Estimating productivity change and its determinants is of great importance when measuring the performance of a firm. A true random effect cost model was employed to measure the cost efficiency of ...water companies in England and Wales from 1993 to 2016. Subsequently, total factor productivity change was estimated and decomposed into cost-efficiency change, technical change, scale efficiency change, output effect and residual price effect. The results indicate that the English and Welsh water industry increased its productivity over the period examined at a rate of about 2.1%, and it was influenced primarily by technical change. The price reviews appear to have a positive impact on the productivity of water-only companies during the whole period examined. In the case of water and sewerage companies, the 1994 and 1999 price reviews had a positive impact on productivity, whereas the last two price reviews had an adverse impact.
Evaluating the performance and analyzing the cost drivers of water utilities is of great interest for water regulators and water sector managers. This study uses a quadratic cost function to ...investigate the existence of economies of scale and scope in the Chilean water and sewerage industry over the period 2010-2017. We also estimate and decompose productivity growth into technical change and scale efficiency change. Technical change is further broken into pure, non-neutral and scale-augmenting technical change. The results indicate that cost savings can be achieved by increases in the scale of production and the separation of water and sewerage services. Productivity progressed favorably throughout the whole period at an annual rate of 8.4%, which was attributed to the scale effect, the adoption of new technologies and a good allocation of resources. Some policy implications are finally discussed based on our findings.
In the face of climate change, it becomes crucial to motivate action and policies within water companies towards achieving carbon neutrality. Estimating the economic consequences of inaction can be a ...compelling catalyst for change. In this study, the carbon inefficiency and overuse of energy among a selection of English and Welsh water companies were assessed, along with their impact on the operational costs of producing and delivering drinking water over the period from 2010 to 2019. In doing so, a stochastic frontier analysis primal system was employed. The findings revealed that, on average, water companies exhibited a carbon inefficiency of 0.699. The overuse of energy relative to other inputs was estimated to be 71.4%. Consequently, water companies incurred a production cost increase of 0.089 £/m3. This research demonstrates that transitioning towards a low‐carbon urban water cycle is not merely an environmental beneficial endeavor; it also involves significant economic advantages.
•We assessed the pure and mixed environmental performance of WWTPs assuming variable returns to scale.•DEA models including undesirable outputs allow quantifying potential reductions in greenhouse ...gases emissions.•All WWTPs exhibited PEPI values equal or higher than MEPI.•Economics of scale do not affect WWTPś mixed environmental performance.
Sanitation and wastewater treatment are essential for protecting human health and environmental sustainability. Treatment processes are not free of environmental impacts; consequently assessment of the environmental performance of wastewater treatment plants (WWTPs) has gained interest in recent years. Unlike other methods, a direct approach is followed to estimate environmental performance indicators (EPIs) using data envelopment analysis (DEA), i.e. an index of overall performance is directly obtained. The present study represents pioneering work to integrate environmental impacts in the assessment of the efficiency of WWTP estimating pure (PEPI) and mixed (MEPI) environmental performance indices for a sample of 60 Spanish WWTPs. Both direct and indirect greenhouse gas (GHG) emissions were considered as undesirable outputs. The best functioning WWTPs to be used as references were identified, and the potential for GHG reductions was quantified. A second-stage analysis was conducted to isolate factors affecting WWTP environmental performance. The results of this study are valuable for WWTP operators and policy makers, since the benchmark procedure allows support for environmental and managerial decision-making.
Acute musculoskeletal (MSK) pain is very common and associated with impaired productivity and high economic burden. Access to timely and personalized, evidence-based care is key to improve outcomes ...while reducing healthcare expenditure. Digital interventions can facilitate access and ensure care scalability.
Present the feasibility and results of a fully remote digital care program (DCP) for acute MSK conditions affecting several body areas.
Interventional single-arm study of individuals applying for digital care programs for acute MSK pain. Primary outcome was the mean change between baseline and end-of-program in self-reported Numerical Pain Rating Scale (NPRS) score and secondary outcomes were change in analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI-GH) and engagement.
Three hundred forty-three patients started the program, of which 300 (87.5%) completed the program. Latent growth curve analysis (LGCA) revealed that changes in NPRS between baseline and end-of-program were both statistically (p < 0.001) and clinically significant: 64.3% reduction (mean - 2.9 points). Marked improvements were also noted in all secondary outcomes: 82% reduction in medication intake, 63% reduction in surgery intent, 40% in fear-avoidance beliefs, 54% in anxiety, 58% in depression and 79% recovery in overall productivity. All outcomes had steeper improvements in the first 4 weeks, which paralleled higher engagement in this period (3.6 vs 3.2 overall weekly sessions, p < 0.001). Mean patient satisfaction score was 8.7/10 (SD 1.26).
This is the first longitudinal study demonstrating the feasibility of a DCP for patients with acute MSK conditions involving several body areas. Major strengths of this study are the large sample size, the wide range of MSK conditions studied, the breadth of outcomes measured, and the very high retention rate and adherence level. The major limitation regards to the absence of a control group.
We observed very high completion and engagement rates, as well as clinically relevant changes in all health-related outcomes and productivity recovery. We believe this DCP holds great potential in the delivery of effective and scalable MSK care.
NCT, NCT04092946 . Registered 17/09/2019.
Musculoskeletal (MSK) pain disproportionately affects people from different ethnic backgrounds through higher burden and less access to care. Digital care programs (DCPs) can improve access and help ...reduce inequities. However, the outcomes of such programs based on race and ethnicity have yet to be studied. We aimed to assess the impact of race and ethnicity on engagement and outcomes in a multimodal DCP for MSK pain. This was an ad hoc analysis of an ongoing decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were stratified by self-reported racial and ethnic group, and their engagement and outcome changes between baseline and 12 weeks were compared using latent growth curve analysis. Outcomes included program engagement (number of sessions), self-reported pain scores, likelihood of surgery, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment. A minimum clinically important difference (MCID) of 30% was calculated for pain, and multivariable logistic regression was performed to evaluate race as an independent predictor of meeting the MCID. A total of 6949 patients completed the program: 65.5% (4554/6949) of them were non-Hispanic White, 10.8% (749/6949) were Black, 9.7% (673/6949) were Asian, 9.2% (636/6949) were Hispanic, and 4.8% (337/6949) were of other racial or ethnic backgrounds. The population studied was diverse and followed the proportions of the US population. All groups reported high engagement and satisfaction, with Hispanic and Black patients ranking first among satisfaction despite lower engagement. Black patients had a higher likelihood to drop out (odds ratio OR 1.19, 95% CI 1.01-1.40, P=.04) than non-Hispanic White patients. Hispanic and Black patients reported the highest level of pain, surgical intent, work productivity, and impairment in activities of daily living at baseline. All race groups showed a significant improvement in all outcomes, with Black and Hispanic patients reporting the greatest improvements in clinical outcomes. Hispanic patients also had the highest response rate for pain (75.8%) and a higher OR of meeting the pain MCID (OR 1.74, 95% CI 1.24-2.45, P=.001), when compared with non-Hispanic White patients, independent of age, BMI, sex, therapy type, education level, and employment status. No differences in mental health outcomes were found between race and ethnic groups. This study advocates for the utility of a DCP in improving access to MSK care and promoting health equity. Engagement and satisfaction rates were high in all the groups. Black and Hispanic patients had higher MSK burden at baseline and lower engagement but also reported higher improvements, with Hispanic patients presenting a higher likelihood of pain improvement.
Background
Comorbidity between musculoskeletal (MSK) pain and depression is highly common, and is associated with a greater symptom burden and greater loss of work productivity than either condition ...alone. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement.
Objective
The aim of this study was to assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels.
Methods
Ad hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP was performed. Three subgroups with different baseline depression severity levels were established based on responses to the Patient Health Questionnaire (PHQ-9): cluster 1 (score<5: minimal depression), cluster 2 (scores 5-10: mild depression), and cluster 3 (score≥10: moderate depression). The mean changes in depression, anxiety, fear-avoidance beliefs, work productivity, and activity impairment and adherence between baseline and end of program (8-12 weeks) were assessed across subgroups by latent growth curve analysis.
Results
From a total of 7785 eligible participants, 6137 (78.83%) were included in cluster 1, 1158 (14.87%) in cluster 2, and 490 (6.29%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not in cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (score of 5 and 10, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from –16.82, 95% CI –20.32 to –13.42 in cluster 1 to –20.10, 95% CI –32.64 to –7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74).
Conclusions
A multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain.
Trial Registration
ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946
Abstract
Water treatment processes are known to consume substantial amounts of energy, making it crucial to understand their efficiency, drivers, and potential energy savings. In this study, we apply ...Efficiency Analysis Tree (EAT), which combines machine learning and linear programming techniques to assess the energy performance of 146 Chilean drinking water treatment plants (DWTPs) for 2020. Additionally, we utilize bootstrap regression techniques to examine the influence of operating characteristics on energy efficiency. The results indicate that the evaluated DWTPs exhibited poor energy performance, with an average energy efficiency score of 0.197. The estimated potential energy savings were found to be 0.005 kWh/m
3
. Several factors, such as the age of the facility, source of raw water, and treatment technology, were identified as significant drivers of energy efficiency in DWTPs. The insights gained from our study can be valuable for policymakers in making informed decisions regarding the adoption of practices that promote efficient and sustainable energy use within the water cycle.
•A global optimisation model was developed aimed to maximise the value of water use.•Modelling for solving water imbalances at river basin level.•Optimisation model including water scarcity cost and ...water quality issues.•Water losses and network connections were integrated in the model.
The integrated water resources management approach has proven to be a suitable option for efficient, equitable and sustainable water management. In water-poor regions experiencing acute and/or chronic shortages, optimisation techniques are a useful tool for supporting the decision process of water allocation. In order to maximise the value of water use, an optimisation model was developed which involves multiple supply sources (conventional and non-conventional) and multiple users. Penalties, representing monetary losses in the event of an unfulfilled water demand, have been incorporated into the objective function. This model represents a novel approach which considers water distribution efficiency and the physical connections between water supply and demand points. Subsequent empirical testing using data from a Spanish Mediterranean river basin demonstrated the usefulness of the global optimisation model to solve existing water imbalances at the river basin level.
Chronic shoulder pain (CSP) is a common condition with various etiologies including rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. It is associated with ...substantial disability and psychological distress, resulting in poor productivity and quality of life. Physical therapy (PT) constitutes the mainstay treatment for CSP, but several barriers exist in accessing care. In recent years, telerehabilitation gained momentum as a potential solution to overcome such barriers. It has shown numerous benefits, including improving access and convenience, promoting patient adherence, and reducing costs. However, to date, no prior RCT has compared fully-remote digital physical therapy (DGPT) to in-person rehabilitation for non-operative CSP.
The aim of this study is to compare clinical outcomes between DGPT and conventional in-person physical therapy in patients with CSP.
Single-center, parallel-group, randomized controlled trial (RCT) involving 82 patients with CSP referred for outpatient physical therapy. Participants were randomized into digital or conventional physical therapy (8-week interventions). The digital intervention consisted of home exercise, education and cognitive behavioral therapy (CBT), using a device with movement digitalization for biofeedback and asynchronous physical therapist monitoring through a cloud-based portal. The conventional group received in-person physical therapy including exercises, manual therapy, education, and CBT. Primary outcome was the change (baseline to 8-weeks) in function and symptoms using the short-form of Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH). Secondary outcome measures included self-reported pain, surgery intent, analgesics intake, mental health, engagement, and satisfaction. All questionnaires were delivered electronically.
Ninety participants were randomized into digital or conventional physical therapy, with 82 receiving the allocated intervention. Both groups experienced significant improvements in function (QuickDASH), with no differences between groups (-1.8, 95%CI -13.5 to 9.8, P=.75). For secondary outcomes, no differences were observed in surgery intent, analgesic intake and mental health or worst pain. Higher reductions were observed in average and least pain in the conventional group, which given the small effect sizes (least pain: 0.15; average pain: 0.16) are unlikely to be clinically meaningful. High adherence and satisfaction were observed in both groups with no adverse events.
This study shows fully-remote digital programs can be viable care delivery models for CSP given their scalability and effectiveness, assessed through comparison with high-dosage, in-person rehabilitation.
ClinicalTrials.gov (NCT04636528).
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