Plastic Recycling Essay Example for Free

Plastic Recycling Essay Due to increased the high residence time in the environment, old and used plastics require recycling to not only ensure clean and healthy environment, but also maximize the resource utility. Sorting/ separation is one of the most important stage in the recycling process as it differentiates the plastics from other materials and categorize it into various forms. Depending on the origin of the plastic materials, the sorting process is made easier especially if there was initial separation at the source where plastics are put in different containers from the others types of wastes. Physical sorting method According to Plunket (2005), this separation method involves use of the visible and physical characteristics of the plastics to remove them from other waste materials or separate different types of plastics. This method is labor intensive as it requires manual inspection through product recognition, color and shape of the materials for the plastic being sorted. Many of the American companies make their products in specific plastic shapes and color therefore making it easy to sort and recycle their plastics from the waste stream. Floating mechanism is increasingly being employed by different recycling plants to separate high and low density plastics depending on weight characteristics (Harper, (2006). Besides, the separating centrifuge is also employed to separate the plastics on the basis of their weight on the high speed rotating drums. According to Nigel (2004), physical sorting process is cost effective in that there is minimal capital investment as the method uses staff and low cost investment machines to sort out the plastics. Unlike in the automated method, there is no need of highly skilled manpower and technology in the process thereby reducing the cost of operation with a great margin. The method is highly suitable for small scale recycling process where the quantity of the plastic to be separated is generally low. However, this method can lead to inaccurate identification and separation due to human error. Types and the speed of separation in the process are highly limited since human beings employ only one visual mode in the identification process. Besides, complications arise when different companies use similar shapes for packaging their products thereby creating confusion and making the companys objective to recycle its plastics be highly compromised. To add to that, the process is highly manual requiring a lot of staff for effective completion which greatly reduces the ability and therefore ineficiency to sort the plastics (Tietenberg Henk, 2006). Plunket (2005) argues that, physical method of sorting plastics is highly uneconomical especially for separating large scale quantities of plastics due to the requirements of large staff numbers at any moment. The quantity of plastics that can be sorted at any moment using the physical method is very limited compared to the automated method. Due to the above inefficiencies, the amount of plastics sorted and recycled is low and therefore not cost effective for recycling companies or the municipal authorities who have large quantities of plastics to be separated. Besides, the method do not guarantee the efficiency required for different plastics to effectively be sorted out. This inefficiency may compromise the products made from the recycled materials at the end of the process (Harper, 2006). Automated sorting method This method employs various auto-separation systems which use sensors in establishing the chemical as well as the physical properties of the plastics to be separated (Tietenberg Henk, 2006). Use of x-rays method of automated separation involves employing the radiation which detects the chlorine elements that are found in the Polyvinyl Chlorides (PVC). This method is highly effective for the plastics that contain PVC but limited in application since it cannot be applied on other plastics. Then, the modern infrared method analysis is being applied on a large scale basis to detect as well as separate plastics of multiple characteristics in their composition. Infrared rays are quantified and categorized on the basis of the characteristics of the specific plastic element type that is needed from the waste stream (Myer, 2007). To add to that, optical scanning is also being used by different industries all over the world where the plastics are separated on the basis of their pigment coloration. It ensures uniformity in the separation process and increases efficiency in the specific separation processes. Automated separation methods have also been effectively applied to separate general plastics from the waste mainstream depending on their main or individual characteristics like High Density Polythrene, Pollythylene Telephthalate and Polypropane. The main advantage of this method is that it is highly effective and the quantities of the plastics that can be sorted at any one moment is very high. Myer (2007) notes that, different types of plastics are also easily recycled as the machine error is highly reduced compared to the high human error in the mechanical system. Also, the method is less labor intensive as it employs the modern technology in enhancing efficiency of the work done. However, the method requires high capital investment to install and operationalize the whole system. Protective equipments for the radiations add to the external costs for the people who work and operate the machines. Infrared and x-ray generating machines require specialized experts to operate thus increasing the overhead cost to a very large extent. Besides, there are high hazard risk levels for the people operating with these machines due to exposure on the dangerous radiations of x-rays and high infrared levels (Nigel, 2004). Though the initial cost of machines installation is relatively high, this method is highly cost-effective in the 21st century due to the increasing need for faster plastic sorting and recycling. It is a great tool for conserving the environment and maximizing the resources utility. The quantity of the plastics that can be sorted out at any moment being very high, then the method ensures that the remaining process and eventual processing into finished products receives enough and correct materials. Conclusion. Sorting as indicated earlier, is one of the most important steps in the recycling process as it makes the remaining processes easier and more effective in their application. It captures the plastic materials either from an integrated mixture in the waste stream or from assorted plastic mixtures therefore making it possible to use the material for further other products development. Automated method is thus more cost effective in sorting the plastics due to its high efficiency in dealing with bulk wastes at any particular moment. As the world consumption patters continue changing year after year, the levels of the plastic wastes are bound to increase in the environment and the most cost effective method of sorting this waste should be adopted (Plunket, 2005). Automated method should be adopted by all the municipal authorities, recycling commercial industries and individual industries which recycle their own wastes as it ensures long term cost effectiveness.

Cost Effectiveness of Dialysis for ESRD Patients

Cost Effectiveness of Dialysis for ESRD Patients From 2002-2009 diabetic nephropathies represented 41% of all end-stage renal (ESRD) patients in St. Lucia, which is significantly higher when compared with global distribution. Renal replacement therapy for ESRD is resource intensive, consuming a significant part of the health budget. Financial pressures on the health system continue to increase in the face of the global financial crisis, yet cost-effectiveness studies of ESRD treatment options are not only scarce but nonexistent in the Eastern Caribbean. A retrospective approach to data collection was used and a Markov model of cost, quality of life and survival will be developed to compare hemodialysis and pharmaceutical management of ESRD among diabetics. Micro-costing was used to assess the cost of hemodialysis for ESRD over the 8 year period. While preliminary findings have not identified whether or not hemodialysis for diabetic nephropathy is cost-effective the economic burden of hemodialysis for diabetic nephropathy was signif icant: EC$6.9 million, in St. Lucia for the 8 year period. Pre-emptive procedures need to be considered for the treatment of diabetes to delay onset or progression of ESRD. From a medical as well as fiscal perspective, prevention is the most cost-effective intervention. The health system in St. Lucia needs to focus attention on effective prevention strategies as the mean age among diabetic ESRD patients is 56 years (2.3SD). This age group is representative of a significant part of the countrys labour force and, if left unchecked, could have serious implications for economic development. Introduction End-stage renal disease (ESRD) and its precursor, chronic kidney disease (CKD), are globally emerging as a significant public health problem, with increasing morbidity and mortality as well as economic implications for healthcare (Szucsa et al., 2004). The World Health Organizations 2002 estimate indicated that globally CKD contributes to over 850,000 deaths and over 15 million disability-adjusted life years, with epidemic rise of ESRD in multiple regions in the world (WHO, 2003). The report also predicted that by 2010 more than 2 million people would require maintenance dialysis worldwide, and global estimates indicate that approximately 30% of patients with ESRD suffer as a consequence of diabetic nephropathy (Zelmer, 2007). The economic pressures of ESRD treatment on the collective health system are well documented. Haller, et al. (2011) identifies it as resource intensive, requiring substantial amounts of finite healthcare funds to treat a small percentage of the population. In 2005 alone, care for ESRD patients in Canada represented 1.2% of all healthcare expenditure, despite a 0.092% incidence of the disease (Zelmer, 2007). In St. Lucia, chronic renal insufficiency as a result of diabetes, hypertension, autosomal dominant polycystic kidney disease, and sickle cell disease are the main reasons for starting dialysis treatment in patients with kidney function failure. This is similar to the findings of Perovià ¡ and Jankovià ¡ (2009). In addition to being a chronic disease with significant morbidity impact, ESRD also involves high-cost treatment options (Zelmer, 2007), which are often limited in developing countries such as St. Lucia. Yet cost-effectiveness studies of the modalities of treatment are few and limited, especially in developing countries (Haller, 2011). Previous research has been conducted to identify the economic impact of the estimated health-care costs for ESRD, as well as the cost-effectiveness of various alternatives for renal replacement therapies; however, similar studies have not been replicated in the Eastern Caribbean. The findings are especially relevant to the health system in St. Lucia, as the incidence of diabetes continues to increase in the Caribbean Region (Henry, 2004). Additionally, the recent decision to expand the dialysis service to two new facilities without understanding the scope and magnitude of the total economic burden of ESRD could prove to be challenging. Cost-effectiveness is the fastest growing field in health research and it embodies a form of full economic evaluation that looks at cost and consequence of health programmes or treatment (Muennig, 2008). Cost-effectiveness analysis (CEA) of intervention programmes as a valuable tool employed by decision-makers can be used to appraise as well as possibly improve how the health system operates. Its application allows policy makers to identify which interventions provide the highest value for money and assist in helping to select interventions and programmes that maximize health for the available resources. Health economists are able to purchase the most health under a fixed budget, prioritizing services within the health sector. CEA therefore requires information to indicate the extent to which current and potential interventions are effective for improving population health, and which resources are required to implement the interventions, i.e., costs (Muennig, 2008). Referring to Palmers 2005 definition that states cost-effectiveness studies compare costs with clinical outcomes measured in natural units, like life expectancy or years of diseases avoided, Glassock (2010) noted that the totality of costs may not necessarily be captured. The inclusion of cost means that the design of the study will incorporate cost-unit analysis as a tool to examine the economic impact of dialysis for ESRD patients with diabetes and cost effectiveness to determine the quality adjusted life year (QALYs) or health related quality of life (HRQoL) for that population. The main outcome measure will focus on costs per quality-adjusted life years ($/QALYs), similar to a study conducted in Austria (Haller et al., 2011). Glassock (2010) notes that community willingness-to-pay is the threshold value used to determine cost effectiveness. He goes on to note that these values vary globally, and are estimated at  £30,000/QALY in the United Kingdom, 40,000/QALY in Europe, Aus $5 0,000/QALY in Australia, and US $90,000/QALY in the United States (Glassock, 2010). In the absence of a national threshold value, one can be established using GDP as an objective economic benchmark, (Eichler, et al., 2004). Cost will be viewed from the perspective of direct spending on health care for dialysis, coupled with the indirect costs of productivity losses due to premature death and short- and long-term disability. The impact of mortality costs as the sum of the discounted present value of current and future productivity losses from premature deaths will be measured from an incident-based human capital approach, drawing from a similar study conducted in Canada in 2000 (Zelmer, 2007). Muennig (2008) posits that because it is often difficult to account for all cost, and the time and resource constraints associated with micro-costing, certain assumptions related to costs are often made during cost-effectiveness analysis. This paper serves to examine the cost-effectiveness of hemodialysis among type 2 diabetics in St. Lucia over an 8 year period (2002-2008). Employing the use of CEA, it aims at comparing the cost and effects or outcomes (cost-effectiveness) of hemodialysis for diabetic nephropathy using the comparator of doing nothing, which in this case is the pharmaceutical management of patients with diabetic nephropathy to delay progression of ESRD. The findings will also help to inform those making policy decisions, and may be useful in establishing a set of priorities for further research, prevention programs, and in the planning of alternative treatments to help alleviate that burden. Perspective of the Study Cost effectiveness of dialysis for ESRD patients with diabetes in St. Lucia will be analyzed from a government perspective. This requires conducting cost analysis that measures the recurring direct and indirect cost of providing the service. In the region, specifically in the country under study, health care organizations rarely know the cost of the service provided and rarely employ the tools needed to assess that cost on a regular basis. In a globally operating economic society, economic trends have made it imperative for both profit and non-profit organizations that provide services, including government agencies, to assess the cost of clinical services provided. Finance for health is not infinite and with substantial budget cuts in the health service industry, there is increasing pressure for health care facilities to become more accountable and efficient with the funds allocated to health care (Basch, 1999). Health economics recognises the need for health services to be provided in a manner that is not only efficient but sustainable. Measuring, understanding and documenting the cost of services makes it easier to improve cost-efficiency of these services; it also highlights the funding needs of the sector and by extension, the government. It also provides an opportunity to establish fees for clients that are based on realistic site costs. Previous studies on cost-effectiveness of treatment options for ESRD have compared different modalities of dialysis or transplantation (Haller et al.; Gonzalez-Perez et al., 2005, Yang et al., 2001). Treatment modalities for ESRD patients in St. Lucia are either hemodialysis or pharmaceutical management. The analysis of hemodialysis versus pharmaceutical management to delay ESRD progression hinges on the fact that the current capacity of the Renal Unit in St. Lucia cannot provide dialysis for all ESRD patients. In an interview dated December 14, 2010 with the head of the Nephrology Unit, Victoria Hospital, Saint Lucia, it was indicated that while dialysis is offered, the increasing ESRD population means that patients are placed on a waiting list if they are not able to commence treatment due to unavailability of space (Olivert Dupree, 2010). If a patients prognosis requires immediate dialysis, he is treated at the private facility and the government absorbs that cost. But it is quit e clear that hemodialysis, like pharmaceutical management, is not the optimal treatment option for ESRD; rather, the optimal protocol is transplantation. The health system in St. Lucia is mandated by its objectives to improve the health of the population and consequently needs to ensure that its limited resources are not devoted to expensive interventions with small effects on population health, while at the same time low cost interventions with potentially greater benefits are not fully implemented (Ministry of Health, Human Services, Family Affairs and Gender Relations, 2000). Methods Data Sources The study population comprises of ESRD patients with diabetic nephropathy. Patients were considered depending on whether they received hemodialysis or whether their diabetes was being pharmaceutically managed to delay ESRD progression. Data was collected retrospectively and the study population was selected from the only public Renal Unit which forms part of the general hospital, Victoria Hospital. While there is another Renal Unit in St. Lucia that offers dialysis, it is a part of the private hospital, which did not wish to participate in this study. Of the 111 patients on dialysis, 45 were due to diabetic nephropathy and 19 were actively receiving dialysis at the time the study was being conducted. The nephrologists identified 12 ESRD patients who were not receiving dialysis but were being managed pharmaceutically. All diabetics who are or have been on dialysis with end-stage renal disease for the period 2002-2009 and were receiving dialysis due to diabetic nephropathy were included in the study. Persons were excluded from this study if they were on dialysis prior to being diagnosed with diabetes. The comparator group differed from the hemodialysis group only in the form of treatment that they are receiving, and consisted of all patients with ESRD due to diabetic nephropathy who are not receiving dialysis but whose diabetes is aggressively managed with medication to delay ESRD progression. Other variables were considered in the study and a standard questionnaire was administered to the study population to obtain data on the socio-economic status of individuals. A pool of eight persons from those who were on dialysis for reasons other than diabetic nephropathy served as a pilot test group for the socio-demographic questionnaire. This group was similar to the study population in terms of gender, education, socio-economic status and geographic location (Table 1). Content analysis was used to evaluate the information obtained from the socio-demographic questionnaire. All study participants received a letter concerning anonymity and confidentiality and informed consent was obtained prior to participation. Ethical approval was obtained from the IRB at St. Georges University and the ethics committee of the Ministry of Health in St. Lucia. A literature review conducted relied upon peer-reviewed economic evaluations of dialysis treatment modalities among diabetic patients. Ebscohost and PubMed were searched using the keywords cost-effectiveness, dialysis, end-stage renal disease, and diabetic nephropathy and was limited to articles published in the last 12 years (2000-2011). Some articles, if they were published outside of the selected timeframe, were accepted based on the strength and relevance of their findings. Articles were included if they had the keywords in the subject headings as well as focusing on Renal Replacement Therapy/economics, Renal Dialysis/economics, Hemodialysis Units, or Kidney Failure. If they included the term peritoneal dialysis or hemodialysis they were also selected. Exclusion criteria comprised of non-English articles and those that did not compare treatment options. A total of 379 articles were identified but 31 were selected as being relevant. Models Used Chronic conditions such as ESRD require continuous treatment and as a consequence, the cost-effectiveness of treatment options over a period of time for a cohort of patients employs the use of the Markov model to investigate long term costs and outcomes. The Markov model developed for this study describes the process of care noting that patients began their progression through the model in either of two states, hospital hemodialysis or pharmaceutical management of type 2 diabetes to delay ESRD progression, with death signifying the end of the cycle. Data on health care costs, transition to other health states and quality of life were inputted into the Markov model. Data was obtained from the Renal Unit at the Victoria Hospital, the public health facility. Data on quality of life was obtained using the 15D, a multidimensional, standardised generic instrument to measure quality or health-related quality of life (Sintonen, 2001). The 15D was used since it combines the advantages of a profile and single index score measure that describes the health status by assessing 15 dimensions. The mean score value for each dimension was used to determine the health related quality of life in the study population. The use of the 15D to measure quality of life outcome was reported in terms of QALYs, a measure of the burden of disease that included the quality and quantity of life lived against a monetary value, medical treatment or intervention. The mean score value for each dimension measured by the 15D was used to determine the health-related quality of life of the study population using the scale provided by Sintonen (2001). The findings were standardized against the burden of disease markers identified by the WHO. Costs and Analysis Cost-effectiveness, examined from a governmental perspective, used the clinical records of the Division of Nephrology patient registration and billing systems at the Victoria Hospital coupled with information from published studies on survival and quality of life among diabetic nephropathy patients. The model used included the direct health service costs associated with the treatment options, and an annual cost per patient was calculated for each health state in the model. Direct healthcare costs associated with dialysis use included costing regular dialysis sessions, complications of the dialysis, such as clotting of the fistula or hypotension episodes, laboratory tests and services required as a consequence of dialysis and medication use as a result of treatment. Assumptions were made on the regularity of direct healthcare cost associated with dialysis, such as that involving laboratory testing and blood transfusions. Micro-costing, collecting data on staffing, consumables, capital , and overheads were used to determine the cost of one session of hemodialysis (Table 2). Structured interviews were used to obtain details regarding staff time allocated to dialysis activities, as well as the regularity of other services used as a result of the treatment options. Capital items were identified as the building space allotted to the Unit for treatment, and equipment such as the dialysis machines and air conditioner unit. Costs have been reported in Eastern Caribbean Dollars (EC) presented at the 2008 level and an equivalent annual cost calculated using a 3 percent discount rate over the predicted life span. Muennig (2008) argues that a governmental perspective can include some aspects of transportantion costs. Evidence from the Minstry of Communication and Works and the Transport Board implies that there is no nationally agreed-upon policy for transport costs. There are variations across St. Lucia in terms of mileage costing; therefore for the purposes of our analysis, transport costs are excluded. The study reviewed costs over an 8 year period (2002-2009). This time frame was partly determined by the availability of the data two years after the programme was initiated and the assumptions made with reference to the analysis were tabulated (Table 3). Incremental costs per QALY gained will be calculated by using the estimates of costs and QALYs for each of the two modalities obtained from the model, and the findings were presented as incremental costs per QALY ($/QALY). The threshold value used to determine cost effectiveness of the intervention was established based on the recommendations of the Commission on Macroeconomics and Health, and CHOICE, which uses gross domestic product (GDP) as an indicator to determine cost-effectiveness. They established that an intervention was highly cost-effective if cost per QALY was less than GDP per capita, it was cost-effective if it was between 1 and 3 times the GDP per capita but was not cost-effective if it was more than 3 times GDP per c apita (WHO, 2011). A one-way sensitivity analysis will be used to investigate variability in the data, varying the discount rate from 3% to 5%, then age weights and finally, the disability weights. A final sensitivity analysis of mortality rates will be conducted since the assumption was that the mortality rates for hemodialysis were the same as those of pharmaceutical management of ESRD diabetics. Based on that assumption it becomes important to identify whether any one of these factors, discounted rates, age weights, and disability weights independently affected the data. Multiple linear regressions will be used to identify how the variables and assumptions affected dialysis lifetime. Preliminary Findings Demographic Characteristics The socio-demographic characteristics of the study population are presented in Table 4. According to the modalities compared the mean ages were 52 years (SD 10.06) for hemodialysis patients and 42 years (10.34SD) for patients who were being pharmaceutically managed. Briefly 62% of the patients were male (Figure 1), 40% had completed only primary level education and 20% had received no formal education. Married patients made up 46.7% of the study group and 26.7% were currently employed; but of these patients 80% of them received some form of family support or National Insurance Corporation (NIC) compensation. There was little variation between the groups (hemodialysis and pharmaceutically managed) in terms of employment and education. ESRD, as a consequence of diabetic nephropathy, represents 41% of all patients who have received hemodialysis for the period 2002-2009 (Figure 2). The end of that 8 year period mortality rate among that population is 53% with the average age of death at 57 years and average dialysis lifetime of 3 years. Costs A list of the parameters used to determine cost is presented in Table 2 and total yearly cost for the period is presented in Table 3. The total cost of dialysis for diabetic nephropathy was EC$6.9 million. From a governmental perspective, in 2009 the total cost of dialysis for diabetic nephropathy patients with ESRD totalled EC $1,002,597.23, accounting for approximately 2.27% of all healthcare expenditure for 0.01% of the population. Secondary and tertiary care services accounted for 59% of the total health budget for 2001-2002, 60% for 2002 -2003 and 64% for 2003-2004. Primary care services accounted for 22% in 2001-2002, 22% 2002-2003 and 18% for 2003-2004 (Figure 3). Discussion This is the first study of its kind in the region. It is able to serve as a precursor to further research and therefore is poised to help guide policies on how cost-effectiveness studies are done in the region. Additionally, there will be future application to decision-making in healthcare. While the absence of other studies that compared the treatment modalities used in this study serves as a limitation to this paper, it remains the only viable comparator that was available to the researcher, and being the first of its kind allows it to inform the existing research. The preliminary findings of this paper have significant implications for health and the operations of the dialysis unit. The literature from other studies (Haller et al, 2011; Zelmer, 2007) indicates that the average lifetime on dialysis is 7-10 years, with survial rates lower among senior adults, aged older than 65 years. The inverse seems to be suggested by the preliminary findings, with an average lifetime of 3 years in patients less than 57 years. The deviation may be attributable to younger persons being less compliant with regular dialysis sessions and the strict dietary and lifestlye adjustments that dialysis requires. Further research would need to be conducted to validate these findings. The economic burden of ESRD for diabetic nephropathy is significant: EC$6.9 million, in St. Lucia for the 8 year period (Table 2). While the focus of this study is on the cost-effectiveness of dialysis, the data identified that health services accounted for most of the observed costs. The governmental perspective of the research restricts the papers ability to adequately address the diabetic nephropathy related morbidity and premature mortality among the study population and the substantial burden that it places on society. The early indicators suggest a need for the effectiveness of the programme to be examined against its objectives and how its outcomes compare with other units within the region or the privately operated unit in St. Lucia. In 2006 Government health expenditure per person per year was EC$499.50 (Ministry of Health, Human Services, Family Affairs and Gender Relations, St. Lucia). Yet for that corresponding period, government spending for dialysis per person per year was EC$48,597.81 (Figure 5), for 0.0014% of the population. St. Lucias GDP for that period is estimated as $6,037.00 PPP (EC$16,299.90) and total expenditure on health is estimated as 6.3% of GPD (Table 5). While cost-effectiveness has not been conclusively established, using the threshold value of GDP as an economic estimate to determine cost-effectiveness, a cost-effective programme is one that is between 1 and 3 times the GDP per capita (WHO, 2011). The National Strategic Health Plan 2006-2011 (2006) posits that the Ministry of Healths actions have not been consistent with its declaration of a commitment to Primary Health Care (PHC) as part of its strategy for National Health development. Health spending continues to increase in the areas of secondary and tertiary care and less of the health budget is spent on primary care. The expansion of hemodialysis to meet the growing ESRD population, and an increased incidence of diabetic nephropathy in St. Lucia has implications for the findings of this study. It is important that focus is directed at primary and secondary interventions aimed at reducing cost of diabetic care and consequently complications from diabetes, such as diabetic nephropathy. Primary interventions are the most cost-effective and as such health promotions to reduce risk of developing diabetes, a risk factor for ESRD, needs to become part of the mandate of the Ministry of Health. A policy on chronic diseases develop ed within the primary healthcare plan that currently exists would help guide that focus. The study was limited by the accuracy and quality of the data, which Basch (1999) argues is a recurring problem in developing countries. There are limitations and difficulties in any attempt to calculate the mean cost of a dialysis session, especially in public facilities where cost is subsidized, as every facet of care and cost associated with the session must be taken into consideration. Consequently, assumptions were made on cost for direct and indirect services related to treatment options compared in this study. Assumptions are justified as this is a non-funded research with time constraints and a need to reduce cost drivers. The study was also limited in its perspective as it could not present on national costs from a societal perspective such as the patients ability to work or opportunity costs. Costs from the private facility could not be used as they did not wish to participate in this study. The inability to capture their costs is relevant as they are used by the government to provide dialysis for ESRD patients whose prognosis prevents them from being placed on a waiting list; this cost is incurred by the government. A patient who commenced dialysis at the private facility and transferred to the Renal Unit at the government facility is not distinguished in the patient register. The strength of the research lies in the use of triangulation to gather and analyse data to ascertain their common conclusion, effectiveness based on costs, and QALYs. Decrop (1999) concurs that one of the main ways to avoid the contentious issue of validity and reliability is the use of triangulation. Triangulation involves the use of multiple data sources in the investigation of a research question for justification or clarification, which in this case involved utilizing primary and secondary data, as well as information from the attending physician. Denzin (1978) also claims that triangulation limits personal and methodological bias as well as enhances the studys generalizability. The use of the Markov model is an inherent strength of the study. Gonzalez-Perez, et al. (2005) argue that the models ability to prognosticate relative effectiveness and cost overtime makes it appropriate for modelling chronic treatment options such as Renal Replacement Therapy (RRT). Cost-effectiveness to determine QALYs as well as the use of a standardized instrument to measure QALY also strengthens the findings of the research. The 15D is recognised as generally being a small measurement burden to both respondents and researchers. As an evaluation tool it is highly reliable due to its repeatability of measurements with minimized random error. The results generated are valid because of the degree of confidence that researchers can place in the inferences that are drawn from the scores. Sintonen (2001) posits that as an instrument to measure cost-effectiveness, it is particularly suitable for calculating quality-adjusted life years (QALYs). While the majority of cost-effectiveness analysis of treatment modalities for diabetic nephropathy focuses on the disease at its latent or progressed stage, Glassock (2010) noted that a study by Gearde et al. (2008) identified that early detection of diabetic nephropathy and intensive pharmaceutical interventions are not only cost effective but significantly reduces the risk of ESRD among type 2 diabetics. These findings are replicated in two studies by Keane and Lyle (2003) and Szucs, et al. (2004) who found that Losartan reduced the incidence of ESRD among diabetics. They went on to argue that proteinuria, which is the single most powerful predictor of CKD in type 2 diabetes, is a simple and inexpensive screening test, and early detection can lead to the early administration of drugs that have been proven to reduce ESRD incidence. Mann, et al. (2010) argue caution against population based screening for CKD, and advocate that screening, as a secondary intervention, should focus on at-risk populations. Their study concluded that targeted screening of people with diabetes is associated with an acceptable cost per QALY in publicly funded healthcare systems. Such an approach can be adopted in the health system in St. Lucia. Cost-effectiveness analysis is able to provide valuable insight to prioritizing within healthcare and so the findings of this research will be able to provide evidence to support efficiency in the use of limited resources. Policy-makers would be able to use these findings to review the decision to expand the number of hemodialysis centres in St. Lucia. Further research to identify more cost-effective treatment options would be the first step to improving efficiency of resource allocation. The preliminary findings have not identified whether or not hemodialysis for diabetic nephropathy is cost-effective. The domination of hemodialysis as a treatment modality for ESRD, despite the plethora of studies that have identified it as the least cost-effective of RRTs (Haller, et al., 2011; Just, et al., 2008, Kontodimopoulos Niakas, 2008), provides the health sector with the evidence needed to revise treatment protocols and an opportunity to improve cost-effectiveness of ESRD treatment. This can be achieved by reducing the use of hemodialysis and introducing as an alternative peritoneal dialysis, which has been cited as being the most effective of dialysis options. Just, et al. (2008) caution that the economics of dialysis in the developing world, where labour may be cheaper than the importation of equipment and solutions, may lead to the perception that peritoneal dialysis is more expensive than hemodialysis. They go on to note that this is not conclusive as there is a dearth in economic evaluations in developing countries to substantiate that view. As an alternative, a well developed CKD Care Program is able to significantly reduce the probability of developing ESRD among at risk populations, as well as significantly lower healthcare costs among ESRD patients (Wei et al., 2010). There is a need to expand the services offered by the Renal Unit as well as its coverage to help achieve that end. Conclusion of Preliminary Findings Despite a declared commitment to Primary Health Care (PHC) as a strategy for National Health development, the Ministry of Healths actions have not been consistent with its declaration. Secondary and tertiary care service is posing a great financial burden on the health system, as purported by the preliminary findings of this paper. Evident in the resource allocations for health in St. Lucia, Primary Care Services are allocated a decreasing or stagnant proportion of the health budget, considered against a decreasing allocation of total public expenditure to health. A sustainable health system needs to maximize the use of health resources, creating a more efficient health system that is capable of providing quality health services in a cost-effective manner in order to maximize population coverage. Primary health care needs to become the thrust used to promote efficiency in health as it is recognized as the most cost-effective of interventions. References Basch, P. (1999). Textbook of International Health

Fuel Gauges :: essays research papers

the is cut and pasted off howstuffworks.com to get an account If you're like me, you like to squeeze every last mile you can out of your tank of fuel. If you could get 20 miles extra from each tank, that could save you two or three trips to the gas station over the course of a year. The main impediment to stretching your mileage is the fuel gauge on your car, which makes you think you have less fuel than you actually do. These devices are notoriously inaccurate, showing empty when there are gallons left in the tank and showing full for the first 50 miles. In this edition of HowStuffWorks, we'll learn why our fuel gauges behave the way they do. There are two main parts to a fuel gauge: the sender, which measures the level of fuel in the tank, and the gauge, which displays that level to the driver. First, let's see how a typical sender works. The sending unit is located in the fuel tank of the car. It consists of a float, usually made of foam, connected to a thin, metal rod. The end of the rod is mounted to a variable resistor. A resistor is an electrical device that resists the flow of electricity. The more resistance there is, the less current will flow. In a fuel tank, the variable resistor consists of a strip of resistive material connected on one side to the ground. A wiper connected to the gauge slides along this strip of material, conducting the current from the gauge to the resistor. If the wiper is close to the grounded side of the strip, there is less resistive material in the path of the current, so the resistance is small. If the wiper is at the other end of the strip, there is more resistive material in the current's path, so the resistance is large. In the sending unit, the fuel has to drop below a certain level before the float starts to drop. When the float is near the top of the tank, the wiper on the variable resistor rests close to the grounded (negative) side, which means that the resistance is small and a relatively large amount of current passes through the sending unit back to the fuel gauge. As the level in the tank drops, the float sinks, the wiper moves, the resistance increases and the amount of current sent back to the gauge decreases.

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How to change the oil and filter on a 1993 VW Corrao VR6 The following instructions are recommended for changing the motor oil on a 1993 Corrado with a 6-cylinder VR6 motor type. Oil changes are necessary to ensure proper lubrication for the engine during use, usually ranging from every 3,000 to 5,000 miles. Over time, the oil breaks down and may cause excess wear on internal parts. The oil filter should also be changed at this time, due to any particles the filter may have caught from the old oil. Depending on your level of mechanical ability and weather conditions, this process should take about an hour or less. Please read all instructions thoroughly before attempting any maintenance. New parts: 6 quarts of oil 1 filter Tools: Floor jack Container for old oil A 6mm Allen wrench for oil filter plug 36mm socket for oil filter housing 19mm socket for drain plug on pan Socket wrench (3/8† or 1/2† is fine) Torque wrench Steps: 1. Warm up the engine by driving around for a few minutes. This will warm up the oil and will decrease the amount of time the oil needs to drain. 2. Park the ...

Analysis of As You Like It by Daniel Maclise :: As You Like It Daniel Maclise Literature Essays

Analysis of As You Like It by Daniel Maclise During the time that France was divided into provinces (or dukedoms as they were called) there reigned in one of these provinces an usurper, who had deposed and banished his elder brother, the lawful duke. The duke, who was thus driven from his dominions, retired with a few faithful followers to the forest of Arden; and here the good duke lived with his loving friends, who had put themselves into a voluntary exile for his sake, while their land and revenues enriched the false usurper; and custom soon made the life of careless ease they led here more sweet to them than the pomp and uneasy splendour of a courtier's life. Here they lived like the old Robin Hood of England, and to this forest many noble youths daily resorted from the court, and did fleet the time carelessly, as they did who lived in the golden age. In the summer they lay along under the fine shade of the large forest trees, marking the playful sports of the wild deer; and so fond were they of these poor dappled fools, who seemed to be the native inhabitants of the forest, that it grieved them to be forced to kill them to supply themselves with venison for their food. When the cold winds of winter made the duke feel the cha nge of his adverse fortune, he would endure it patiently, and say: 'These chilling winds which blow upon my body are true counsellors; they do not flatter, but represent truly to me my condition; and though they bite sharply, their tooth is nothing like so keen as that of unkindness and ingratitude. I find that howsoever men speak against adversity, yet some sweet uses are to be extracted from it; like the jewel, precious for medicine, which is taken from the head of the -venomous and despised toad.' In this manner did the patient duke draw a useful moral from everything that he saw; and by the help of this moralizing turn, in that life of his, remote from public haunts, he could find tongues in trees, books in the running brooks, sermons in stones, and good in everything. The banished duke had an only daughter, named Rosalind, whom the usurper, duke Frederick, when he banished her father, still retained in his court as a companion for his own daughter Celia.

Software Development Life Cycle

SOFTWARE DEVELOPMENT LIFE CYCLE SUMMARY SOFTWARE DEVELOPMENT LIFE CYCLE is basically a framework which describes the activities performed at each stage of a software development Project. These activities involve stages like the requirements, design, implementation, testing, installation and maintenance. In the information technology industry, SDLC plays a big role. No software development process will ever be completed efficiently and also meeting the budget client requirements without SDLC. This is because SDLC involves a structural framework which describes the phases involved in information system development. SDLC in management is an important factor which needs to be taken into consideration if you want a software development project to be resounding success. The phases of SDLC can vary somewhat but generally include the following: Conceptualization Requirements and cost/benefits analysis Detailed specification of the software requirements Software design Programming Testing User and technical training; and Maintenance The following are some basic popular models that are adopted by many software development firms System Development Life Cycle (SDLC) Model Prototyping Model Rapid Application Development Model Component Assembly Model As part of my research project I would be studying the core principles of SDLC. I would also perform research on available SDLC models in the information technology industry. System Development Life Cycle (SDLC) Model This is also known as Classic Life Cycle Model (or) Linear Sequential Model (or) Waterfall Method. This model has the following. Most software teams still use a waterfall process for development projects. Taking an extreme waterfall approach means that you complete a number of phases in a strictly ordered sequence: requirements analysis, design, implementation/integration, and then testingg activities. 1. System/Information Engineering and Modeling As software is always of a large system (or business), work begins by establishing the requirements for all system elements and then allocating some subset of these requirements to software. This system view is essential when the software must interface with other elements such as hardware, people and other resources. System is the basic and very critical requirement for the existence of software in any entity. So if the system is not in place, the system should be engineered and put in place. In some cases, to extract the maximum output, the system should be re-engineered and spruced up. Once the ideal system is engineered or tuned, the development team studies the software requirement for the system. 2. Software Requirement Analysis This process is also known as feasibility study. In this phase, the development team visits the customer and studies their system. They investigate the need for possible software automation in the given system. By the end of the feasibility study, the team furnishes a document that holds the different specific recommendations for the candidate system. It also includes the personnel assignments, costs, project schedule, target dates etc†¦. The requirement gathering process is intensified and focussed specially on software. To understand the nature of the program(s) to be built, the system engineer or â€Å"Analyst† must understand the information domain for the software, as well as required function, behavior, performance and interfacing. The essential purpose of this phase is to find the need and to define the problem that needs to be solved . 3. System Analysis and Design In this phase, the software development process, the software's overall structure and its nuances are defined. In terms of the client/server technology, the number of tiers needed for the package architecture, the database design, the data structure design etc†¦ are all defined in this phase. A software development model is thus created. Analysis and Design are very crucial in the whole development cycle. Any glitch in the design phase could be very expensive to solve in the later stage of the software development. Much care is taken during this phase. The logical system of the product is developed in this phase. 4. Code Generation The design must be translated into a machine-readable form. The code generation step performs this task. If the design is performed in a detailed manner, code generation can be accomplished without much complication. Programming tools like compilers, interpreters, debuggers etc†¦ are used to generate the code. Different high level programming languages like C, C++, Pascal, Java are used for coding. With respect to the type of application, the right programming language is chosen. 5. Testing Agile software development refers to a group of software development methodologies based on iterative development, where requirements and solutions evolve through collaboration between self-organizing cross-functional teams. Agile methods generally promote a disciplined project management process that encourages frequent inspection and adaptation, a leadership philosophy that encourages teamwork, self-organization and accountability, a set of engineering best practices intended to allow for rapid delivery of high-quality software, and a business approach that aligns development with customer needs and company goals. Agile methods have much in common with the â€Å"Rapid Application Development† techniqu

Hackers: Outlaws and Angels Essay

Outlaws and Angels is a very interesting documentary that outlines the technology and intelligence that has permeated the hacker community. Hackers is someone who breaks into computers and computer networks, either for profit or motivated by the challenge. The subculture that has evolved around hackers is often referred to as the computer underground but is now an open community. Ian Murphy, also known as Captain Zap, is said to have done the ‘greatest hack ever’. Was the first cracker to be tried and convicted as a felon. Murphy broke into AT&T’s computers in 1981 and changed the internal clocks that metered billing rates. People were getting late-night discount rates when they called at midday. Of course, the bargain-seekers who waited until midnight to call long distance were hit with high bills. Murphy, now the chairman of IAM/Secure Data System, was the inspiration for the movie â€Å"Sneakers.† Another story about hacking is when the famous movie Star Wars first came out, hundreds and thousands of people have to wait in line for hours to watch it. But a group of hackers have watched it and spreads it in the internet for about a week before the premiere. They successfully hacked the Star Wars database and took the movie data. So at first the term hacker referred to just people who breaks computer security. But later ‘hacker’ splits to two main sides. The Black Hats and the White Hats. A white hat hacker breaks security for non-malicious reasons, for instance testing their own security system. This classification also includes individuals who perform penetration tests and vulnerability assessments within a contractual agreement. Often, this type of ‘white hat’ hacker is called an ethical hacker. The International Council of Electronic Commerce Consultants, also known as the EC-Council has developed certifications, courseware, classes, and online training covering the diverse arena of Ethical Hacking. A black hat is the villain or bad guy, especially in a western movie in which such a character would wear a black hat in contrast to the hero’s white hat. A black hat hacker, sometimes called â€Å"cracker,† is someone who breaks computer security without authorization or uses technology usually a computer, phone system or network for malicious reasons such as vandalism, credit card fraud, identity theft, piracy, or other types of illegal activity. After learning much about hackers and internet security, we now know that the internet isn’t the  safest place and that we need protection as much as we can. The least we can do right now is to keep our own system safe. Little things like keeping a strong password, not sharing any account with somebody else can help in improving our security.