Economic Evaluation of an Enhanced Post-Discharge Home-Based Care Program for Stroke Survivors.

OBJECTIVES: To examine the cost-effectiveness of an enhanced postdischarge home-based care program for stroke survivors compared with usual care. METHODS: This was a trial-based economic evaluation study. One hundred and sixteen patients with ischemic stroke were recruited from neurology units in a Chinese hospital and randomized into intervention (n = 58) or usual care groups (n = 58). The intervention commenced with predischarge planning and transitioned to home follow-up postdischarge. Trained nurse case managers supported by an interdisciplinary team provided comprehensive assessment, individualized goal setting, and skill training to support home-based rehabilitation for intervention group participants. Standard care was provided to usual care group participants. Total cost and quality-adjusted life-years gained at 3-month (T1), 6-month (T2), and 12-month (T3) follow-ups were calculated. The incremental cost-effectiveness ratios between the groups were obtained. RESULTS: The intervention group showed a significant increase in utility compared with the usual care group at T1 (P = .003), T2 (P = .007), and T3 (P < .001). The average total QALY gain from baseline for the intervention group was higher than for the usual care group at all time points. The likelihood of being cost-effective ranged from 61.9% to 67.2% from the provider perspective, and from 59.7% to 66.8% from the societal perspective. CONCLUSIONS: The results showed that the intervention program was cost-effective with significantly higher quality-adjusted life-years for stroke survivors when compared with usual care. It provides economic evidence to support the development of home-based stroke rehabilitation program, especially in the low- and middle-income countries.

Health risk assessment of heavy metals in wild fish and seasonal variation and source identification of heavy metals in sediments: a case study of typical urban river in Xi'an, China.

In order to determine the status of heavy metal pollution in river sediments and wild fish in Xi'an, concentrations of heavy metals (Cr, Ni, Cu, Zn, As, and Pb) were collected and analyzed in sediments and wild fish during dry season (October-November 2020) and wet season (June-July 2021). This study aimed to investigate the spatial and temporal variations of heavy metals in urban rivers of Xi'an, China. Their distribution characteristics and sources as well their pollution levels and health risks were assessed. The findings revealed that influenced by human activities, the heavy metal content in sediments (mg·kg-1 dry weight) in wet season was ranked as follows: Cr (73.09) > Zn (63.73) > Pb (40.31) > Ni (31.52) > Cu (24.86) > As (6.83); in the dry season: Zn (94.07) > Cr (69.59) > Cu (34.24) > Ni (33.60) > Pb (32.87) > As (7.60). Moreover, 32 fish samples from six species indicated an average metal content trend (mg·kg-1 wet weight) of Zn (8.70) > Cr (0.57) > Pb (0.28) > Ni (0.27) > Cu (0.24) > As (0.05). The potential ecological risk indices for sediment heavy metal concentrations in both seasons were well below the thresholds, which indicates that the aquatic environment is in safe level. The analysis of the potential ecological risk of sediment heavy metal concentrations indicates that the aquatic environment is safe for the time being. Based on the estimated daily intake (EDI), target risk quotient (THQ), total target risk quotient (TTHQ), cancer risk (CR), total cancer risk (TCR), and the permissible safety limits set by the agencies, the consumption of the fish examined is safe for human health. However, the presence of Cr and As in wild fish should still be a concern for human health, especially for children. The cumulative effect of heavy metals and the bioconcentration factor (BCF) suggest that sediment and heavy metals in fish are closely related, with higher concentrations in fish living in the bottom layer of the water column than in other water layers, and increasing with increasing predator levels. Correlation analysis and PMF modeling identified and determined four comparable categories of potential sources, namely, (1) atmospheric deposition and traffic sources, (2) agricultural sources, (3) industrial sources, and (4) natural sources.

Mom's Good Mood: screening and management of perinatal depression within primary healthcare system in China-protocol for an effectiveness-implementation design study.

INTRODUCTION: The management of perinatal depression (PND) is challenging in China. The Thinking Healthy Programme (THP), developed under the core theory of cognitive-behavioural therapy, is an evidence-based approach that is recommended as a psychosocial intervention for managing PND in low/middle-income countries. Sparse evidence has been generated, however, to assess the effectiveness of THP and guide its implementation in China. METHODS AND ANALYSIS: A hybrid type II effectiveness-implementation study is ongoing in four cities in Anhui Province, China. A comprehensive online platform, Mom's Good Mood (MGM), has been developed. Perinatal women are screened using the WeChat screening tool (ie, Edinburgh Postnatal Depression Scale embedded as metrics) in clinics. Different intensities of the intervention are delivered through the mobile application for different degrees of depression, according to the stratified care model. The THP WHO treatment manual has been tailored to be the core component of intervention. Guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, process evaluations will be conducted to identify the facilitators and barriers to implementation and to modify the implementation strategy; summative evaluations will be carried out to examine the effectiveness of MGM in the management of PND within the primary healthcare system in China. ETHICS AND DISSEMINATION: Ethics approval and consent for this programme were obtained from Institutional Review Boards in China: Anhui Medical University, Hefei, People's Republic of China (20170358). Results will be submitted to relevant conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER: ChiCTR1800016844.

Occurrence and risk assessment of PAHs from athletic fields under typical rainfall events.

Six polycyclic aromatic hydrocarbons (PAHs) including naphthalene (Nap), fluorene (Flu), phenanthrene (Phe), fluoranthene (Fla), pyrene (Pyr), and chrysene (Chr) were detected in runoff from five athletic fields during three rainfall events. The event mean concentration (EMC) of ∑6PAHs ranged from 3.96 to 23.23 µg/L, which was much higher than the EMC in urban traffic area runoff. Except for Nap, the PAH concentrations followed in the order of artificial turf > badminton court > basketball court > plastic runway > optennis court. The surface characteristics of the athletic fields, such as the composition of materials and roughness, played an essential role in the release of PAHs. ∑6PAHs concentration during the 2nd rainfall event (July 22nd) was the highest among the three rainfall events, indicating that high rainfall intensity facilitated the PAHs release. PAHs during three rainfall events showed little first flush effect except for the artificial turf during the 2nd (22nd July) and 3rd (29th July) rainfall events. The first flush effect could be affected by rainfall characters, PAH properties, and surface characteristics of athletic fields. Ecological risk assessment showed that PAHs in runoff corresponded to moderate-to-high risk, while health risk assessment showed that PAHs could pose a potential carcinogenic danger to human health via dermal contact.

Assessment of Aging-Related Function Variations of P-gp Transporter in Old-Elderly Chinese CHF Patients Based on Modeling and Simulation.

BACKGROUND AND OBJECTIVES: P-glycoprotein (P-gp) is one of the most intensely studied transporters owing to its broad tissue distribution and substrate specificity. Existing research suggests that the risk of systemic exposure to dabigatran etexilate (DABE) and digoxin, two P-gp probe substrates in vivo, has significantly increased in elderly patients. We applied a model-based quantitative pharmacological approach to assess aging-related P-gp changes in the Chinese old-elderly population. METHODS: Population pharmacokinetic (PopPK) modeling was first performed using clinical pharmacokinetic data to explore the effect of age on the pharmacokinetic characteristics of dabigatran (DAB, the active principle of DABE) and digoxin in elderly Chinese patients. Corresponding physiologically based pharmacokinetic (PBPK) models were established to further explain the elevated systemic exposure to these two drugs. Eventually, standard dosing regimens of DABE and digoxin were assessed in Chinese old-elderly patients with chronic heart failure (CHF) with different stages of renal impairment. RESULTS: PopPK analysis suggested that age as a covariate had an additional effect on the apparent clearance of these two drugs after correcting for creatinine clearance. PBPK simulation results suggested that disease-specific pathophysiological changes could explain DAB exposure in the young elderly. In the elderly population, 17.1% of elevated DAB exposure remained unexplained, and 25.5% of the reduced P-gp function associated with aging was ultimately obtained using sensitivity analysis. This value was further validated using digoxin data obtained by PBPK modeling. The simulation results suggest that CHF patients with advanced age and moderate-to-severe renal impairment require heightened vigilance for elevated exposure risk during the use of DABE and digoxin. CONCLUSIONS: Aging might be a significant risk factor for elevated systemic exposure to DAB and digoxin by reducing P-gp-mediated efflux in the Chinese old elderly population.

Quantifying the Carbon Reduction Potential of Recycling Construction Waste Based on Life Cycle Assessment: A Case of Jiangsu Province.

The recycling of construction waste is key to reducing waste generation and CO2 emissions. This study aimed to develop a quantitative model for analyzing the carbon reduction potential of recycling construction, demolition, and renovation waste (CDRW) in Jiangsu province. The waste generation rate calculation method and nonlinear autoregressive artificial neural network model were used to estimate and predict CDRW generation. The life cycle assessment was performed to calculate the carbon reduction potential of recycling CDRW. In quantifying the carbon reduction potential, not only construction and demolition waste, but also renovation waste was considered for the first time. The results showed that the total carbon reduction potential of recycling CDRW increased from 3.94 Mt CO2e in 2000 to 58.65 Mt CO2e in 2020. Steel and concrete were the main contributors. By scenario analysis, the carbon reduction potential of fully recycling CDRW in 2020 increased by 37.79 Mt CO2e, a growth rate of 64%. The study further predicts future CDRW generation and the corresponding carbon reduction potential. Our conclusions indicate that 245.45 Mt of CDRW will be generated in 2030, and carbon reduction potential may reach 82.36 Mt CO2e. These results will help the government manage construction waste better and reach early achievement of the carbon peak target.

Economics of Minimalist Transcatheter Aortic Valve Replacement: Results From the 3M-TAVR Economic Study.

BACKGROUND: The 3M-TAVR trial (3M-Transcatheter Aortic Valve Replacement) demonstrated the feasibility and safety of next-day hospital discharge after transfemoral TAVR with implementation of a minimalist pathway. However, the economic impact of this approach is unknown. Therefore, we evaluated costs for patients undergoing minimalist TAVR compared with conventional TAVR. METHODS: We used propensity matching to compare resource utilization and costs (from a US health care system perspective) for patients in the 3M-TAVR trial with those for transfemoral TAVR patients enrolled in the contemporaneous S3i trial (PARTNER SAPIEN-3 Intermediate Risk). Procedural costs were estimated using measured resource utilization for both groups. For the S3i group, all other costs through 30-day follow-up were assessed by linkage with Medicare claims; for 3M, these costs were assessed using regression models derived from S3i cost and resource utilization data. RESULTS: After 1:1 propensity matching, 351 pairs were included in our study (mean age 82, mean Society of Thoracic Surgery risk score 5.3%). There were no differences in death, stroke, or rehospitalization between the 3M-TAVR and S3i groups through 30-day follow-up. Index hospitalization costs were $10 843/patient lower in the 3M-TAVR cohort, driven by reductions in procedure duration, anesthesia costs, and length of stay. Between discharge and 30 days, costs were similar for the 2 groups such that cumulative 30-day costs were $11 305/patient lower in the 3M-TAVR cohort compared with the S3i cohort ($49 425 versus $60 729, 95% CI for difference $9378 to $13 138; P<0.001). CONCLUSIONS: Compared with conventional transfemoral TAVR, use of a minimalist pathway in intermediate-risk patients was associated with similar clinical outcomes and substantial in-hospital cost savings, which were sustained through 30 days. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02287662.

Resampling-based cost loss attention network for explainable imbalanced diabetic retinopathy grading.

Diabetic retinopathy (DR) is currently considered to be one of the most common diseases that cause blindness. However, DR grading methods are still challenged by the presence of imbalanced class distributions, small lesions, low accuracy of small sample classes and poor explainability. To address these issues, a resampling-based cost loss attention network for explainable imbalanced diabetic retinopathy grading is proposed. First, the progressively-balanced resampling strategy is put forward to create a balanced training data by mixing the two sets of samples obtained from instance-based sampling and class-based sampling. Subsequently, a neuron and normalized channel-spatial attention module (Neu-NCSAM) is designed to learn the global features with 3-D weights and a weight sparsity penalty is applied to the attention module to suppress irrelevant channels or pixels, thereby capturing detailed small lesion information. Thereafter, a weighted loss function of the Cost-Sensitive (CS) regularization and Gaussian label smoothing loss, called cost loss, is proposed to intelligently penalize the incorrect predictions and thus to improve the grading accuracy of small sample classes. Finally, the Gradient-weighted Class Activation Mapping (Grad-CAM) is performed to acquire the localization map of the questionable lesions in order to visually interpret and understand the effect of our model. Comprehensive experiments are carried out on two public datasets, and the subjective and objective results demonstrate that the proposed network outperforms the state-of-the-art methods and achieves the best DR grading results with 83.46%, 60.44%, 65.18%, 63.69% and 92.26% for Kappa, BACC, MCC, F1 and mAUC, respectively.

Exploring Spatial Relationship between Restoration Suitability and Rivers for Sustainable Wetland Utilization.

Wetlands are important ecosystems for biodiversity preservation and environmental regulation. However, the integrity of wetland ecosystems has been seriously compromised and damaged due to the reckless and indiscriminate exploitation of wetland resources during economic development by human society. Hence, wetland restoration has now attracted wide attention. Understanding wetland restoration suitability and its relationship with river grade and river distance is an important step in further implementing wetland restoration and ensuring an orderly wetland development and utilization. In this study, wetland restoration suitability is evaluated combining natural and human factors. Taking its result as an important basis, the spatial distribution characteristics of different levels of wetland restoration suitability are discussed for the studied region; the percentage distribution of different levels of wetland restoration suitability is analyzed for 10 km long buffer zones of rivers of different grades, and the association between the distribution of different levels of wetland restoration suitability and the river distance (2, 4, 6, 8, and 10 km) is also analyzed for different buffer zones of rivers in different grades. Our findings show that the spatial distribution of wetland restoration suitability is closely associated with the grade of rivers and the distance of the wetland patches from the river. The higher the river grade, the higher the percentage of the wetland with high restoration suitability within the same river distance. The percentage of wetlands with high restoration suitability has shown a notably decreasing trend as the river distance increases for the areas beside rivers of all grades, while the percentage of a wetland area with relatively high restoration suitability tends to increase as the river distance increases for the areas beside rivers of grade I and II and does not have a noticeable trend to change as the river distance changes for the area beside rivers of other grades. Results of this can provide technical support for wetland restoration suitability evaluation for plain areas, a spatial reference for wetland restoration prioritizing, and an orderly wetland development and utilization in future studies and planning.

Occurrence, source identification, and ecological risk assessment of polycyclic aromatic hydrocarbons in sediments of the Pearl River Delta, China.

The pollution characteristics, sources, and ecological risk of polycyclic aromatic hydrocarbons (PAHs) in surface sediment samples from the river networks and outlets of the Pearl River Delta (PRD) were investigated. The total PAH concentrations were in the range of 69.1-1297 ng g-1 in river networks and 56.6-617 ng g-1 in river outlets. The results of source identification showed that PAHs in sediments were mainly derived from combined sources of coke tar and liquid fossil fuel combustion, coal/wood combustion, and petroleum contamination. The ecological risks of PAHs were evaluated based on sediment quality guidelines (SQG), mean probable effects levels quotient values (PEL-Q), and the toxicity equivalence factor (TEQBaP) method. The ecological risks of PAHs in sediments were at moderate levels in the Pearl River Delta. Although no high risk was found, regular and continuous monitoring of PAHs in sediments needs to be performed.

The Risk Factors-Based Nursing Case Management Could Effectively Reduce the Incidence of Pressure Sores in Hospitalized Patients.

BACKGROUND: To explore the effects of risk factors-based nursing management on the occurrence of pressure sores in hospitalized patients. METHODS: From Jan 2018 to Jun 2018, 289 hospitalized patients were divided into pressure sores group [100] and control group [189] for retrospective analysis. Overall, 260 hospitalized patients from Jun 2018 to Dec 2018 were followed up for nursing intervention. Overall 130 patients received risk factors-based nursing case management were in the intervention group, whereas 130 patients who received routine nursing care were in the control group. The chi-square test and t-test were used to compare the count data and the measurement data between groups, respectively. RESULTS: Age, body weight and proportions of patients with impaired nutritional intake, diabetes or stroke in pressure sores group were higher than those in normal group (P<0.05). Hospital stay and operative time in pressure sores group was longer than those in normal group (P<0.05). The frequency of assistant activity in pressure sores group was significantly lower than that in control group (P<0.05).In addition, the score of uroclepsia in pressure sores group was lower than that in normal group (P<0.05). Patients in the intervention group showed lower risk for pressure sores and more satisfied than patients in control group (P<0.001). CONCLUSION: Advanced age, high body weight, diabetes and stroke, long hospital stay, long operative time, poor nutritional status and severe uroclepsia were independent risk factors of pressure sores. Risk factors-based nursing case management can effectively reduce the occurrence and risk of pressure sores for hospitalized patients.

Predicting Decreased Activities of Daily Living in Patients with Moyamoya Disease after Revascularization: Development and Assessment of a New Predictive Nomogram.

The aim of this study was to develop and validate a nomogram model to predict the risk of decreased activities of daily living (ADLs) in patients with moyamoya disease (MMD) following revascularization. The nomogram model was constructed based on data from 292 patients with MMD that were treated at Qilu Hospital of Shandong University from January 2018 to June 2019. The prediction model was assessed using a dataset of 119 patients with MMD collected from July 2019 to June 2020. Patients were evaluated with a general information questionnaire and the Mini Mental Status Examination, Hospital Anxiety and Depression Scale, Social Support Rating Scale, and ADL Scale. Multivariable logistic regression analysis was applied to build a prediction model incorporating the features selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the prediction model were assessed using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis. Predictors contained in the nomogram included gender, age, monthly income, hypertension, and cognitive function and depression scores. The areas under the ROC curves of the training and testing datasets were 0.938 and 0.853, respectively. The prediction model displayed good calibration, and the decision curve analysis showed that it had a wide range of clinical applications. This novel predictive could be conveniently used to predict the risk of the decreased living activity ability in patients with MMD.

Two-year PAD-related health care costs in patients undergoing lower extremity endovascular revascularization: results from the LIBERTY 360° trial.

BACKGROUND: Multiple studies have demonstrated the high economic burden related to the management of lower extremity peripheral artery disease (PAD). This is the first study to examine long-term PAD-related costs among unselected patients undergoing endovascular intervention, and to investigate how clinical and anatomic factors impact cost outcomes over time. METHODS AND RESULTS: We performed a prospective health economic study alongside the LIBERTY 360° trial (ClinicalTrials.gov; identifier NCT01855412) - a prospective, multi-center study evaluating the long-term outcomes of endovascular revascularization to treat claudication or critical limb ischemia. Costs (2018) were calculated using a combination of standard "bottom-up" cost accounting methods (for index procedures), itemized hospital charges and department level cost-to-charge ratios (for non-procedural hospital resources), national Medicare Severity-Diagnosis Related Group-specific average reimbursements (for follow-up hospitalizations) and Medicare payments (for outpatient/chronic care). Methods for the analysis of censored cost data were used to adjust cost estimates for patients with incomplete follow-up. Independent predictors of cumulative 2-year costs were explored using generalized linear models. A total of 1,189 patients were included (500 Rutherford 2-3, 589 Rutherford 4-5, 100 Rutherford 6). Mean total costs associated with the index procedure hospitalization increased with Rutherford classification ($10,304, $11,418, and $19,403 for Rutherford 2-3, 4-5, and 6, respectively; p < 0.01 in all pairwise comparisons). Mean total 2-year follow-up costs were $11,416, $24,846, and $25,720 for Rutherford 2-3, 4-5, and 6, respectively (p < 0.001 comparing Rutherford 2-3 to the other 2 groups; p = 0.09 comparing Rutherford 4-5 and Rutherford 6). Key predictors of higher cumulative 2-year costs included female sex, pedal lesion location, severe lesion calcification, the presence of one or more chronic total occlusions, the number of wounds present on the target limb at baseline, and Rutherford classification. CONCLUSIONS: Among patients with symptomatic lower extremity PAD undergoing endovascular revascularization, initial treatment costs and total 2-year costs vary significantly according to clinical and lesion-level characteristics, as well as symptom burden.

Utility of Normalized TdP Score System in Drug Proarrhythmic Potential Assessment: A Blinded in vitro Study of CiPA Drugs.

Drugs that prolong QT may cause torsade de pointes (TdP). However, translation of nonclinical assessment of QT prolongation or hERG channel, targeted by QT-prolonging drugs, into clinical TdP risk has been insufficient to date. In this blinded study, we confirmed the utility of a Normalized TdP Score System in predicting drug-induced TdP risks among 34 drugs, including 28 with low, intermediate, and high TdP risks under the Comprehensive In Vitro Proarrhythmia Assay (CiPA) initiative plus six compounds with names blinded to the investigators, using the rabbit ventricular wedge assay. Concentration-dependent TdP scores were determined by drug-induced changes in QT, Tp-e , and proarrhythmias. Disclosure of the names and testing concentrations was made after completion of the experiments and report to the sponsors. Drugs' normalized TdP scores were calculated thereafter based on their respective free clinical maximum concentration (Cmax ). Drugs' normalized TdP scores were calculated and ranked for 33 drugs, excluding 1 investigational drug, and the TdP risks of the 28 CiPA drugs were correctly distinguished according to their respective categories of low, intermediate, and high TdP risks under the CiPA initiative. Accordingly, we are able to propose the cutoff values of the normalized TdP scores at 1 × Cmax : ≤ 0, > 0 to < 0.65 and ≥ 0.65, respectively, for low, intermediate, and high risk. This blinded study supports utility of our Normalized TdP Score System in predicting drug-induced TdP risks in 33 drugs, including 28 used for characterization of other assays under the CiPA initiative. However, these results need to be replicated in other laboratories.

Effective adsorption of diclofenac sodium from neutral aqueous solution by low-cost lignite activated cokes.

Activated cokes have attracted great interest inwater treatment to remove organic pollutants due to their low cost and specific textural properties. In this study, adsorptive removal of diclofenac sodium (DCF) from neutral aqueous solution by available lignite activated cokes (LACs) was reported for the first time. Diclofenac sodium could be quickly removed from aqueous solution by LAC-2, with the maximum Langmuir adsorption capacity qm of 224 mg/g at pH 6.5. Characterization results (including scanning electron microscopy, transmission electron microscopy, elemental analyses, Boehm titrations, N2 adsorption-desorption isotherms and Fourier transform infrared spectroscopy) and a series of adsorption kinetics, adsorption isotherms model studies revealed that high porosity with developed macro- and micropore structures on LAC-2, as well as high content of phenolic groups, could obviously enhance the DCF adsorption capacity and rate. Moreover, LAC-2 showed high affinity towards DCF at low concentrations, as well as good reusability after three adsorption-desorption cycles. pH effect studies revealed that hydrogen-bonding interaction plays an important role during adsorption, accompanied with certain contribution from electrostatic interaction and π-π interaction. This study indicates the promising potential of LAC-2 as an efficient, low-cost and recyclable material for DCF removal from water bodies.

The Impact of the Economic Corridor on Economic Stability: A Double Mediating Role of Environmental Sustainability and Sustainable Development Under the Exceptional Circumstances of COVID-19.

This study discusses the impact of different economic indicators on economic stability, including honest leadership, improved infrastructure, revenue generation, and CPEC taking into account the double mediating role of environmental sustainability and sustainable development, while considering the latest COVID-19 situation. This study adopted primary data collection methods and obtained data from the employees of CPEC by using questionnaires and smart-PLS for analysis purposes. The results revealed that honest leadership, improved infrastructure, revenue generation, and CPEC have a positive nexus with economic stability. Despite the severe impact of COVID-19 on the country's economy, the economic corridor plays a vital role in stabilizing the state's economy and supports all those related to this phenomenal project either directly or indirectly.

In-Hospital Costs and Costs of Complications of Chronic Total Occlusion Angioplasty: Insights From the OPEN-CTO Registry.

OBJECTIVES: The aim of this study was to describe the costs of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and the association of complications during CTO PCI with costs and length of stay (LOS). BACKGROUND: CTO PCI generally requires more procedural resources and carries higher risk for complications than PCI of non-CTO vessels. The costs of CTO PCI using the hybrid approach have not been described, and no studies have examined the impact of complications on in-hospital costs and LOS in this population. METHODS: Costs were calculated for 964 patients in the 12-center OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures) registry using prospectively collected resource utilization and billing data. Multivariate models were developed to estimate the incremental costs and LOS associated with complications. Attributable costs and LOS were calculated by multiplying the independent cost of each event by its frequency in the population. RESULTS: Mean costs for the index hospitalization were $17,048 ± 9,904; 14.5% of patients experienced at least 1 complication. Patients with complications had higher mean hospital costs (by $8,603) and LOS (by 1.5 days) than patients without complications. Seven complications were independently associated with increased costs and 6 with LOS; clinically significant perforation and myocardial infarction had the greatest attributable cost per patient. Overall, complications accounted for $911 per patient in hospital costs (5.3% of the total costs) and 0.2 days of additional LOS. CONCLUSIONS: Complications have a significant impact on both LOS and in-hospital costs for patients undergoing CTO PCI. Methods to identify high-risk patients and develop strategies to prevent complications may reduce CTO PCI costs.

Infrastructure Shapes Differences in the Carbon Intensities of Chinese Cities.

The carbon intensity of economic activity, or CO2 emissions per unit GDP, is a key indicator of the climate impacts of a given activity, business, or region. Although it is well-known that the carbon intensity of countries varies widely according to their level of economic development and dominant industries, few studies have assessed disparities in carbon intensity at the level of cities due to limited availability of data. Here, we present a detailed new inventory of emissions for 337 Chinese cities (every city in mainland China including 333 prefecture-level divisions and 4 province-level cities, Beijing, Tianjin, Shanghai, and Chongqing) in 2013, which we use to evaluate differences of carbon intensity between cities and the causes of those differences. We find that cities' average carbon intensity is 0.84 kg of CO2 per dollar of gross domestic product (kgCO2 per $GDP), but individual cities span a large range: from 0.09 to 7.86 kgCO2 per $GDP (coefficient of variation of 25%). Further analysis of economic and technological drivers of variations in cities' carbon intensity reveals that the differences are largely due to disparities in cities' economic structure that can in turn be traced to past investment-led growth. These patterns suggest that "carbon lock-in" via socio-economic and infrastructural inertia may slow China's efforts to reduce emissions from activities in urban areas. Policy instruments targeted to accelerate the transition of urban economies from investment-led to consumption-led growth may thus be crucial to China meeting both its economic and climate targets.

Cost-Effectiveness of Long-Term Ticagrelor in Patients With Prior Myocardial Infarction: Results From the PEGASUS-TIMI 54 Trial.

BACKGROUND: In patients with a myocardial infarction (MI) 1 to 3 years earlier, treatment with ticagrelor + low-dose aspirin (ASA) reduces the risk of cardiovascular (CV) death, MI, or stroke compared with low-dose aspirin alone, but at an increased risk of major bleeding. OBJECTIVES: The authors evaluated cost-effectiveness of ticagrelor + low-dose ASA in patients with prior MI within the prior 3 years. METHODS: The authors performed a prospective economic substudy alongside the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis In Myocardial Infarction 54) trial, which randomized 21,162 patients to ASA alone, ticagrelor 60 mg twice daily + low-dose ASA, or ticagrelor 90 mg twice daily + low-dose ASA. Medical resource use data were collected over a median 33-month follow-up. Costs were assessed from the U.S. health care system perspective. In-trial data relating to survival, utility, and costs were combined with lifetime projections to evaluate lifetime cost-effectiveness of the Food and Drug Administration-approved lower-dose ticagrelor regimen (60 mg twice daily). RESULTS: Hospitalization costs were similar for ticagrelor 60 mg and placebo ($2,262 vs. $2,333; 95% confidence interval for difference -$303 to $163; p = 0.54); after inclusion of a daily ticagrelor 60 mg cost of $10.52, total costs were higher for ticagrelor ($10,016 vs. $2,333; 95% CI: $7,441 to $7,930; p < 0.001). In-trial quality-adjusted life-years (QALYs) were similar (2.28 vs. 2.27; p = 0.34). Over a lifetime horizon, ticagrelor was associated with QALY gains of 0.078 and incremental costs of $7,435, yielding an incremental cost-effectiveness ratio (ICER) of $94,917/QALY gained. Several high-risk groups had more favorable ICERs, including patients with >1 prior MI, multivessel disease, diabetes, renal dysfunction (all with ICERs $50,000 to $70,000/QALY gained), patients age <75 years (ICER = $44,779/QALY gained), and patients with peripheral artery disease (ICER = $13,427/QALY gained). CONCLUSIONS: For patients with a history of MI >1 year previously, long-term treatment with ticagrelor 60 mg + low-dose ASA yields a cost-effectiveness ratio suggesting intermediate value based on current guidelines. Ticagrelor appears to provide higher value for patients in several recognized high-risk subgroups. (Prevention of Cardiovascular Events [e.g., Death From Heart or Vascular Disease, Heart Attack, or Stroke] in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562).