mean trays/day: 9.2 ± 3.2) had an MSQ of 17 trays/day. The total inventory decreased to 255 instruments, corresponding to a procurement cost of $266,900 with savings of $55,260 and reprocessing cost of $41,562 with savings of $163/year. After 33 trial surgeries, user satisfaction improved from 50% to 97% (p < .05). Standardization to a single SL tray using the inventory optimization model led to increased efficiency, satisfaction, and significant savings through aggregating specific service demands. The inventory optimization model could provide custom solutions for various institutions with the potential for large-scale financial savings. Thus, future work using this model at different centres will be necessary to validate these results.

Impact of establishing a respiratory high dependency unit for SCAP patients on the therapeutic effect, prognosis, and expenditure: a retrospective case-control study.

To explore the effects of establishing a high dependency unit (HDU) on the prognosis, outcome, and expenditure of patients with severe community-acquired pneumonia (SCAP). 108 SCAP patients were recruited from the respiratory intensive care unit (RICU) of the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. Of these, 87 qualified the study-selection criteria and were divided into HDU group (treated in HDU after discharge from RICU prior to transfer to normal unit) (n = 40) and normal group (not treated in the HDU) (n = 47). In the 87 patients, 40 were divided into HDU group, which meant they transferring to HDU when got stable while another 47 were divided into normal group which meant they staying longer in RICU and transferring to normal unit when got stable. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, duration of mechanical ventilation, hospital infection, intensive care unit syndrome, length of stay, and expenditure were compared between the two groups. The primary outcome was discharging from hospital while the secondary outcome was length of stay. There was no significant difference with respect to noninvasive ventilation time, oxygenation index, or APACHE II and SOFA scores at admission or discharge from RICU (P > 0.05). The mean invasive ventilation time (176 ± 160 h) of the HDU group was not significantly different from that in the normal group (206 ± 179 h). The period of sequential noninvasive ventilation in the HDU group (135 ± 82 h) was significantly shorter than that in the normal group (274 ± 182 h, P < 0.05). The HDU group had a shorter length of stay in hospital and RICU, and incurred lesser expenditure than patients in the normal group (P < 0.05). Patients in HDU group had almost the same therapeutic effect with shorter length of stay in hospital and RICU, and lesser expenditure.

Inventory Optimization in the Perioperative Care Department Using Kotter's Change Model.

BACKGROUND: Perioperative services have been scrutinized in the context of cost containment in health care, particularly in the procurement and reprocessing of surgical instruments. Although solutions such as surgical instrument inventory optimization (IO) have been proposed, there is a paucity of literature on how to implement this change. The purpose of this project was to describe the implementation of an IO using Kotter's Change Model (KCM). METHODS: This study was conducted at a tertiary academic hospital across the four highest-volume surgical services. The IO was implemented using the steps outlined by KCM: (1) create coalition, (2) create vision for change, (3) establish urgency, (4) communicate the vision, (5) empower broad-based action, (6) generate short-term wins, (7) consolidate gains, and (8) anchor change. This process was evaluated using inventory metrics, operational efficiency metrics, and clinician satisfaction. RESULTS: Total inventory was reduced by 37.7%, with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1,333 hours per annum and labor cost savings of $39,995 per annum. Depreciation cost savings were $64,320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80.0% post-IO. CONCLUSION: This is the first study to describe the successful implementation of KCM to facilitate change in the perioperative setting. This success contributes to the growing body of literature supporting KCM as a valuable change management tool in health care.

Efficiency of unlocking or locking existing protected areas for identifying complementary areas for biodiversity conservation.

It is well known that existing protected areas (PAs) should function as focal areas for expanding PA systems. The optimal complementary conservation areas are often identified by implementing two approaches in systematic conservation planning, i.e., unlocking or locking existing PAs. However, evidence-based studies are lacking for clarifying the efficiencies of these two planning approaches. With Sichuan in southwest China - part of a global biodiversity hotspot - as one case, this study first assessed the ecological representativeness of existing nature reserves (NRs). Using 32 natural vegetation types as the conservation features, we then implemented a systematic conservation planning process by running Marxan software with NR-unlocked and NR-locked scenarios. A human disturbance index was also included as a penalty function in Marxan for achieving cost-effective planning. We finally investigated the efficiencies of the unlocking and locking planning approaches by comparing the outcomes of the NR-unlocked and NR-locked scenarios. We found that existing NRs were geographically biased towards the western mountainous regions with high elevations and low human disturbance levels. For achieving the same quantitative conservation targets, the total area of the NR-locked priority conservation areas was 18.6% larger than that of the NR-unlocked areas, whereas the area of NR-locked complementary areas to existing NRs was 15.3% smaller than that of NR-unlocked ones. Moreover, the NR-locked priority conservation areas had higher ecological representativeness than NR-unlocked areas. The results suggest that if a completely new PA system is to be established without considering existing PAs, the unlocking approach could more efficiently achieve the full conservation targets at lower costs of land area and with better connected habitats. When existing PAs must be used as focal areas for expansion, the locking approach is more cost-effective for filling conservation gaps by requiring smaller amounts of complementary areas. Our analysis provides evidence-based support for expanding the current PA systems in a cost-effective manner.

Effects of environmental regulation on the upgrading of Chinese manufacturing industry.

In recent years, China has constantly strengthened environmental regulation (ER) to force the manufacturing industry to upgrade. This study theoretically analyzes interaction mechanism of ER on the upgrading of manufacturing industry through foreign direct investment (FDI) and technological innovation (TI) and carries out empirical verification by using provincial panel data from 2000 to 2016 in China. The results demonstrate that the current ER intensity in China is unable to directly promote the upgrading of manufacturing industry, while through the interaction effects of FDI and TI do boost the upgrading of the industry. The above mechanisms are also robust even if we take the regional heterogeneity into consideration. Basic education and urbanization are favorable for the upgrading of the manufacturing industry. However, the increase in dependence on foreign trade is not conducive to upgrading manufacturing industry. Chinese government should further strengthen ER and give full play of the interaction mechanism of ER to guide the flow of foreign investment and force enterprises to carry out TI. In the meanwhile, Chinese government also needs to ensure balanced regional development, thus better promoting the upgrading of manufacturing industry.

Preliminary report on Sichuan golden snub-nosed monkeys (Rhinopithecus roxellana roxellana) at Laohegou Nature Reserve, Sichuan, China.

Comparative studies of subspecies under different ecological environments offer insights into intraspecies evolutionary adaptive mechanisms. Golden snub-nosed monkeys (Rhinopithecus roxellana) include three subspecies in China classified mainly by their morphological variations: R. r. roxellana (Sichuan and Gansu province), R. r. qinlingensis (Shaanxi province) and R. r. hubeiensis (Hubei province). These three subspecies live in three isolated area with different environments. Past works focused on the last two subspecies, but little information of habitat and behaviors of the nominated subspecies (R. r. roxellana) is available to date. We conducted a two-year study on the diet, activity budget, home range and social organization of 4 herds of R. r. roxellana, based on a total of 106 days' observation in Laohegou (LHG) Nature Reserve, Sichuan province. By using scan sampling method, our results suggest that the R. r roxellana feeds predominantly on leaves (77.5%), and spends more time feeding (40.0%) and resting (27.0%) while compared to the other two subspecies. Kernel Density Estimation Method based on GPS technology confirms that R. r roxellana has relatively larger home ranges (49.1 km2). The unit size (8.3 ± 3.5 individuals) of R. r roxellana is also smaller. Therefore, it is possible that differences in food availability in relation to habitats have important impacts on the feeding strategy and social system of the golden snub-nosed monkey. These results provide data to further explore intraspecific adaptations of living primates.

Determining the cost-effectiveness of endoscopic surveillance for gastric cancer in patients with precancerous lesions.

AIM: To identify the optimal strategy for gastric cancer (GC) prevention by evaluating the cost-effectiveness of esophagogastroduodenoscopy (EGD)-based preventive strategies. METHODS: We conducted a model-based cost-effectiveness analysis. Adopting a healthcare payer's perspective, Markov models simulated the clinical experience of the target population (Singaporean Chinese 50-69 years old) undergoing endoscopic screening, endoscopic surveillance and usual care of do-nothing. The screening strategy examined the cohort every alternate year whereas the surveillance strategy provided annual EGD only to people with precancerous lesions. For each strategy, discounted lifetime costs ($) and quality adjusted life years (QALY) were estimated and compared to generate incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analysis was conducted to identify influential parameters and quantify the impact of model uncertainties. RESULTS: Annual EGD surveillance with an ICER of $34 200/QALY was deemed cost-effective for GC prevention within the Singapore healthcare system. To inform implementation, the models identified six influential factors and their respective thresholds, namely discount rate (<4.20%), age of starting surveillance (>51.6 years), proportion of program cost in delivering endoscopy (<65%), cost of follow-up EGD (<$484), utility of stage 1 GC patients (>0.72) and odds ratio of GC for high-risk subjects (>3.93). The likelihood that surveillance is the most cost-effective strategy is 69.5% accounting for model uncertainties. CONCLUSION: Endoscopic surveillance of gastric premalignancies can be a cost-effective strategy for GC prevention. Its implementation requires careful assessment on factors influencing the actual cost-effectiveness.

Social organization of white-headed langurs (Trachypithecus leucocephalus) in the Nongguan Karst Hills, Guangxi, China.

The number of males per group is the most variable aspect of primate social organization and is often related to the monopolizability of females, which is mainly determined by the number of females per group and their reproductive synchrony. Colobines show both inter-specific and intra-specific variations in the number of males per group. Compared with other colobine species, little is known about the social organization of white-headed langur (Trachypithecus leucocephalus), despite its endangered status and unusual limestone habitat. As a part of a long-term study of the white-headed langurs in the Nongguan Karst Hills, Guangxi, China, we quantitatively investigated their social organization by analyzing census data from 1998 to 2003. The population censuses revealed that the predominant social organization of bisexual groups was the one-male group, similar to a previous report on this species and many other Asian colobines. In such groups, one adult male associated with 5.1 adult females, 0.1 sub-adult males, 2.6 juveniles and 2.9 infants on average, with a mean group size of 11.7 individuals. In addition, three multi-male groups were recorded, consisting of 2-3 adult males, 1-5 adult females, 0-2 sub-adult males, 0-7 juveniles and 0-2 infants. They did not contain more adult females than the one-male groups and were unstable in group membership. The langurs outside bisexual groups were organized into small nonreproductive groups or lived as solitaries. The nonreproductive groups averaged 1.3 adult males, 1.3 sub-adult males and 2.6 juveniles. Juvenile females were present in such groups on 52.4% of all occasions. As predicted by the monopolization model, the prevalence of the one-male pattern in this species may mainly be attributed to the small number of females in the group. The possible reasons for the occurrence of multi-male groups and the presence of juvenile females in nonreproductive groups are also discussed.