Procedural volume,cost, and reimbursement of outpatient incisional hernia repair: implications for payers and providers

Objective: This analysis aimed to evaluate trends in volumes and costs of primary elective incisional ventral hernia repairs (IVHRs) and investigated potential cost implications of moving procedures from inpatient to outpatient settings.

Methods: A time series study was conducted using the Premier Hospital Perspective^® Database (Premier database) for elective IVHR identified by International Classification of Diseases, Ninth revision, Clinical Modification codes. IVHR procedure volumes and costs were determined for inpatient, outpatient, minimally invasive surgery (MIS), and open procedures from January 2008–June 2015. Initial visit costs were inflation-adjusted to 2015?US dollars. Median costs were used to analyze variation by site of care and payer. Quantile regression on median costs was conducted in covariate-adjusted models. Cost impact of potential outpatient migration was estimated from a Medicare perspective.

Results: During the study period, the trend for outpatient procedures in obese and non-obese populations increased. Inpatient and outpatient MIS procedures experienced a steady growth in adoption over their open counterparts. Overall median costs increased over time, and inpatient costs were often double outpatient costs. An economic model demonstrated that a 5% shift of inpatient procedures to outpatient MIS procedures can have a cost surplus of?～?US $1.8 million for provider or a cost-saving impact of US $1.7 million from the Centers for Medicare &; Medicaid Services perspective.

Limitations: The study was limited by information in the Premier database. No data were available for IVHR cases performed in free-standing ambulatory surgery centers or federal healthcare facilities.

Conclusion: Volumes and costs of outpatient IVHRs and MIS procedures increased from January 2008–June 2015. Median costs were significantly higher for inpatients than outpatients, and the difference was particularly evident for obese patients. A substantial cost difference between inpatient and outpatient MIS cases indicated a financial benefit for shifting from inpatient to outpatient MIS.     

Evaluating alternative concepts of bus-based park and ride

Whilst it has been used since the 1960s, the UK government have promoted bus-based Park and Ride (P&R) particularly heavily over the last 20 years as a tool to deal with traffic congestion and air pollution. There has long since been a view however that P&R in its current guise may actually be exacerbating the problems of traffic congestion, fuel use and emissions instead of mitigating them. This paper aims to reconsider this proposition whilst also testing a range of alternative forms of car–bus interchange in the context of traffic reduction, drawing on evidence from a large survey of P&R users in Cambridge, UK. Overall the results suggest that while current P&R significantly increases the vehicle miles travelled by its users, some of the alternative models presented potentially offer considerable improvements.     

Food Values Applied to Livestock Products

Food values have been proposed in previous research as a method of identifying stable constructs of consumer preference. We conducted an online survey of 1950 US respondents using best–worst scaling applying the concept of food values to four specific meat and dairy products: ground beef, beef steak, chicken breast, and milk. We test the applicability of general food values to specific products, while further discovering the nature of heterogeneity of values by defining classes of respondents. Our findings suggest that the general food values previously proposed apply well to specific products of the livestock industry. We also found that the differences between consumer classes were driven primarily by price sensitivity, with many of the most important and least important values remaining the same.     

Responding to climate and other change processes in complex contexts:: Challenges facing development of adaptive policy frameworks in the Ganga Basin

The Ganga Basin, one of the world's most densely populated and vulnerable regions, is also among the world's most dynamic hydrological systems. Rivers exiting the Himalaya deposit massive amounts of sediment in the plains and shift their courses regularly. The natural dynamics of this system have a direct impact on populations. On August 18th, 2008, for example, embankments on the Kosi River (a tributary to the Ganges), failed and the channel shifted by as much as 120 km (Sinha, 2008 [1]) displacing over sixty thousand people in Nepal and three and a half million in India. Transport and power systems disrupted across large areas. The embankment failure was not caused by an extreme event. Instead the breach represented a failure of interlinked physical and institutional infrastructure systems in an area characterized by complex social, political, and environmental relationships.Projected climate changes in the Ganga Basin are likely to greatly exacerbate vulnerability (Adaptation Study Team, 2008 [2]). While the Kosi breach had nothing to do with climate change, such events will increase if climatic variability, sediment transport, and extreme events increase. Understanding how populations can respond to the dynamic nature of rivers such as the Kosi is, as a result, essential to develop strategies for adapting to climatic change. Understanding is also essential at the policy level for building adaptive capacity. The challenge is to identify policy frameworks and their relationship to interlinked physical and institutional infrastructure combinations that create environments enabling adaptation within households, communities, and regions.This paper explores the challenges and opportunities facing the development of adaptive policy frameworks in the Ganga Basin. The characteristics of frameworks that are adaptive in themselves and enable adaptation along with their relationship to different types of interlinked institutional and infrastructure systems are explored first. Following this, the case of the Kosi embankment along with the projected impacts of climate change across the Ganga Basin is used to identify the key challenges and opportunities that are common in many regions. The paper concludes with specific observations on the development of adaptive policy frameworks for responding to climate change in complex developing country contexts.     

Conceptualizing leadership across cultures

In this article, we summarize research on how the meaning of leadership varies systematically across cultures, and describe the conflict in the literature between the quest for universals and the identification of cultural contingencies in leadership theory. We review the literature on the relationships between cultural dimensions and leadership, and discuss implications of this range of research for management practice.     

Grit and self-employment: a multi-country study

Blending the literatures on grit and self-employment, we propose the role of grit in separating the self-employed from the employed. Based on a sample of 13,210 respondents from nine countries, our results indicate that not only is grit related to self-employment, but also grit is more strongly related to self-employment for risk-takers, females, and younger individuals. The findings are robust, controlling for several individual characteristics and alternate specifications, and have implications for the broader literature on self-employment.     

Transfer Pricing for the Rest of Us

Transfer pricing is a frequently discussed but often misunderstood aspect of international business. This article describes what it is, its legitimate functions in accounting for international intra-firm transactions, and its use by corporations for tax optimization. However, there may be mitigating factors that make efforts to optimize taxes more apparent than real. The issues of transfer pricing require sophisticated economic analysis for understanding and resolution, particularly as they relate to the internal and external pricing environment faced by a firm and the principles of profit allocation among different parts of a firm.