Cost-effectiveness and budget impact of the microprocessor-controlled knee C-Leg in transfemoral amputees with and without diabetes mellitus.

BACKGROUND: The safe use of a prosthesis in activities of daily living is key for transfemoral amputees. However, the number of falls varies significantly between different prosthetic device types. This study aims to compare medical and economic consequences of falls in transfemoral amputees who use the microprocessor-controlled knee joint C-Leg with patients who use non-microprocessor-controlled (mechanical) knee joints (NMPK). The main objectives of the analysis are to investigate the cost-effectiveness and budget impact of C-Legs in transfemoral amputees with diabetes mellitus (DM) and without DM in Germany. METHODS: A decision-analytic model was developed that took into account the effects of prosthesis type on the risk of falling and fall-related medical events. Cost-effectiveness and budget impact analyses were performed separately for transfemoral amputees with and without DM. The study took the perspective of the statutory health insurance (SHI). Input parameters were derived from the published literature. Univariate and probabilistic sensitivity analyses (PSA) were performed to investigate the impact of changes in individual input parameter values on model outcomes and to explore parameter uncertainty. RESULTS: C-Legs reduced the rate of fall-related hospitalizations from 134 to 20 per 1000 person years (PY) in amputees without DM and from 146 to 23 per 1000 PY in amputees with DM. In addition, the C-Leg prevented 15 or 14 fall-related death per 1000 PY. Over a time horizon of 25 years, the incremental cost-effectiveness ratio (ICER) was 16,123 Euro per quality-adjusted life years gained (QALY) for amputees without DM and 20,332 Euro per QALY gained for amputees with DM. For the period of 2020-2024, the model predicted an increase in SHI expenditures of 98 Mio Euro (53 Mio Euro in prosthesis users without DM and 45 Mio Euro in prosthesis users with DM) when all new prosthesis users received C-Legs instead of NMPKs and 50% of NMPK user whose prosthesis wore out switched to C-Legs. Results of the PSA showed moderate uncertainty and a probability of 97-99% that C-Legs are cost-effective at an ICER threshold of 40,000 Euro (≈ German GDP per capita in 2018) per QALY gained. CONCLUSION: Results of the study suggest that the C-Leg provides substantial additional health benefits compared with NMPKs and is likely to be cost-effective in transfemoral amputees with DM as well as in amputees without DM at an ICER threshold of 40,000 Euro per QALY gained.

Economic benefits of microprocessor controlled prosthetic knees: a modeling study.

BACKGROUND: Advanced prosthetic knees allow for more dynamic movements and improved quality of life, but payers have recently started questioning their value. To answer this question, the differential clinical outcomes and cost of microprocessor-controlled knees (MPK) compared to non-microprocessor controlled knees (NMPK) were assessed. METHODS: We conducted a literature review of the clinical and economic impacts of prosthetic knees, convened technical expert panel meetings, and implemented a simulation model over a 10-year time period for unilateral transfemoral Medicare amputees with a Medicare Functional Classification Level of 3 and 4 using estimates from the published literature and expert input. The results are summarized as an incremental cost effectiveness ratio (ICER) from a societal perspective, i.e., the incremental cost of MPK compared to NMPK for each quality-adjusted life-year gained. All costs were adjusted to 2016 U.S. dollars and discounted using a 3% rate to the present time. RESULTS: The results demonstrated that compared to NMPK over a 10-year time period: for every 100 persons, MPK results in 82 fewer major injurious falls, 62 fewer minor injurious falls, 16 fewer incidences of osteoarthritis, and 11 lives saved; on a per person per year basis, MPK reduces direct healthcare cost by $3676 and indirect cost by $909, but increases device acquisition and repair cost by $6287 and total cost by $1702; on a per person basis, MPK is associated with an incremental total cost of $10,604 and increases the number of life years by 0.11 and quality adjusted life years by 0.91. MPK has an ICER ratio of $11,606 per quality adjusted life year, and the economic benefits of MPK are robust in various sensitivity analyses. CONCLUSIONS: Advanced prosthetics for transfemoral amputees, specifically MPKs, are associated with improved clinical benefits compared to non-MPKs. The economic benefits of MPKs are similar to or even greater than those of other medical technologies currently reimbursed by U.S. payers.

Quantifying the potential export flows of used electronic products in Macau: a case study of PCs.

The used electronic product (UEP) has attracted the worldwide attentions because part of e-waste may be exported from developed countries to developing countries in the name of UEP. On the basis of large foreign trade data of electronic products (e-products), this study adopted the trade data approach (TDA) to quantify the potential exports of UEP in Macau, taking a case study of personal computers (PCs). The results show that the desktop mainframes, LCD monitors, and CRT monitors have more low-unit-value trades with higher trade volumes in the past 10 years, while the laptop and tablet PCs, as the newer technologies, owned the higher ratios of the high-unit-value trades. During the period of 2005-2015, the total mean exports for used laptop and tablet PCs, desktop mainframes, and LCD monitors were approximately 18,592, 79,957, and 43,177 units, respectively, while the possible export volume of used CRT monitors was higher, up to 430,098 units in 2000-2010. Noticed that these potential export volumes could be the lower bound because not all used PCs may be shipped using the PC trade code. For all the four kinds of used PCs, the majority (61.6-98.82%) of the export volumes have gone to Hong Kong, followed by Mainland China and Taiwan. Since 2011, there was no CRT monitor export; however, the other kinds of used PC exports will still exist in Macau in the future. The outcomes are helpful to understand and manage the current export situations of used products in Macau, and can also provide a reference for other countries and regions.

Direct medical costs of accidental falls for adults with transfemoral amputations.

BACKGROUND: Active individuals with transfemoral amputations are provided a microprocessor-controlled knee with the belief that the prosthesis reduces their risk of falling. However, these prostheses are expensive and the cost-effectiveness is unknown with regard to falls in the transfemoral amputation population. The direct medical costs of falls in adults with transfemoral amputations need to be determined in order to assess the incremental costs and benefits of microprocessor-controlled prosthetic knees. OBJECTIVE: We describe the direct medical costs of falls in adults with a transfemoral amputation. STUDY DESIGN: This is a retrospective, population-based, cohort study of adults who underwent transfemoral amputations between 2000 and 2014. METHODS: A Bayesian structural time series approach was used to estimate cost differences between fallers and non-fallers. RESULTS: The mean 6-month direct medical costs of falls for six hospitalized adults with transfemoral amputations was US$25,652 (US$10,468, US$38,872). The mean costs for the 10 adults admitted to the emergency department was US$18,091 (US$-7,820, US$57,368). CONCLUSION: Falls are expensive in adults with transfemoral amputations. The 6-month costs of falls resulting in hospitalization are similar to those reported in the elderly population who are also at an increased risk of falling. Clinical relevance Estimates of fall costs in adults with transfemoral amputations can provide policy makers with additional insight when determining whether or not to cover a prescription for microprocessor-controlled prosthetic knees.

Low-Cost Microprocessor-Controlled Rotating Stage for Medium-Throughput Time-Lapse Plant Phenotyping.

Here we provide the instructions to build a cost-friendly rotating stage, which enables time-lapse phenotyping of seedlings, grown vertically on in vitro plates, in a medium-throughput manner.

A Lab Assembled Microcontroller-Based Sensor Module for Continuous Oxygen Measurement in Portable Hypoxia Chambers.

BACKGROUND: Hypoxia-based cell culture experiments are routine and essential components of in vitro cancer research. Most laboratories use low-cost portable modular chambers to achieve hypoxic conditions for cell cultures, where the sealed chambers are purged with a gas mixture of preset O2 concentration. Studies are conducted under the assumption that hypoxia remains unaltered throughout the 48 to 72 hour duration of such experiments. Since these chambers lack any sensor or detection system to monitor gas-phase O2, the cell-based data tend to be non-uniform due to the ad hoc nature of the experimental setup. METHODOLOGY: With the availability of low-cost open-source microcontroller-based electronic project kits, it is now possible for researchers to program these with easy-to-use software, link them to sensors, and place them in basic scientific apparatus to monitor and record experimental parameters. We report here the design and construction of a small-footprint kit for continuous measurement and recording of O2 concentration in modular hypoxia chambers. The low-cost assembly (US$135) consists of an Arduino-based microcontroller, data-logging freeware, and a factory pre-calibrated miniature O2 sensor. A small, intuitive software program was written by the authors to control the data input and output. The basic nature of the kit will enable any student in biology with minimal experience in hobby-electronics to assemble the system and edit the program parameters to suit individual experimental conditions. RESULTS/CONCLUSIONS: We show the kit's utility and stability of data output via a series of hypoxia experiments. The studies also demonstrated the critical need to monitor and adjust gas-phase O2 concentration during hypoxia-based experiments to prevent experimental errors or failure due to partial loss of hypoxia. Thus, incorporating the sensor-microcontroller module to a portable hypoxia chamber provides a researcher a capability that was previously available only to labs with access to sophisticated (and expensive) cell culture incubators.

Low-cost USB interface for operant research using Arduino and Visual Basic.

This note describes the design of a low-cost interface using Arduino microcontroller boards and Visual Basic programming for operant conditioning research. The board executes one program in Arduino programming language that polls the state of the inputs and generates outputs in an operant chamber. This program communicates through a USB port with another program written in Visual Basic 2010 Express Edition running on a laptop, desktop, netbook computer, or even a tablet equipped with Windows operating system. The Visual Basic program controls schedules of reinforcement and records real-time data. A single Arduino board can be used to control a total of 52 inputs/output lines, and multiple Arduino boards can be used to control multiple operant chambers. An external power supply and a series of micro relays are required to control 28-V DC devices commonly used in operant chambers. Instructions for downloading and using the programs to generate simple and concurrent schedules of reinforcement are provided. Testing suggests that the interface is reliable, accurate, and could serve as an inexpensive alternative to commercial equipment.

Developing prescribing guidelines for microprocessor-controlled prosthetic knees in the South East England.

BACKGROUND AND AIM: Microprocessor-controlled prosthetic knees have gained increasing popularity over the last decade. Research supports their provision to address specific problems or to achieve certain rehabilitation goals. However, there are yet no agreed protocols or prescribing criteria to assist clinicians in the identification and appropriate selection of suitable users. The aim is to reach professionals' agreement on specific prescribing guidelines for microprocessor-controlled prosthetic knees. TECHNIQUE: The study involved multidisciplinary teams from the Inter Regional Prosthetic Audit Group, representing nine Prosthetic Rehabilitation Centres in the South East England region. We used the Delphi technique with a total of three rounds to reach professionals' agreement. DISCUSSION: The prescribing guidelines were agreed and will be reviewed and updated depending on new research evidence and technical advances. CLINICAL RELEVANCE: This project is highly useful for professionals in a clinic setting to aid in appropriate patient selection and to justify the cost of prescribing microprocessor-controlled prosthetic knees.

Outcomes associated with the use of microprocessor-controlled prosthetic knees among individuals with unilateral transfemoral limb loss: a systematic review.

Microprocessor-controlled prosthetic knees (MPKs) have been developed as an alternative to non-microprocessor-controlled knees (NMPKs) to address challenges facing individuals with lower-limb loss. A body of scientific literature comparing MPKs and NMPKs exists but has yet to be critically appraised. Therefore, we conducted a systematic review to examine outcomes associated with the use of these interventions among individuals with transfemoral limb loss. A search of biomedical databases identified 241 publications, of which 27 met the inclusion and exclusion criteria and were reviewed for methodological quality and content. We developed 28 empirical evidence statements (EESs) in 9 outcome categories (metabolic energy expenditure, activity, cognitive demand, gait mechanics, environmental obstacle negotiation, safety, preference and satisfaction, economics, and health and quality of life) based on findings in the literature. The level of evidence supporting these EESs varied due to quantity, quality, and consistency of the results. EESs supported by a moderate level of evidence that noted significant differences between MPKs and NMPKs were derived in five of the nine outcome categories. The results from this review suggest that evidence exists to inform clinical practice and that additional research is needed to confirm existing evidence and better understand outcomes associated with the use of NMPKs and MPKs.

Desktop microsimulation: a tool to improve efficiency in the medical office practice.

Because the economic crisis in the United States continues to have an impact on healthcare organizations, industry leaders must optimize their decision making. Discrete-event computer simulation is a quality tool with a demonstrated track record of improving the precision of analysis for process redesign. However, the use of simulation to consolidate practices and design efficiencies into an unfinished medical office building was a unique task. A discrete-event computer simulation package was used to model the operations and forecast future results for four orthopedic surgery practices. The scenarios were created to allow an evaluation of the impact of process change on the output variables of exam room utilization, patient queue size, and staff utilization. The model helped with decisions regarding space allocation and efficient exam room use by demonstrating the impact of process changes in patient queues at check-in/out, x-ray, and cast room locations when compared to the status quo model. The analysis impacted decisions on facility layout, patient flow, and staff functions in this newly consolidated practice. Simulation was found to be a useful tool for process redesign and decision making even prior to building occupancy.

Effects of lower limb prosthesis on activity, participation, and quality of life: a systematic review.

BACKGROUND: Effects presented on the use of assistive devices such as prosthesis are often based on laboratory findings (i.e. efficacy). OBJECTIVES: To summarise and evaluate findings from studies on effectiveness of lower limb prostheses for adults in real life contexts, primarily in terms of activity, participation, and quality of life (QoL) and secondarily in terms of user satisfaction, use/non-use, and/or cost-effectiveness. STUDY DESIGN: Systematic review. METHODS: We included controlled studies and non-controlled follow-up studies including both baseline and follow-up data. Using 14 different databases supplemented with manual searches, we searched for studies published from 1998 until June 2009. RESULTS: Out of an initial 818 identified publications, eight met the inclusion criteria. Four studies reported on the effectiveness of a microprocessor-controlled knee (MP-knee) compared to a non-microprocessor-controlled knee (NMP-knee). Results were inconsistent except for quality of life and use/non-use, where the authors reported an improvement with the MP-knee compared to the NMP-knee. The remaining four studies included a diversity of prosthetic intervention measures and types of endpoints. CONCLUSIONS: Overall, there was an inconsistency in results and study quality. This review highlights the need for high-quality research studies that reflect the effectiveness of different prosthesis interventions in terms of users' daily living and QoL. CLINICAL RELEVANCE: Clinical guidelines are important to every practitioner. Information on expected effectiveness from assistive devices should be well founded and contain both facts about the device quality and its contribution to users' daily lives. Thus, studies based on users' experiences from prosthetic use in everyday life activities are of great importance.

Point-of-care technology supports bedside documentation.

As the conversion to an electronic health record intensifies, the question of which data-entry device works best in what environment and situation is paramount. Specifically, what is the best mix of equipment to purchase and install on clinical units based on staff preferences and budget constraints? The authors discuss their evaluation of stationary personal computers, workshops on wheels, and handheld tablets related to timeliness of data entry and their use of focus groups to ascertain the pros/cons of data-entry devices and staff preferences. An assessment of the implications for costs related to the timeliness of data entry is also presented.

Laptop programs for students.

With the continuing decline in costs of technology, programs are proliferating worldwide to put networked laptop computers into the hands of millions of students on a routine basis. The reasons policy-makers support these programs are based on economic arguments, equity concerns, and widespread interest in education reform. Studies of laptop programs in schools report that they increase students' engagement in school, improve technology skills, and have positive effects on students' writing. However, evidence of the effectiveness of large-scale laptop programs in other learning domains is scarce. Research in many nations suggests that laptop programs will be most successful as part of balanced, comprehensive initiatives that address changes in education goals, curricula, teacher training, and assessment.

Mobile computing initiatives within pharmacy education.

OBJECTIVES: To identify mobile computing initiatives within pharmacy education, including how devices are obtained, supported, and utilized within the curriculum. METHODS: An 18-item questionnaire was developed and delivered to academic affairs deans (or closest equivalent) of 98 colleges and schools of pharmacy. RESULTS: Fifty-four colleges and schools completed the questionnaire for a 55% completion rate. Thirteen of those schools have implemented mobile computing requirements for students. Twenty schools reported they were likely to formally consider implementing a mobile computing initiative within 5 years. CONCLUSIONS: Numerous models of mobile computing initiatives exist in terms of device obtainment, technical support, infrastructure, and utilization within the curriculum. Responders identified flexibility in teaching and learning as the most positive aspect of the initiatives and computer-aided distraction as the most negative, Numerous factors should be taken into consideration when deciding if and how a mobile computing requirement should be implemented.

A self-analysis of the NASA-TLX workload measure.

Computer use and, more specifically, the administration of tests and materials online continue to proliferate. A number of subjective, self-report workload measures exist, but the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is probably the most well known and used. The aim of this paper is to consider the workload costs associated with the computer-based and paper versions of the NASA-TLX measure. It was found that there is a significant difference between the workload scores for the two media, with the computer version of the NASA-TLX incurring more workload. This has implications for the practical use of the NASA-TLX as well as for other computer-based workload measures.