Are cost advantages from a modern Indian hospital transferable to the United States?

BACKGROUND: Multiple modern Indian hospitals operate at very low cost while meeting US-equivalent quality accreditation standards. Though US hospitals face intensifying pressure to lower their cost, including proposals to extend Medicare payment rates to all admissions, the transferability of Indian hospitals' cost advantages to US peers remains unclear. METHODS: Using time-driven activity-based costing methods, we estimate the average cost of personnel and space for an elective coronary artery bypass graft (CABG) surgery at two American hospitals and one Indian hospital (NH). All three hospitals are Joint Commission accredited and have reputations for use of modern performance management methods. Our case study applies several analytic steps to distinguish transferable from non-transferable sources of NH's cost savings. RESULTS: After removing non-transferable sources of efficiency, NH's residual cost advantage primarily rests on shifting tasks to less-credentialed and/or less-experienced personnel who are supervised by highly-skilled personnel when perceived risk of complications is low. NH's high annual CABG volume facilitates such supervised work "downshifting." The study is subject to limitations inherent in case studies, does not account for the younger age of NH's patients, or capture savings attributable to NH's negligible frequency of re-admission or post-acute care facility placement. CONCLUSIONS: Most transferable bases for a modern Indian hospital's cost advantage would require more flexible American states' hospital and health professional licensing regulations, greater family participation in inpatient care, and stronger support by hospital executives and clinicians for substantially lowering the cost of care via regionalization of complex surgeries and weekend use of costly operating rooms.

Computational reconfigurable imaging spectrometer.

We demonstrate a novel hyperspectral imaging spectrometer based on computational imaging that enables sensitive measurements from smaller, noisier, and less-expensive components (e.g. uncooled microbolometers), making it useful for applications such as small space and air platforms with strict size, weight, and power requirements. The computational reconfigurable imaging spectrometer (CRISP) system exploits platform motion and a spectrally coded focal-plane mask to temporally modulate the optical spectrum, enabling simultaneous measurement of multiple spectral bins. Demodulation of this coded pattern returns an optical spectrum in each pixel.

Effective care for high-need patients: opportunities for improving outcomes, outcomes, value, and health

Today, 1 percent of patients account for more than 20 percent of health care expenditures, and 5 percent account for nearly half of the nation's spending on health care (Figure S-1) (Mitchell, 2016). Improving care management for this population while balancing quality and associated costs is at the forefront of national health care goals, and reaching this particular goal will require active involvement of a broad range of stakeholders at multiple levels. To advance insights and perspectives on how to better manage the care of this population and to stimulate actions on opportunities for improving outcomes and reducing the costs of health care, the National Academy of Medicine (NAM), through its Leadership Consortium for a Value & Science-Driven Health System (the Leadership Consortium), in partnership with the Harvard T.H. Chan School of Public Health (HSPH), the Bipartisan Policy Center (BPC), The Commonwealth Fund, and the Peterson Center on Healthcare­which funded this initiative­has undertaken a collaborative assessment on strategies for better serving high-need patients. The NAM was tasked with bringing together experts and stakeholders over the course of three workshops held between July 2015 and October 2016 to consider and reflect upon the key issues for improving care for high-need patients and summarizing the presentations, discussions, and literature for publication. This publication reports and reflects on the following issues: (1) key characteristics of high-need patients; (2) the use of a patient categorization scheme­or a taxonomy­as a tool to inform and target care; (3) promising care models and attributes to better serve this patient population, as well as insights on "matching" these models to specific patient groups; and (4) areas of opportunity for policy-level action to support the spread and scale of evidence-based programs. The publication concludes by exploring common themes and opportunities for action in the field.

Effects of season on ecological processes in extensive earthen tilapia ponds in Southeastern Brazil.

In Southeastern Brazil tilapia culture is conducted in extensive and semi-intensive flow-through earthen ponds, being water availability and flow management different in the rainy and dry seasons. In this region lettuce wastes are a potential cheap input for tilapia culture. This study examined the ecological processes developing during the rainy and dry seasons in three extensive flow-through earthen tilapia ponds fertilized with lettuce wastes. Water quality, plankton and sediment parameters were sampled monthly during a year. Factor analysis was used to identify the ecological processes occurring within the ponds and to construct a conceptual graphic model of the pond ecosystem functioning during the rainy and dry seasons. Processes related to nitrogen cycling presented differences between both seasons while processes related to phosphorus cycling did not. Ecological differences among ponds were due to effects of wind protection by surrounding vegetation, organic loading entering, tilapia density and its grazing pressure on zooplankton. Differences in tilapia growth among ponds were related to stocking density and ecological process affecting tilapia food availability and intraspecific competition. Lettuce wastes addition into the ponds did not produce negative effects, thus this practice may be considered a disposal option and a low-cost input source for tilapia, at least at the amounts applied in this study.

Effects of season on ecological processes in extensive earthen tilapia ponds in Southeastern Brazil

Abstract In Southeastern Brazil tilapia culture is conducted in extensive and semi-intensive flow-through earthen ponds, being water availability and flow management different in the rainy and dry seasons. In this region lettuce wastes are a potential cheap input for tilapia culture. This study examined the ecological processes developing during the rainy and dry seasons in three extensive flow-through earthen tilapia ponds fertilized with lettuce wastes. Water quality, plankton and sediment parameters were sampled monthly during a year. Factor analysis was used to identify the ecological processes occurring within the ponds and to construct a conceptual graphic model of the pond ecosystem functioning during the rainy and dry seasons. Processes related to nitrogen cycling presented differences between both seasons while processes related to phosphorus cycling did not. Ecological differences among ponds were due to effects of wind protection by surrounding vegetation, organic loading entering, tilapia density and its grazing pressure on zooplankton. Differences in tilapia growth among ponds were related to stocking density and ecological process affecting tilapia food availability and intraspecific competition. Lettuce wastes addition into the ponds did not produce negative effects, thus this practice may be considered a disposal option and a low-cost input source for tilapia, at least at the amounts applied in this study.

Resumo No sudeste do Brasil, a criação extensiva e semi-intensiva de tilápias é realizada em viveiros escavados com fluxo contínuo, com a disponibilidade e manejo do fluxo de água diferentes nas épocas chuvosa e seca. Na região, os resíduos de alface são um recurso potencialmente de baixo custo para a tilapicultura. Este estudo examinou os processos ecológicos ocorrendo em três viveiros escavados com fluxo contínuo fertilizados com restos de alface para criação extensiva de tilápias durante as épocas chuvosa e seca. Parâmetros de qualidade de água, plâncton e sedimento foram amostrados mensalmente durante um ano. A análise de fator foi utilizada para identificar os processos ecológicos nos viveiros e elaborar um modelo gráfico do funcionamento do ecossistema dos viveiros durante as duas épocas. Os processos relacionados ao ciclo do nitrogênio mostraram diferenças entre as duas épocas, enquanto que os processos relacionados com o ciclo do fósforo não foram influenciados pela época. As diferenças ecológicas entre os viveiros foram principalmente devido aos efeitos do vento, adição de material orgânico e densidade de estocagem. Diferenças no crescimento das tilápias entre os viveiros relacionaram-se com a densidade de estocagem e os processos ecológicos afetando a disponibilidade de alimento e a competição intraespecífica. A adição dos restos de alface nos viveiros não resultou em efeitos negativos, assim esta prática pode ser considerada um destino alternativo e um recurso de baixo custo para a criação extensiva de tilápias, pelo menos nas quantidades investigadas neste estudo.

Effects of season on ecological processes in extensive earthen tilapia ponds in Southeastern Brazil / Efeitos da época sobre os processos ecológicos em viveiros escavados para criação extensiva de tilápias no Sudeste do Brasil

Abstract In Southeastern Brazil tilapia culture is conducted in extensive and semi-intensive flow-through earthen ponds, being water availability and flow management different in the rainy and dry seasons. In this region lettuce wastes are a potential cheap input for tilapia culture. This study examined the ecological processes developing during the rainy and dry seasons in three extensive flow-through earthen tilapia ponds fertilized with lettuce wastes. Water quality, plankton and sediment parameters were sampled monthly during a year. Factor analysis was used to identify the ecological processes occurring within the ponds and to construct a conceptual graphic model of the pond ecosystem functioning during the rainy and dry seasons. Processes related to nitrogen cycling presented differences between both seasons while processes related to phosphorus cycling did not. Ecological differences among ponds were due to effects of wind protection by surrounding vegetation, organic loading entering, tilapia density and its grazing pressure on zooplankton. Differences in tilapia growth among ponds were related to stocking density and ecological process affecting tilapia food availability and intraspecific competition. Lettuce wastes addition into the ponds did not produce negative effects, thus this practice may be considered a disposal option and a low-cost input source for tilapia, at least at the amounts applied in this study.

Resumo No sudeste do Brasil, a criação extensiva e semi-intensiva de tilápias é realizada em viveiros escavados com fluxo contínuo, com a disponibilidade e manejo do fluxo de água diferentes nas épocas chuvosa e seca. Na região, os resíduos de alface são um recurso potencialmente de baixo custo para a tilapicultura. Este estudo examinou os processos ecológicos ocorrendo em três viveiros escavados com fluxo contínuo fertilizados com restos de alface para criação extensiva de tilápias durante as épocas chuvosa e seca. Parâmetros de qualidade de água, plâncton e sedimento foram amostrados mensalmente durante um ano. A análise de fator foi utilizada para identificar os processos ecológicos nos viveiros e elaborar um modelo gráfico do funcionamento do ecossistema dos viveiros durante as duas épocas. Os processos relacionados ao ciclo do nitrogênio mostraram diferenças entre as duas épocas, enquanto que os processos relacionados com o ciclo do fósforo não foram influenciados pela época. As diferenças ecológicas entre os viveiros foram principalmente devido aos efeitos do vento, adição de material orgânico e densidade de estocagem. Diferenças no crescimento das tilápias entre os viveiros relacionaram-se com a densidade de estocagem e os processos ecológicos afetando a disponibilidade de alimento e a competição intraespecífica. A adição dos restos de alface nos viveiros não resultou em efeitos negativos, assim esta prática pode ser considerada um destino alternativo e um recurso de baixo custo para a criação extensiva de tilápias, pelo menos nas quantidades investigadas neste estudo.

Time-driven activity-based costing of multivessel coronary artery bypass grafting across national boundaries to identify improvement opportunities: study protocol.

INTRODUCTION: Coronary artery bypass graft (CABG) surgery is a well-established, commonly performed treatment for coronary artery disease--a disease that affects over 10% of US adults and is a major cause of morbidity and mortality. In 2005, the mean cost for a CABG procedure among Medicare beneficiaries in the USA was $32, 201 ± $23,059. The same operation reportedly costs less than $2000 to produce in India. The goals of the proposed study are to (1) identify the difference in the costs incurred to perform CABG surgery by three Joint Commission accredited hospitals with reputations for high quality and efficiency and (2) characterise the opportunity to reduce the cost of performing CABG surgery. METHODS AND ANALYSIS: We use time-driven activity-based costing (TDABC) to quantify the hospitals' costs of producing elective, multivessel CABG. TDABC estimates the costs of a given clinical service by combining information about the process of patient care delivery (specifically, the time and quantity of labour and non-labour resources utilised to perform each activity) with the unit cost of each resource used to provide the care. Resource utilisation was estimated by constructing CABG process maps for each site based on observation of care and staff interviews. Unit costs were calculated as a capacity cost rate, measured as a $/min, for each resource consumed in CABG production. Multiplying together the unit costs and resource quantities and summing across all resources used will produce the average cost of CABG production at each site. We will conclude by conducting a variance analysis of labour costs to reveal opportunities to bend the cost curve for CABG production in the USA. ETHICS AND DISSEMINATION: All our methods were exempted from review by the Stanford Institutional Review Board. Results will be published in peer-reviewed journals and presented at scientific meetings.

Prospective trial of adipose-derived regenerative cell (ADRC)-enriched fat grafting for partial mastectomy defects: the RESTORE-2 trial.

AIMS: Women undergoing breast conservation therapy (BCT) for breast cancer are often left with contour defects and few acceptable reconstructive options. RESTORE-2 is the first prospective clinical trial using autologous adipose-derived regenerative cell (ADRC)-enriched fat grafting for reconstruction of such defects. This single-arm, prospective, multi-center clinical trial enrolled 71 patients post-BCT with defects ≤150 mL. METHODS: Adipose tissue was collected via syringe lipoharvest and then processed during the same surgical procedure using a closed automated system that isolates ADRCs and prepares an ADRC-enriched fat graft for immediate re-implantation. ADRC-enriched fat graft injections were performed in a fan-shaped pattern to prevent pooling of the injected fat. Overall procedure times were less than 4 h. The RESTORE-2 protocol allowed for up to two treatment sessions and 24 patients elected to undergo a second procedure following the six month follow-up visit. RESULTS: Of the 67 patients treated, 50 reported satisfaction with treatment results through 12 months. Using the same metric, investigators reported satisfaction with 57 out of 67 patients. Independent radiographic core laboratory assessment reported improvement in the breast contour of 54 out of 65 patients based on blinded assessment of MRI sequence. There were no serious adverse events associated with the ADRC-enriched fat graft injection procedure. There were no reported local cancer recurrences. Injection site cysts were reported as adverse events in ten patients. CONCLUSION: This prospective trial demonstrates the safety and efficacy of the treatment of BCT defects utilizing ADRC-enriched fat grafts.

Barrier control in tunneling e+-e- photoproduction.

Tunneling electron-positron pair production is studied in a new setup in which a strong low-frequency and a weak high-frequency laser field propagate in the same direction and collide head-on with a relativistic nucleus. The electron-positron pair-production rate is calculated analytically in the limit in which in the nucleus rest frame, the strong field is undercritical and the frequency of the weak field is below and close to the pair-production threshold. By changing the frequency of the weak field, one can reduce the tunneling barrier substantially. As a result, tunneling pair production is shown to be observable with presently available technology.

Bremsstrahlung in alpha decay reexamined.

A high-statistics measurement of bremsstrahlung emitted in the alpha decay of (210)Po has been performed, which allows us to follow the photon spectra up to energies of approximately 500 keV. The measured differential emission probability is in good agreement with our theoretical results obtained within the quasiclassical approximation as well as with the exact quantum mechanical calculation. It is shown that, due to the small effective electric dipole charge of the radiating system, a significant interference between the electric dipole and quadrupole contributions occurs, which is altering substantially the angular correlation between the alpha particle and the emitted photon.

Polarizing mechanisms for stored and beams interacting with a polarized target.

The kinetics of the polarization buildup during the interaction of stored protons (antiprotons) with a polarized target is considered. It is demonstrated that for small scattering angles, when a projectile remains in the beam, the polarization buildup is completely due to the spin-flip transitions. The corresponding cross sections turn out to be negligibly small for a hydrogen gas target as well as for a pure electron target. For the latter, the filtering mechanism also does not provide a noticeable beam polarization.

Semi-intensive treatment plants for wastewater reuse in irrigation.

Semi-intensive technologies are a middle term between intensive ones (e.g., activated sludge with a retention time of hours) and extensive ones (e.g., stabilization ponds with a retention time of several weeks). The most common semi-intensive configuration used in Israel is made of anaerobic ponds followed by aerated lagoons. These small low-energy units remove about 75-80% of the BOD and are followed by wastewater reservoirs for storage and complementary treatment. The reduction in loading allows a flexible operation of the reservoirs for the removal of other pollutants, while providing storage capacity to cope with the changes in water demand for irrigation during the year. In schemes for wastewater reuse in irrigation, this lay-out has proved to be low-cost, low-energy, flexible, reliable and efficient. Variations of this basic configuration are the use of UASB reactors instead of anaerobic ponds, aerated lagoons in series or low-rate trickling filters instead of aerated lagoons, constructed wetlands or rock-filters for algae removal, etc. Semi-intensive technologies use less energy than intensive ones, and less land than extensive ones. They can remove as much BOD as intensive ones, and as much pathogens and refractory pollutants as extensive ones. They release no or very small amounts of sludge.

Experimental investigation of high-energy photon splitting in atomic fields.

Data analysis of an experiment in which photon splitting in atomic fields was observed is presented. The experiment was performed at the tagged photon beam of the ROKK-1M facility at the VEPP-4M collider. In the energy region of 120-450 MeV, statistics of 1.6x10(9) photons incident on the BGO target was collected. About 400 candidate photon-splitting events were reconstructed. Within the attained experimental accuracy, the experimental results are consistent with the calculated exact atomic-field cross section. The predictions obtained in the Born approximation differ significantly from the experimental results.

Radiative corrections and parity nonconservation in heavy atoms.

The self-energy and the vertex radiative corrections to the effect of parity nonconservation in heavy atoms are calculated analytically in orders Zalpha2 and Z2alpha3ln((lambda(C)/r(0)), where lambda(C) and r(0) are the Compton wavelength and the nuclear radius, respectively. The sum of the radiative corrections is -0.85% for Cs and -1.41% for Tl. Using these results, we have performed analysis of the experimental data on atomic parity nonconservation. The values obtained for the nuclear weak charge, Q(W)=-72.90(28)exp(35)theor for Cs, and Q(W)=-116.7(1.2)exp(3.4)(theor) for Tl, agree with predictions of the standard model. As an application of our approach, we have also calculated analytically the dependence of the Lamb shift on the finite size of the nucleus.

Expanding health insurance coverage for smoking cessation treatments: experience of the Pacific Business Group on Health.

The business case for health insurance coverage of smoking cessation treatments by employers is a strong one. Smoking is one of the nation's costliest health problems, in both human and financial terms. The science behind smoking cessation treatment and promotion of treatment is strong; the cost effectiveness of smoking cessation treatment is among the highest in all of medicine, the time required before a positive return on investment is reasonable for employers, and the short-term costs of treatments are well estimated and manageable for health plans and employers. Armed with this business case, the PBGH Negotiating Alliance has expanded health insurance to include pharmacotherapy, over the counter or by prescription, and behavioral interventions. Because PBGH has been a national leader, we hope that other employers, employer coalitions, and public purchasers will follow their lead. The potential health effect of even small reductions in smoking are striking, and unlike other chronic illnesses, nicotine addiction is curable, at both individual and societal levels. Thus, if employers make the investment in smoking cessation and other tobacco control today, they face the real possibility that the need for such outlays could decrease in the future.

Relativistic corrections to the electric polarizability of compound systems.

The widely used relation alpha; = alpha(0)+Deltaalpha for the electric polarizability, where Deltaalpha is proportional to the r.m.s. charge radius of the system, is revisited within a simple model of two spinless particles bound electromagnetically. A complete set of the relativistic corrections to alpha(0) following from the Breit Hamiltonian is obtained. It is shown that these corrections modify the result for alpha; in comparison to that obtained with alpha(0) taken in the nonrelativistic approximation. We propose that the same situation can take place in the more complicated case of hadrons. Special attention is devoted to the correct definition of the center-of-mass coordinates which are found to be very important.

Selective referral to high-volume hospitals: estimating potentially avoidable deaths.

CONTEXT: Evidence exists that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs) for certain conditions. However, few employers, health plans, or government programs have attempted to increase the number of patients referred to HVHs. OBJECTIVES: To determine the difference in hospital mortality between HVHs and LVHs for conditions for which good quality data exist and to estimate how many deaths potentially would be avoided in California by referral to HVHs. DESIGN, SETTING, AND PATIENTS: Literature in MEDLINE, Current Contents, and First-Search Social Abstracts databases from January 1, 1983, to December 31, 1998, was searched using the key words hospital, outcome, mortality, volume, risk, and quality. The highest-quality study assessing the mortality-volume relationship for each given condition was identified and used to calculate odds ratios (ORs) for in-hospital mortality for LVHs vs HVHs. These ORs were then applied to the 1997 California database of hospital discharges maintained by the California Office of Statewide Health Planning and Development to estimate potentially avoidable deaths. MAIN OUTCOME MEASURES: Deaths that potentially could be avoided if patients with conditions for which a mortality-volume relationship had been treated at an HVH vs LVH. RESULTS: The articles identified in the literature search were grouped by condition, and predetermined criteria were applied to choose the best article for each condition. Mortality was significantly lower at HVHs for elective abdominal aortic aneurysm repair, carotid endarterectomy, lower extremity arterial bypass surgery, coronary artery bypass surgery, coronary angioplasty, heart transplantation, pediatric cardiac surgery, pancreatic cancer surgery, esophageal cancer surgery, cerebral aneurysm surgery, and treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). A total of 58,306 of 121,609 patients with these conditions were admitted to LVHs in California in 1997. After applying the calculated ORs to these patient populations, we estimated that 602 deaths (95% confidence interval, 304-830) at LVHs could be attributed to their low volume. Additional analyses were performed to take into account emergent admissions and distance traveled, but the impact of loss of continuity of care for some patients and reduction in the availability of specialists for patients remaining at LVHs could not be assessed. CONCLUSIONS: Initiatives to facilitate referral of patients to HVHs have the potential to reduce overall hospital mortality in California for the conditions identified. Additional study is needed to determine the extent to which selective referral is feasible and to examine the potential consequences of such initiatives.

[Surgery for blepharoptosis in muscular dystrophy].

In some muscular dystrophies there is ocular involvement characterized by blepharoptosis and ophthalmoplegia. These conditions occur in chronic progressive external ophthalmoplegia, oculopharyngeal muscular dystrophy, mitochondrial myopathy, myotonic dystrophy, and ocular myasthenia, among others. Although they differ in their systemic clinical manifestations and in genetic inheritance, ocular involvement is common to all of them. Manifestations include bilateral progressive blepharoptosis with or without extraocular muscle malfunction. During surgical repair of the ptotic eyelid, consideration must be given to eyeball movements, in addition to maximal eyelid elevation, and to avoiding overcorrection and consequent corneal overexposure, leading to dryness and visual impairment. With these muscular dystrophic disorders, resection of the levator muscle or blepharoplasty alone does not suffice. Follow-up shows that most patients need a secondary repair after a short while. Operative correction uses a frontalis sling for eyelid elevation and support. A series of 8 patients with these diseases, operated on by various surgical techniques during the past 7 years, is presented.