The Feasibility of a Land Ferry System to Reduce Highway Maintenance Cost and Associated Externalities.

This study provides an economic evaluation for a Land Ferry, which is a rail system capable of carrying trucks and all other types of vehicles, passengers, and cargo. The Land Ferry system involves a sliding loading system to roll heavy loads onto a flatbed; as a result, loading and unloading of all vehicles and cargo could be accomplished simultaneously. The evaluation for this system included (1) the design of a new track alignment over which the Land Ferry system would run, (2) evaluation of various sources of power, (3) estimation of how many local jobs the Land Ferry would generate, and (4) a benefit-cost analysis. It was estimated that the Land Ferry would create over 45,788 temporary jobs in Nevada during the three-year construction period and 318 permanent jobs during operation. The majority of the benefits were attributed to savings in travel time ($356.4 M), vehicle operating costs ($1000.4 M), reduction of accidents ($544.6 M), and pavement maintenance ($503.2 M). These benefits would be a consequence of the shift of trucks from the highway, thus resulting in higher speeds, decrease fuel consumption, and decrease vehicle maintenance costs. The overall benefit-cost ratio of 1.7 implies a cost-effective project.

Dosing Accuracy of Direct Oral Anticoagulants in an Academic Medical Center.

BACKGROUND/OBJECTIVE: Direct-acting oral anticoagulants (DOACs) are increasingly used to prevent or treat thromboembolism. We conducted a study to compare how well initial DOAC prescribing for adult inpatients adhered to dosing recommendations approved by the US Food and Drug Administration (FDA). DESIGN: Retrospective analysis. SETTING: Single academic medical center, July 1, 2014 to June 30, 2015. PATIENTS: 508 adult inpatients. MEASUREMENTS: DOAC prescriptions were evaluated to determine whether they met FDA-recommended dosing and administration according to patient age, weight, sex, race, kidney function, diagnoses, and concomitant medications. RESULTS: DOACs were prescribed in 635 admissions (247 apixaban, 97 dabigatran, 291 rivaroxaban). The indication was atrial fibrillation/flutter in 465 admissions (8% with bioprostheses or valve repair), chronic deep vein thrombosis (DVT) in 67, acute DVT in 32, chronic pulmonary embolism in 23, acute pulmonary embolism in 19, DVT prevention after hip or knee surgery in 19, and non-FDA-approved indications in 10. Sixteen percent of orders for venous thromboembolic disease were for patients with active malignancy. Dosages not concordant with recommendations were prescribed for apixaban in 18% of admissions, for rivaroxaban in 14%, and for dabigatran in 7% (𝑃 = 0.04). Lower than recommended dosing was more common than higher than recommended dosing (𝑃 < 0.05). Half the deviations were continuations of outpatient dosing. Atrial fibrillation/flutter and post-hip or -knee surgery dosing deviations were more common than venous thromboembolic disease deviations (𝑃 < 0.001) but were not related to prescriber specialty. CONCLUSIONS: DOAC prescribing recommendation deviations that can affect clinical efficacy were identified. Education and point-of-care decision support tools for improving dosing are needed, as are outcome data for patients who receive DOACs at lower than recommended dosing or for off-label indications.