Improving the Cost-efficiency of Preventive Chemotherapy: Impact of New Diagnostics on Stopping Decisions for Control of Schistosomiasis.

BACKGROUND: Control of schistosomiasis (SCH) relies on the regular distribution of preventive chemotherapy (PC) over many years. For the sake of sustainable SCH control, a decision must be made at some stage to scale down or stop PC. These "stopping decisions" are based on population surveys that assess whether infection levels are sufficiently low. However, the limited sensitivity of the currently used diagnostic (Kato-Katz [KK]) to detect low-intensity infections is a concern. Therefore, the use of new, more sensitive, molecular diagnostics has been proposed. METHODS: Through statistical analysis of Schistosoma mansoni egg counts collected from Burundi and a simulation study using an established transmission model for schistosomiasis, we investigated the extent to which more sensitive diagnostics can improve decision making regarding stopping or continuing PC for the control of S. mansoni. RESULTS: We found that KK-based strategies perform reasonably well for determining when to stop PC at a local scale. Use of more sensitive diagnostics leads to a marginally improved health impact (person-years lived with heavy infection) and comes at a cost of continuing PC for longer (up to around 3 years), unless the decision threshold for stopping PC is adapted upward. However, if this threshold is set too high, PC may be stopped prematurely, resulting in a rebound of infection levels and disease burden (+45% person-years of heavy infection). CONCLUSIONS: We conclude that the potential value of more sensitive diagnostics lies more in the reduction of survey-related costs than in the direct health impact of improved parasite control.

Optimizing next-generation sequencing efficiency in clinical settings: analysis of read length impact on cost and performance.

BACKGROUND: The expansion of sequencing technologies as a result of the response to the COVID-19 pandemic enabled pathogen (meta)genomics to be deployed as a routine component of surveillance in many countries. Scaling genomic surveillance, however, comes with associated costs in both equipment and sequencing reagents, which should be optimized. Here, we evaluate the cost efficiency and performance of different read lengths in identifying pathogens in metagenomic samples. We carefully evaluated performance metrics, costs, and time requirements relative to choices of 75, 150 and 300 base pairs (bp) read lengths in pathogen identification. RESULTS: Our findings revealed that moving from 75 bp to 150 bp read length approximately doubles both the cost and sequencing time. Opting for 300 bp reads leads to approximately two- and three-fold increases, respectively, in cost and sequencing time compared to 75 bp reads. For viral pathogen detection, the sensitivity median ranged from 99% with 75 bp reads to 100% with 150-300 bp reads. However, bacterial pathogens detection was less effective with shorter reads: 87% with 75 bp, 95% with 150 bp, and 97% with 300 bp reads. These findings were consistent across different levels of taxa abundance. The precision of pathogen detection using shorter reads was comparable to that of longer reads across most viral and bacterial taxa. CONCLUSIONS: During disease outbreak situations, when swift responses are required for pathogen identification, we suggest prioritizing 75 bp read lengths, especially if detection of viral pathogens is aimed. This practical approach allows better use of resources, enabling the sequencing of more samples using streamlined workflows, while maintaining a reliable response capability.

Cost-benefit ratio of modern medical education using micro-costing: a model calculation using the example of an innovative breast brachytherapy workshop.

BACKGROUND AND PURPOSE: Radiation oncology is an essential component of therapeutic oncology and necessitates well-trained personnel. Multicatheter brachytherapy (MCBT) is one radiotherapeutic option for early-stage breast cancer treatment. However, specialized hands-on training for MCBT is not currently included in the curriculum for residents. A recently developed hands-on brachytherapy workshop has demonstrated promising results in enhancing knowledge and practical skills. Nevertheless, these simulation-based teaching formats necessitate more time and financial resources. Our analyses include computational models for the implementation and delivery of this workshop and can serve as a basis for similar educational initiatives. METHODS: This study aimed to assess the cost-effectiveness of a previously developed and evaluated breast brachytherapy simulation workshop. Using a micro-costing approach, we estimated costs at a detailed level by considering supplies, soft- and hardware, and personnel time for each task. This method also allows for a comprehensive evaluation of the costs associated with implementing new medical techniques. The workshop costs were divided into two categories: development and workshop execution. The cost analysis was conducted on a per-participant basis, and the impact on knowledge improvement was measured using a questionnaire. RESULTS: The total workshop costs were determined by considering the initial workshop setup expenses including the development and conceptualization of the course with all involved collaborators, as well as the costs incurred for each individual course. The workshop was found to be financially efficient, with a per-participant cost of €â€¯39, considering the industrial sponsorship provided for brachytherapy equipment. In addition, we assessed the workshop's efficacy by analyzing participant feedback using Likert scale evaluations. The findings indicated a notable enhancement in both theoretical and practical skills among the participants. Moreover, the cost-to-benefit ratio (CBFR) analysis demonstrated a CBFR of €â€¯13.53 for each Likert point increment. CONCLUSION: The hands-on brachytherapy workshop proved to be a valuable and approximately cost-effective educational program, leading to a significant enhancement in the knowledge and skills of the participants. Without the support of industrial sponsorship, the costs would have been unattainable.

Identification of Surgeon Outliers to Improve Cost Efficiency: A Novel Use of the Centers for Medicare and Medicaid Quality Payment Program.

BACKGROUND: Bundled payment programs for total joint arthroplasty (TJA) have become popular among both private and public payers. Because these programs provide surgeons with financial incentives to decrease costs through reconciliation payments, there is an advantage to identifying and emulating cost-efficient surgeons. The objective of this study was to utilize the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) in combination with institutional data to identify cost-efficient surgeons within our region and, subsequently, identify cost-saving practice patterns. METHODS: Data was obtained from the CMS QPP for total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeons within a large metropolitan area from January 2019 to December 2021. A simple linear regression determined the relationship between surgical volume and cost-efficiency. Internal practice financial data determined whether patients of identified surgeons differed with respect to x-ray visits, physical therapy visits, out-of-pocket payments to the practice, and whether surgery was done in hospital or surgical center settings. RESULTS: There were 4 TKA and 3 THA surgeons who were cost-efficiency outliers within our area. Outliers and nonoutlier surgeons had patients who had similar body mass index, American Society of Anesthesiologists Physical Status Score, and age-adjusted Charlson Comorbidity Index scores. Patients of these surgeons had fewer x-ray visits for both TKA and THA (1.06 versus 1.11, P < .001; 0.94 versus 1.15, P < .001) and lower out-of-pocket costs ($86.10 versus $135.46, P < .001; $116.10 versus $177.40, P < .001). If all surgeons performing > 30 CMS cases annually within our practice achieved similar cost-efficiency, the savings to CMS would be $17.2 million for TKA alone ($75,802,705 versus $93,028,477). CONCLUSIONS: The CMS QPP can be used to identify surgeons who perform cost-efficient surgeries. Practice patterns that result in cost savings can be emulated to decrease the cost curve, resulting in reconciliation payments to surgeons and institutions and cost savings to CMS.

Haematoma block is the most efficient technique for closed forearm fracture reduction: a retrospective cohort study.

BACKGROUND: Forearm fractures are a common ED presentation. This study aimed to compare the resource utilisation of three anaesthetic techniques used for closed forearm fracture reduction in the ED: haematoma block (HB), Bier's block (BB) and procedural sedation (PS). METHODS: A retrospective multicentre cohort study was conducted of adult patients presenting to either Port Macquarie Base Hospital ED or Kempsey District Hospital ED in New South Wales, Australia, from January 2018 to June 2021. Patients requiring a closed reduction in the ED were included. ED length of stay (LOS) was compared using a likelihood ratio test. Successful reduction on the first attempt and the number of ED specialists present for each method were both modelled with a linear regression. Staff utilisation by the level of training, cost of consumables and complications for each group were presented as descriptive statistics. RESULTS: A total of 226 forearm fractures were included. 84 used HB, 35 BB and 107 PS. The mean ED LOS was lowest for HB (187.7 min) compared with BB (227.2 min) and PS (239.3 min) (p=0.023). The number of ED specialists required for PS was higher when compared with HB and BB (p=0.001). The cost of consumables and a total number of staff were considerably lower for HB compared with PS and BB methods. PS had the highest proportion of successful reductions on the first attempt (94.4%) compared with BB (88.6%) and HB (76.2%) (p=0.006). More patients experienced complications from PS (17.8%) compared with BB (14.3%) and HB (13.1%). CONCLUSIONS: In this study, the HB method was the most efficient as it was associated with a shorter ED LOS, lower cost and staff resource utilisation. Although PS had a significantly greater proportion of successful reductions on the first attempt, HB had fewer complications than BB and PS. EDs with limited resources should consider using HB or BB as the initial technique for fracture reduction with PS used for failed HB or when regional blocks are contraindicated.

Cost-efficiency analysis of multiple ecosystem services across forest management regimes.

Forest management is at the crossroads of economic, environmental, and social goals, often requiring strategic trade-offs. As global demands surge, it's vital to employ management strategies fostering multifunctional landscapes, enabling ecosystem integrity while procuring resources. Historically, the boreal forest in Fennoscandia has been intensively managed for timber, causing environmental shifts and conflicts with biodiversity conservation and climate mitigation policies. Application of current management practices while increasing harvests are a threat to both biodiversity and carbon stocks. To explore this issue, we quantify the cost-efficiency of two forest management regimes: rotation forestry (RF) and continuous cover forestry (CCF), considering specific forest attributes like soil type (mineral and peat soils), site type (fertility classes) and tree stand age, which have been underexplored in previous research. We simulated 45,559 forest stands for 100 years in Northern boreal forests of Finland. We proposed two straightforward cost-efficiency indices (CEI) to evaluate the performance of these management regimes, specifically focusing on their impact on economic output, biodiversity conservation (measured as a biodiversity index for six forest vertebrates, including five bird species and one mammal) and carbon stock. Our findings suggest that continuous cover forestry holds the potential to deliver more cost-efficient ecosystem services and maintain greater biodiversity compared to rotation forestry approaches. Continuous cover forestry, however, is not optimal for all at management units, which calls for alternative management options depending on the stand characteristics. The cost-efficiency indices performance of rotation forestry and continuous cover forestry depend on the characteristics of the initial stand which is largely determined by the previous management of the stand. Our results contribute to guiding forest management towards enhanced sustainability and ecological balance. The great variation in stand characteristics suggest a need for diverse management strategies to create multifunctional landscapes. Our proposed cost-efficiency indices could serve as practical tools for decision-making.

Yield and Efficiency of a Population-Based Mass Tuberculosis Screening Intervention Among Persons With Diabetes in Jiangsu Province, China.

BACKGROUND: The evidence-base for mass tuberculosis screening among persons with diabetes (PWD) is poor. We evaluated the yield and costs of mass screening among PWD in eastern China. METHODS: We included individuals with type 2 diabetes from 38 townships in Jiangsu Province. Screening comprised of physical examinations, symptom screening, and chest X-rays; smear and culture testing were performed through clinical triage. We assessed the yield and number needed to screen (NNS) to detect 1 tuberculosis case among all PWD, those with symptoms, and with suggestive chest X-rays. Unit costing was collected to estimate screening costs and to calculate cost per case detected. We performed a systematic review of other mass tuberculosis screening programs concentrated on PWD. RESULTS: Of 89 549 screened PWD, 160 were diagnosed with tuberculosis (179 cases per 100 000 persons; 95% confidence interval [CI]: 153-205). The NNS was 560 (95% CI: 513-606), 248 (95% CI: 217-279), and 36 (95% CI: 24-48) among all participants, with abnormal chest X-rays, and symptoms. The cost per case was high overall (US$13 930) but lower with symptoms (US$1037) and high fasting blood glucose levels (US$6807). From systematic review, the pooled NNS to detect one case among all PWD (regardless of symptoms or chest X-ray results) in high- versus low-burden settings was 93 (95% CI: 70-141) versus 395 (95% CI: 283-649). CONCLUSIONS: A mass tuberculosis screening program focused on PWD was feasible however, the overall yield was low and not cost-efficient. Risk-stratified approaches may be practical among PWD in low- and medium tuberculosis burden settings.

The cost and cost efficiency of conducting a 24-h dietary recall using INDDEX24, a mobile dietary assessment platform, compared with pen-and-paper interview in Viet Nam and Burkina Faso.

The INDDEX24 Dietary Assessment Platform (INDDEX24) was developed to facilitate the collection of 24-h dietary recall (24HR) data. Alongside validation studies in Viet Nam and Burkina Faso in 2019-2020, we conducted activity-based costing studies to estimate the cost of conducting a 24HR among women of reproductive age using INDDEX24 compared with the pen-and-paper interview (PAPI) approach. We also modelled alternative scenarios in which: (1) 25-75 % of dietary reference data were borrowed from the INDDEX24 Global Food Matters Database (FMDB); (2) all study personnel were locally based and (3) national-scale surveys. In the primary analysis, in Viet Nam, the 24HR cost US $111 004 ($755/respondent, n 147) using INDDEX24 and $120 483 ($820/respondent, n 147) using PAPI. In Burkina Faso, the 24HR cost $78 105 ($539/respondent, n 145) using INDDEX24 and $79 465 ($544/respondent, n 146) using PAPI. In modelled scenarios, borrowing dietary reference data from the FMDB decreased the cost of INDDEX24 by 17-34 % (Viet Nam) and 5-15 % (Burkina Faso). With all locally based personnel, INDDEX24 cost more than PAPI ($498 v. $448 per respondent in Viet Nam and $456 v. $410 in Burkina Faso). However, at national scales (n 4376, Viet Nam; n 6500, Burkina Faso) using all locally based personnel, INDDEX24 was more cost-efficient ($109 v. $137 per respondent in Viet Nam and $123 v. $148 in Burkina Faso). In two countries and under most circumstances, INDDEX24 was less expensive than PAPI. Higher INDDEX24 survey preparation costs (including purchasing equipment) were more than offset by higher PAPI data entry, cleaning and processing costs. INDDEX24 may facilitate cost-efficient dietary data collection.

Could an optimally fitted categorization of difference between multi-disease score and multi-symptom score be a practical indicator aiding in improving the cost-effectiveness of healthcare delivery for older adults in developing countries?

BACKGROUND: Physio-psycho-socioeconomical health comprehensively declines during aging, the complexity of which is challenging to measure. Among the complexity, multiple chronic disorders continuously cumulated during aging, further aggravating the challenge. METHODS: A population-based survey on Comprehensive Ageing Health Assessment was conducted in older adults (age > = 60) enrolled from hospital settings and community settings in 13 working centers in six subnational regions in China. Cross-sectional datasets of 8,093 older participants with approximately complete assessment results were collected for the present analysis. Individual's multi-disease or multi-symptom was respectively scored by summing coexistent multiple diseases or multiple symptoms by respective weighting efficient for Self-Rated Health (SRH). Individual's age-dependent health decline was further summed of four SRH-weighted scores for daily function (activity of daily life, ADL), physical mobility (an average of three metrics), cognitive function (mini mental state examination, MMSE) and mental being (geriatric depression scale, GDS) plus multi-disease score (MDS) and multi-symptom score (MSS).Multi-disease patten among 18 diseases or multi-symptom pattern among 15 symptoms was latent-clustered in the older adults, the optimal outcome of which was categorized into high, moderate or low aging-associated clusters, respectively. Percentage distribution was compared between overall health decline score and multi-disease pattern cluster or multi-symptom patten cluster. A new variable of difference between MDS and MSS (hereinafter terming DMM) that displayed linear variation with socioeconomic factors was further fitted using multilevel regression analyses by substantial adjustments on individual confounders (level-1) and subnational region variation (level-2). RESULTS: Consistent gradient distribution was shown between health decline and multimorbidity pattern cluster in the older adults. DMM was found linearly varied with personal education attainment and regional socioeconomic status. Using optimally fitted stratification of DMM (DMM interval = 0.02), an independent U-shaped interrelated tendency was shown between health decline, multi-disease and multi-symptom, which could be well explained by regional disparities in socioeconomic status. CONCLUSION: Newly developed metrics for age-dependent health decline and aging-associated multimorbidity patten were preliminarily validated from within. The new variable of optimally fitted categorization of DMM might function as a practical indicator aiding in improving the cost-effectiveness and reduce inequity of healthcare delivery for older adults in developing countries.

Optimising ambulance conveyance rates and staff costs by adjusting proportions of rapid-response vehicles and dual-crewed ambulances: an economic decision analytical modelling study.

AIM: To model optimum proportions of dual-crewed ambulances (DCAs) and rapid-response vehicles (RRVs) in Ambulance Trusts with a view to generating a policy brief for one Ambulance Trust and a modelling tool for other Trusts on the strategic procurement and allocation of emergency vehicle (EV) resources. METHODS: Historical EV assignments for 12 months of emergency calls in 2019 were provided by an NHS Ambulance Trust and analysed for backup, see and treat, and patient to hospital conveyance. Unit costs were derived for paramedics and technicians using Agenda for Change pay rates. Time cycles were assigned for RRV and DCA attendances and unit costs assigned to these. Information was put into a decision analytical model to estimate the costs and numbers of vehicles attending incidents based on relative proportions of available RRVs and DCAs. RESULTS: Of 711 992 calls attended by 837 107 EVs, 514 766 (72.3%) required at least one emergency department conveyance. The rate of conveyance was significantly lower when RRVs arrived first on the scene. 27 883 out of 529 693 (5.3%) DCAs first arriving at an incident required some backup, and this was also factored into the model. Modelling demonstrated high conveyance rates were counterproductive when increasing the relative proportions of RRVs to DCAs. For example, with conveyance rates of 65%, increasing the RRVs increased the cost and numbers of vehicles attending per incident. At lower conveyance rates, however, there was a levelling around 30% where it could become cost-effective to increase the relative proportions of RRVs to DCAs. CONCLUSION: At current overall conveyance rates, there is no benefit in increasing the relative proportions of RRVs to DCAs unless additional benefits can be realised that bring the conveyance rates down.

Refresh Rate-Based Caching and Prefetching Strategies for Internet of Things Middleware.

One of the research directions in Internet of Things (IoT) is the field of Context Management Platforms (CMPs) which is a specific type of IoT middleware. CMPs provide horizontal connectivity between vertically oriented IoT silos resulting in a noticeable difference in how IoT data streams are processed. As these context data exchanges can be monetised, there is a need to model and predict the context metrics and operational costs of this exchange to provide relevant and timely context in a large-scale IoT ecosystem. In this paper, we argue that caching all transient context information to satisfy this necessity requires large amounts of computational and network resources, resulting in tremendous operational costs. Using Service Level Agreements (SLAs) between the context providers, CMP, and context consumers, where the level of service imperfection is quantified and linked to the associated costs, we show that it is possible to find efficient caching and prefetching strategies to minimize the context management cost. So, this paper proposes a novel method to find the optimal rate of IoT data prefetching and caching. We show the main context caching strategies and the proposed mathematical models, then discuss how a correctly chosen proactive caching strategy and configurations can help to maximise the profit of CMP operation when multiple SLAs are defined. Our model is accurate up to 0.0016 in Root Mean Square Percentage Error against our simulation results when estimating the profits to the system. We also show our model is valid using the t-test value tending to 0 for all the experimental scenarios.

The Economic Impact of Standardization and Digitalization in the Operating Room: A Systematic Literature Review.

Hospital face increased resource constraints and competition. This escalates the need for efficiency optimization especially in resource-intense areas, such as the Operating Room (OR). Efficiency cannot happen at expenses of patient outcomes. Innovative digital support systems (DSS) have been introduced into the market to support established standardization methods of intraoperative workflows further. This review aimed to analyze whether applied standardization methods and implemented DSS of intraoperative surgical workflows lead to increasing efficiency and demonstrate economic improvements. A systematic review of intraoperative surgical workflows standardization and digitalization was performed. Journal articles and reviews from 2000 to 2023 were retrieved from EBSCO, PubMed, and Scopus databases, as well as the internal database of Johnson & Johnson. 17 articles showed a significant increase in efficiency through standardization, which led to cost reductions between $70.20 to $3,516 per case without negatively impacting quality. Five additional articles on DSS demonstrated a significant positive impact on efficiency and quality. Reduction in OR-time between 6 to 22% per case was one main contributor. No literature on DSS revealed any correlated economic impact. Selected standardization methods and introduced DSS for intraoperative surgical workflows effectively increase efficiency while maintaining or even improving quality. Demonstrated cost-effectiveness of non-digital standardization methods across surgical areas requires more research on complex and resource-intensive procedures and the economic value of DSS to support hospital management's strategic decisions to overcome the increasing economic burden.

Artificial intelligence for waste management in smart cities: a review.

The rising amount of waste generated worldwide is inducing issues of pollution, waste management, and recycling, calling for new strategies to improve the waste ecosystem, such as the use of artificial intelligence. Here, we review the application of artificial intelligence in waste-to-energy, smart bins, waste-sorting robots, waste generation models, waste monitoring and tracking, plastic pyrolysis, distinguishing fossil and modern materials, logistics, disposal, illegal dumping, resource recovery, smart cities, process efficiency, cost savings, and improving public health. Using artificial intelligence in waste logistics can reduce transportation distance by up to 36.8%, cost savings by up to 13.35%, and time savings by up to 28.22%. Artificial intelligence allows for identifying and sorting waste with an accuracy ranging from 72.8 to 99.95%. Artificial intelligence combined with chemical analysis improves waste pyrolysis, carbon emission estimation, and energy conversion. We also explain how efficiency can be increased and costs can be reduced by artificial intelligence in waste management systems for smart cities.

Cost-Efficiency Optimization Serves as a Conserved Mechanism that Promotes Osteosarcoma in Mammals.

Mutations that reduce the biosynthetic cost of ATP production or increase the gene translation efficiency (tAI) are favorable for rapid cell growth and proliferation and therefore likely to be observed in tumors. Whether the mutations in tumors optimize the trade-off between the ATP biosynthesis cost and gene translation efficiency by increasing the tAI/ATP ratio is currently unknown. We retrieved transcriptome data of normal and osteosarcoma tissue samples from humans and mice and identified tumor-specific mutations in each species by using stringent cutoffs and outgroup information. We compared the tAI/ATP values of genes before and after mutation. The tAI/ATP profile was found to be highly conserved in humans and mice, and also correlated with the essentiality of genes. Tumor-specific rather than shared mutations were found to lead to increased tAI/ATP values in both species. Thus, tumor-specific mutations were found to optimize the cost-efficiency trade-off by increasing the tAI/ATP ratio of genes in osteosarcoma. This may indicate an evolutionarily conserved mechanism that promotes tumorigenesis by facilitating rapid cell growth and proliferation.

Expanded access to anticancer treatments from conversion to biosimilar pegfilgrastim-cbqv in US breast cancer patients.

Aim: To estimate cost-savings from conversion to biosimilar pegfilgrastim-cbqv that could be reallocated to provide budget-neutral expanded access to AC (doxorubicin/cyclophosphamide) and TCH (docetaxel/carboplatin/trastuzumab) in breast cancer (BC) patients. Methods: Simulation modeling in panels of 20,000 BC and 5000 HER2+ (HER2+ BC) patients, varying treatment duration (one-six cycles) and conversion rates (10-100%), to estimate cost-savings and additional AC and TCH treatment that could be provided. Results: In 20,000 patients, cost-savings of $1,083 per-patient per-cycle translate to $21,652,064 (one cycle) to $129,912,397 (six cycles). Savings range from $5,413,016 to $32,478,097, respectively, in the 5000-patient HER2+ BC panel. Conclusion: Conversion to pegfilgrastim-cbqv could save up to $130 million and provide more than 220,000 additional cycles of antineoplastic treatment on a budget-neutral basis to BC patients.

Lay abstract Pegfilgrastim is used to prevent low white blood cell count in patients receiving chemotherapy. Comparable to a generic version of a drug, a biosimilar is a follow-on version of a biologic treatment. We calculated the savings from using biosimilar pegfilgrastim in a hypothetical group of 20,000 patients with breast cancer receiving chemotherapy with AC (doxorubicin/cyclophosphamide). We then computed the number of additional doses of AC chemotherapy that could be purchased with those savings. We did the same for a group of 5000 HER2+ breast cancer patients treated with TCH (docetaxel/carboplatin/trastuzumab). Using biosimilar pegfilgrastim could save $1,083 per patient per cycle. If all patients were treated with biosimilar pegfilgrastim over six cycles, $129.9 million could be saved in the AC group and $32.5 million in the TCH group. This could provide 220,468 additional AC doses and 6981 TCH doses. Biosimilar pegfilgrastim can generate significant savings. These savings can be used to provide additional patients with chemotherapy cost-free.

Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial.

BACKGROUND: Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial. METHODS: Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve. RESULTS: 69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72-80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care. CONCLUSION: These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients' perception of this model of care are needed. CLINICAL TRIAL REGISTRATION: The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533.

Design of Cost-Efficient Optical Fronthaul for 5G/6G Networks: An Optimization Perspective.

Currently, 5G and the forthcoming 6G mobile communication systems are the most promising cellular generations expected to beat the growing hunger for bandwidth and enable the fully connected world presented by the Internet of Everything (IoE). The cloud radio access network (CRAN) has been proposed as a promising architecture for meeting the needs and goals of 5G/6G (5G and beyond) networks. Nevertheless, the provisioning of cost-efficient connections between a large number of remote radio heads (RRHs) in the cell sites and the baseband unit (BBU) pool in the central location, known as the fronthaul, has emerged as a new challenge. Many wired and wireless solutions have been proposed to address this bottleneck. Specifically, optical technologies presented by passive optical networks (PONs) are introduced as the best suitable solution for 5G and beyond network fronthaul due to their properties of providing high capacity and low latency connections. We considered time and wavelength division multiplexed passive optical networks (TWDM-PONs) as a fronthaul for 5G and beyond. Taking that into consideration, in this paper, we propose an integer linear program (ILP) that results in the optimal optical fronthaul deployment while minimizing the total cost of 5G and beyond instances. However, for larger network instances, solving the ILP problem becomes unscalable and time-consuming. To address that, we developed two heuristic-based algorithms (the K-means clustering algorithm and the one based on the genetic algorithm-GA). We evaluated the suitability of our proposed ILP and heuristic algorithms in simulations by utilizing them to plan different network instances (dense and sparse).

Evaluating priority locations and potential benefits for building a nation-wide fuel break network in Portugal.

Despite growing interest in developing extensive fuel treatment programs to prevent catastrophic wildfires in the Mediterranean region, there is little information on the projected effectiveness of fuel treatments in terms of avoided exposure and risk. In Portugal, a fuel management plan aiming to prevent loss of lives, reduce large fires (>500 ha), and reduce annual burned area is under implementation, with particular emphasis on the nation-wide fuel break network (FBN). In this study, we evaluated the effectiveness of the planned FBN in terms of meeting fire management objectives, costs, and benefits. We first estimated the overall effectiveness of the FBN at intersecting modeled large fires (>500 ha) and at reducing exposure to protected areas and residential buildings using wildfire simulation modeling. Then, the fuel break burn-over percentage, i.e. the percentage of fires that are not contained at the FBN, was modeled as a function of pre-defined flame length thresholds for individual FBN segments. For the planned FBN, the results suggested a potential reduction of up to 13% in the annual burned area due to large fires (ca. 13,000 ha), of up to 8% in the annual number of residential buildings exposed (ca. 100 residential buildings), and up to 14% in the annual burned area in protected areas (ca. 2400 ha). The expected burn-over percentage was highly variable among the segments in response to estimated fire intensity, and an average decrease of 40% of the total benefits was estimated. The most important fuel breaks typically showed a higher percentage of fire burn-over, and hence reduction in effectiveness. We also showed that the current implementation of FBN follows a random sequence, suboptimal for all objectives. Our results suggest that additional landscape-scale fuel reduction strategies are required to meet short-term national wildfire management targets.

Aerial and underwater drones for marine litter monitoring in shallow coastal waters: factors influencing item detection and cost-efficiency.

Although marine litter monitoring has increased over the years, the pollution of coastal waters is still understudied and there is a need for spatial and temporal data. Aerial (UAV) and underwater (ROV) drones have demonstrated their potential as monitoring tools at coastal sites; however, suitable conditions for use and cost-efficiency of the methods still need attention. This study tested UAVs and ROVs for the monitoring of floating, submerged, and seafloor items using artificial plastic plates and assessed the influence of water conditions (water transparency, color, depth, bottom substrate), item characteristics (color and size), and method settings (flight/dive height) on detection accuracy. A cost-efficiency analysis suggests that both UAV and ROV methods lie within the same cost and efficiency category as current on-boat observation and scuba diving methods and shall be considered for further testing in real scenarios for official marine litter monitoring methods.

The productivity growth of euro area banks.

We study the performance of the banking system in the Eurozone over the period 2006-2017 as measured by total factor productivity growth (TFPG) and its components. We find that Total Factor Productivity growth for the median euro area bank decreased from around 2.6% in 2007 to below 1.7% in 2017, driven mainly by a decline in technical efficiency. In addition, we control for unobserved heterogeneity across banks and disentangle persistent and time-varying inefficiency in the banking sector. This modelling choice is important to avoid distorted and biased inefficiency estimates. We find that cost efficiency in the euro area banking sector amounted to around 84% on average over the 2006 to 2017 period. The largest part of bank inefficiency is persistent, suggesting that structural long-term factors (such as location, client structure, macroeconomic environment, regulation, etc.) play a bigger role than time-varying factors.