Assessment of the urban waterlogging resilience and identification of its driving factors: A case study of Wuhan City, China.

With rapid urbanization and extreme rainstorm events associated with climate change, urban waterlogging has become one of the most frequent and severe disasters globally. In this study, a multi-dimensional and multi-process index system based on the Pressure-State-Response (PSR) framework was developed to measure the level of urban waterlogging resilience (UWR). The spatial distribution of UWR on a block scale was explored based on the entropy weight method with the natural breakpoint method (EWM-NBM) in the central district of Wuhan City, China. In addition, the effects of the runoff control facilities and early warning measures on UWR were also quantified. Further, the Geodetector was used to investigate the main driving factors of UWR and their interactions. Results showed that the constructed index system for UWR based on the PSR framework performed reasonably, and the EWM-NBM was validated to be effective in the integrated assessment. In terms of the validation results, 82.72 % of the recorded waterlogging points belonged to high and very-high risk levels. The spatial heterogeneity of UWR was significant in the study area where the higher-level UWR mainly appears in the areas near the undeveloped suburban and water bodies (lakes and rivers), and the lower-level UWR was concentrated in central urban areas with more impervious surfaces. There was a clear increasing trend in UWR after the implementation of runoff control facilities and early warning measures, but its spatial distribution remained almost invariant. Among all the indexes, the impervious surface percentage had the strongest (69.58 %) explanatory ability for the UWR, and mean annual precipitation (15.51 %), GDP (14.03 %), and population density (11.98 %) also demanded attention. Most driving factors of UWR showed nonlinear interactions. This research could provide a benchmark for urban planning to enhance UWR to mitigate the waterlogging within the main urban area.

Minimum Volume Standards for Surgical Care of Early-Stage Lung Cancer: A Cost-Effectiveness Analysis.

BACKGROUND: Multiple stakeholders have advocated for minimum volume standards for complex surgical procedures. The Leapfrog Group recommends that patients with non-small cell lung cancer (NSCLC) receive surgical resection at hospitals that perform at least 40 lung resections annually. However, the cost-effectiveness of this paradigm is unknown. METHODS: A cost-effectiveness analysis was performed on 90-day and 5-year horizons for patients with clinical stage I NSCLC undergoing surgical resection at hospitals stratified by Leapfrog standard. Model inputs were derived from either the literature or a propensity score-matched cohort using the National Cancer Database. For the 5-year horizon, we simulated using a Markov model with 1-year cycle. Incremental cost-effectiveness ratio (ICER) was calculated to evaluate cost-effectiveness. RESULTS: For the 90-day horizon, resection at a Leapfrog hospital was more costly ($25 567 vs $25 530) but had greater utility (0.185 vs 0.181 quality-adjusted life-years), resulting in an ICER of 10 506. Similarly, for the 5-year horizon, resection at a Leapfrog hospital was more costly ($26 600 vs $26 495) but more effective (3.216 vs 3.122 quality-adjusted life-years), resulting in an ICER of 1108. When the costs for long-distance travel, lodging, and loss of productivity for caregivers were factored in, the ICER was 20 499 during the 5-year horizon for resection at Leapfrog hospitals. Using a willingness-to-pay threshold of $50 000, resection at a Leapfrog hospital remained cost-effective. CONCLUSIONS: Receiving surgery for clinical stage I NSCLC at hospitals that meet Leapfrog volume standards is cost-effective. Payers and policymakers should consider supporting patient and caregiver travel to higher volume institutions for lung cancer surgery.

Efficiency and driving force assessment of an integrated urban water use and wastewater treatment system: Evidence from spatial panel data of the urban agglomeration on the middle reaches of the Yangtze River.

With the rapid development of urban agglomerations, urban water use and wastewater environments have gradually constrained sustainable development and caused increasing concern. In this paper, we selected the urban agglomeration on the middle reaches of the Yangtze River (UAMRYZ) as a typical area. We proposed an integrated urban water use and wastewater treatment (UWUWT) system and its urban water use (UWU) subsystem and urban wastewater treatment (UWT) subsystem. Moreover, an integrated two-stage slacks-based measure (SBM) data envelopment analysis (DEA) model was used to evaluate the efficiency of the UWUWT system and its subsystem during 2010 to 2017. Additionally, the multiscale geographically weighted regression (MGWR) model was adopted to analyze the influence mechanism of each factor on the defined system. The results indicated that the tendency of UWU efficiency and UWUWT efficiency were similar and mainly showed the same trend with an 'N' shape in a time-dependent manner for the UAMRYZ and provinces, respectively. Furthermore, the UWU efficiency and UWUWT efficiency of each city showed strong spatiotemporal heterogeneity. The UWT efficiency of the UAMRYZ and its representative cities was stable in the region and always had a higher value. With continuous economic development and increased interregional foreign trade, the UWU subsystem efficiency and the UWUWT system efficiency had a significant increase for cities along the entire river in the Yangtze Basin. The regional differences of the overall UWU efficiency, UWT efficiency and UWUWT efficiency gradually decreased and the efficiency has gradually improved from 2010 to 2017. Attribution analysis showed that the secondary industry was the main constraining factor, while the water resource was the most acceleration factor for the UWUWT system in most areas and the UWT subsystem for all cities. Our study evaluated the specific insufficiencies of the defined system and supported regulatory policies.

Different-team procurements: A potential solution for the unintended consequences of change in lung allocation policy.

The new lung allocation policy has led to an increase in distant donors and consequently enhanced logistical burden of procuring organs. Though early single-center studies noted similar outcomes between same-team transplantation (ST, procuring team from transplanting center) and different-team transplantation (DT, procuring team from different center), the efficacy of DT in the contemporary era remains unclear. In this study, we evaluated the trend of DT, rate of transplanting both donor lungs, 1-year graft survival, and risk of Grade 3 primary graft dysfunction (PGD) using the Scientific Registry of Transplant Recipient (SRTR) database from 2006 to 2018. A total of 21619 patients (DT 2085, 9.7%) with 19837 donors were included. Utilization of DT decreased from 15.9% in 2006 to 8.5% in 2018. Proportions of two-lung donors were similar between the groups, and DT had similar 1-year graft survival as ST for both double (DT, HR 1.108, 95% CI 0.894-1.374) and single lung transplants (DT, HR 1.094, 95% CI 0.931-1.286). Risk of Grade 3 PGD was also similar between ST and DT. Given our results, expanding DT may be a feasible option for improving lung procurement efficiency in the current era, particularly in light of the COVID-19 pandemic.

Impact of Nighttime Lung Transplantation on Outcomes and Costs.

BACKGROUND: Previous studies in the field of organ transplantation have shown a possible association between nighttime surgery and adverse outcomes. We aim to determine the impact of nighttime lung transplantation on postoperative outcomes, long-term survival, and overall cost. METHODS: We performed a single-center retrospective cohort analysis of adult lung transplant recipients who underwent transplantation between January 2006 and December 2017. Data were extracted from our institutional Lung Transplant Registry and Mid-America Transplant services database. Patients were classified into 2 strata, daytime (5 AM to 6 PM) and nighttime (6 PM to 5 AM), based on time of incision. Major postoperative adverse events, 5-year overall survival, and 5-year bronchiolitis obliterans syndrome-free survival were examined after propensity score matching. Additionally we compared overall cost of transplantation between nighttime and daytime groups. RESULTS: Of the 740 patients included in this study, 549 (74.2%) underwent daytime transplantation and 191 (25.8%) underwent nighttime transplantation (NT). Propensity score matching yielded 187 matched pairs. NT was associated with a higher risk of having any major postoperative adverse event (adjusted odds ratio, 1.731; 95% confidence interval, 1.093-2.741; P = .019), decreased 5-year overall survival (adjusted hazard ratio, 1.798; 95% confidence interval, 1.079-2.995; P = .024), and decreased 5-year bronchiolitis obliterans syndrome-free survival (adjusted hazard ratio, 1.556; 95% confidence interval, 1.098-2.205; P = .013) in doubly robust multivariable analyses after propensity score matching. Overall cost for NT and daytime transplantation was similar. CONCLUSIONS: NT was associated with a higher risk of major postoperative adverse events, decreased 5-year overall survival, and decreased 5-year bronchiolitis obliterans syndrome-free survival. Our findings suggest potential benefits of delaying NT to daytime transplantation.

Local versus distant lung donor procurement does not influence short-term clinical outcomes.

OBJECTIVE: The purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. METHODS: This single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. RESULTS: Of the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). CONCLUSIONS: Local lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.

Shipping Lungs Greater Distances Increases Costs Without Cutting Waitlist Mortality.

BACKGROUND: On November 24, 2017, a change in lung allocation policy was initiated to replace the donor service area with a 250-nautical-mile radius circle around the donor hospital. We aim to analyze the consequences of this change, including organ acquisition cost and transplant outcomes, at the national level. METHODS: Data on adult patients undergoing lung transplantation between April 27, 2017, and June 22, 2018 (30 weeks before to 30 weeks after allocation policy change) were extracted from the Scientific Registry of Transplant Recipients database. Patients were classified into pre-change and post-change subgroups. Six-month overall survival was evaluated by Kaplan-Meier analysis. Organ acquisition costs were compared between the pre-change and post-change groups. RESULTS: Of the 3317 adult patients removed from the waiting list during the study period (pre-change 1637 vs post-change 1680), 2734 underwent transplantation (pre-change 1371 of 1637 [83.8%] vs post-change 1363 of 1680 [81.1%]), and 382 died or became too sick to be transplanted (pre-change 168 of 1637 [10.3%] vs post-change 214 of 1680 [12.7%], P = .077). Six-month survival rates of transplanted patients were similar between the two groups. However, average organ acquisition costs increased after policy change (pre-change $50,735 ± $10,858 vs post-change $53,440 ± $10,247, P < .001) with an increase in nonlocal donors (pre-change 44.3% vs post-change 68.9%, P < .001). CONCLUSIONS: Organ acquisition costs and resource utilization increased with the new lung allocation policy, whereas deaths on the waiting list or after transplantation did not decrease. Further optimization of the allocation policy is necessary to balance access to transplant and proper stewardship of human and financial resources.