Increased Cost With Use of Brand-Name Bowel Preparation by Patients With Medicare Part D From 2013 to 2015.

High-quality bowel preparation (prep) before colonoscopy is essential for the success of the procedure.1 Bowel preps should be safe, tolerable, efficacious, and allow for visualization of polyps 5 mm or larger.2 Full-volume (4 L) polyethylene glycol-3350 with electrolyte solution (PEG-ELS) has been considered a standard bowel prep regimen, with good safety and efficacy profiles, and is available as a generic.2.

A new algorithm for design, operation and cost assessment of struvite (MgNH4PO4) precipitation processes.

Deliberate struvite (MgNH4PO4) precipitation from wastewater streams has been the topic of extensive research in the last two decades and is expected to gather worldwide momentum in the near future as a P-reuse technique. A wide range of operational alternatives has been reported for struvite precipitation, including the application of various Mg(II) sources, two pH elevation techniques and several Mg:P ratios and pH values. The choice of each operational parameter within the struvite precipitation process affects process efficiency, the overall cost and also the choice of other operational parameters. Thus, a comprehensive simulation program that takes all these parameters into account is essential for process design. This paper introduces a systematic decision-supporting tool which accepts a wide range of possible operational parameters, including unconventional Mg(II) sources (i.e. seawater and seawater nanofiltration brines). The study is supplied with a free-of-charge computerized tool (http://tx.technion.ac.il/~agrengn/agr/Struvite_Program.zip) which links two computer platforms (Python and PHREEQC) for executing thermodynamic calculations according to predefined kinetic considerations. The model can be (inter alia) used for optimizing the struvite-fluidized bed reactor process operation with respect to P removal efficiency, struvite purity and economic feasibility of the chosen alternative. The paper describes the algorithm and its underlying assumptions, and shows results (i.e. effluent water quality, cost breakdown and P removal efficiency) of several case studies consisting of typical wastewaters treated at various operational conditions.

Asymmetric synthesis of alpha-aminophosphonates using the inexpensive chiral catalyst 1,1'-binaphthol phosphate.

Asymmetric addition under mild conditions of dialkyl phosphites on aldimines derived from cinnamaldehyde catalyzed by the inexpensive chiral organocatalyst (R)-3,3'-[4-fluorophenyl](2)-1,1'-binaphthol phosphate has been found effective to give new alpha-amino-phosphonates 9 in moderate yields (30-65%) and enantiomeric excess (8.4%-61.9%).

Evaluation of corrosion control products on a distribution system through crowdsourcing.

Crowdsourcing of citizens was used to determine the effectiveness of corrosion control in a water distribution system. This study examines the frequency and severity of "Red Water" complaints over a period of 4 years, and two different corrosion control chemicals, polyphosphate and zinc orthophosphate. The data revealed that the frequency of Red Water complaints was higher when using zinc orthophosphate while the severity (higher iron) was higher when using polyphosphates. Varying the dose of zinc orthophosphate to account for cold months induced a greater number of customer complaints. Moreover, corrosion coupons studies suggest similar performance of both corrosion inhibitor products. The corrosion and complaints might be driven by microbial-induced processes in which diatoms might play a significant role.

Use of Premixed Parenteral Nutrition During a Phosphate Shortage in a Non-Critically Ill Population.

BACKGROUND: Drug shortages pose prescribing problems to clinicians. During fiscal year (FY) 2014, an acute shortage of intravenous potassium phosphate (K-Phos IV), a common supplement in parenteral nutrition (PN), prompted the use of premixed instead of individualized PN to conserve K-Phos IV. Here we quantify the K-Phos IV conserved by using premixed PN and the associated cost differences. MATERIALS AND METHODS: Costs of preparing premixed PN vs individualized PN of equivalent composition were calculated for FY 2014 at a single-center tertiary care facility. Quantity and cost of K-Phos IV saved were calculated based on the number of premixed PN prescriptions. Costs for FY 2015 were projected based on drug costs from July 2014. RESULTS: During FY 2014, prescribing premixed in lieu of individualized PN conserved 16,440 mmol K-Phos IV but increased the cost of PN by $4080.45. However, increases in K-Phos IV cost at the end of FY 2014 resulted in premixed PN as a relatively less expensive therapy than individualized PN for our institution. Cost savings of $7092.20 due to use of premixed PN is projected for FY 2015. CONCLUSIONS: Prescribing premixed PN conserves K-Phos IV during shortages, but it increased direct drug spending in non-critically ill patients at our institution during FY 2014. Persistent shortages can drive market costs of K-Phos IV, however, necessitating frequent reconsideration of resource utilization.

Potential phosphorus recovery by struvite formation.

Formation of struvite (MgNH4PO4 x 6H2O) at sewage treatment works can cause operational problems and decrease efficiency. Struvite has a commercial value and the controlled formation and recovery of it would be beneficial. A mass balance was conducted at full scale across the whole sewage treatment plant in order to identify a stream to conduct bench-scale struvite crystallisation studies. The most suitable stream was identified as the centrifuge liquors. The average flow of the liquor stream was 393 m3 d(-1) and the composition was as follows: 167 mg L(-1) phosphorus, 44 mg L(-1) magnesium, 615 mg L(-1) ammonium, 56 mg L(-1) calcium and 2580 mg L(-1) of alkalinity. The pH averaged at 7.6 and the stream had a predicted struvite precipitation potential of 140 mg L(-1). Struvite crystallisation occurred quickly during the trials, by raising the pH of the centrifuge liquors to 9.0 and dosing with magnesium. Up to 97% phosphorus removal as struvite was achieved. Struvite formation occurred when the molar ratio of magnesium:phosphorus was at least 1.05:1. Below this ratio phosphorus removals of 72% were observed, but not exclusively as struvite. Annual yields of struvite were calculated to be 42-100 tonnes a year, depending on the dose regime. Revenue from the sale of produced struvite could be between Pound Sterling8400 and Pound Sterling20,000 a year.

Immobilization of lead and zinc in scrubber residues from MSW combustion using soluble phosphates.

The immobilization of MSWI-scrubber residues with soluble PO4(3-) was studied and compared to the immobilization using cement. The DIN 38414-S4 leaching protocol and pH dependent leaching were used to evaluate the leaching of Pb and Zn. Four different scrubber residues from MSW combustion (Pb concentration: 2.8-4.8 mg/g; Zn concentration: 3.0-12.3 mg/g) were mixed with water and cement or Na2HPO4 as source of soluble PO4(3-) at dosages of at least 0, 0.1, 0.2, 0.3 and 0.4 g per g residue. With cement as well as with PO4(3-) a reduction in Pb and Zn leaching was observed. With 0.4 g cement per g residue, the Pb leaching was reduced by a factor ranging from 70 to 100, but still exceeded the Pb landfill limit of 2 mg/l. With PO4(3-) the Pb leaching was reduced with a factor of 100-300 to below 2 mg/l. The Zn landfill limit (10 mg/l) was only exceeded by one untreated residue. Adding 0.2 g cement or 0.1 g PO4(3-) per g of that residue was enough to reduce leaching below 10 mg/l. However, when 0.6 g Na2HPO4 per g residue was added to a lime based scrubber residue, an increase in Zn leaching up to 12.5 mg/l was observed due to an increase in pH of up to 13.0. When using NaH2PO4 and H3PO4 no such increase in Zn leaching was observed. pH dependent leaching performed on one of the four residues showed that in the pH range of 2.5-6, Pb leaching was 100-50 times lower with Na2HPO4 treatment than with cement. In the pH range from 7-11, almost equal results were obtained for cement treated and Na2HPO4 treated residue. Above a pH of 12, Pb leaching was three times lower for the PO(4)(3-)-treated residue than for the cement treated residue. With soluble PO4(3-), Pb leaching below 2 mg/l could be attained at a dosage of 0.27 g PO4(3-)/g residue. With cement, Pb leaching was never below 2 mg/l.

Three years experience of operating and selling recovered struvite from full-scale plant.

The adoption of phosphorus removal at sewage treatment works (STW) creates two main problems. Firstly large amounts of sludge are produced and secondly the quantity of the effluent deteriorates due to the increase in the phosphorus load of the sidestream. Furthermore, these processes do not remove phosphorus in a form that would enable it to be recycled. Therefore in order to control these process difficulties and produce a recyclable phosphorus product a sidestream struvite crystallisation reactor was developed. The struvite was produced in a fluidised bed reactor using dewatered filtrate from anaerobic sludge digestion. Magnesium hydroxide was added in a magnesium to phosphate ratio of 1:1 and the pH was adjusted to between 8.2-8.8 with the addition of sodium hydroxide. A retention time of 10 days alowed the growth of pellets between 0.5-1.0 mm in size. The recovered struvite contained only minute traces of toxic substances and was sold to fertiliser companies for 27,000 yen tonne(-1). It is used to enhance existing fertilisers, which are widely used on paddy rice, vegetables and flowers.

High quality potassium phosphate production through step-by-step glycerol purification: a strategy to economize biodiesel production.

The cost of biodiesel production can be reduced by a number of strategies such as utilization of waste cooking oils and non-edible plant oils as well as implementation of improved separation technologies. In addition, processes dealing with the glycerol by-product can have economic benefits. In the present study, acidification of crude glycerol with phosphoric acid to pH 9.67 followed by acidification to 4.67 was implemented to produce high quality potassium phosphate during glycerol purification. KH(2)PO(4), K(2)HPO(4), glycerol and free fatty acids (FFAs) with a purity of 98%, 98.05%, 96.08% and 99.58% were obtained, respectively.

Budget-impact model for colonoscopy cost calculation and comparison between 2 litre PEG+ASC and sodium picosulphate with magnesium citrate or sodium phosphate oral bowel cleansing agents.

OBJECTIVE: With the availability of several bowel cleansing agents, physicians and hospitals performing colonoscopies will often base their choice of cleansing agent purely on acquisition cost. Therefore, an easy to use budget impact model has been developed and established as a tool to compare total colon preparation costs between different established bowel cleansing agents. METHODS: The model was programmed in Excel and designed as a questionnaire evaluating information on treatment costs for a range of established bowel cleansing products. The sum of costs is based on National Health Service reference costs for bowel cleansing products. Estimations are made for savings achievable when using a 2-litre polyethylene glycol with ascorbate components solution (PEG+ASC) in place of other bowel cleansing solutions. Test data were entered into the model to confirm validity and sensitivity. The model was then applied to a set of audit cost data from a major hospital colonoscopy unit in the UK. RESULTS: Descriptive analysis of the test data showed that the main cost drivers in the colonoscopy process are the procedure costs and costs for bed days rather than drug acquisition costs, irrespective of the cleansing agent. Audit data from a colonoscopy unit in the UK confirmed the finding with a saving of £107,000 per year in favour of PEG+ASC when compared to sodium picosulphate with magnesium citrate solution (NaPic+MgCit). For every patient group the model calculated overall cost savings. This was irrespective of the higher drug expenditure associated with the use of PEG+ASC for bowel preparation. Savings were mainly realized through reduced costs for repeat colonoscopy procedures and associated costs, such as inpatient length of stay. CONCLUSIONS: The budget impact model demonstrated that the primary cost driver was the procedure cost for colonoscopy. Savings can be realized through the use of PEG+ASC despite higher drug acquisition costs relative to the comparator products. From a global hospital funding perspective, the acquisition costs of bowel preparations should not be used as the primary reason to select the preferred treatment agent, but should be part of the consideration, with an emphasis on the clinical outcome.

Low-cost struvite production using source-separated urine in Nepal.

This research investigated the possibility of transferring phosphorus from human urine into a concentrated form that can be used as fertilizer in agriculture. The community of Siddhipur in Nepal was chosen as a research site, because there is a strong presence and acceptance of the urine-diverting dry toilets needed to collect urine separately at the source. Furthermore, because the mainly agricultural country is landlocked and depends on expensive, imported fertilizers, the need for nutrient security is high. We found that struvite (MgNH(4)PO(4)·6H(2)O) precipitation from urine is an efficient and simple approach to produce a granulated phosphorus fertilizer. Bittern, a waste stream from salt production, is a practical magnesium source for struvite production, but it has to be imported from India. Calculations show that magnesium oxide produced from locally available magnesite would be a cheaper magnesium source. A reactor with an external filtration system was capable of removing over 90% of phosphorus with a low magnesium dosage (1.1 mol Mg mol P), with coarse nylon filters (pore width up to 160±50 µm) and with only one hour total treatment time. A second reactor setup based on sedimentation only achieved 50% phosphate removal, even when flocculants were added. Given the current fertilizer prices, high volumes of urine must be processed, if struvite recovery should be financially sustainable. Therefore, it is important to optimize the process. Our calculations showed that collecting the struvite and calcium phosphate precipitated spontaneously due to urea hydrolysis could increase the overall phosphate recovery by at least 40%. The magnesium dosage can be optimized by estimating the phosphate concentration by measuring electrical conductivity. An important source of additional revenue could be the effluent of the struvite reactor. Further research should be aimed at finding methods and technologies to recover the nutrients from the effluent.

Prospective, randomized, single-blind comparison of two preparations for screening flexible sigmoidoscopy.

BACKGROUND: The best and most cost-effective bowel cleansing regimen for patients undergoing flexible sigmoidoscopy is not known. The aim of this study was to compare patient tolerance, quality of preparation, and cost of 2 bowel cleansing regimens for flexible sigmoidoscopy. METHODS: Two hundred fifty consecutive patients referred for screening flexible sigmoidoscopy were randomized to receive an oral preparation (45 mL oral sodium phosphate and 10 mg bisacodyl) or an enema preparation (2 Fleet enemas and 10 mg bisacodyl). Tolerance of the preparation was graded as easy, tolerable, slightly difficult, extremely difficult, or intolerable. The endoscopist was blinded to which preparation the patient received and graded the quality of the preparation as poor, fair, good, or excellent. Cost was calculated by adding the cost of the medications and the cost for the nursing time required to prepare the patient for endoscopy. RESULTS: Patients in the oral preparation group were more likely to grade the preparation as easy or tolerable when compared with the enema group (96.8% vs. 56.4%, p < 0.001). The endoscopist graded the quality of the preparation as good or excellent in 86.5% of the patients in the oral preparation group compared with 57.3% in the enema group (p < 0.001). In the oral preparation group, the mean nursing time (34.6 vs. 65.3 minutes, p < 0.001) and cost ($16.39 vs. $31.13, p < 0.001) were significantly less than in the enema group. CONCLUSIONS: An oral sodium phosphate preparation results in a superior quality endoscopic examination that is better tolerated and more cost-effective than enemas in patients undergoing screening flexible sigmoidoscopy.

A quality improvement project comparing two regimens of medication for colonoscopy preparation.

As part of an ongoing performance evaluation and Quality Improvement (QI) program at the U. S. National Naval Medical Center in Bethesda, Maryland, two bowel preparations that were concurrently in use (Fleet Phospho-soda and Colyte/Dulcolax) were evaluated for patient tolerance and preference, efficacy, and cost. Anonymous patient questionnaires were distributed during a three-phase assessment that took place over an 18-month period. This approach identified preconceived ideas regarding bowel preparations and contributed to development of objective information regarding the bowel preparations currently available. The outcome of this QI project altered the previous routine and resulted in the adoption of Fleet Phospho-soda as the preferred medication for colon preparation prior to colonoscopy, based on superior bowel cleansing as judged by the physicians, higher patient preference and compliance, similar tolerance, and lower cost.

Meta-analysis and cost comparison of polyethylene glycol lavage versus sodium phosphate for colonoscopy preparation.

BACKGROUND: Although polyethylene glycol lavage solutions are widely used for colonoscopy preparation, evidence suggests that sodium phosphate is better tolerated and has similar efficacy. The purpose of this study was to compare compliance with and efficacy of polyethylene glycol and sodium phosphate using meta-analysis and to compare the cost of colonoscopy with both methods. METHODS: We used Medline to identify all randomized controlled trials comparing the two preparations. Study methods were evaluated, and quantitative data were abstracted independently, including inability to complete the preparation and preparation quality, rated as adequate or excellent. A random effects model was used to calculate the pooled relative risk. Direct costs and literature-based probability estimates were used to compare costs. RESULTS: Among 1286 subjects from eight colonoscopist-blinded trials, the pooled relative risk of inability to complete the preparation was 0.23 (95% CI [0.18-0.28]) in favor of sodium phosphate. Although the best estimate of the relative risk for an adequate quality preparation revealed therapeutic equivalence (relative risk = 1.06: 95% CI [0.95-1.19]), an excellent quality preparation was more likely with sodium phosphate (relative risk = 1.72: 95% CI [1.16-2.53]). Assuming reexamination rates from published literature of 3% and 8% for sodium phosphate and polyethylene glycol, respectively, direct costs of colonic examination were $465 and $503. There were no clinically important adverse effects with either method. CONCLUSION: The results suggest that sodium phosphate is as effective and less costly, with a more easily completed preparation, compared with polyethylene glycol and is the preferred method of preparation for colonoscopy for certain patient subgroups.