Cost effectiveness of total knee arthroplasty from a health care providers' perspective before and after introduction of an interdisciplinary clinical pathway - is investment always improvement?

<p>Abstract</p> <p>Background</p> <p>Total knee arthroplasty (TKA) is an effective, but also cost-intensive health care intervention for end stage osteoarthritis. This investigation was designed to evaluate the cost-effectiveness of TKA before versus after introduction of an interdisciplinary clinical pathway from a University Orthopedic Surgery Department's cost perspective as an interdisciplinary full service health care provider.</p> <p>Methods</p> <p>A prospective trial recruited two sequential cohorts of 132 and 128 consecutive patients, who were interviewed by means of the WOMAC questionnaire. Direct process costs from the health care providers' perspective were estimated according to the German DRG calculation framework. The health economic evaluation was based on margiual cost-effectveness ratios (MCERs); an individual marginal cost effectiveness relation ≤ 100 € per % WOMAC index increase was considered as primary endpoint of the confirmatory cohort comparison. The interdisciplinary clinical pathway under consideration primarily consisted of a voluntary preoperative personal briefing of patients concerning postoperatively expectable progess in health status and optimum use of walking aids after surgery. All patients were supplied with written information on these topics, attendance of the personal briefing also included preoperative training for postoperative mobilisation by the Department's physiotherapeutic staff.</p> <p>Results</p> <p>An individual marginal cost effectiveness relation ≤ 100 €/% WOMAC index increase was found in 38% of the patients in the pre pathway implementation cohort versus in 30% of the post pathway implementation cohort (Fisher p = 0.278). Both cohorts showed substantial improvement in WOMAC scores (39 versus 35% in median), whereas the cohort did not differ significantly in the median WOMAC score before surgery (41% for the pre pathway cohort versus 44% for the post pathway cohort). Despite a locally significant decrease in costs (4303 versus 4194 € in median), the individual cost/benefit relation became worse after introduction of the pathway: for the first cohort the MCER was estimated 108 € per gained % WOMAC index increase (86 - 150 €/%) versus 118 €/% WOMAC gain (93 - 173 €/%) in the second cohort after pathway implementation. In summary, the proposed critical pathway for TKA could be shown to be significantly cost efficient, but not cost effective concerning functional outcome, when the above individual marginal cost effectiveness criterion was concentrated on.</p> <p>Conclusions</p> <p>The introduction of an interdisciplinary clinical pathway does not necessarily improve patient related outcomes. On the contrary, cost effectiveness from the health care providers' perspective may even turn out remarkably reduced in the setting considered here (functional outcome assessment after treatment by a full service health care provider).</p

Genetic indicators of iron limitation in wild populations of \u3cem\u3eThalassiosira oceanica\u3c/em\u3e from the northeast Pacific Ocean

Assessing the iron (Fe) nutritional status of natural diatom populations has proven challenging as physiological and molecular responses can differ in diatoms of the same genus. We evaluated expression of genes encoding flavodoxin (FLDA1) and an Fe-starvation induced protein (ISIP3) as indicators of Fe limitation in the marine diatom Thalassiosira oceanica. The specificity of the response to Fe limitation was tested in cultures grown under Fe- and macronutrient-deficient conditions, as well as throughout the diurnal light cycle. Both genes showed a robust and specific response to Fe limitation in laboratory cultures and were detected in small volume samples collected from the northeast Pacific, demonstrating the sensitivity of this method. Overall, FLDA1 and ISIP3 expression was inversely related to Fe concentrations and offered insight into the Fe nutritional health of T. oceanica in the field. As T. oceanica is a species tolerant to low Fe, indications of Fe limitation in T. oceanica populations may serve as a proxy for severe Fe stress in the overall diatom community. At two shallow coastal locations, FLD1A and ISIP3 expression revealed Fe stress in areas where dissolved Fe concentrations were high, demonstrating that this approach may be powerful for identifying regions where Fe supply may not be biologically available

Effects of clinical pathways in the joint replacement: a meta-analysis

<p>Abstract</p> <p>Background</p> <p>A meta-analysis was performed to evaluate the use of clinical pathways for hip and knee joint replacements when compared with standard medical care. The impact of clinical pathways was evaluated assessing the major outcomes of in-hospital hip and knee joint replacement processes: postoperative complications, number of patients discharged at home, length of in-hospital stay and direct costs.</p> <p>Methods</p> <p>Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched. The search was performed from 1975 to 2007. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Jadad methodological approach and on the New Castle Ottawa Scale. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software, version 4.2.</p> <p>Results</p> <p>Twenty-two studies met the study inclusion criteria and were included in the meta-analysis for a total sample of 6,316 patients. The aggregate overall results showed significantly fewer patients suffering postoperative complications in the clinical pathways group when compared with the standard care group. A shorter length of stay in the clinical pathway group was also observed and lower costs during hospital stay were associated with the use of the clinical pathways. No significant differences were found in the rates of discharge to home.</p> <p>Conclusion</p> <p>The results of this meta-analysis show that clinical pathways can significantly improve the quality of care even if it is not possible to conclude that the implementation of clinical pathways is a cost-effective process, because none of the included studies analysed the cost of the development and implementation of the pathways. Based on the results we assume that pathways have impact on the organisation of care if the care process is structured in a standardised way, teams critically analyse the actual organisation of the process and the multidisciplinary team is highly involved in the re-organisation. Further studies should focus on the evaluation of pathways as complex interventions to help to understand which mechanisms within the clinical pathways can really improve the quality of care. With the need for knee and hip joint replacement on the rise, the use of clinical pathways might contribute to better quality of care and cost-effectiveness.</p

Molecular Characterization of Organosulfates in Organic Aerosols from Shanghai and Los Angeles Urban Areas by Nanospray-Desorption Electrospray Ionization High-Resolution Mass Spectrometry

Fine aerosol particles in the urban areas of Shanghai and Los Angeles were collected on days that were characterized by their stagnant air and high organic aerosol concentrations. They were analyzed by nanospray-desorption electrospray ionization mass spectrometry with high mass resolution (m/Δm = 100,000). Solvent mixtures of acetonitrile and water and acetonitrile and toluene were used to extract and ionize polar and nonpolar compounds, respectively. A diverse mixture of oxygenated hydrocarbons, organosulfates, organonitrates, and organics with reduced nitrogen were detected in the Los Angeles sample. A majority of the organics in the Shanghai sample were detected as organosulfates. The dominant organosulfates that were detected at two locations have distinctly different molecular characteristics. Specifically, the organosulfates in the Los Angeles sample were dominated by biogenic products, while the organosulfates of a yet unknown origin found in the Shanghai sample had distinctive characteristics of long aliphatic carbon chains and low degrees of oxidation and unsaturation. The use of the acetonitrile and toluene solvent facilitated the observation of this type of organosulfates, which suggests that they could have been missed in previous studies that relied on sample extraction using common polar solvents. The high molecular weight and low degree of unsaturation and oxidization of the uncommon organosulfates suggest that they may act as surfactants and plausibly affect the surface tension and hygroscopicity of atmospheric particles. We propose that direct esterification of carbonyl or hydroxyl compounds by sulfates or sulfuric acid in the liquid phase could be the formation pathway of these special organosulfates. Long-chain alkanes from vehicle emissions might be their precursors

Poisoning the Well – Exploring the Great Firewall’s Poisoned DNS Responses

One of the primary fltering methods that the Great Firewall of China (GFW) relies on is poisoning DNS responses for certain domains. When a DNS request is poisoned by the GFW, multiple DNS responses are received - both legitimate and poisoned responses. While most prior research into the GFW focuses on the poisoned responses, ours also considers the legitimate responses from the DNS servers themselves. We fnd that even when we ignored the immediate poisoned responses, the cache from the DNS servers themselves are also poisoned.We also fnd and discuss the IP addresses within the DNS responses we get; in particular 9 IP addresses that are returned as a result for many diferent poisoned domains. We present the argument that this type of attack may not be primarily targeted directly at users, but at the underlying DNS infrastructure within China

Analysing censorship circumvention with VPNs via DNS cache snooping

Anecdotal evidence suggests an increasing number of people are turning to VPN services for the properties of privacy, anonymity and free communication over the internet. Despite this, there is little research into what these services are actually being used for. We use DNS cache snooping to determine what domains people are accessing through VPNs. This technique is used to discover whether certain queries have been made against a particular DNS server. Some VPNs operate their own DNS servers, ensuring that any cached queries were made by users of the VPN. We explore 3 methods of DNS cache snooping and briefly discuss their strengths and limitations. Using the most reliable of the methods, we perform a DNS cache snooping scan against the DNS servers of several major VPN providers. With this we discover which domains are actually accessed through VPNs. We run this technique against popular domains, as well as those known to be censored in certain countries; China, Indonesia, Iran, and Turkey. Our work gives a glimpse into what users use VPNs for, and provides a technique for discovering the frequency with which domain records are accessed on a DNS server

Analysing censorship circumvention with VPNs via DNS cache snooping

Anecdotal evidence suggests an increasing number of people are turning to VPN services for the properties of privacy, anonymity and free communication over the internet. Despite this, there is little research into what these services are actually being used for. We use DNS cache snooping to determine what domains people are accessing through VPNs. This technique is used to discover whether certain queries have been made against a particular DNS server. Some VPNs operate their own DNS servers, ensuring that any cached queries were made by users of the VPN. We explore 3 methods of DNS cache snooping and briefly discuss their strengths and limitations. Using the most reliable of the methods, we perform a DNS cache snooping scan against the DNS servers of several major VPN providers. With this we discover which domains are actually accessed through VPNs. We run this technique against popular domains, as well as those known to be censored in certain countries; China, Indonesia, Iran, and Turkey. Our work gives a glimpse into what users use VPNs for, and provides a technique for discovering the frequency with which domain records are accessed on a DNS server

Poisoning the Well – Exploring the Great Firewall’s Poisoned DNS Responses

One of the primary fltering methods that the Great Firewall of China (GFW) relies on is poisoning DNS responses for certain domains. When a DNS request is poisoned by the GFW, multiple DNS responses are received - both legitimate and poisoned responses. While most prior research into the GFW focuses on the poisoned responses, ours also considers the legitimate responses from the DNS servers themselves. We fnd that even when we ignored the immediate poisoned responses, the cache from the DNS servers themselves are also poisoned.We also fnd and discuss the IP addresses within the DNS responses we get; in particular 9 IP addresses that are returned as a result for many diferent poisoned domains. We present the argument that this type of attack may not be primarily targeted directly at users, but at the underlying DNS infrastructure within China