A framework for evaluating the economic impact of case management

Confusion about the cost-effectiveness of case management stems partly from poorly defined assumptions about outcomes and unclear theories of how case management affects costs. The authors discuss how cost-effectiveness is influenced by the characteristics of various case management models, characteristics of the clients served, and contextual factors, including resources available in the treatment system and financial incentives built into various payment mechanisms. Important differences exist between case management models in the mechanisms favored for managing resources, including whether the client or the case manager is primarily responsible for directing the course of treatment, whether reduction in hospitalizations is a primary goal, whether team case management is used, and how the size of caseloads is determined.     

A deterministic model for the economic evaluation of broiler production systems

A deterministic model for the economic evaluation of broiler production and the derivation of economic values in broiler breeding was developed and tested. The model distinguishes four production stages: multiplier breeder, hatchery, commercial grower, and processor. The processor is included to determine relationships for the price per kilogram of live weight and the quality of the carcass, either on a "whole sale" or "further processed" base. Quantity of product output for the system is fixed by a predetermined amount of kilogram carcass of final product broilers finished by the commercial grower. Profitability of production and cost prices per unit product for subsequent stages can be calculated. Exogenous parameters are easily changeable in order to calculate profitability and cost prices for different production levels or production circumstances. Economic values can be derived considering influences of changes in genetic merit for performance traits on profitability or cost price, for integrated and nonintegrated production systems. By changing exogenous parameters, the model can also be used to analyze profitability or derive economic values for other meat-type poultry, such as turkey.     

Results of the economic evaluation of the first study. A multinational prospective economic evaluation. FIRST Investigators. Flolan International Randomized Survival Trial

We present the prospective economic evaluation that served as a secondary endpoint for the FIRST study, a randomized international multicenter trial of patients with severe congestive heart failure. Although the clinical results of this study were disappointing, we demonstrated the feasibility of incorporating prospective economic evaluation in phase III clinical trials.     

浅谈Microsoft Excel在建设项目经济评价中的应用

介绍Excel软件的功能、编制原则，并结合具体实例进行分析说明。     

Low-bandwidth telemedicine for remote orthotic assessment

The 1,3-1,4-beta-glucanases from Bacillus macerans and Bacillus licheniformis, as well as related hybrid enzymes, are stable proteins comprised of one compact jellyroll domain. Their structures are studied in an effort to reveal the degree of redundancy to which the three-dimensional structure of protein domains is encoded by the amino acid sequence. For the hybrid 1,3-1,4-beta-glucanase H(A16-M), it could be shown recently that a circular permutation of the sequence giving rise to the variant cpA16M-59 is compatible with wildtype-like enzymatic activity and tertiary structure (Hahn et al., Proc. Natl. Acad. Sci. USA 91:10417-10421, 1994). Since the circular permutation yielding cpA16M-59 mimicks that found in the homologous enzyme from Fibrobacter succinogenes, the question arose whether de novo circular permutations, not guided by molecular evolution of the 1,3-1,4-beta-glucanases, could also produce proteins with native-like fold. The circularly permuted variants cpA16M-84, cpA16M-127, and cpA16M-154 were generated by PCR mutagenesis of the gene encoding H(A16-M), synthesized in Escherichia coli and shown to be active in beta-glucan hydrolysis. CpA16M-84 and cpA16M-127 were crystallized in space groups P2(1) and P1, respectively, and their crystal structures were determined at 1.80 and 2.07 A resolution. In both proteins the main parts of the beta-sheet structure remain unaffected by the circular permutation as is evident from a root-mean-square deviation of main chain atoms from the reference structure within the experimental error. The only major structural perturbation occurs near the novel chain termini in a surface loop of cpA16M-84, which becomes destabilized and rearranged. The results of this study are interpreted to show that: (1) several circular permutations in the compact jellyroll domain of the 1,3-1,4-beta-glucanases are tolerated without radical change of enzymatic activity or tertiary structure, (2) the three-dimensional structures of simple domains are encoded by the amino acid sequence with sufficient redundancy to tolerate a change in the sequential order of secondary structure elements along the sequence, and (3) the native N-terminal region is not needed to guide the folding polypeptide chain toward its native conformation.     

冶金矿山企业经济效益评价指标体系的构筑

指标体系的建立是冶金矿山企业经济效益评价的基础.根据指标体系构筑的原则,采用13家冶金矿山的数据,运用多元统计分析方法,对指标体系的建立展开讨论,为构筑矿山经济效益评价指标体系提供了新的途径和方法.     

A review and economic evaluation of bronchodilator delivery methods in hospitalized patients

BACKGROUND: Bronchodilator delivery by metered dose inhaler (MDI) to treat airflow obstruction is considered to be less expensive and as effective as nebulized therapy. OBJECTIVES: To document the utilization of bronchodilator delivery methods in a tertiary care Canadian university teaching hospital and to perform an economic evaluation. METHODS: A prospective 6-week audit of 4 preselected hospital wards (respiratory, thoracic surgery, general surgery, and a general internal medicine clinical teaching unit) and a cost-minimization economic evaluation were performed. Bronchodilator (salbutamol and ipratropium bromide) doses, frequency, and delivery methods, either MDI or wet nebulizer (WN), were recorded for 95 patients treated with aerosolized bronchodilators. Direct costs for medications and hourly wages including benefits and equipment were obtained. Time and motion studies identified time allocated to MDI and WN delivery. We used sensitivity analyses to test assumptions that could significantly affect treatment costs, especially assumptions about medications, labor, and spacer devices. Costs are expressed in Canadian dollars (Can$1 = US$0.75). RESULTS: Sixty-seven patients (70.5%) were treated with WN, 6 (6.3%) with MDI, and 22 (23.2%) with both WN and MDI. Self-administration of salbutamol by MDI was the least expensive: $1.27 for 200-microgram doses and $1.73 for 400-microgram doses compared with $2.62 for a 2.5-mg dose delivered by WN. The difference in cost between equivalent treatments (400-microgram MDI vs 2.5-mg WN) is only $0.89. Sensitivity analyses showed that MDI was the least expensive therapy when self-administration was possible and for all levels of supervision if more than 4 minutes was needed to administer a WN treatment. CONCLUSIONS: Bronchodilator delivery by WN is commonly prescribed for hospitalized patients despite evidence for equivalency of effect using MDI and in the absence of substitution protocols. Previous studies have estimated a far greater cost differential based on unrealistic labor estimates. We found that supervision of patients using MDIs minimized the differential cost between WN and MDI therapy and that cost savings are maximal in patients who can self-administer MDI therapy. Methodologically sound economic evaluations can better identify true cost savings and variables that need further study.     

Prenatal screening for cystic fibrosis carriers: an economic evaluation

The cloning of the CFTR gene has made it technically possible to avert the unwanted birth of a child with cystic fibrosis (CF). Several large trials offering prenatal CF carrier screening suggest that such screening is practical and that identified carriers generally use the information obtained. Therefore, a critical question is whether the cost of such screening is justified. Decision analysis was performed that used information about choices that pregnant women were observed to make at each stage in the Rochester prenatal carrier-screening trial. The cost of screening per CF birth voluntarily averted was estimated to be $1,320,000-$1,400,000. However, the lifetime medical cost of the care of a CF child in today's dollars was estimated to be slightly>$1,000,000. Therefore, despite both the high cost of carrier testing and the relative infrequency of CF conceptions in the general population, the averted medical-care cost resulting from choices freely made are estimated to offset approximately 74%-78% of the costs of a screening program. At present, if it is assumed that a pregnancy terminated because of CF is replaced, the marginal cost for prenatal CF carrier screening is estimated to be $8,290 per quality-adjusted life-year. This value compares favorably with that of many accepted medical services. The cost of prenatal CF carrier screening could fall to equal the averted costs of CF patient care if the cost of carrier testing were to fall to $100.     

"Telestroke" : the application of telemedicine for stroke

BACKGROUND: Time is of the essence for effective intervention in acute ischemic stroke. Efforts including stroke teams that are "on call" around-the-clock are emerging to reduce the time from emergency room arrival to evaluation and treatment. SUMMARY OF COMMENT: Based on the results of the NINDS rt-PA Stroke Trial, which demonstrated both clinical effectiveness in reducing neurological deficits and disability and cost savings to health care systems, many community hospitals and managed-care organizations are exploring methods to enhance and expedite acute stroke care in their local communities. Only a small fraction of acute stroke victims is currently treated with thrombolytics (<1.5% nationally), and few benefit from the expertise and experience of the stroke teams. It is essential to develop new paradigms to improve acute stroke care in all settings, rural and urban. Rapid linkages to expert stroke care can help the underserved areas. Telemedicine for stroke, "Telestroke, " uses state-of-the-art video telecommunications that may be a potential solution and may maximize the number of patients given effective acute stroke treatment across the country and across the world. Telestroke could facilitate remote cerebrovascular specialty consults from virtually any location within minutes of attempted contact, adding greater expertise to the care of any individual patient. This model also has the potential to enhance patient entry into clinical trials. Telestroke would enhance stroke education through the use of Internet-based interactives for health-care professionals and patients. Education would be facilitated through the creation of telecommunication-linked classes providing interactive information on stroke care and prevention to places where they are otherwise not available. Health-care professionals will gain experience and expertise through the interaction with a remote expert--telementoring. Telestroke provides an excellent medium for data collection and an unprecedented opportunity for quality assurance. Monitoring of an entire tele-interaction can offer real-time assessments, which can then be analyzed in-depth at a later date for unique insights into health-care delivery. Prehospital use of telemedicine for stroke is already being piloted, linking patients in the ambulance to the emergency department. Legal and economic parameters must be established for telemedicine in the areas of reimbursement, liability, malpractice insurance, licensing, and credentialing. Issues of protection of privacy and confidentiality, informed consent, product liability, and industry standards must be addressed to facilitate the use of this new and potentially useful technology. CONCLUSIONS: Computer-based technology can now be used to integrate electronic medical information, clinical assessment tools, neuroradiology, laboratory data, and clinical pathways to bring state-of-the-art expert stroke care to underserved areas.     

A genetic framework for floral patterning

The initial steps of flower development involve two classes of consecutively acting regulatory genes. Meristem-identity genes, which act early to control the initiation of flowers, are expressed throughout the incipient floral primordium. Homeotic genes, which act later to specify the identity of individual floral organs, are expressed in distinct domains within the flower. The link between the two classes of genes has remained unknown so far. Here we show that the meristem-identity gene LEAFY has a role in controlling homeotic genes that is separable from its role in specifying floral fate. On the basis of our observation that LEAFY activates different homeotic genes through distinct mechanisms, we propose a genetic framework for the control of floral patterning.     

A framework for integrated quality improvement

The importance of maintaining and improving quality is well understood in most health care organizations. This work becomes more challenging as internal and external conditions rapidly change. A quality improvement framework was developed to help clinicians and administrators organize intergrated, multifaceted quality programs that have the flexibility necessary for success in today's fast-paced health care environment.     

黄金矿山综合经济效益的灰色评估

本文偿试性地应用灰色系统理论中的灰色聚类评估模型,对山东省七个黄金矿山的综合经济效益进行了评价,得出了山东省黄金矿山的综合经济效益较好的合理结论。     

A conceptual framework for the clinical test situation.

The need to account for the adaptive behavior of the patient in the clinical test situation is discussed with respect to the relative rather than absolute nature of test responses. Adaptation-level (AL) theory is proposed as a framework of reference for adaptive behavior of the patient in the clinical situation, as well as for clinical judgment and prediction. The theory of AL possesses the relativity and operational validity required for dealing with complex clinical phenomena. Implications of the AL model for clinical theory, experimentation, and practice are suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost issues surrounding the use of computerized telemedicine for obstetric ultrasonography

Whole-body plethysmography is not included in guidelines from regulatory authorities for the development of treatments or delivery devices for lung disease, despite its potential advantages compared to spirometry. Two separate studies were undertaken to assess the use of specific airway conductance (sGaw) as a pharmacodynamic endpoint for the comparison of two bronchodilator delivery systems (a novel dry powder inhaler and a standard metered dose inhaler). The first pilot study involved delivery of a single dose of salbutamol (200 micrograms) to 12 healthy volunteers and determination of sGaw up to 120 min after treatment. The second study involved delivery of cumulative doses of salbutamol (100, 200 and 400 micrograms) to 19 healthy volunteers with demonstrated reversibility of sGaw to the bronchodilator and measurement of sGaw up to 240 min after treatment. In both studies, increases in sGaw after treatment were significant compared to placebo and larger than the recorded increases in FEV1. Increases in sGaw were similar for both delivery devices and support the therapeutic equivalence of the two products. Power calculations indicated that the second study had appropriate statistical power to discriminate between treatments. It is concluded that the assessment of sGaw in healthy volunteers may be a useful and sensitive pharmacodynamic endpoint for use in the development of bronchodilators and their delivery devices.     

钢铁企业综合技术经济指标的神经网络评价模型研究

利用BP神经网络理论建立技术经济指标评估的数学模型,采用3层神经网络,进行多因素输入建模.通过对模型的训练,使网络的实际输出值与期望输出值的误差均方值最小.经仿真计算证明,该数学模型具有较好的辨识精度.     

Early experience using telemedicine for neonatal surgical consultations

BACKGROUND/PURPOSE: Telemedicine affords the opportunity to extend the presence of surgical evaluation to centers without an on-site pediatric surgeon. However, concern for cost, accuracy of diagnosis, and physician acceptance have limited its use. METHODS: Using a low-cost, desktop computer-based system, this study was designed to test the effectiveness of telemedicine in neonatal surgical consultation. RESULTS: Early experience with six video-teleconference (VTC) and six store-and-forward consultations are presented. Diagnosis was established accurately in all cases. With the three intestinal cases (jejunal atresia, duplication cyst, and r/o malrotation), diagnostic studies were guided by the images transmitted with the consult. Earlier care could be implemented in other cases. Technical problems were encountered primarily with the VTC modality, which also proved more consuming of physician time. CONCLUSIONS: Telemedicine was used successfully in each case and proved accurate in diagnosis and guiding further evaluation. This is the first report of the use of telemedicine for surgical consultation in the intensive care nursery.