Identifying drivers of cost in pediatric liver transplantation.

Understanding the economics of pediatric liver transplantation (LT) is central to high-value care initiatives. We examined cost and resource utilization in pediatric LT nationally to identify drivers of cost and hospital factors associated with greater total cost of care. We reviewed 3295 children (<21 y) receiving an LT from 2010 to 2020 in the Pediatric Health Information System to study cost, both per LT and service line, and associated mortality, complications, and resource utilization. To facilitate comparisons, patients were stratified into high-cost, intermediate-cost, or low-cost tertiles based on LT cost. The median cost per LT was $150,836 [IQR $104,481-$250,129], with marked variance in cost within and between hospital tertiles. High-cost hospitals (HCHs) cared for more patients with the highest severity of illness and mortality risk levels (67% and 29%, respectively), compared to intermediate-cost (60%, 21%; p <0.001) and low-cost (51%, 16%; p <0.001) hospitals. Patients at HCHs experienced a higher prevalence of mechanical ventilation, total parental nutrition use, renal comorbidities, and surgical complications than other tertiles. Clinical (27.5%), laboratory (15.1%), and pharmacy (11.9%) service lines contributed most to the total cost. Renal comorbidities ($69,563) and total parental nutrition use ($33,192) were large, independent contributors to total cost, irrespective of the cost tertile ( p <0.001). There exists a significant variation in pediatric LT cost, with HCHs caring for more patients with higher illness acuity and resource needs. Studies are needed to examine drivers of cost and associated outcomes more granularly, with the goal of defining value and standardizing care. Such efforts may uniquely benefit the sicker patients requiring the strategic resources located within HCHs to achieve the best outcomes.

The Importance of Community-Based and Community-Partnered COVID-19 Testing for Reducing Disparities Among African American Populations.

Background: Health inequalities in African American communities have been further exacerbated by COVID-19. Public health departments and other safety-net providers across the United States have partnered with community-based organizations to address barriers to COVID-19 testing in disproportionately impacted communities. This narrative review summarizes lessons learned from published examples of these community-based COVID-19 testing efforts. Methods: We searched online databases for peer-reviewed articles on community-based COVID-19 testing interventions in the United States aimed at increasing COVID-19 testing among African American populations. We abstracted information about each example and synthesized the primary lessons learned and key aspects that contributed to their success. Results: Seven examples of community-based COVID-19 testing aimed at increasing testing among African Americans and other underserved populations were identified and described, across various U.S. locations and involving multiple types of partners (1) St. Paul, MN (faith, health centers, Mayo Clinic); (2) Chicago, IL (university hospital and health centers); (3) NC (health centers, Community Advisory Board); (4) Baltimore, MD (hospitals, community clinic, mobile clinic); (5) Marion County, FL (health department and community partners); (6) New Orleans, LA (health department and health system); and (7) New York City, NY health and hospital system, mobile clinic). Discussion: Several key aspects of the COVID-19 testing models included the following: (1) close proximity of the testing site to affected communities and availability of walk-up and drive-through testing options; (2) partnerships between safety-net providers and broad community networks, which facilitated outreach and trust; (3) increased resources for safety-net providers; and (4) the use of data to identify areas of need and track impact. The merging of resources and relationships among well-equipped, safety-net providers and other health care institutions and culture-rich, community-centered organizations, to jointly address structural and systemic inequities, is key to cultivating health equity in the distribution of COVID-19 testing and other essential public health services.

Impact of Food Insecurity Nutrition Incentives on Household Fruit and Vegetable Expenditures.

OBJECTIVE: Evaluate the impact of the Food Insecurity Nutrition Incentive (FINI) grant program on self-reported fruit and vegetable (FV) expenditures. DESIGN: Pre-post quasi-experimental study design. SETTING: Farmers markets and grocery stores in states with FINI projects. PARTICIPANTS: A total of 2,471 Supplemental Nutrition Assistance Program (SNAP) households in 4 intervention groups who lived near a FINI retailer (farmers market or grocery store) and 4 matched comparison groups who did not live near a FINI retailer. MAIN OUTCOME MEASURES: Awareness and use of point-of-sale incentives and changes in self-reported monthly household FV expenditures. ANALYSIS: Ordinary least squares intent-to-treat regression model using lagged dependent variable model framework. RESULTS: Awareness of FINI was higher among households who were near a FINI retailer and had shopped there before FINI than those who lived near a FINI retailer but had not shopped there before FINI; the number of information sources from which SNAP participants heard about FINI was positively associated with incentive receipt (P < 0.05). Among those who received incentives, the average amount of incentives received at the last shopping trip ranged from $15 to $23. The FINI program had a positive impact on the average monthly FV expenditures for those in the farmers market shopper, grocery store shopper, and grocery store general intervention groups-increases ranged from $9 to $15 (P < 0.05). CONCLUSIONS AND IMPLICATIONS: Point-of-sale incentives were associated with an increase in FV expenditures among SNAP households. Further research is needed to examine (1) effective messaging strategies to increase incentive awareness and (2) the long-term impact of incentives on FV expenditures.

Heterogeneity in Economic and Carbon Benefits of Electric Technology Vehicles in the US.

To broadly contribute to sustainable mobility, electric technology vehicles (hybrid, electric, and plug-in-hybrid) must become more price competitive with internal combustion vehicles. This study assesses the economic and carbon benefits of electric technology vehicles in the U.S., accounting for household-by-household behavioral variability and geographical differences in fuel and electricity prices. This finer resolution provides insight into subsets of the population for whom adoption is economically or environmentally favorable, allowing us to construct marginal abatement cost curves for CO2 that account for geographic, behavioral, and stock heterogeneities. Currently, low gasoline prices and high initial expense means that, without subsidies, few consumers benefit financially from electric technology vehicles (1.7% of drivers). However, improved technology dramatically and nonlinearly increases both the number of consumers that benefit and corresponding carbon emissions that could be abated without government subsidy. Our results clarify cost targets that electric vehicle technology must achieve in order to deliver net financial and subsidy-free environmental benefits.

Analysis of the Effect of Race, Socioeconomic Status, and Center Size on Unrelated National Marrow Donor Program Donor Outcomes: Donor Toxicities Are More Common at Low-Volume Bone Marrow Collection Centers.

Previous studies have shown that risks of collection-related pain and symptoms are associated with sex, body mass index, and age in unrelated donors undergoing collection at National Marrow Donor Program centers. We hypothesized that other important factors (race, socioeconomic status [SES], and number of procedures at the collection center) might affect symptoms in donors. We assessed outcomes in 2726 bone marrow (BM) and 6768 peripheral blood stem cell (PBSC) donors collected between 2004 and 2009. Pain/symptoms are reported as maximum levels over mobilization and collection (PBSC) or within 2 days of collection (BM) and at 1 week after collection. For PBSC donors, race and center volumes were not associated with differences in pain/symptoms at any time. PBSC donors with high SES levels reported higher maximum symptom levels 1 week after donation (P = .017). For BM donors, black males reported significantly higher levels of pain (OR, 1.90; CI, 1.14 to 3.19; P = .015). No differences were noted by SES group. BM donors from low-volume centers reported more toxicity (OR, 2.09; CI, 1.26 to 3.46; P = .006). In conclusion, race and SES have a minimal effect on donation-associated symptoms. However, donors from centers performing ≤ 1 BM collection every 2 months have more symptoms after BM donation. Approaches should be developed by registries and low-volume centers to address this issue.

Estimating demand and unmet need for allogeneic hematopoietic cell transplantation in the United States using geographic information systems.

PURPOSE: Allogeneic hematopoietic cell transplantation (HCT) is an increasingly used therapy for many patients with hematologic malignancies and other marrow failure or immune system disorders. The purpose of this study was to quantify and visualize both the demand and unmet need for HCT. METHODS: HCT use for 2012 was described using the Center for International Blood and Marrow Transplant Research registry. Potential demand for HCT was calculated using 2012 SEER data and published literature for HCT-treatable conditions. Point locations of transplant centers were geocoded using geographic information system (GIS) software; Thiessen polygons were created to establish adult (age 20 to 74 years) and pediatric (age 0 to 19 years) market areas. Market-area population estimates were calculated using 2012 population estimates by age aggregated by census block. RESULTS: US market areas for HCTs were identified separately for transplant centers treating adult (n = 62) and pediatric patients (n = 52). Overall HCT demand among adults was 16,096, with an unmet need for HCTs of 10,276 patients. For pediatric patients, the total demand was 4,561, with an unmet need of 3,213 potential recipients. Evaluation of adult and pediatric market areas indicated that the largest unmet needs tended to be in areas with large populations. CONCLUSION: Market-area maps and statistics developed using GIS will help communicate the unmet need for HCT, inform policy, and assist transplant centers in planning for the anticipated growth in HCT use.

Consumption-weighted life cycle assessment of a consumer electronic product community.

A new approach for quantifying the net environmental impact of a "community" of interrelated products is demonstrated for consumer electronics owned by an average U.S. household over a 15-year period (1992-2007). This consumption-weighted life cycle assessment (LCA) methodology accounts for both product consumption (number of products per household) and impact (cumulative energy demand (MJ) and greenhouse gas emissions (MT CO2 eq) per product), analyzed using a hybrid LCA framework. Despite efficiency improvements in individual devices from 1992 to 2007, the net impact of the entire product community increased, due primarily to increasing ownership and usage. The net energy impact for the product community is significant, nearly 30% of the average gasoline use in a U.S. passenger vehicle in 2007. The analysis points to a large contribution by legacy products (cathode ray tube televisions and desktop computers), due to historically high consumption rates, although impacts are beginning to shift to smaller mobile devices. This method is also applied to evaluate prospective intervention strategies, indicating that environmental impact can be reduced by strategies such as lifespan extension or energy efficiency, but only when applied to all products owned, or by transforming consumption trends toward fewer, highly multifunctional products.

Patient perceptions of patient-centred care: empirical test of a theoretical model.

AIM: Patient perception measures are gaining increasing interest among scholars and practitioners. The aim of this study was to empirically examine a conceptual model of patient-centred care using patient perception survey data. BACKGROUND: Patient-centred care is one of the Institute of Medicine's objectives for improving health care in the 21st century. Patient interviews conducted by the Picker Institute/Commonwealth Fund in the 1980s resulted in a theoretical model and survey questions with dimensions and attributes patients defined as patient-centered. METHOD: The present study used survey data from patients with overnight visits at 142 U.S. hospitals. RESULTS: Regression analysis found significant support for the theoretical model. Perceptions of emotional support had the strongest relationship with overall care ratings. Coordination of care, and physical comfort were strongly related as well. CONCLUSION: Understanding how patients experience their care can help improve understanding of what patients believe is patient-centred, and of how care processes relate to important patient outcomes.

Siting is a constraint to realize environmental benefits from carbon capture and storage.

Carbon capture and storage (CCS) for coal power plants reduces onsite carbon dioxide emissions, but affects other air emissions on and offsite. This research assesses the net societal benefits and costs of Monoethanolamine (MEA) CCS, valuing changes in emissions of CO2, SO2, NOX, NH3 and particulate matter (PM), including those in the supply chain. Geographical variability and stochastic uncertainty for 407 coal power plant locations in the U.S. are analyzed. The results show that the net environmental benefits and costs of MEA CCS depend critically on location. For a few favorable sites of both power plant and upstream processes, CCS realizes a net benefit (benefit-cost ratio >1) if the social cost of carbon exceeds $51/ton. For much of the U.S. however, the social cost of carbon must be much higher to realize net benefits from CCS, up to a maximum of $910/ton. While the social costs of carbon are uncertain, typical estimates are in the range of $32-220 per ton, much lower than the breakeven value for many potential CCS locations. Increased impacts upstream from the power plant can dramatically change the social acceptability of CCS and needs further consideration and analysis.

Examining the effect of EVS spending on HCAHPS scores: a value optimization matrix for expense management.

Using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey the Centers for Medicare & Medicaid Services' Value-Based Purchasing program has now linked patient care experience rating to hospital revenue reimbursement, thereby establishing a key relationship between revenue cycle management and the patient experience. However, little data exist on the effect of hospital resource spending on patient HCAHPS ratings. This article examines environmental services (EVS) expenses and HCAHPS ratings on hospital cleanliness and overall patient experience ratings to determine how these variables are related. No linear relationship between EVS expense spending and HCAHPS ratings was found, but post hoc analysis identified a matrix that differentiated on hospital cleanliness ratings and overall EVS spending. A value score was calculated for each quadrant of the matrix, and it was determined that organizational value derives from management of expense spending rather than pursuit of high HCAHPS scores. A value optimization matrix is introduced, and its four quadrants are described. With increased emphasis on subjective patient experience measures attached to financial consequences, leaders in the healthcare industry must understand the link between expense management and HCAHPS performance. This study has shown that effective operations are derived from the efficient use of resources and are supported by strong leadership, strategic management, and a culture of patient-centered achievement. The capacity of healthcare organizations to identify their unique costs-to-outcomes balance through the value optimization matrix will help provide them with a means to ensure that optimal value is extracted from all expense spending.

Modeling cascading diffusion of new energy technologies: case study of residential solid oxide fuel cells in the US and internationally.

Subsidy programs for new energy technologies are motivated by the experience curve: increased adoption of a technology leads to learning and economies of scale that lower costs. Geographic differences in fuel prices and climate lead to large variability in the economic performance of energy technologies. The notion of cascading diffusion is that regions with favorable economic conditions serve as the basis to build scale and reduce costs so that the technology becomes attractive in new regions. We develop a model of cascading diffusion and implement via a case study of residential solid oxide fuel cells (SOFCs) for combined heating and power. We consider diffusion paths within the U.S. and internationally. We construct market willingness-to-pay curves and estimate future manufacturing costs via an experience curve. Combining market and cost results, we find that for rapid cost reductions (learning rate = 25%), a modest public subsidy can make SOFC investment profitable for 20-160 million households. If cost reductions are slow however (learning rate = 15%), residential SOFCs may not become economically competitive. Due to higher energy prices in some countries, international diffusion is more favorable than domestic, mitigating much of the uncertainty in the learning rate.

Cardiovascular disease among Black Americans: comparisons between the U.S. Virgin Islands and the 50 U.S. states.

OBJECTIVES: Consistent findings show that black Americans have high rates of cardiovascular disease (CVD) and related behavioral risk factors. Despite this body of work, studies on black Americans are generally limited to the 50 U.S. states. We examined variation in CVD and related risk factors among black Americans by comparing those residing within the U.S. Virgin Islands (USVI) with those residing in the 50 U.S. states and Washington, D.C. (US 50/DC) and residing in different regions of the US 50/DC (Northeast, Midwest, South, and West). METHODS: Using data from the 2007 and 2009 Behavioral Risk Factor Surveillance System, we compared CVD and CVD risk factor prevalence in non-Hispanic black people (≥20 years of age) in the USVI and US 50/DC, examining the relative contributions of health behaviors, health insurance, and socioeconomic status (SES). RESULTS: Accounting for age, sex, education, health insurance, and health behaviors, US 50/DC black Americans were significantly more likely than USVI black people to report ever having a stroke and coronary heart disease, and to be hypertensive, diabetic, or obese. While there was heterogeneity by region, similar patterns emerged when comparing the USVI with different regions of the US 50/DC. CONCLUSION: USVI black people have lower CVD and risk factor prevalence than US 50/DC black people. These lower rates are not explained by differences in health behaviors or SES. Understanding health in this population may provide important information on the etiology of racial/ethnic variation in health in the U.S. and elsewhere, and highlight relevant public health policies to reduce racial/ethnic group disparities.

Dose modification factor analysis of multilumen balloon brachytherapy applicator with Monte Carlo simulation.

The Contura brachytherapy applicator is a silicone balloon with five lumens in which a high-dose-rate brachytherapy source can traverse. Multilumen applicators, like the Contura, are used in accelerated partial breast irradiation (APBI) brachytherapy in instances where asymmetric dose distributions are desired; for example, when the applicator surface-to-skin thickness is small (< 7 mm). In these instances, the air outside the patient and the lung act as a poor scattering medium, scattering less dose back into the breast and affecting the dose distribution. The recent report by Task Group 186 of the American Association of Physicists in Medicine (AAPM) has outlined the importance of moving towards brachytherapy dose calculations using heterogeneity corrections. However, at this time, many commercial treatment planning systems do not correct for tissue heterogeneity, which can result in inaccuracies in the planned dose distribution. To quantify the deviation in the skin dose we utilize the dose modification factor (DMF), defined as the ratio of the dose rate at 1 cm beyond the applicator surface with homogenous medium, to the dose rate at 1 cm with heterogeneous medium. This investigation models the Contura applicator with the Monte Carlo N-Particle code version 5, and determines a DMF through simulation. Taking all geometrical considerations into account, an accurate model of the Contura balloon applicator was created in MCNP and used to run simulations. The dose modification factor was found to be only slightly dependent on whether the dose distribution was symmetric or asymmetric. These results indicate that the dose delivered to part of the PTV may be lower than the planned dose by up to 12%, and that these brachytherapy plans should be viewed with caution. In addition to studying the effects of backscatter, an evaluation was made regarding the capabilities of the Contura device to shape an asymmetric dose distribution. We compared these results to a previous study of a MammoSite ML and a SAVI device and found that the dose shaping capabilities of the Contura were quite similar to that of the MammoSite ML, but markedly inferior to the SAVI.

Institutional disposition and management of end-of-life electronics.

Institutions both public and private face a challenge to develop policies to manage purchase, use, and disposal of electronics. Environmental considerations play an increasing role in addition to traditional factors of cost, performance and security. Characterizing current disposition practices for end-of-life electronics is a key step in developing policies that prevent negative environmental and health impacts while maximizing potential for positive social and economic benefits though reuse. To provide a baseline, we develop the first characterization of quantity, value, disposition, and flows of end-of-life electronics at a major U.S. educational institution. Results of the empirical study indicate that most end-of-first-life electronics were resold through public auction to individuals and small companies who refurbish working equipment for resale or sell unusable products for reclamation of scrap metal. Desktop and laptop computers sold for refurbishing and resale averaged U.S. $20-100 per unit, with computers sold directly to individuals for reuse reaching $250-350 per unit. This detailed assessment was coupled with a benchmarking survey of end-of-life electronics management practices at other U.S. universities. Survey results indicate that while auctions are still commonplace, an increasing number of institutions are responding to environmental concerns by creating partnerships with local recycling and resale entities and mandating domestic recycling. We use the analyses of current disposition practices as input to discuss institutional strategies for managing electronics. One key issue is the tension between benefits of used equipment sales, in terms of income for the institution and increased reuse for society, and the environmental risks because of unknown downstream practices.

Dynamic hybrid life cycle assessment of energy and carbon of multicrystalline silicon photovoltaic systems.

This paper advances the life cycle assessment (LCA) of photovoltaic systems by expanding the boundary of the included processes using hybrid LCA and accounting for the technology-driven dynamics of embodied energy and carbon emissions. Hybrid LCA is an extended method that combines bottom-up process-sum and top-down economic input-output (EIO) methods. In 2007, the embodied energy was 4354 MJ/m(2) and the energy payback time (EPBT) was 2.2 years for a multicrystalline silicon PV system under 1700 kWh/m(2)/yr of solar radiation. These results are higher than those of process-sum LCA by approximately 60%, indicating that processes excluded in process-sum LCA, such as transportation, are significant. Even though PV is a low-carbon technology, the difference between hybrid and process-sum results for 10% penetration of PV in the U.S. electrical grid is 0.13% of total current grid emissions. Extending LCA from the process-sum to hybrid analysis makes a significant difference. Dynamics are characterized through a retrospective analysis and future outlook for PV manufacturing from 2001 to 2011. During this decade, the embodied carbon fell substantially, from 60 g CO(2)/kWh in 2001 to 21 g/kWh in 2011, indicating that technological progress is realizing reductions in embodied environmental impacts as well as lower module price.