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Background: A lack of knowledge exists on real world hospital strategies that seek to improve quality, while reducing or containing costs. The aim of this study is to identify hospitals that have implemented such strategies and determine factors influencing the implementation. Methods: We searched PubMed, EMBASE, Web of Science, Cochrane Library and EconLit for case studies on hospitalwide strategies aiming to increase quality and reduce costs. Additionally, grey literature databases, Google and selected websites were searched. We used inductive coding to identify factors relating to implementation of the strategies. Results: The literature search identified 4198 papers, of which our included 17 papers describe 19 case studies from five countries, mostly from the United States. To accomplish their goals, hospitals use different management strategies, such as continuous quality improvement (CQI), clinical pathways, Lean, Six Sigma and value-based healthcare (VBHC). Reported effects on both quality and costs are predominantly positive. Factors identified to be relevant for implementation were categorized in eleven themes: (1) strategy, (2) leadership, (3) engagement, (4) reorganization, (5) finances, (6) data and information technology (IT), (7) projects, (8) support, (9) skill development, (10) culture, and (11) communication. Recurring barriers for implementation are a lack of physician engagement, insufficient financial support, and poor data collection. Conclusion: Hospital strategies that explicitly aim to provide high quality care at low costs may be a promising option to bend the cost curve while improving quality. We found a limited amount of studies, and varying contexts across case studies. This underlines the importance of integrated evaluation research. When implementing a quality enhancing, cost reducing strategy, we recommend considering eleven conditions for successful implementation that we were able to derive from the literature. [ABSTRACT FROM AUTHOR]

Background: The estimated cost per year of injuries in collegiate athletics has been reported to be billions of dollars in the United States. Injury prevention programs are often assessed only by their ability to reduce injuries, and there is little evidence of any potential reduction in associated health care costs. Purpose: To investigate changes in injury-related health care costs at a National Collegiate Athletic Association (NCAA) Division I university after the implementation of an injury prevention program. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 12 sports teams that used the injury prevention program (user group) and 16 teams that did not implement the program (nonuser group). The injury surveillance and prevention system (Sparta Science) utilized a commercially available force-plate system to assess kinematic variables, flag high-risk athletes, and guide individual conditioning programs. Data were obtained from 3 academic years before (2012-2014) and 2 academic years after (2015-2016) implementation of the Sparta Science system. The number of injuries and associated health care costs (surgery, clinic visits, imaging, and physical therapy) were compared between users and nonusers. Results: Total average annual injuries did not change significantly between users and nonusers after implementation of the program; however, users demonstrated a 23% reduction in clinic visits as compared with a 14% increase for nonusers (P =.049). Users demonstrated a 13% reduction in associated health care encounters, compared with a 13% increase for nonusers (P =.032). Overall health care costs changed significantly for both groups, with an observed 19% decrease ($2,456,154 to $1,978,799) for users and an 8% increase ($1,177,542 to $1,270,846) for nonusers (P <.01 for both). Costs related to associated health care encounters also decreased by 20% for users as compared with a 39% increase for nonusers (P =.027). Conclusion: This study demonstrated the ability to significantly reduce injury-related health care costs in NCAA Division I athletes via a comprehensive injury surveillance and prevention program utilizing force-plate technology. Given the substantial and appropriate focus on value of care delivery across the US health care system, we recommend the continued study of sports injury surveillance and prevention programs for reducing injury-related health care costs. [ABSTRACT FROM AUTHOR]

The current growth of the geriatric population and increased burden on trauma services throughout the United States (US) has created a need for systems that can improve patient care and reduce hospital costs. We hypothesize that the multidisciplinary services provided through the Geriatric Injury Institute (GII) can reduce hospital costs, improve patient triage throughput, and decrease hospital length of stay (LOS). Methods and Material: We performed a single-center, retrospective chart review of our Level II trauma center registry and electronic medical records of patients ages 65 and older who satisfied trauma activation/code criteria between July 1, 2014, to June 30, 2016 (N = 663). Patients presenting from July 1, 2014, to June 30, 2015, were grouped as Pre-GII, while those presenting from July 1, 2015, to June 30, 2016, were grouped as Post-GII. Primary outcomes were emergency department (ED) triage time, overall LOS, and hospital costs. Secondary outcomes included patient disposition, mortality, and health assessments. Statistical comparisons were made using a one-way analysis of variance and Mann-Whitney U test. Results: Pre-GII vs. Post-GII average ages and the Injury Severity Score (ISS) were not statistically different (p>0.05). The average LOS was similar between the Pre-GII and Post-GII groups (4.64 ± 4.42 days vs. 4.26 ± 5.58 days, p = 0.48). More patients were discharged earlier (≤ 4 days; 64% vs. 73%) as well as discharged to home (37% vs. 45%) in the Post-GII group. The total cost savings were $53,000 with a median savings of $1061 per patient ($8808 vs. $7747, p = 0.04). Savings were highest during the first two days of admission (p = 0.03). The reduction in ED triage time was not significant (310.7 minutes vs 219. 8 minutes, p > 0.05). Conclusion: With the increase in geriatric trauma, innovative models of care are needed. Our study suggests that the GII multidisciplinary approach to trauma services can lower overall hospital costs. [ABSTRACT FROM AUTHOR]

A number of economic factors have collided recently: the step drop in the price of oil, uncertainty in the United States and global economies, and mixed signals from economic and political leaders of many countries. All of these conditions have placed companies, especially those affected by oil prices under difficult economic stress. Companies are taking radical actions to, reduce capital and operational spending and in general, reduce cost. These economic pressures can be onerous on all areas of a business, but especially on the production floor‐level operations. Cost‐cutting dicta come from the executive levels, demanding a significant reduction in operating expenses or capital expenditures even when production levels are stable or increasing. While all areas of a company feel the impacts, key process safety impacts are felt on the shop floor; by the exact people, process safety is meant to protect, the operators, maintenance personnel and their supervisors. During these times of extreme economic pressure, it is imperative that process safety systems are not allowed to lose effectiveness. This article is intended to serve as a reminder of some impacts of cost cutting and to present tools to combat the loss of process safety effectiveness. [ABSTRACT FROM AUTHOR]

Purpose Reduction in waste of intravenous (IV) tacrolimus, an immunosuppressant used to prevent graft-versus-host disease in allogeneic hematopoietic stem cell transplantation recipients, was evaluated after standardizing the concentration. Methods A single-center, retrospective cohort study at a large academic comprehensive cancer center was performed comparing patient-specific intravenous tacrolimus doses (tacrolimus doses in 50, 100, or 250 mL of normal saline based on manufacturer’s recommended concentration) to tacrolimus intravenous standard concentration (tacrolimus 1 mg in 250 mL of normal saline) continuous intravenous infusion titrated to prescribed dose. The cohort study was performed on two hematopoietic stem cell transplantation nursing units consisting of a prepilot phase during which time patient-specific intravenous tacrolimus doses were compounded and administered, followed by the pilot phase during which patients received tacrolimus intravenous standard concentration. The primary endpoint was reduction in tacrolimus intravenous bags wasted. Secondary endpoints were drug cost savings, decreased intravenous infusion line supplies, decrease in time needed to execute dose changes, reduction in infusion pump alerts, and number of patient safety events. Results Compared to the prepilot phase, there was a 64% reduction in tacrolimus intravenous bags wasted during the pilot phase (p = 0.029), resulting in a mean monthly total cost savings of $224.31 for pilot units. Intravenous pump line use was reduced by 18% (p = 0.067), yielding a monthly total cost savings of $84.02 for pilot units. The median time needed to execute dose changes and intravenous pump overrides was significantly reduced (p < 0.0001, p < 0.0001, respectively). Conclusion This interdisciplinary quality improvement initiative led to increased efficiency, reduction in waste, and decreased intravenous pump alerts utilizing tacrolimus intravenous standard concentration. [ABSTRACT FROM AUTHOR]

As a result of the aging of American society and the fact that older persons require a great deal more healthcare and much more expensive treatments, the costs are on the rise and spiraling out of control. As a solution, ethicists Daniel Callahan and others have proposed healthcare rationing on the basis of age. On the basis of utilitarian ethicist, these writers have argued that age-based rationing will lead to the provision of healthcare to the greatest number of people. Of course, utilizing other ethical theories other writers have opposed the rationing of healthcare on the basis of age. The paper presents the arguments made, and the ethical theories employed, by both sides, which suggest an ethical dilemma, thus most probably a debate about age-based rationing in the future. The author found it interesting to seek the views of professors teaching healthcare -related courses about this type of rationing. Utilizing grounded theory/ quantitative research methodology, designing a questionnaire that included some 14 questions, the author interviewed some 18 professors of healthcare courses in Pennsylvania. Utilizing grounded theory in the analysis of the results of the interviews led to some eight interesting themes, which are presented and analyzed in the paper. After presenting the results of that study, and not finding the application of age-based rationing feasible, the paper also discusses other alternative solutions for reducing healthcare costs, including the notion of fair innings suggested by Allan Williams. All these alternatives are discussed in the paper. [ABSTRACT FROM AUTHOR]

Offshore wind is one of the most fascinating industries in the renewable energy sector and it is experiencing a remarkable growth. Offshore wind energy generation offers an opportunity in the race to decrease the dependence on fossil fuels, reduce green house emissions, increase energy security and create employment opportunities. UK has proven success in offshore wind and has been enjoying the economic benefits of offshore wind since over a decade. Offshore wind energy is an emergent renewable energy industry in the United States. The United States is coping up with the challenges and heading up fast to catch up with the industry. India is still in its infancy stage where the policy frameworks are framed by MNRE government and getting ready with the tools to enter into the offshore market. This paper researches the current situation and trend of offshore wind industries in UK and US, from aspects of policy, grid connections, operation and maintenance and cost reduction and analyses the proper direction and pathways of the industry to India. Therefore this paper highlights the scenario as to how these three countries UK, USA and India, respectively, are enabling offshore wind, to make a vital and sizeable contribution to the low carbon economy. [ABSTRACT FROM AUTHOR]

Modern strategic techniques have been increasingly applied in recent years, both in manufacture and retail, individually or concurrently. The main goal of their application in the retail business is continuous improvement, in particular by reducing costs of competitiveness and (business and financial) performance, while increasing customer satisfaction and meeting the needs of customers/consumers. One of the most important strategic techniques increasingly used not only in manufacturing but also in modern retail is outsourcing, which basically involves purchasing goods and/or services from independent external suppliers. The research in contemporary practice of the retail business has revealed that the application of outsourcing technique contributes to stronger commitment of management towards the activities that are the core of competitiveness, reducing costs, improving competitiveness and creating added value. All this has a long-term impact on improving performance in the retail sector. Starting from the developed theory and conducted practical research, this paper emphasizes the importance and specific problems of application of outsourcing the strategic technique in the modern retail. Their knowledge is very important for an effective implementation of outsourcing as a function of improving overall performance in retail. This is especially true for retailers in developing and transition countries, as it is the case, for example, with Serbia, where the use of outsourcing is at a very low level compared to developed countries. In the future, because of its economic importance, outsourcing will certainly be more applied in the retail sector of respective countries, with the expectation of a growing trend at approximately the same level as it is in developed countries in Europe and America. [ABSTRACT FROM AUTHOR]

Purpose – The aim of this paper is to present the initiatives that libraries and information services should take from the standpoint of management or services in times of economic crisis or recession such as the one currently occurring. When budget cuts, downsizing and cuts in equipment are continuous, it is important to reflect on the path that each library should take to overcome the crisis while providing users the services they require. Design/methodology/approach – There are projects internationally, including, inter alia, Pulman and Calimera, which highlight the supportive role of lifelong training, of both formal and informal education and of the libraries' contribution to social and economic development. They even claim that along with archives and museums, libraries should collaborate in developing a strong local economy by supporting local businesses and industry in different ways (offering information services, stimulating the acquisition of basic skills and providing career guidance). Logically, the public library is not the only – and may not even be the principal agent or the one most associated with this problem – which can address job insecurity, economic hardship and people's need for training. However, in the author's view it can have a significant and active role, in coordination with other agents, and it is important to take advantage of its potential: its collections, the training of its staff members, its familiarity with the everyday life of towns and cities, its openness to everyone without any preconditions, etc. Findings – In recent years some libraries have seen their financial resources reduced, or have remained stagnant in face of an increased demand for service. A first consideration in this context, which might be very hard but is unavoidable when faced with such a reality, is the need to rethink which services to keep and which to reduce or cancel if there is insufficient funding. At times it is necessary to choose what to do without. Originality/value – Public libraries are increasingly becoming more of a social space where all people can go for information, learning and culture, regardless of their age, level, training or background. The library as a resource, which in many cases is public, and which enables individuals to enjoy their right to information should be defended to the fullest in times such as these. Also, to the greatest extent possible, libraries should be used in a compensatory manner, targeting people with fewer resources who are in need of skills that enable them to return to the workplace or reduce the consequences of lack of income. [ABSTRACT FROM AUTHOR]

Purpose – This article seeks to provide insight on how librarians managed through the recession. It aims to highlight key areas of concern such as budgets and personnel. It is the culmination of two surveys administered in the succeeding summers of 2009 and 2010. Design/methodology/approach – The library community was notified of the surveys and provided the surveys' link via numerous library listservs. The same listservs were used for each survey. The responses received were from representatives of academic, special and public libraries. Findings – An examination of the surveys reveals that budget cuts were worse in fiscal year (FY) 2009 than they were in 2010. Suggesting the cuts enacted in FY 2009 were effective thus less severe cuts were needed in FY 2010. Stress levels were high for FY 2009 and inched higher in FY 2010. There was no significant help, in terms of cost sharing for purchases, from the departments within the organizations the libraries served. Best practice suggestions were offered in many areas to include communication, purchasing and personnel. Originality/value – When the economy experiences a contraction, businesses, governments and the general population begins to rein in expenses. This affects libraries of all types, special, academic and public. The article explores how the library community dealt with this issue and provides information that generates problem solving ideas for those in budgetary and leadership roles. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to establish a scale for the measurement of proactive improvement, in general, and then more specifically in terms of cost- and service-focused improvement in logistics outsourcing arrangements. Design/methodology/approach - Upon completing a review of the literature, scale development is completed in five phases. The first two phases focus on item generation and qualitative validation. The third phase (quantitative pilot testing) involves a sample of 220 logistics managers in Germany. The fourth phase replicates these findings with a sample of 250 US logistics managers. The final phase differentiates the general scale tested and replicated in the previous two phases by assessing the merit of cost- and service-focused scales adapted from the general scale among a separate sample of 298 logistics managers in Germany. Findings - After eliminating one measurement item, the German and US samples provide support for a four-item scale to measure general proactive improvement. Subsequent analysis with a separate sample finds strong support for scales that are adapted to capture the distinct aspects of cost- and service-focused improvement. Research limitations/implications - Research indicates that one of the key differentiators in the success of logistics outsourcing relationships is the service provider's ability to achieve proactive improvement, or customer-oriented ex post adaptations that benefit the customer after the relationship's formation. Little empirical research has been conducted to assess the influence and merit of such improvements. The establishment of valid scales is an important initial step towards understanding the value and nature of proactive improvement in logistics outsourcing relationships. Practical implications - Future research using the established scales should help provide practitioners with a better understanding of the value and nature of proactive improvement in logistics outsourcing relationships. Originality/value - The paper employs a thorough multi-phase/multi-sample approach across two distinct countries to devise a scale for an important construct in logistics outsourcing research. [ABSTRACT FROM AUTHOR]

This article presents approaches for overcoming the obstacles in the path to integrating Department of Defense (DoD) test and evaluation (T&E) and training communities to better support the modern-day warfighter and to enable new opportunities for shared investment, development, and process improvement. Testing and training, now managed under separate fiscal and managerial constructs, are hindered from establishing shared capabilities by distinctly different goals and funding. Each community must synchronize its priorities and funding with those of the other community to secure joint investments. A two-community perspective of the future path was expressed at the International Test and Evaluation Association (ITEA) Open Forum on Testing and Training. The proposed path to achieving integration of testing and training includes the establishment of a singular management backbone that encourages joint investment to eliminate duplication of effort and thus, systemically bring about cost reduction and enhance effectiveness across both communities. Such a shared backbone would enhance testing, training, inter operability, and warfighting through the increased commonality and realism of warfighting systems prior to fielding. [ABSTRACT FROM AUTHOR]

Introduction: This study evaluated the impact of establishing an inpatient teleneurology consultation service alongside an already established telestroke network on the stroke transfers to the hub. The study also aimed to assess the financial impact of establishing this network., Methods: Prospectively collected data on all stroke patients evaluated through our telestroke and teleneurology networks between January 2008 and March 2018 were interrogated. For all spokes (eight sites) that had both teleneurology and telestroke services, we compared the rate of transfers to the hub before and after the establishment of the teleneurology network in August 2014. The cost reduction was estimated using the Medicare 5% standard analytic files., Results: A total of 4296 stroke patients were evaluated during the study period. Of these, 2493 were seen before and 1803 were seen after the implementation of the teleneurology network at the included sites. Patients in the pre-teleneurology group were older (66.4 years ( SD  = 14.7 years) vs. 67.8 years ( SD  = 15.1 years); p  = 0.002). Otherwise, there were no differences in baseline characteristics. Patients in the pre-teleneurology group were more likely to be transferred to the telestroke hub (29.4% vs. 20.2%; p  < 0.001). The estimated mean cost reduction for each one minus the cost of transfer was estimated to be US$4997., Discussion: The implementation of an inpatient teleneurology network was associated with a significant reduction in the transfer rate of stroke patients to hospitals with a higher level of care and could lead to a significant cost reduction.

Objective: To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance., Data Sources: National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016)., Study Design: We compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates., Principal Findings: Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician-led (68.3 vs 49.6 percent) and served higher-risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI -77.9, 243.1]), outpatient spending per beneficiary year (-24.0 [95% CI -248.9, 200.8]), and specialist visits per 1000 beneficiary years (369.7 [95% CI -9.3, 748.7])., Conclusion: Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts., (© Health Research and Educational Trust.)

As a result of the coronavirus disease 2019 (COVID-19) pandemic, virtually all in-person outpatient visits were canceled in many parts of the country between March and May 2020. We sought to estimate the potential impact of COVID-19 on the operating expenses and revenues of primary care practices. Using a microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements, including telemedicine visits, we estimated that over the course of calendar year 2020, primary care practices would be expected to lose 67,774 in gross revenue per full-time-equivalent physician (the difference between 2020 gross revenue with COVID-19 and the anticipated gross revenue if COVID-19 had not occurred). We further estimated that the cost at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices would be $15.1 billion. This could more than double if COVID-19 telemedicine payment policies are not sustained.

Medicare's Merit-based Incentive Payment System (MIPS) includes episode-based cost measures that evaluate Medicare expenditures for specific conditions and procedures. These measures compare clinicians' cost performance and, along with other MIPS category scores, determine Medicare Part B clinician payment adjustments. The measures do not include risk adjustment for social risk factors. We found that adjusting for individual and community social risk did not have a meaningful impact on clinicians' cost measure performance. Across eight cost measures, 1.4 percent of clinician groups, on average, had an absolute change in their cost measure performance percentile of 10 percent or more (range, 0.4-3.4 percent). Prior analyses have generally found higher health care costs for patients with increased social risk. MIPS episode-based cost measures are distinct from previous cost measures because they only include costs related to the specific condition being evaluated. This unique approach may explain why costs were similar for patients with high and low social risk before any risk adjustment. MIPS episode-based cost measures do not appear to penalize clinicians who primarily care for patients with increased social risk.

The federal Strong Start for Mothers and Newborns initiative supported alternative approaches to prenatal care, enhancing service delivery through the use of birth centers, group prenatal care, and maternity care homes. Using propensity score reweighting to control for medical and social risks, we evaluated the impacts of Strong Start's models on birth outcomes and costs by comparing the experiences of Strong Start enrollees to those of Medicaid-covered women who received typical prenatal care. We found that women who received prenatal care in birth centers had lower rates of preterm and low-birthweight infants, lower rates of cesarean section, and higher rates of vaginal birth after cesarean than did the women in the comparison groups. Improved outcomes were achieved at lower costs. There were few improvements in outcomes for participants who received group prenatal care, although their costs were lower in the prenatal period, and no improvements in outcomes for participants in maternity care homes.

With the coronavirus disease 2019 (COVID-19) pandemic, one of the major concerns is the direct medical cost and resource use burden imposed on the US health care system. We developed a Monte Carlo simulation model that represented the US population and what could happen to each person who got infected. We estimated resource use and direct medical costs per symptomatic infection and at the national level, with various "attack rates" (infection rates), to understand the potential economic benefits of reducing the burden of the disease. A single symptomatic COVID-19 case could incur a median direct medical cost of $3,045 during the course of the infection alone. If 80 percent of the US population were to get infected, the result could be a median of 44.6 million hospitalizations, 10.7 million intensive care unit (ICU) admissions, 6.5 million patients requiring a ventilator, 249.5 million hospital bed days, and $654.0 billion in direct medical costs over the course of the pandemic. If 20 percent of the US population were to get infected, there could be a median of 11.2 million hospitalizations, 2.7 million ICU admissions, 1.6 million patients requiring a ventilator, 62.3 million hospital bed days, and $163.4 billion in direct medical costs over the course of the pandemic.

When the Affordable Care Act (ACA) became law in 2010, public opinion of it was narrowly divided and deeply partisan. Our review of 102 nationally representative public opinion polls in the period 2010-19 reveals that opinion remains divided and has shifted in a sustained way at only two points in time: in a negative direction following technical problems in the first enrollment period, and in a positive direction after President Donald Trump's election and subsequent Republican repeal efforts. In late 2019 the ACA was more popular than ever, yet partisan divisions have gotten larger rather than smaller. Many core elements of the law remain popular across partisan groups, even as fewer people recognize the ACA as the source of some of these provisions. While Republicans may never embrace the law that is seen as President Barack Obama's legacy, the public's reluctance to see certain benefits taken away will continue to be a roadblock for people who would seek to repeal or dismantle it.

Background: Care pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience., Methods: A historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores., Results: In total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (-8.501%, 95% confidence interval [CI] -9.639 to -7.350), a decrease in LOS (-26.966%, 95% CI -28.516 to -25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient., Conclusion: TKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually., (Copyright © 2019 Elsevier Inc. All rights reserved.)

In 2015 the Food and Drug Administration approved filgrastim-sndz (Zarxio), the first US biosimilar. Following rapid uptake, by March 2018 filgrastim-sndz accounted for 47 percent of filgrastim administrations among commercially insured and 42 percent among Medicare Advantage beneficiaries. The initial cost difference between the originator and biosimilar was 31 percent in the former population but negligible in the latter.