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Background Chronic obstructive lung disease, specifically chronic asthma and COPD, impacts more than 500 million adults worldwide, and is associated with high healthcare spending and significant disease-related morbidity. While the direct impact of substance use disorder is well documented, little is known about the indirect impact of substance misuse within this patient population. The healthcare cost and indirect morbidity secondary to substance misuse in obstructive lung disease has yet to be quantified. Objective To determine the indirect impact of substance misuse on disease severity, healthcare utilization and healthcare costs in patients with chronic obstructive lung disease across the United States. Methods Utilizing data from the 2012–2015 National Readmissions Database (NRD) patients with a diagnosis of COPD or asthma were identified. Documented substance misuse, rates of hospitalization, frequency of hospital readmission, markers of admission severity and cost were assessed utilizing weighted regression analysis. Results A total of 1,087,226 patients with an index admission for asthma or COPD were identified. Substance misuse was documented in 4.0% of patients. Substance misuse was associated with a 30% increase in odds of readmission and a higher cost per index admission. The additional index admission costs totaled $24 million for our cohort. Conclusion Substance misuse is associated with an increase in healthcare utilization and healthcare cost in patients with chronic obstructive lung disease. Targeting substance misuse in this patient population has the potential for significant cost savings to the healthcare system. [ABSTRACT FROM AUTHOR]

This study presents the deployment of antepsin (sucralfate) as corrosion inhibitor of mild steel in H2SO4 medium. Chemical (gravimetric) and electrochemical (potentiodynamic polarization and electrochemical impedance spectroscopy) techniques were used in the corrosion control investigation. The antepsin drug was characterized by gas chromatography mass spectrophotometer (GCMS) and Fourier transform infrared (FTIR) spectroscopy. Effects of inhibitor concentration, temperature and time on weight loss, corrosion rate, inhibition efficiency and degree of surface coverage were examined. Thermodynamic and adsorption properties of the corrosion inhibition process were determined. Inhibition efficiency was optimized using central composite design tool of Design Expert software version 12. Potentiodynamic polarization and electrochemical impedance spectroscopy were employed to determine the type and effectiveness of the inhibitor. As a confirmatory test, scanning electron microscopy (SEM) was employed to examine the surface morphology of the mild steel samples. Analysis of the results showed that major constituents of antepsin include tetradecanoate, metronidazole, hexadecanoic acid, methyl ester and 11-octadecenoic acid. The predominant functional groups include; C=O stretch, C-H bend and symmetric and asymmetric =C-O-C. Adsorption of the molecules of antepsin on the surface of the mild steel was spontaneous and occurred in agreement with physical adsorption. A quadratic model adequately described the relationship between inhibition efficiency and corrosion control variables of concentration of the inhibitor, temperature and time. Optimum inhibition efficiency of antepsin was obtained as 86.75%. Chemical and electrochemical results agreed that antepsin is suitable for corrosion control of mild steel in H2SO4 solution. Antepsin acted as mixed-type inhibitor (controlled both cathodic and anodic reactions). [ABSTRACT FROM AUTHOR]

This work focuses on the removal of oil from polluted water surface using activated biomass such as ogbono shell. The shell was carbonized at a temperature of 600°C for 4h and then further modified with stearic acid. Characterization of the adsorbent produced was carried out using Scanning electron microscopy (SEM) to study the surface morphology of raw and grafted ogbono shell. Fourier Transform Infra-red Spectroscopy (FTIR) was used to investigated the functional group of different minerals. Proximate analysis was carried out to determine the surface area of the agro wastes before and after modification. Batch experiments were carried out to investigate the effects of the oil water ratio, temperature, pH and contact time on the sorption capacities of the adsorbents. Physiochemical characterization of the adsorbents revealed that surface area increased from 114 cm2 to 190.5 cm2 after modification. SEM and FTIR results revealed that more micro porous surfaces were created on the surface of the adsorbent after modification. Batch adsorption experiments with esterified ogbono shell revealed that 96% of crude oil was removed at a pH of 5 with oil water ratio of 1.4/100 cm3 after 50 min at a temperature of 90°C. Esterified ogbono shell was found to be a good adsorbent for the removal of oil layer from polluting water surface. [ABSTRACT FROM AUTHOR]

The twentieth century French philosopher, Albert Camus, in his reflection on the nature of human existence asserts the legitimacy of asking if man’s life has any meaning. Even if it does, he continues, is that meaning reassuring enough for one to keep struggling to live? In response to these reflections, existentialism agrees that the only meaning that life can have is the meaning created by an individual himself through his choices and actions. It therefore becomes necessary that man’s choices and actions should be his and not another’s, given that the individual is a surer and a trusted source of reason than religion, government or any social institution. Above all, man is most himself when he is authentic which is to say that his actions must be solely informed by his choices. But many a time, we find conformists who are thoughtlessly playing out the role that social and religious structures have established for them without any critical attempt to articulate such a condition; such people are considered “nothing” in existential terms. Put differently, such people do not exist which presupposes the need for their revolt against conformism. Thus, Camus’ The Plague is weaved around the dialectics of conformism and revolt respectively. Against this backdrop, this study—a hasty reflection on Camusian principles on existentialism—will explore the sequence of conformism and revolt as presented in The Plague.

Abstract Background Preventing HIV transmission is a worldwide public health issue. Vertical transmission of HIV from a mother can be prevented with diagnosis and treatment, but screening incurs cost. The U.S. Virgin Islands follows the mainland policy on antenatal screening for HIV even though HIV prevalence is higher and rates of antenatal care are lower. This leads to many cases of vertically transmitted HIV. A better policy is required for the U.S. Virgin Islands. Methods The objective of this research was to estimate the cost-effectiveness of relevant HIV screening strategies for the antenatal population in the U.S. Virgin Islands. An economic model was used to evaluate the incremental costs and incremental health benefits of nine different combinations of perinatal HIV screening strategies as compared to existing practice from a societal perspective. Three opportunities for screening were considered in isolation and in combination: by 14 weeks gestation, at the onset of labor, or of the infant after birth. The main outcome measure was the cost per life year gained (LYG). Results Results indicate that all strategies would produce benefits and save costs. Universal screening by 14 weeks gestation and screening the infant after birth is the recommended strategy, with cost savings of $1,122,787 and health benefits of 310 LYG. Limitations include the limited research on the variations in screening acceptance of screening based on specimen sample, race and economic status. The benefits of screening after 14 weeks gestation but before the onset of labor were also not addressed. Conclusion This study highlights the benefits of offering screening at different opportunities and repeat screening and raises the question of generalizing these results to other countries with similar characteristics.

Alcohol use disorder (AUD) is associated with significant direct morbidity and mortality. The impact of alcohol on chronic asthma and obstructive lung disease is unknown. AUD treatment may represent a potential target to improve healthcare utilization and healthcare costs in this patient population. Utilizing data from the 2012-2015 Nationwide Readmissions Database (NRD) and Nationwide Emergency Department Sample (NEDS), patients with a primary admission diagnosis of asthma or COPD were identified. Documented substance misuse, rates of hospitalization, frequency of hospital readmission, markers of admission severity, and cost were assessed. Within the NEDS cohort, 2,048,380 patients with a diagnosis of COPD or asthma were identified. Patients with documented AUD were more likely to present with respiratory failure [OR 1.32 (1.26, 1.39); p < 0.001] and more likely to require mechanical ventilation in the emergency room [OR 1.30 (1.19, 1.42); p < 0.001]. Within the NRD cohort, 1,096,663 hospital admissions were identified, of which 4.1% had documented AUD. AUD was associated with an increased length of stay [percentage increase estimate: 5% (4,6); p < 0.001], increased hospitalization cost, and an increased likelihood of 30-day readmission in patients with a primary admission diagnosis of COPD or asthma [OR 1.24 (1.2, 1.28); p < 0.001]. AUD is associated with increased disease morbidity and healthcare utilization in patients admitted with asthma or COPD. This impact persists after adjusting for substance misuse and associated comorbidities. Identifying and treating AUD in this patient population may improve disease, patient, and health-system outcomes. [ABSTRACT FROM AUTHOR]

Background: Lung transplantation is a lifesaving intervention for people with advanced lung disease, but it is costly and resource-intensive. To investigate the cost-effectiveness of lung transplantation as a treatment option in pulmonary disease, we must understand costs attributable to end-of-life hospitalizations for end-stage lung disease., Research Question: What are the costs associated with end-of-life hospitalizations for people with pulmonary disease, and how have these trends changed over time?, Study Design and Methods: Adults aged 18 to 74 years with hospitalization data in the Cost and Utilization Project National Inpatient Sample data from 2009 to 2019 with a pulmonary disease admission were included in this analysis. Those with a history of lung transplantation were excluded. International Classification of Diseases codes were used to identify pulmonary disease admissions, complications, and procedures and interventions. Total charges were calculated for hospitalizations and stratified by patient status at time of discharge. Trends in charges over time were assessed by demographic and hospital factors., Results: One hundred nine thousand nine hundred twenty-four (4.1%) hospital admissions for pulmonary disease resulted in in-hospital mortality. Those with obstructive lung disease accounted for 94.1% of hospitalizations and 88.1% cases of in-hospital mortality. Estimated costs for end-of-life hospitalizations were $29,981 on average with wide variation in cost by diagnosis and procedure utilization. Inpatient costs were highest for younger people who received more procedures. Among the most expensive admissions, mechanical ventilation accounted for the greatest proportion of interventions. Significant increases in the use of mechanical ventilation, extracorporeal membrane oxygenation, and dialysis occurred over the time period. The rate of hospital transfers increased with a proportionately greater increase across admissions resulting in in-hospital mortality., Interpretation: Costs accrued during end-of-life hospitalizations vary across people but represent a significant health care cost that can be averted for selected people who undergo lung transplantation. These costs should be considered in studies of cost-effectiveness in lung transplantation., Competing Interests: Financial/Nonfinancial Disclosures None declared., (Published by Elsevier Inc.)

Objectives: To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache., Background: Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization., Methods: This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated., Results: Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase., Conclusion: Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department., (© 2023 The Authors. Headache: The Journal of Head and Face Pain published by Wiley Periodicals LLC on behalf of American Headache Society.)

Background and Objective: To evaluate a novel measure of compliance, follow-up appointment delay, and assess its relationship with clinical and sociodemographic factors in patients undergoing treatment for diabetic macular edema (DME)., Patients and Methods: This is a comparative case series of patients treated for DME. The novel measure of compliance - the time in days from the intended day of return and actual day of return, or follow-up appointment delay - was studied and compared to a traditional measure: the percentage of visits missed. These were correlated with clinical and sociodemographic characteristics: best-corrected visual acuity, hemoglobin A1C percent (HbA1c), median household income, smoking status, type of insurance held, marital status, gender, and age. Univariate and multivariable analyses were conducted., Results: One hundred fifty-five patients (212 eyes) were included in the study. The median times between recommended and actual appointments was 5.0 days (range: 2.0-14.0 days). The mean percentage of visits missed was 31.7% (± 13.3%). The two measures of compliance were positively associated, but the correlation was moderate (r = 0.44). Non-white race, lack of bilateral injections, and higher baseline HBA1c were significant predictors of a median time greater than 7 days between the intended and actual follow-up dates., Conclusions: The current study identified a novel method of measuring compliance of DME patients seen by retina specialists and has identified non-white race, lack for bilateral treatment, and poorer glycemic control as risk factors for noncompliance. [ Ophthalmic Surg Lasers Imaging Retina. 2021;52:200-206.] .

Background: There has been increasing focus on both patient-reported outcome measurement (PROM) collection and patient satisfaction ratings; nevertheless, little is known about their relationship., Objectives: To determine the association between patient experience with PROM collection and visit satisfaction and to identify characteristics of better ratings for each., Methods: This cross-sectional observational study included all patients seen in 15 neurological clinics who completed PROMs as well as 6 questions on the patient experience with PROMs at least once from October 1, 2015 to December 31, 2016. Visit satisfaction was evaluated using a composite measure of physician communication, overall physician rating, and the likelihood of recommending that physician as indicated on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey. Predictors of PROM experience and satisfaction were identified using proportional odds and logistic regression models, respectively., Results: There were 6454 patients (average age 58 ± 15 years, 59% women) who completed PROMs and responded to the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey. There were significant positive associations between each PROM experience question and visit satisfaction (r = 0.11-0.19; P<.010), although factors predicting visit satisfaction differed from those predicting PROM experience. A differential effect of PROMs on visit satisfaction was identified for patients who were nonwhite, had lower income, and had more comorbidities., Conclusions: Although there was a significant association between better PROM experience and higher visit satisfaction, relationships with clinical characteristics differed, providing insights into how PROMs may be associated with patients' visit satisfaction. Further research is necessary to confirm whether PROMs can be used to improve visit satisfaction, particularly in patients who historically have reported lower quality of care., (Copyright © 2019 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) demonstrate the process of integrating technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) present data on the utility of the C3 app in facilitating decision-making throughout the injury recovery process. A multi-disciplinary team of experts in concussion care was formed to develop an evidence-informed algorithm, outlining best practices for the clinical management of concussion along three phases of recovery - acute, subacute, and post-concussive. A custom mobile application, the Cleveland Clinic Concussion (C3) app was developed and validated to provide a platform for the systematic collection of objective, biomechanical outcomes and to provide guidance in clinical decision-making in the field and clinical environments. The Cleveland Clinic Concussion app included an electronic incident report, assessment modules to measure important aspects of cognitive and motor function, and a return to play module to systematically document the six phases of post-injury rehabilitation. The assessment modules served as qualifiers within the carepath algorithm, driving referral for specialty services as indicated. Overall, the carepath coupled with the C3 app functioned in unison to facilitate communication among the interdisciplinary team, prevent stagnant care, and drive patients to the right provider at the right time for efficient and effective clinical management.

Objective: To quantify the neurologic patient experience with patient-reported outcome measures (PROMs) and identify factors associated with a positive PROMs experience., Methods: This retrospective study included all patients seen in 6 neurologic clinics who completed patient experience questions at least once between October 2015 and September 2016. Questions assessed overall satisfaction with PROMs, as well as 4 facets of the PROM experience: usefulness of questions, ease of understanding, effect on communication with provider, and effect on control of their own care. Clinic and patient characteristics were summarized across questions and predictors of response were identified using multivariable proportional odds models., Results: A total of 16,157 patients answered generic and condition-specific PROMs, as well as questions on their experience with completing PROMs. The majority of patients agreed/strongly agreed questions were easy to understand (96%), useful (83%), and improved communication (78%) and control (71%). After adjustment for other factors, being younger, black, or depressed, or having lower household income, were independent predictors of high satisfaction with PROMs. Patients who indicated the system improved communication and control of care were more often male, black, and lower income. Variability in responses was shown by clinic., Conclusion: Given the growing importance of patient satisfaction in health care, the patient experience with PROMs is a critical component of their successful implementation and utilization. Findings from this study support the feasibility of collecting PROMs in neurologic practice and the potential as a tool to optimize patient-centered neurologic care., (© 2018 American Academy of Neurology.)

Intensive care unit telemedicine (tele-ICU) is technology enabled care delivered from off-site locations that was developed to address the increasing complexity of patients and insufficient supply of intensivists. Although tele-ICU deployment is increasing, it continues to cover only a small proportion of ICU patients. This is primarily due to expense, with first-year costs exceeding $50,000 per bed. Meta-analyses of outcomes indicate survival benefits and quality improvements, albeit with significant heterogeneity. Depending on the context, a wide range of estimated incremental cost-effectiveness ratios reflects variable effects on cost and outcomes, such as mortality or length of stay. Tele-ICUs may fit within a hybrid model of care to complement high-intensity ICU staff coverage. However, more research is required to foster consensus and determine best practices. This review summarizes data on tele-ICU structure, operations, outcomes, and costs. Evidence was extracted from meta-analyses, with secondary data from Cleveland Clinic's tele-ICU experience., Competing Interests: Conflict of Interest Disclosure: The authors have completed and submitted the Methodist DeBakey Cardiovascular Journal Conflict of Interest Statement and none were reported.

Study Objective: Gastric cancer is the fifth most common malignancy and second leading cause of cancer-related mortality. Chemotherapy options for patients who fail first-line treatment are limited. Thus the objective of this study was to assess the cost-effectiveness of second-line treatment options for patients with advanced or metastatic gastric cancer., Design: Cost-effectiveness analysis using a Markov model to compare the cost-effectiveness of six possible second-line treatment options for patients with advanced gastric cancer who have failed previous chemotherapy: irinotecan, docetaxel, paclitaxel, ramucirumab, paclitaxel plus ramucirumab, and palliative care., Measurements and Main Results: The model was performed from a third-party payer's perspective to compare lifetime costs and health benefits associated with studied second-line therapies. Costs included only relevant direct medical costs. The model assumed chemotherapy cycle lengths of 30 days and a maximum number of 24 cycles. Systematic review of literature was performed to identify clinical data sources and utility and cost data. Quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were calculated. The primary outcome measure for this analysis was the ICER between different therapies, where the incremental cost was divided by the number of QALYs saved. The ICER was compared with a willingness-to-pay (WTP) threshold that was set at $50,000/QALY gained, and an exploratory analysis using $160,000/QALY gained was also used. The model's robustness was tested by using 1-way sensitivity analyses and a 10,000 Monte Carlo simulation probabilistic sensitivity analysis (PSA). Irinotecan had the lowest lifetime cost and was associated with a QALY gain of 0.35 year. Docetaxel, ramucirumab alone, and palliative care were dominated strategies. Paclitaxel and the combination of paclitaxel plus ramucirumab led to higher QALYs gained, at an incremental cost of $86,815 and $1,056,125 per QALY gained, respectively. Based on our prespecified WTP threshold, our base case analysis demonstrated that irinotecan alone is the most cost-effective regimen, and both paclitaxel alone and the combination of paclitaxel and ramucirumab were not cost-effective (ICER more than $50,000). Both 1-way sensitivity analyses and PSA demonstrated the model's robustness. PSA illustrated that paclitaxel plus ramucirumab was extremely unlikely to be cost-effective at a WTP threshold less than $400,000/QALY gained., Conclusion: Irinotecan alone appears to be the most cost-effective second-line regimen for patients with gastric cancer. Paclitaxel may be cost-effective if the WTP threshold was set at $160,000/QALY gained., (© 2016 Pharmacotherapy Publications, Inc.)

Objectives: Intrathecal drug delivery systems represent an important component of interventional strategies for refractory chronic pain syndromes. Continuous intrathecal administration of opioids results in higher subarachnoid drug concentrations, improved pain scores, and less frequent side effects when compared with systemic opioid administration. Substantial costs arise at the time of surgical implantation and at revision for battery depletion or treatment of a complication. Despite current widespread use, the real-world longevity and cost of implanted intrathecal pumps (ITP) has not been fully quantified., Materials and Methods: Patients with an ITP implanted at Cleveland Clinic Pain Management Center between January 1998 and December 2012 were included. ITP longevity was calculated as the time between implant and explant for depletion of the system's battery. Using the 2013 fee schedule of the Centers for Medicare & Medicaid Services, the daily cost of having a functioning ITP was calculated. The costs of office visits for pump refills and the cost of intrathecal medications were not included, nor were the possible savings due to decreased utilization of alternate medical services., Results: Three hundred sixty-five patients had 559 pumps implanted. Postlaminectomy syndrome was the most common indication (40%). The median system longevity for all pumps was 5.4 years (97.5% confidence interval: [5.0, 5.8]), including pumps extracted prematurely, as well as those that reached the elective replacement interval. The median ITP longevity was 5.9 years (95% confidence interval: [5.6, 6.1]) for pumps explanted for end of battery life. The median system cost per day was $10.46. The median cost per day of pumps explanted for end of battery life was $9.26, versus $44.59 for pumps explanted prematurely due to complications., Conclusions: Overall, the cohort experienced an increased incidence of pump-related complications and a device longevity that was within the range of the manufacturer's anticipated lifespan. Increasing the lifespan of the ITP and improving patient selection have the potential to significantly improve the cost-effectiveness of intrathecal therapy., (© 2014 International Neuromodulation Society.)

Background: Volatile anesthetic prices differ substantially. But differences in drug-acquisition cost would be inconsequential if hospitalization were prolonged by more soluble anesthetics. The authors tested the hypothesis that the duration of hospitalization is prolonged with isoflurane anesthesia., Methods: Initially, the authors queried their electronic records and used propensity matching to generate homogeneous sets of adults having inpatient noncardiac surgery who were given desflurane, sevoflurane, and isoflurane. The authors then conducted a prospective alternating intervention trial in which adults (mostly having colorectal surgery) were assigned to isoflurane or sevoflurane, based on protocol., Results: In the retrospective analysis, 2,898 matched triplets were identified among 43,352 adults, each containing one patient receiving isoflurane, desflurane, and sevoflurane, respectively. The adjusted geometric mean (95% CI) hospital length-of-stay for the isoflurane cases was 2.85 days (2.78-2.93); this was longer than that observed for both desflurane (2.64 [2.57-2.72]; P<0.001) and sevoflurane (2.55 [2.48-2.62]; P<0.001). In the prospective trial (N=1,584 operations), no difference was found; the adjusted ratio of means (95% CI) of hospital length-of-stay in patients receiving isoflurane versus sevoflurane was 0.98 (0.88-1.10), P=0.77, with adjusted geometric means (95% CI) estimated at 4.1 (3.8-4.4) and 4.2 days (3.8-4.5), respectively., Conclusions: Results of the propensity-matched retrospective analysis suggested that avoiding isoflurane significantly reduced the duration of hospitalization. In contrast, length-of-stay was comparable in our prospective trial. Volatile anesthetic choice should not be based on concerns about the duration of hospitalization. These studies illustrate the importance of following even the best retrospective analysis with a prospective trial.

Background: Preventing HIV transmission is a worldwide public health issue. Vertical transmission of HIV from a mother can be prevented with diagnosis and treatment, but screening incurs cost. The U.S. Virgin Islands follows the mainland policy on antenatal screening for HIV even though HIV prevalence is higher and rates of antenatal care are lower. This leads to many cases of vertically transmitted HIV. A better policy is required for the U.S. Virgin Islands., Methods: The objective of this research was to estimate the cost-effectiveness of relevant HIV screening strategies for the antenatal population in the U.S. Virgin Islands. An economic model was used to evaluate the incremental costs and incremental health benefits of nine different combinations of perinatal HIV screening strategies as compared to existing practice from a societal perspective. Three opportunities for screening were considered in isolation and in combination: by 14 weeks gestation, at the onset of labor, or of the infant after birth. The main outcome measure was the cost per life year gained (LYG)., Results: Results indicate that all strategies would produce benefits and save costs. Universal screening by 14 weeks gestation and screening the infant after birth is the recommended strategy, with cost savings of $1,122,787 and health benefits of 310 LYG. Limitations include the limited research on the variations in screening acceptance of screening based on specimen sample, race and economic status. The benefits of screening after 14 weeks gestation but before the onset of labor were also not addressed., Conclusion: This study highlights the benefits of offering screening at different opportunities and repeat screening and raises the question of generalizing these results to other countries with similar characteristics.